Proton Therapy Center
BUENOS AIRES and ARGENTINA
Dr. Cesar Cucho
- Proton Therapy in a Nutshell
The treatment of cancer diseases with proton rays is a part of the radiant exposure therapies. The use of X- rays (photons) and fast electrons has been familiar to the treatment of malignant tumours for over 50 years.
There is a significant distinction between conventional radiation treatments and proton radiotherapy. The key feature of proton therapy is that when treating a patient, one can select proton beam energies and appropriate beam modifiers such that the proton beam stops on the distant side of the target (cancer) volume, thereby entirely sparing the non- affected tissues beyond cancer from receiving a dose of radiation, high energy x-ray beams pass through cancer and deposit considerable potentially destructive energy in the normal tissues beyond the cancer.
Thus, with comparable treatment techniques, non- affected tissues surrounding cancer deep in the body might receive only one-half as large a radiation dose with proton therapy than they would receive with high energy x-ray treatment. Therefore, in many clinical situations, this sharply defined tailoring of the radiation dose to the target volume with protons offers the potential of delivering higher radiation doses to cancers than with x-rays, while causing much fewer adverse effects in the adjacent normal tissues. This precision gives proton therapy a significant advantage in treating patients in whom the local control of cancer may greatly increase the likelihood of cure.
- Masterminds and Creators
Dr. Cesar Cucho in Partnership with Iseetrade Ltd
- Initiation of the reference centre of simultaneous chemo/radio therapy
Head of Finance and Administration: Mike Tuna
- long-time administrative director of the Iseetrust – Iseetrade Financials’, focused on
- establishing innovative systems in neurosurgery, cardiology and gastroenterology
- pioneering efficient controlling in public health
- setting up powerful programs to acquire wealthy patients from the Middle East, Asia and Europe
Responsibility for Physics: A team of physicians will be set up. Practitioners of applied physics with long-time experience at the national nuclear research laboratories.
Picture Giving Methods are at the core of state of the art cancer diagnosis and essential for the breakthrough of proton therapy. The issue will be represented with experience from software development and customize.
System Integration maintains network building and operating of high precision workstations and their connection to the outside. Experience with state of the art financial software packages as well as with ERP and management information systems is ensured.
- Competitive Position
For the time being the competitive environment is characterized by outlines of projects and letters of intent. The Buenos Aires Proton Therapy Centre (BA) Project is completed since more than a year. Until now, unfortunately, the medical operation could not go operative. The start-up problems are caused by the very specific proton machinery that has been specifically developed by the manufacturer Accel for the centre in Munich.
Other manufacturers like IBA and Hitachi have built proton centres that went into operation without facing comparable difficulties.
The University of Loma Linda (Cal., USA) pioneered the proton therapy with more than 10,000 treatments since 1990. The General Hospital Boston (Mass., USA), serving as Harvard’s medical centre, went into the clinical business of proton therapy at the end of 2001. Currently, clinical studies of prostate cancer and different brain tumours are conducted. Centres with treatment cases of clinical relevance are operated in China and Korea. New centres are set up in Florida and Texas that currently begin to treat patients. Altogether, more than 40,000 patients were treated worldwide until now. The practice is evaluated clinically and has the admittance of the U.S.’s FDA.
The proton centre Bonn will use the current state of the art proton machinery and methodology.
The Proton Therapy Centre’s target group are those patients, who are affected by cancer diseases that are specifically appropriate for proton radiation. Those are particularly abdominal and thoracic tumours as well as those of the prostate gland.
The case numbers are as follows
- 400,000 new cancer diseases in Germany per annum
- 70,000 of those especially appropriate for proton therapy
- 15,000 of those in nearby German regions plus at least 25,000 in market
relevant EU countries
The capacity of the proton centre amounts to about 3,600 patients per annum. That makes up to a market share of almost 20% (national) and less than 10% including EU foreign countries. A liquidation agreement with AOK Bavaria has been arranged which will serve as a prototype for nationwide remuneration regulation. A flat fee of € 17,500 was agreed upon. Private health insurance companies will pay at least the same.
Past technological breakthroughs in the German medicine system indicate that a pressure will occur to maintain comprehensive remuneration of proton therapy. Proton therapy as in comparison with conventional cancer treatment produces considerable welfare effects. The proton ray treatment costs more than conventional radiotherapy but considerably less than alternatively required surgery. Conventional cancer treatment requires constantly attendant efforts like chemotherapy and time consuming rehabilitation cures. Therefore, the average advantage of proton therapy sums up to € 15,000 taken the specific relapse
frequencies of proton treatable tumours.
Furthermore, the patients the patients benefit from the reliable disappearance of collateral damages like hair loss at chemotherapy and impotence prostate gland surgery.
An especially interesting target group are individually paying patients: nowadays they often pay macabre sums to get inadequate cures that usually are nothing than quackery. Often proton therapy can be the suitable course of action to their needs. This group requires separate marketing approaches.
