Adoption of Radiation Technology Among Privately Insured Nonelderly Patients With Cancer in the United States, 2008 to 2014: A Claims-Based Analysis

Insurance Denials and Patient Treatment in a Large Academic Radiation Oncology Center

Importance

Insurance barriers to cancer care can cause significant patient and clinician burden.

Objective

To investigate the association of insurance denial with changes in technique, dose, and time to delivery of radiation oncology treatment.

Design, Setting, and Participants

In this single-institution cohort analysis, data were collected from patients with payer-denied authorization for radiation therapy (RT) from November 1, 2021, to December 8, 2022. Data were analyzed from December 15, 2022, to December 31, 2023.

Exposure

Insurance denial for RT.

Main Outcomes and Measures

Association of these denials with changes in RT technique, dose, and time to treatment delivery was assessed using χ2 tests.

Results

A total of 206 cases (118 women [57.3%]; median age, 58 [range, 26-91] years) were identified. Most insurers (199 [96.6%]) were commercial payers, while 7 (3.4%) were Medicare or Medicare Advantage. One hundred sixty-one patients (78.2%) were younger than 65 years. Of 206 cases, 127 (61.7%) were ultimately authorized without any change to the requested RT technique or prescription dose; 56 (27.2%) were authorized after modification to RT technique and/or prescription dose required by the payer. Of 21 cases with required prescription dose change, the median decrease in dose was 24.0 (range, 2.3-51.0) Gy. Of 202 cases (98.1%) with RT delivered, 72 (34.9%) were delayed for a mean (SD) of 7.8 (9.1) days and median of 5 (range, 1-49) days. Four cases (1.9%) ultimately did not receive any authorization, with 3 (1.5%) not undergoing RT, and 1 (0.5%) seeking treatment at another institution.

Conclusions and Relevance

In this cohort study of patients with payer-denied cases, most insurance denials in radiation oncology were ultimately approved on appeal; however, RT technique and/or effectiveness may be compromised by payer-mandated changes. Further investigation and action to recognize the time and financial burdens on clinicians and clinical effects on patients caused by insurance denials of RT is needed.

Physics and biomedical challenges of cancer therapy with accelerated heavy ions

Radiotherapy should have low toxicity in the entrance channel (normal tissue) and be very effective in cell killing in the target region (tumour). In this regard, ions heavier than protons have both physical and radiobiological advantages over conventional X-rays. Carbon ions represent an excellent combination of physical and biological advantages. There are a dozen carbon-ion clinical centres in Europe and Asia, and more under construction or at the planning stage, including the first in the USA. Clinical results from Japan and Germany are promising, but a heated debate on the cost-effectiveness is ongoing in the clinical community, owing to the larger footprint and greater expense of heavy ion facilities compared with proton therapy centres. We review here the physical basis and the clinical data with carbon ions and the use of different ions, such as helium and oxygen. Research towards smaller and cheaper machines with more effective beam delivery is necessary to make particle therapy affordable. The potential of heavy ions has not been fully exploited in clinics and, rather than there being a single 'silver bullet', different particles and their combination can provide a breakthrough in radiotherapy treatments in specific cases.

Cost-Effectiveness Models of Proton Therapy for Head and Neck: Evaluating Quality and Methods to Date

PURPOSE

Proton beam therapy (PBT) is associated with less toxicity relative to conventional photon radiotherapy for head-and-neck cancer (HNC). Upfront delivery costs are greater, but PBT can provide superior long-term value by minimizing treatment-related complications. Cost-effectiveness models (CEMs) estimate the relative value of novel technologies (such as PBT) as compared with the established standard of care. However, the uncertainties of CEMs can limit interpretation and applicability. This review serves to (1) assess the methodology and quality of pertinent CEMs in the existing literature, (2) evaluate their suitability for guiding clinical and economic strategies, and (3) discuss areas for improvement among future analyses.

MATERIALS AND METHODS

PubMed was queried for CEMs specific to PBT for HNC. General characteristics, modeling information, and methodological approaches were extracted for each identified study. Reporting quality was assessed via the Consolidated Health Economic Evaluation Reporting Standards 24-item checklist, whereas methodologic quality was evaluated via the Philips checklist. The Cooper evidence hierarchy scale was employed to analyze parameter inputs referenced within each model.

