## 9 Comparative Radiotherapy Costs  
We stated in the preamble that there are some 39 conventional accelerator centers around the world used for proton and heavy ion cancer therapy. The sites in Europe are shown in Figure 23.  
It has been mentioned [3] that particle therapy is potentially a more effective therapeutic procedure than photon therapy. How costly is particle therapy? [PERSON] _et al_. [124] have estimated the capital costs for: (a) combined proton/carbon facility; (b) proton only facility; and (c) photon facility to be: (a) 139 million \(\copyright\); (b) 95 million \(\copyright\); and (c) 23 million \(\copyright\).  
The relative cost of treatment can also depend on where the tumor is located. The high cost of accelerator hadron treatment is evident when one considers the size of a typical hadron therapy facility (as shown for example in Figure 24). The cost figures presented in [PERSON] _et al_. are very similar to those cited in [3].  
Two very important systematic literature reviews of the clinical cost-effectiveness of conventional accelerator driven hadron therapy were carried out in 2007 and 2012 [12, 125]. The conclusion of the first survey was \"existing data do not suggest that the rapid expansion of hadron therapy (HT) as  
Figure 23: Proton and ion therapy centers in Europe [123].  
Figure 24: The Binecker Proton Therapy Center in Munich. The large capital costs can be mitigated if a number of treatment areas are provided which results in more patients being treated. It is important to point out that in the future costs could be further reduced if compact cyclotrons are used.  
a major modality would be appropriate. Further research into clinical and cost-effectiveness of HT is needed.\" In the second survey some 5 years later, this conclusion was slightly tempered with the \"aim of building enough proton therapy facilities and run clinical trials to draw firm conclusions about the clinical effectiveness of charged particle therapy to best current practice\".  
The cost of establishing a laser-based therapy center can potentially be much cheaper although one must be cautious here because all essential components must be considered and no center has yet been built. Significant cost reduction in the laser case can be possible if: (a) future high power lasers become much more compact and can therefore be housed in a smaller building; (b) radiation shielding can be significantly reduced; and (c) if an optical gantry were possible that could be lighter and smaller than that associated with a conventional accelerator-based system. Costs for a laser-driven facility have been estimated by a number of authors to be between 10 and 20 million \(\epsilon\)[75; 124; 125]. The Thales laser company recently developed the Bella laser (at a cost near $11 million) which is used at the Lawrence Berkeley National Laboratory. With petawatt peak power capability it has potential for accelerating protons to energies suitable for radiotherapy [126].  
Although most developing countries would find the costs required for a conventional accelerator-based hadron therapy center to be prohibitive they might find a laser-based system to be more affordable given national budgets. These countries could potentially afford 5-10 million \(\epsilon\) to initiate a laser-driven beam center that can guide future innovation. Such startup laser systems may not be able to provide 250 MeV protons for deep tumor therapy but they can establish the necessary foundation and suitably comprehensive thinking.  
Finally it should be emphasized that the center costs mentioned in this section are limited to the cyclotron and treatment rooms and for the basic laser and a single treatment room. Critical and detailed comparisons have not been made rigorously for the two approaches to proton therapy.