State of the Proton Therapy Market entering 2017...Proton Therapy was seen to be most efficacious for treating Pediatric Cancer and for Base of Skull Treatment For lung and prostate

Robust Insight Ltd | www.robust-insight.co.uk | Regent's Court, Princess Street, Hull, UK HU2 8BA

Scott Owens, Managing Director, Robust Insight [email protected]

State of the Proton Therapy Market entering 2017

01

Proton Therapy Market Study

2

Method and DemographicsWho wants Proton TherapyBenefits of Proton TherapyBarriers to GrowthBelieve in the FutureMarketsConclusion

Robust Insight Ltd | www.robust-insight.co.uk | Regent's Court, Princess Street, Hull, UK HU2 8BA 3

Methodology

Robust Insight Ltd, an independent market research consultancy, was commissioned by IBA to undertake an online survey with 1,200 hospitals to better understand their use of and attitudes towards Proton Therapy

A total of 222 replies were received from 205 institutions in 29 countries – giving a response rate of 19%

The results of some questions have been compared with the last time the study was run in 2009

In the analysis, organizations not active in cancer treatment now have been removed

Demographics

4

31%

17%

14%

11%

3%

3%

2%

0%

0%

18%

Medical Physicist

Radiation Oncologist

Physician / MD

Allied Health Professional

Board Member

Practice Manager / HospitalAdministrator

Surgeon

CEO / MD

CFO or Equivalent Capacity

Others

Primary Role

36%

22%

14%

10%

17%

Already purchased/ using

Actively considering

Actively considered anddecided no

Not enough information

Not interested

Interest in Proton Therapy

What is your primary role in a hospital? n=222How would you characterize your center’s current level of interest in Proton Therapy? n=201

55%34%

11%

Region

North America Western Europe Other

Which country is your practice based in? n=222

A large proportion of the respondents are already familiar with Proton Therapy

02


5


1.8

1.6

1.1

1.0

0.8

0.6

0.6

0.4

-0.4

Radiation Physicists

Radiation Oncologists

Department Chair

Patient organizations

Board of Directors

C-Level Executives

Medical Oncologists

Cancer surgeons

Insurance Payers

To what extent did the following groups support or oppose the decision to invest in Proton Therapy?

Mean score

6Strongly opposed (-3) Opposed (-1) Neutral (0) Supported (+1) Strongly supported (+3)

Support for Proton Therapy

Radiation Physicists and Radiation Oncologists were the most likely groups to support Proton Therapy

Insurance Payers were the only group seen to oppose Proton Therapy

Base size n=146 (Actively considering, already purchased & decided no)

03


7


8

82%

79%

73%

72%

69%

62%

14%

Lower risk of treatment induced disorders

Potential for retreatment due to lower radiationdose in surrounding tissues

Potential for Dose Escalation

Precise dose delivery fewer side effects thanIMRT

Better quality of life during and after treatment

Potential for Hypofractionation

Lower cost of treatment for some indications

Below is a list of potential advantages of Proton Therapy versus traditional Radiation Therapy. Which of the following were you

aware of before this study?

Base size n=222

Awareness of the benefits of Proton Therapy versus traditional Radiation Therapy

Around four in five respondents were aware Proton Therapy had a lower risk of treatment induced disorders (82%) or had the potential for retreatment (79%) versus traditional Radiation Therapy

They were least likely to be aware that Proton Therapy was lower in cost for some indications

Benefits of Proton Therapy are well recognized even if the respondents are not considering Proton Therapy

Interest in Proton TherapyPurchased

/ usingn=72


n=45

Decided non=29

Not interested

n=34


89% 69% 76% 82%

Potential for retreatment due to lower radiation dose in surrounding tissues

86% 67% 72% 82%

Potential for Dose Escalation 82% 69% 52% 79%

Precise dose delivery fewer side effects than IMRT

78% 56% 72% 68%


83% 64% 59% 56%

Potential for Hypofractionation 69% 49% 62% 62%


19% 22% 7% 3%

9

70%

57%

47%

40%

36%

35%

35%





Potential for retreatment due to lower radiationdose in surrounding tissues

Potential for Dose Escalation

Potential for Hypofractionation

Based on your knowledge of Radiation Therapy, which of the benefits would you like further proof of Proton Therapy efficacy?

Respondents were most likely to require further proof of lower cost of treatment for some indications when considering the benefits of Proton Therapy versus Radiation Therapy (70%)

Only around a third required further proof of the potential for dose escalation (35%) or hypofractionation (35%)

Base size n=222

Proton Therapy benefits requiring further proof

Interest in Proton TherapyPurchased /

usingn=72


n=45

Decided non=29

Not interested

n=34


69% 64% 69% 86%


54% 51% 55% 81%


49% 42% 31% 71%

Lower risk of treatment induced disorders 42% 44% 28% 48%

Potential for retreatment due to lower radiation dose in surrounding tissues

35% 51% 38% 43%

Potential for Dose Escalation 47% 40% 17% 33%

Potential for Hypofractionation 43% 40% 24% 43%

10

68

47

39

27

20

15

10

14

9

7

17

28

26

34

20

25

26

18

21

13

9

9

21

22

26

31

30

29

37

41

2

5

3

5

8

7

10

10

9

11

1

2

3

7

20

12

15

17

14

18

4

8

8

4

6

11

9

12

11

10

85%

75%

64%

62%

40%

40%

36%

32%

29%

20%

Pediatric Cancer

Base of Skull Treatment

Central Nervous System

Head and Neck Cancer

Prostate Cancer

Larger Sarcomas

Lung Cancer

Lymphomas

Gastrointestinal

Gynecologic Cancer whole pelvis

In your opinion, how efficacious do you think Proton Therapy would be in the treatment of the following cancers compared to conventional Radiation Therapies?