RESULTS

At the time of study, only 4 formal CEMs specific to PBT for HNC had been published (2005, 2013, 2018, 2020). The parameter inputs among these various Markov cohort models generally referenced older literature, excluding many clinically relevant complications and applying numerous hypothetical assumptions for toxicity states, incorporating inputs from theoretical complication-probability models because of limited availability of direct clinical evidence. Case numbers among study cohorts were low, and the structural design of some models inadequately reflected the natural history of HNC. Furthermore, cost inputs were incomplete and referenced historic figures.

CONCLUSION

Contemporary CEMs are needed to incorporate modern estimates for toxicity risks and costs associated with PBT delivery, to provide a more accurate estimate of value, and to improve their clinical applicability with respect to PBT for HNC.

Multiple Computed Tomography Robust Optimization to Account for Random Anatomic Density Variations During Intensity Modulated Proton Therapy

Purpose

To propose a method of optimizing intensity modulated proton therapy (IMPT) plans robust against dosimetric degradation caused by random anatomic variations during treatment.

Methods and Materials

Fifteen patients with prostate cancer treated with IMPT to the pelvic targets were nonrandomly selected. On the repeated quality assurance computed tomography (QACTs) for some patients, bowel density changes were observed and caused dose degradation because the treated plans were not robustly optimized (non-RO). To mitigate this effect, we developed a robust planning method based on 3 CT images, including the native planning CT and its 2 copies, with the bowel structures being assigned to air and tissue, respectively. The RO settings included 5 mm setup uncertainty and 3.5% range uncertainty on 3 CTs. This method is called pseudomultiple-CT RO (pMCT-RO). Plans were also generated using RO on the native CT only, with the same setup and range uncertainties. This method is referred to as single-CT RO (SCT-RO). Doses on the QACTs and the nominal planning CT were compared for the 3 planning methods.

Results

All 3 plan methods provided sufficient clinical target volumes D95% and V95% on the QACTs. For pMCT-RO plans, the normal tissue D_max on QACTs of all patients was at maximum 109.1%, compared with 144.4% and 116.9% for non-RO and SCT-RO plans, respectively. On the nominal plans, the rectum and bladder doses were similar among all 3 plans; however, the volume of normal tissue (excluding the rectum and bladder) receiving the prescription dose or higher is substantially reduced in either pMCT-RO plans or SCT-RO plans, compared with the non-RO plans.

Conclusions

We developed a robust optimization method to further mitigate undesired dose heterogeneity caused by random anatomic changes in pelvic IMPT treatment. This method does not require additional patient CT scans. The pMCT-RO planning method has been implemented clinically since 2017 in our center.

Dosimetric predictors of patient-reported toxicity after prostate stereotactic body radiotherapy: Analysis of full range of the dose-volume histogram using ensemble machine learning

BACKGROUND AND PURPOSE

This study aims to evaluate the associations between dosimetric parameters and patient-reported outcomes, and to identify latent dosimetric parameters that most correlate with acute and subacute patient-reported urinary and rectal toxicity after prostate stereotactic body radiotherapy (SBRT) using machine learning methods.

MATERIALS AND METHODS

Eighty-six patients who underwent prostate SBRT (40 Gy in 5 fractions) were included. Patient-reported health-related quality of life (HRQOL) outcomes were derived from bowel and bladder symptom scores on the Expanded Prostate Cancer Index Composite (EPIC-26) at 3 and 12 months post-SBRT. We utilized ensemble machine learning (ML) to interrogate the entire dose-volume histogram (DVH) to evaluate relationships between dose-volume parameters and HRQOL changes. The latent predictive dosimetric parameters that were most associated with HRQOL changes in urinary and rectal function were thus identified. An external cohort of 26 prostate SBRT patients was acquired to further test the predictive models.

RESULTS

Bladder dose-volume metrics strongly predicted patient-reported urinary irritative and incontinence symptoms (area under the curves [AUCs] of 0.79 and 0.87, respectively) at 12 months. Maximum bladder dose, bladder V102.5%, bladder volume, and conformity indices (V50/VPTV and V100/VPTV) were most predictive of HRQOL changes in both urinary domains. No strong rectal toxicity dosimetric association was identified (AUC = 0.64).

CONCLUSION

We demonstrated the application of advanced ML methods to identify a set of dosimetric variables that most highly correlated with patient-reported urinary HRQOL. DVH quantities identified with these methods may be used to achieve outcome-driven planning objectives to further reduce patient-reported toxicity with prostate SBRT.

