Back in 2016, Joern Meissner, CEO of Meissner Consulting, provided HealthCare Business News with a detailed outline of what goes into opening a new proton therapy facility. We checked back in with Dr. Meissner for an update on his insights and to find out how the process has evolved in the last four years.

HCB News: When planning a new proton therapy facility, what are some of the very first questions that must be asked?
Joern Meissner: The first questions need to deal with the business plan’s top line: who will refer patients to the center? Many proton therapy facilities overestimate the number of patients that will be arriving at their door with reimbursement for the treatment. How many patients shall be treated per year using conventional multi-fraction treatments? How will future treatment technologies like FLASH or Arc be incorporated? Answers to these questions will then need to be balanced against number of treatment rooms, proton therapy vendor’s specifications, and of course budget.

Presently, I would consider a two- or three-treatment room facility to have the best return on investment. This would allow about 800 to 1500 patient per year using present day technology treatment. FLASH would increase the capacity of the facility and may increase wall thicknesses in some areas.

HCB News: Does that mean you are in favor or multiroom facilities instead of single room facilities?
JM: There is a specific place for both types. Multiroom facilities likely have the better return on investment, can treat more patient and optimizes operation and maintenance cost, especially if the facility is standalone. Whereas, single room systems, for example IBA’s ProteusOne, Varian’s ProBeam 360° Single Room, or the MEVION S250i Proton Therapy Systems, fill a niche for local or decentralized radio oncology centers.

In the past few years I have seen many more single room systems sold than multiroom systems. If an existing radio oncology center already has a few linacs operating, the addition of one proton treatment room can benefit from a lot of synergies and optimize overall operational costs.

HCB News: How does one go about selecting a design and construction team?
JM: Even before the proton vendors provide their formal bid, a test fit layout should be obtained from each of candidate. The footprint each vendors’ vault requires is different, and seldom includes the clinical area required to operate the future facility efficiently.

When we receive the vendors’ generic test fits, we usually integrate those with the clinical user’s ideas on workflow, adapted to the specific piece of land available. Once a vendor is selected, the clinical layout and the associated technical rooms can be detailed in the design development stage, and handed off to locally registered architect and engineering (A&E) firms to create construction drawings.

With this in mind, the selection of the design team should be based on proton therapy experience. The design team operates close to the project developer and integrates the clinical user and vendor requirements. In most countries the construction drawings need to be issued by locally registered A&E firms. A successful project manager will involve the local design team already in the design development stage as a consultant for local building codes and practices.

HCB News: Who are the key stakeholders in a proton construction job, and what advice do you have for keeping them all on the same page?
JM: Proton therapy centers are very complex projects with many stakeholders: clinical users, investors and health care payers, proton therapy vendors, architects and engineers, shielding and regulatory experts, construction companies.

To keep them on the same page, one needs an experienced proton project manager, key performance indicators of which many are related to the schedule, and independent quality assurance processes for progress monitoring. Having raised two children, I feel that incentive programs can provide much better results than contractual penalties; a healthy mix of the two is advisable.

On a more technical level, the design and if possible, also the construction planning, should be done in 3D BIM models, where clashes are much easier to recognize and resolve than in 2D drawings.

HCB News: What are some common causes of construction delays, and what can be done to mitigate them?
JM: The separation of the foundation permit from the building permit can be very beneficial for project efficiency, if the structural engineer has the relevant information as early as possible. There is no substantial cost difference, if a concrete wall is 200 cm or 240 cm thick, but assuming the more conservative thickness for the foundation will prevent delays after the shielding consultant confirms the final thickness. Well-functioning ground water retention and water proofing concepts are also fundamental to minimizing delays.

Many other causes of construction delays can be attributed to undetected clashes of different trades by not having coordinated the 3D design models in enough detail, having left items for “field coordination” or “to be designed by the general contractor” in the design documents.

HCB News: Are there different options for radiation shield vendors? How does one navigate those options?
JM: Shielding walls also have a structural function and typically contain embedded conduits, ducts and water pipes. In-situ poured walls can provide for those functions, but a shielding block design needs to consider those aspects separately.

In-situ poured structural concrete is available all over the world at relatively low cost, any high-density material option can quickly cost 3-10x as much and may have to be shipped in. For shielding calculations, it is not relevant if a material is installed in blocks, or poured in situ; from a cost perspective there is a substantial difference; from a schedule perspective this difference may not be easily measurable.

A cost and construction-savvy shielding consultant should review the initial design in the early schematic design phase, and in interactive discussions with key stakeholders come up with an optimized best-guess-design for the stakeholder’s needs (e.g. regulatory, safety, cost, footprint, schedule, etc.). This design should start with conservative wall thicknesses, so that the structural engineers and architects do not have cumbersome change requests later. A complete shielding validation for conventional and future FLASH therapy should start with this best guess design and can take between 3 weeks and 6 months. Ideally the shielding consultant also works with 3D BIM models, so that results can be imported automatically into the architect’s design, and misunderstandings of 2D drawings can be avoided.

HCB News: Back in 2016 you highlighted some of the key performance indicators (KPIs) of a new proton therapy facility. Have there been any major changes in the KPIs in the last four years?
JM: The article in 2016 has sparked many requests from project developers how to define KPIs more relevant to the specific project they were working on. The main process to develop the KPIs is still valid today. For a good tracking of the project’s success, it is necessary to generate detailed KPIs and ensure that they are measurable. Some will focus on design; others will focus on construction execution. KPIs need to be set up by experts of the respective trade and it takes a collaborative effort to set up all KPIs for a project.

HCB News: From start to finish, how long does it take before a proton therapy facility can start receiving patients?
JM: With the right team, and with the willingness of the project developer to move some of the already planned expenditures to the early design phases, the time to first patient can be significantly influenced. An experienced design team can have construction drawings ready three to four months after vendor selection. In many countries, foundation permits can be applied for separately from the main building permit. With this, the construction part can be ready for equipment installation in 10 – 14 months, depending on construction organization and size of the facility. From installation start until handover of the first treatment room to the customer, 10 months seem to be a good estimate from past experience. A typical two to three-month clinical validation period by the user will follow before treatment can begin.

It is unlikely that all phases run smoothly for a project, hence an overall optimistic estimate would be 2.5 – 3 years starting at proton therapy vendor selection until first patient.