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Yu JB, Luh JY, Mantz CA. Practical Implications of the American Society for Radiation Oncology Radiation Oncology Case Rate Program Proposal for Radiation Oncologists. Pract Radiat Oncol 2024; 14:196-199. [PMID: 38237890 DOI: 10.1016/j.prro.2023.12.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 12/20/2023] [Accepted: 12/21/2023] [Indexed: 02/05/2024]
Abstract
The American Society for Radiation Oncology has proposed the Radiation Oncology Case Rate Program (ROCR) to advocate for fair reimbursement for radiation oncologists. ROCR would replace Medicare fee-for-service with a case rate payment for each of the 15 most common cancer types treated with external beam or stereotactic radiation therapy. This topic discussion attempts to provide a concise overview of the practical implications for radiation oncologists should the ROCR payment program be legislated by Congress and subsequently implemented by the Center for Medicare and Medicaid Services. This topic discussion covers the practical changes to billing and reimbursement, the Health Equity Achievement in Radiation Therapy payment, the Quality of Care requirement, and the available tool to calculate the effect of the ROCR based on an individual practice's case mix.
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Affiliation(s)
- James B Yu
- Connecticut Radiation Oncology, Hartford, Connecticut; Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center at Yale, New Haven, Connecticut.
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Yu JB, Sun Y, Jia AY, Vince RA, Shoag JE, Zaorsky NG, Spratt DE. Increasing Use of Shorter-Course Radiotherapy for Prostate Cancer. JAMA Oncol 2023; 9:1696-1701. [PMID: 37796479 PMCID: PMC10557029 DOI: 10.1001/jamaoncol.2023.4267] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 07/21/2023] [Indexed: 10/06/2023]
Abstract
Importance Randomized clinical trials have demonstrated the noninferiority of shorter radiotherapy (RT) courses (termed hypofractionation) compared with longer RT courses in patients with localized prostate cancer. Although shorter courses are associated with cost-effectiveness, convenience, and expanded RT access, their adoption remains variable. Objective To identify the current practice patterns of external beam RT for prostate cancer in the US. Design, Setting, and Participants This cohort study obtained data from the National Cancer Database, which collects hospital registry data from more than 1500 accredited US facilities on approximately 72% of US patients with cancer. Patients were included in the sample if they had localized prostate adenocarcinoma that was diagnosed between 2004 and 2020 and underwent external beam RT with curative intent. Analyses were conducted between February and March 2023. Exposures Radiotherapy schedules, which were categorized as ultrahypofractionation (≤7 fractions), moderate hypofractionation (20-30 fractions), and conventional fractionation (31-50 fractions). Main Outcomes and Measures Longitudinal pattern in RT fractionation schedule was the primary outcome. Multivariable logistic regression was performed to evaluate the variables associated with shorter RT courses. Covariables included age, National Comprehensive Cancer Network risk group, rurality, race, facility location, facility type, median income, insurance type or status, and Charlson-Deyo Comorbidity Index. Results A total of 313 062 patients with localized prostate cancer (mean [SD] age, 68.8 [7.7] years) were included in the analysis. There was a temporal pattern of decline in the proportion of patients who received conventional fractionation, from 76.0% in 2004 to 36.6% in 2020 (P for trend <.001). From 2004 to 2020, use of moderate hypofractionation increased from 22.0% to 45.0% (P for trend <.001), and use of ultrahypofractionation increased from 2.0% to 18.3% (P for trend <.001). By 2020, the most common RT schedule was ultrahypofractionation for patients in the low-risk group and moderate hypofractionation for patients in the intermediate-risk group. On multivariable analysis, treatment at a community cancer program (compared with academic or research program; odds ratio [OR], 0.54 [95% CI, 0.52-0.56]; P < .001), Medicaid insurance (compared with Medicare; OR, 1.49 [95% CI, 1.41-1.57]; P < .001), Black race (compared with White race; OR, 0.90 [95% CI, 0.87-0.92]; P < .001), and higher median income (compared with lower median income; OR, 1.28 [95% CI, 1.25-1.31]; P < .001) were associated with receipt of shorter courses of RT. Conclusions and Relevance Results of this cohort study showed an increase in the use of shorter courses of RT for prostate cancer from 2004 to 2020; a number of social determinants of health appeared to be associated with reduced adoption of shorter treatment courses. Realignment of reimbursement models may be necessary to enable broader adoption of ultrahypofractionation to support technology acquisition costs.