1 Efficacy demonstrated 2 3 4 5 Efficacy NOT demonstrated Don't know

EFFICACIOUS NET

(1or2)

Proton Therapy was seen to be most efficacious for treating Pediatric Cancer and for Base of Skull Treatment For lung and prostate cancers, 40 and 36% of the respondents believe that efficacy of Proton Therapy has been demonstrated. Proton Therapy was seen as least efficacious for Gastrointestinal and Gynecological Cancer

Base size n=222

Efficaciousness of Proton Therapy compared to conventional Radiation Therapies

11

Efficaciousness (2009 vs. 2016)

+19%

+11%

+11%+24%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Pediatric Cancer Base of Skull Treatment Prostate Cancer Lung Cancer

Evolution from 2009 to 2016

2009 2016

Proton Therapy is seen as more efficacious in 2016 than in 2009 for certain types of cancer

In the 2009 study, there were 238 respondents with similar geographical distribution and degree of familiarity with Proton Therapy

In your opinion, how efficacious do you think Proton Therapy would be in the treatment of the following cancers compared to conventional Radiation Therapies? % based on those who answered 1 or 2

Base size 2016 n=222Base size 2009 n=238

04


12


13

54%

51%

48%

36%

32%

27%

23%

21%

19%

17%

More proof of efficacy

Getting adequate reimbursement

Better funding options for Protontherapy centers

Having enough patients to treat

Getting government authorization

Increased referrals from generaloncologists / physicians

Increased public awareness

Availability of staff to supportoperations

Better ROI for Proton Therapy centers

Land and space availability

In your opinion, what are the biggest barriers to the growth of Proton Therapy in your market?

Biggest barriers to the growth of Proton Therapy

Base size n=222

The biggest barriers impacting the growth of Proton Therapy were seen to be proof of efficacy (54%), adequate reimbursement (51%) and funding (48%)

Return on Investment (19%) and land/space availability (17%) were less of a concern

05


14


15

1

3

2

2

5

6

4

7

11

15

17

18

18

17

18

28

36

36

55

59

46

40

33

31

22

15

22

14

9

10

77%

73%

68%

55%

42%

41%

There will be more and more evidence on the clinical benefits of ProtonTherapy

The availability of Proton Therapy will have a growing impact on centerreputations

Proton Therapy will continue to grow rapidly

Referrals from general oncologists / physicians will continue to grow sharply

Insurance coverage for Proton Therapy treatment will improve

Other treatment options will emerge that provide the same benefits of Protontherapy (high dosage, lower side effects) at a lower cost

In your opinion how likely are the following?

Very unlikely Unlikely Neutral Likely Very likely

Future of Proton Therapy

68% of the respondents believe that Proton Therapy will continue to grow rapidly Around three quarters felt it was likely / very likely that there would be more evidence on the clinical benefits of

Proton Therapy (77%) or the availability of Proton Therapy would have a growing impact on center reputations (73%)Base size n=222

LIKELY NET

16

Future of Proton Therapy (by purchase group)

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

There will be more and moreevidence on the clinical

benefits of Proton Therapy

The availability of ProtonTherapy will have a growing

impact on centerreputations

Proton Therapy will continueto grow rapidly

Referrals from generaloncologists / physicians will

continue to grow sharply

In your opinion how likely are the following?

Purchased / using n=72 Actively considering n=45 Decided no n=29 Not interested n=34 All groups are confident that

Proton Therapy will continue to grow and have a growing impact on center reputations, even people that decided not to purchase

Base size n=180

17

Maybe a multi-room system

27%

Maybe a compact system

65%

Neither8%

Do you think one of these solutions might ever fit your needs?

Proton Therapy Solutions

Almost two-thirds were interested in a compact system

A compact system in this study is defined as a single-room Proton Therapy system

Base size n=108

18

Proton Therapy Solutions (by purchase group)

Among the group of respondents that decided no to Proton Therapy in the past, a compact system might fit the needs in the future for 68% of them

Base size n=108

0%

10%

20%

30%

40%

50%

60%

70%

80%

Maybe a multi-room system Maybe a compact system Neither

Do you think one of these solutions might ever fit your needs?

Purchased / using n=45 Actively considering n=29 Decided no n=34

06


19


20

Purchase of Proton Therapy system

49%

23%

6%

4%

3%

1%

0%

0%

0%

11%

3%

IBA

Varian Medical Systems

Mevion Medical Systems

Siemens

Hitachi

SHI

Mitsubishi

Protom International

ProNova Solutions

Other

Don't know

From which company did you purchase your Proton Therapy system? Around half purchased from IBA and a

quarter from Varian

“Other” means academic or research solutions developed in-house

Base size n=72

07



21

22

Conclusion

The majority felt Proton Therapy would continue to grow rapidly

There was widespread awareness of the benefits of Proton Therapy versus traditional Radiation Therapy, although many wanted further proof of the lower cost of treatment for certain indications

Proton Therapy is seen as more efficacious today than in 2009 for certain types of cancer

Proton Therapy was considered highly efficaciousness for certain types of cancer like Pediatric and Base of Skull Treatment, efficaciousness for cancers like lung and prostate although many felt Proton Therapy’s efficacy had not been fully demonstrated for Gastrointestinal and Gynecological Cancer

The biggest barriers impacting the growth of Proton Therapy were proof of efficacy, adequate reimbursement and funding, whilst return on investment and space availability were less of a concern

Concerns about cost meant most were more interested in a compact system rather than a large-scale, multi-room system

Documents

State of the Proton Therapy Market entering 2017...Proton Therapy was seen to be most efficacious for treating Pediatric Cancer and for Base of Skull Treatment For lung and prostate