- Capital Requirements and Investment Expenditure
The core of the center is a proton accelerator equipped with 4 treatment units (gantries). The central processing unit producing the proton radiation is a cyclotron which is budgeted with costs in the range of 35 Mil. €. The treatment units consist of three pipe-shaped gantries to treat tumours in the upper part of the body and a special radiation unit (Fixbeam) to treat tumours at the head. For these treatment units cost in the range of 60-80 Mil. € is budgeted.
The building to be erected has a volume of 45,000 cubic metres. Ventilation, air conditioning and water cooling must satisfy extremely high and very specific standards. Expenses in a range of 35 Mil. € are scheduled. The information technology networking makes particularly high demands: in view of the essential influence of latest picture giving methods on precision and finally the success of the treatment.
The same applies to diagnostic and other accompanying conventional medical equipment. Each of both positions is budgeted with 10-15 Mil. €. Project management must start in the pre-phase and is required for stable clinical operations. Taking the experience of the first German project in Munich budgeted cost of 13 Mil. € is indispensable to provide short-term availability of the centre’s operation. The budget includes research and development cost as well as autonomous implementation activities that commonly occur in a project with a size and complexity like this.
Cost of personnel and operation during the training phase is budgeted in unity with interest expenditures throughout the construction time of approximately 3 years: they sum up to almost 20 Mil. €.
# position investment (T €)
1) construction, technical equipment (TGA)
2) proton cyclotron
4) conventional medical equipment
5) Information technology, picture giving advice
6) project management (full service)
7) pre-operational expenditure
The budget is based on project know-how of project participants. In addition, participants had recourse to duty and obligation manuals of three other well-advanced proton centre projects. Every budget position was broken down by one quarter. Consequently, a first rough liquidity plan could be generated.
State of the art project management tools and methodology ensure cost and time efficiency. A neutral unit, exclusively obliged to the investors’ committee, maintains steady cost and time control. Therefore, continuous maintaining of time schedules and cost guidelines is ensured. Furthermore, a person-bound transfer of the Munich project’s experiences is facilitated.
Realisation plan with time planning of the activities
The following project steps are planned with the following time axis:
- Production total concept (including architectural and medicine-technical requirement catalogue) 07/2018
- Location choice 11/2017
- Hit of local cooperation arrangements 08/2018
- Property choice 07/2018
- Production business plan (finally) 8/2018
- Financing planning/capital acquisition 07/2018
- 07/2018 create building law for protons
- Building application 11/2018
- Purchase of land/lease 10/2018
- Works contract 12/2018
- Device order Med. area incl. protons and cyclotron 03/2019
- Shell/building removal from 03/2019 to 06/2020
- Devices introduce and assembly as well as building completion from 06/2019 to 12/2019
- Adjustment / Pro amount from 01/2020 to 03/2020
- Check/decrease ray protection from 04/2020 to 07/2020
- Licensing for patient’s treatment 08/2020
- the first patient’s radiotherapy 09/2020
- More positively Gross Cash Flow 12/2021
- Forecast 2021
The business figures presented in the following overview are based on the probable middle development scenario. A pessimistic and an optimistic scenario have been evaluated as well for purposes of sensitivity analysis. The outcome confirms the midway scenario.
The probable scenario is marked by the following parameters:
- As of 2022 the remuneration will descend slowly (steps of 500 € every second year).
- The staffing was developed according to the specific German standards binding Universities’ medical centres. A training phase
of 10months is scheduled. Cost of personnel is extrapolated at 3% increase.
- The increase of the energy cost is calculated at 8%.
- Maintenance cost of the proton equipment is computed at the rates the manufacturers ask for currently. Previous breakthroughs in medical technology show considerable cost reductions after the pioneer phase.
- All other operative cost is calculated in such a way that budgets cannot be exceeded. Marketing expenses are budgeted with 2 % of revenues for the first two years. Later on the budget remains at 0.5 %.
- The assets’ balance sheet deductions are computed at
- 33 years with regard to the building
- 12 years with regard to the proton equipment
- 5 years with regard to all other assets
The table depicts the probable development following the midway scenario:
If one lets this personnel expenditure together with the other operating expenses in the profit and loss calculation (GuV) flow in, one receives the Gross Cash Flow without write-off, interest and taxes.
Gross Cash Flow in 1000 €:
shall be calculated with the given market.
Is to be held on at this point, that to bring already in the first year of the patient’s company – also after consideration of a possible demand failure (by precash on zero) from not paid private calculations – a more positive Gross Cash Flow is reached.
In the following table the operating result is taking into account the income documented on top to the Gross Cash Flow and issues as well as the write-offs, complements around a cost-accounting payment of interest of 8.5% on the whole investment of 180 € of Mil. shown.
Result before taxes in 1000 €
It becomes evident that already from the second operational year with lasting effect good profits are gained. The first operational year encloses only four months and one works exclusively only with private patients.
In case the complete investment is financed by bank loans a profit of more than 10 % will be achieved. The alternative will give the managing equity firm20 % during the holding time until the end of 2010 and the investment funds taking over as of the beginning of 2011 an annual yield up to 10%.
Profit increases will appear in the course of project execution:
conventional cost-cutting will be accompanied by result driven management systems and capacity oriented resource allocation.