Clinical utilization of radiation therapy in Korea, 2016

Radiotherapy (RT) is one of the primary cancer treatment modalities. To estimate the actual utilization of RT and infrastructure in Korea, the current study was performed. Data from 2012 to 2016 were extracted from the Health Insurance Review and Assessment Service. In addition, a nationwide survey was conducted to collect the statistics of RT facilities, equipment and human resources in Korea. The total number of patients treated with RT was 72 563 in 2016. The five cancers that were most commonly treated with RT in 2016 were breast, lung, colorectal, liver and prostate cancer. According to analyses of specific treatment modalities, the number of patients treated with intensity-modulated radiotherapy (IMRT), stereotactic radiation therapy (SRT) and proton therapy increased from 6670, 6306 and 50 in 2012 to 21584, 9048 and 703 in 2016, respectively. Ninety radiation oncology centers were working in 2015 and there were a total of 213 megavoltage teletherapy machines. In 2015, 310 patients were treated per megavoltage RT machine, 246 patients per radiation oncologist, 501 patients per medical physicist and 111 patients per radiotherapy technologist. In conclusion, the number of patients who underwent RT in Korea has increased steadily from 2012 to 2016. The IMRT utilization rate remarkably increased in 2016, and the number of patients treated with advanced treatment modalities such as IMRT, SRT and proton therapy is expected to increase.

Patterns of stereotactic body radiation therapy: The influence of lung cancer treatment on prostate cancer treatment

INTRODUCTION

Technology availability and prior experience with novel cancer treatments may partially drive their use. We sought to examine this issue in the context of stereotactic body radiation therapy (SBRT) by studying how its use for an established indication (lung cancer) impacts its use for an emerging indication (prostate cancer).

METHODS

Using SEER-Medicare from 2007 to 2011, we developed prostate cancer-specific physician-hospital networks. Our primary dependent variable was SBRT use for prostate cancer and our primary independent variable was SBRT use for lung cancer, both at the network level. To assess the influence of SBRT availability and experiential use, we generated predicted probabilities of SBRT use for prostate cancer stratified by a network's use of lung cancer SBRT, adjusting for network characteristics. To assess intensity of use, we examined the correlation between the proportion of prostate cancer patients and lung cancer patients receiving SBRT within a network.

RESULTS

We identified 316 networks that served 41,034 prostate cancer and 83,433 lung cancer patients. A network was significantly more likely to use SBRT for prostate cancer if that network used SBRT for lung cancer (e.g., in 2011, odds ratio [OR] 12.7; 95% confidence interval [CI] 3.9-41.8). The Pearson's correlation between the proportion of prostate cancer patients and lung cancer patients receiving SBRT in a network was 0.34, which was not statistically significant (P = 0.12).

CONCLUSIONS

SBRT availability and experiential use for lung cancer influences its use for prostate cancer, but intensity of use for one does not relate to intensity of use for the other.

Declining brachytherapy utilization for cervical cancer patients - Have we reversed the trend?

OBJECTIVE

Studies examining temporal trends in cervical brachytherapy use are conflicting and examined different health insurance populations. This study examined brachytherapy utilization over time by health insurance type and whether reported declines in brachytherapy have reversed.

METHODS

The National Cancer Database (NCDB) was queried for patients with FIGO IIB-IVA cervical cancer treated with definitive chemoradiotherapy between 2004 and 2014, identifying 17,442 patients. Brachytherapy utilization over time and by insurance type and other sociodemographic factors were compared using binary logistic regression. A sensitivity analysis was done in a sub-cohort of patients using the boost modality variable in the NCDB.

RESULTS

Brachytherapy utilization declined during 2008-10 (52.6%) compared to 2004-2007 (54.4%; odds ratio [OR] 0.93, 95% confidence interval [CI] 0.86-1.01) and declines were disproportionately larger for patients with government insurance (49.4% vs 52.3%, respectively) than privately-insured patients (57.6% vs 58.9%, respectively). However, rates of brachytherapy use subsequently recovered during 2011-14 in all insurance groups (58.0%, OR 1.24, 95% CI 1.16-1.34) and was especially improved for Medicaid (OR 1.44, 95% CI 1.26-1.65) and uninsured patients (OR 1.28, 95% CI 1.03-1.57). Sensitivity analysis using the boost modality variable confirmed these trends.

