This is a health-economic study from Japan. Using Markov model with the two existing levels of fees for PBT in social insurance i.e. 2,735,000 Japanese yen (US$20,652) or 1,600,000 yen (US$13,913), this study has found that PBT is a cost-effective alternative to 3D-CRT for locally advanced esophageal cancer. The estimated incremental cost-effectiveness ratio (ICER) is 14,025,268 yen (US$121,958) per QALY for the higher fee level and 7,026,402 yen (US$61,099) for the lower fee level. The effectiveness of PBT and 3D-CRT were estimated 2.62 and 2.51 QALY. The Japanese threshold for cost-effectiveness of anticancer therapy of 7,500,000 yen (US$65,217) per quality-adjusted life years (QALY) gain, the inclusion of PBT for locally advanced esophageal cancer in the benefit package of social insurance is cost-effective if a lower fee is applied.