Prostate Cancer Patients Report on Benefits of Proton Therapy: Follow-on Study

1. Prostate Cancer Patients Report on Benefits of Proton Therapy: Follow-on Study PRESENTED TO: The National Proton Conference PREPARED FOR: The National Association for Proton Therapy (NAPT) PREPARED BY: Joan DaVanzo, Ph.D., M.S.W., and Kevin Reuter April 1, 2014

2. Purpose and Overview • The National Association for Proton Therapy (NAPT) commissioned Dobson DaVanzo & Associates, LLC (Dobson | DaVanzo) to investigate clinical outcomes and patient satisfaction through a follow-on study to a 2013 report of patients treated with proton therapy for prostate cancer • Our 2014 results are highly consistent with the results from the 2013 study • We also present new analyses based on information captured in a revised and enhanced survey instrument

3. 2013 Survey Overview • Last year’s survey was completed by approximately 2,000 prostate cancer therapy patients who received proton therapy between 1991 and 2010 • The survey instrument collected information related to: • Patient demographics • Patient clinical characteristics • Pre-treatment complaints • Post-treatment Health Related Quality of Life (HRQOL) • Patient satisfaction • The survey incorporated a validated instrument, known as the Expanded Prostate Index Composite (EPIC), developed by the University of Michigan and UCLA to measure prostate cancer patients’ self-reported HRQOL • Scores were calculated on a 1-100 scale with 100 indicating the best HRQOL

4. 2014 Survey Overview • The 2014 NAPT survey was completed by 3,798 prostate cancer therapy patients who received proton therapy between 1991 and 2013 • This was approximately twice the number of patients completing the 2013 survey and represents approximately 17% of all patients who received proton therapy for treatment of prostate cancer during this time period • Surveys were completed by former patients across 12 different proton therapy centers, an additional 5 centers from 2013 • The survey instrument collected similar information to the 2013 survey, as well as additional information on • Patient demographics, including health insurance and education • Patient clinical characteristics, including pre-treatment chronic conditions • Patients’ decision to choose proton therapy • This year’s survey continued to collect important HRQOL information, but used the validated short-form EPIC instrument to reduce burden on respondents

5. 2013 Survey Results • High levels of patient satisfaction • Approximately 99% of respondents believed they had made the best treatment decision for themselves • Post-treatment HRQOL comparable to healthy individuals • Those who received proton therapy for the treatment of prostate cancer had similar urinary, bowel, and hormonal HRQOL measures as a cancer-free control group • There were some differences across treatment modalities • Respondents treated with photon therapy in addition to proton therapy had lower bowel, sexual, and hormonal HRQOL scores compared to those receiving only proton therapy (p<0.05) • Respondents treated with hormone therapy in addition to proton therapy had lower sexual and hormonal HRQOL scores compared to those receiving only proton therapy (p<0.05)

6. 2014 Survey Methodology • Baseline statistics calculated on the patient population (e.g., age, time since treatment, clinical characteristics) • EPIC scores and patient satisfaction statistics also calculated for survey respondents • HRQOL measures cross tabulated with time since completion of proton therapy, age, pre-treatment health status, and treatment modality (proton therapy only, hormone therapy in addition to proton, and photon therapy in addition to proton) • Multivariate regression analyses used to identify significant predictors of high HRQOL scores

7. Patient Demographics

8. Average Time Since Treatment Distribution of Respondents by Time since Treatment

9. Patient Demographics: New Information Collected in 2014 Survey • Health insurance • 61% Commercially-insured • 51% Medicare • 8% Military health insurance • 6% MediGap • Education • 99% high school graduates or additional education • 68% completed 4-year college degree or additional education • Chronic conditions prior to treatment • 1.1 chronic conditions on average • Most commonly reported chronic conditions: • 42% high blood pressure or hypertension • 18% arthritis or rheumatism • 11% diabetes

10. Patient Satisfaction in 2014 Comparable to 2013 Survey Group • Of those responding to the 2014 survey: • 98% believed they had made the best treatment decision for themselves • 98% rated their proton therapy experience as “excellent” (88%) or “good” (10%) • 96% were “satisfied” (15%) or “extremely satisfied” (81%) with their proton therapy treatment • 96% have recommended proton therapy to others

11. Recurrence of Prostate Cancer: 2014 Survey • 97% of respondents reported no recurrence of cancer • This is consistent with recent findings from a study by the University of Florida1 and favorable compared to other treatment modalities • According to a recent estimate, 10 to 30% of prostatectomy patients have a recurrence of prostate cancer during their lifetime • According to a 2006 study, 11% of IMRT patients have a recurrence of prostate cancer within 8 years following their treatment3 Sources: 1. University of Florida Proton Therapy Institute. (2014). Proton therapy for prostate cancer results in long-term patient survival and excellent quality of life. 2. Patient Advocates for Advanced Cancer Treatments. (2012). Prostate Cancer Recurrence After Prostatectomy 3. Zelefsky et. al (2006). Long-Term Outcome of High Dose Intensity Modulated Radiation Therapy for Patients With Clinically Localized Prostate Cancer. The Journal of Urology, 176 (4):1415-1419

12. HRQOL: Comparison of 2013 and 2014 Survey Results to Control Group • Proton therapy patients completing the 2013 and 2014 survey had similar urinary, bowel, and sexual HRQOL measures as a control group of healthy individuals EPIC HRQOL Scores of Patients Who Have Received Only Proton Therapy for Treatment of Prostate Cancer

13. HRQOL by Treatment Modality: 2014 Survey EPIC HRQOL Scores by Treatment Modality Note: *p<0.05, **p<0.01 Circled in red= Significantly lower HRQOL than control group

14. HRQOL by Treatment Modality: 2014 Survey (Cont’d.) • Those receiving hormone therapy in addition to proton therapy had significantly lower urinary incontinence, urinary irritative, and sexual HRQOL compared to the control group (p<0.05) • Those receiving photon therapy and those receiving photon and hormone therapy had lower bowel and sexual HRQOL on average than the control group (p<0.05)

15. HRQOL by Time Since Completion of Therapy: 2014 Survey EPIC HRQOL Scores by Length of Time since Treatment Note: *p<0.05, **p<0.01 Lowest scores for each HRQOL category

16. Regression Analysis: 2014 Survey • Modeled the determinants of the self-reported, post-treatment urinary, bowel and sexual HRQOL to identify the factors most predictive of a high HRQOL score • Only the model predicting sexual HRQOL was significant, predicting 27% of the variance in sexual HRQOL. • Significant predictors of higher HRQOL included: • Higher education (p<0.001) • Presence of commercial (p<0.05) or MediGap insurance (p<0.001) • Significant predictors of lower HRQOL included: • Presence of sexual function problems prior to treatment (p<0.001) • Presence of chronic conditions prior to treatment (p<0.001) • Increased age (p<0.001) • Longer time since treatment (p<0.001) • Receiving hormone therapy (p<0.05) or photon therapy (p<0.001)

17. Why Did Patients Choose Proton Therapy Over Other Treatment Modalities? 2014 Survey • The most common reason for choosing proton therapy over other treatment modalities was the desire for fewer side effects than other treatment options • Decision to Choose Proton Therapy, Side Effects, 2014 Survey Results

18. Questions?

19. Dobson DaVanzo & Associates, LLC (Dobson|DaVanzo) is a health care economics consulting firm based in the Washington, D.C. metropolitan area. Contact information: (703) 260-1760joan.davanzo@dobsondavanzo.com www.dobsondavanzo.com 450 Maple Avenue East, Suite 303 Vienna, VA 22180