CONCLUSIONS

In patients with FIGO IIB-IVA cervical cancer treated with definitive chemoradiotherapy from 2004 to 2014, brachytherapy utilization declined during the late 2000s and disproportionately affected patients with government insurance, but subsequently recovered in the early 2010s. Since government insurance covers vulnerable patient populations at-risk for future declines in brachytherapy use, proposed alternative payment models should incentivize cervical brachytherapy to solidify gains in brachytherapy utilization.

How might financial pressures have impacted brachytherapy? A proposed narrative to explain the declines in cervical and prostate brachytherapy utilization

Rates of brachytherapy administration in the United States have declined for both cervical and prostate cancers, and we argue that the available facts suggest financial considerations are a major contributor to this issue. In this narrative, we discuss financial pressures that have existed for cervical and prostate brachytherapy and how they may have influenced their declining usage, consider other proposed influences, and provide suggestions for future research to understand the scope of the issue.

Comparative Toxicities and Cost of Intensity-Modulated Radiotherapy, Proton Radiation, and Stereotactic Body Radiotherapy Among Younger Men With Prostate Cancer

Purpose To compare the toxicities and cost of proton radiation and stereotactic body radiotherapy (SBRT) with intensity-modulated radiotherapy (IMRT) for prostate cancer among men younger than 65 years of age with private insurance. Methods Using the MarketScan Commercial Claims and Encounters database, we identified men who received radiation for prostate cancer between 2008 and 2015. Patients undergoing proton therapy and SBRT were propensity score-matched to IMRT patients on the basis of clinical and sociodemographic factors. Proportional hazards models compared the cumulative incidence of urinary, bowel, and erectile dysfunction toxicities by treatment. Cost from a payer's perspective was calculated from claims and adjusted to 2015 dollars. Results A total of 693 proton therapy patients were matched to 3,465 IMRT patients. Proton therapy patients had a lower risk of composite urinary toxicity (33% v 42% at 2 years; P < .001) and erectile dysfunction (21% v 28% at 2 years; P < .001), but a higher risk of bowel toxicity (20% v 15% at 2 years; P = .02). Mean radiation cost was $115,501 for proton therapy patients and $59,012 for IMRT patients ( P < .001). A total of 310 SBRT patients were matched to 3,100 IMRT patients. There were no significant differences in composite urinary, bowel, or erectile dysfunction toxicities between SBRT and IMRT patients ( P > .05), although a higher risk of urinary fistula was noted with SBRT (1% v 0.1% at 2 years; P = .009). Mean radiation cost for SBRT was $49,504 and $57,244 for IMRT ( P < .001). Conclusion Among younger men with prostate cancer, proton radiation was associated with significant reductions in urinary toxicity but increased bowel toxicity at nearly twice the cost of IMRT. SBRT and IMRT were associated with similar toxicity profiles; SBRT was modestly less expensive than IMRT.

Provider variability in intensity modulated radiation therapy utilization among Medicare beneficiaries in the United States

BACKGROUND

In this study, we sought to examine the variation in intensity modulated radiation therapy (IMRT) use among radiation oncology providers.

METHODS AND MATERIALS

The Medicare Physician and Other Supplier Public Use File was queried for radiation oncologists practicing during 2014. Healthcare Common Procedural Coding System code 77301 was designated as IMRT planning with metrics including number of total IMRT plans, rate of IMRT utilization, and number of IMRT plans per distinct beneficiary.

RESULTS

Of 2759 radiation oncologists, the median number of total IMRT plans was 26 (mean, 33.4; standard deviation, 26.2; range, 11-321) with a median IMRT utilization rate of 36% (mean, 43%; standard deviation, 25%; range, 4% to 100%) and a median number of IMRT plans per beneficiary of 1.02 (mean, 1.07; range, 1.00-3.73). On multivariable analysis, increased IMRT utilization was associated with male sex, academic practice, technical fee billing, freestanding practice, practice in a county with 21 or more radiation oncologists, and practice in the southern United States (P < .05). The top 1% of users (28 providers) billed a mean 181 IMRT plans with an IMRT utilization rate of 66% and 1.52 IMRT plans per beneficiary. Of these 28 providers, 24 had billed technical fees, 25 practiced in freestanding clinics, and 20 practiced in the South.

CONCLUSIONS

Technical fee billing, freestanding practice, male sex, and location in the South were associated with increased IMRT use. A small group of outliers shared several common demographic and practice-based characteristics.