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Affiliation(s)
- James B. Yu
- Department of Radiation Oncology, St Francis Hospital, Hartford, Connecticut
| | - Yilun Sun
- Department of Population Quantitative Health Science, Case Western Reserve University, Cleveland, Ohio
- Department of Radiation Oncology, University Hospitals (UH) Seidman Cancer Center, Case Western Reserve University, Cleveland, Ohio
| | - Angela Y. Jia
- Department of Radiation Oncology, University Hospitals (UH) Seidman Cancer Center, Case Western Reserve University, Cleveland, Ohio
| | - Randy A. Vince
- Department of Urology, UH Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Jonathan E. Shoag
- Department of Urology, UH Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Nicholas G. Zaorsky
- Department of Radiation Oncology, University Hospitals (UH) Seidman Cancer Center, Case Western Reserve University, Cleveland, Ohio
| | - Daniel E. Spratt
- Department of Radiation Oncology, University Hospitals (UH) Seidman Cancer Center, Case Western Reserve University, Cleveland, Ohio
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Marta GN, Moraes FY, de Oliveira Franco RC, de Andrade Carvalho H, Gouveia AG, de Lima Gössling GC, de Jesus RG, Ferraris G, Schuffenegger PM, Bardales GS, Chacón MAP, Murillo R, Sánchez LEM, Gamarra-Cabezas E, Rosa AA, da Silva MF, de Mattos MD, Morais DCR, de Castro DG, Dal Pra A, Amêndola BE, Barros JM, Lara TM, Isa N, de la Mata Moya D, Hidalgo I, Velilla DG, Loayza LEA, Montenegro FG, Sanchez Chacin NO, Werutsky G, Viani GA. Moderately hypofractionated post-operative radiation therapy for breast cancer: preferences amongst radiation oncologists from countries in Latin America and the Caribbean. Rep Pract Oncol Radiother 2023; 28:340-351. [PMID: 37795395 PMCID: PMC10547413 DOI: 10.5603/rpor.a2023.0046] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 06/27/2023] [Indexed: 10/06/2023] Open
Abstract
Background The safety and effectiveness of moderately hypofractionated post-operative radiation therapy for breast cancer were demonstrated by several trials. This study aimed to evaluate the current patterns of practice and prescription preference about moderately hypofractionated post-operative radiation therapy to assess possible aspects that affect the decision-making process regarding the use of fractionation in breast cancer patients in Latin America and the Caribbean (LAC). We also aimed to identify factors that can restrain the utilization of moderately hypofractionated post-operative radiation therapy for breast cancer. Materials an methods Radiation oncologists from LAC were invited to contribute to this study. A 38-question survey was used to evaluate their opinions. Results A total of 173 radiation oncologists from 13 countries answered the questionnaire. The majority of respondents (84.9%) preferred moderately hypofractionated post-operative radiation therapy as their first choice in cases of whole breast irradiation. Whole breast plus regional nodal irradiation, post-mastectomy (chest wall and regional nodal irradiation) without reconstruction, and post-mastectomy (chest wall and regional node irradiation) with reconstruction hypofractionated post-operative radiation therapy was preferred by 72.2% 71.1%, and 53.7% of respondents, respectively. Breast cancer stage, and flap-based breast reconstruction were the factors associated with absolute contraindications for the use of hypofractionated schedules. Conclusion Even though moderately hypofractionated post-operative radiation therapy for breast cancer is considered a new standard to the vast majority of the patients, its unrestricted application in clinical practice across LAC still faces reluctance.
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Affiliation(s)
- Gustavo Nader Marta
- Department of Radiation Oncology, Hospital Sírio-Libanês, Sao Paulo, Brazil
- Latin American Cooperative Oncology Group (LACOG), Brazil
| | - Fabio Y. Moraes
- Latin American Cooperative Oncology Group (LACOG), Brazil
- Department of Oncology, Division of Radiation Oncology, Queen’s University — Kingston Health Science Centre, Kingston, ON, Canada
| | | | - Heloísa de Andrade Carvalho
- Latin American Cooperative Oncology Group (LACOG), Brazil
- Department of Radiology and Oncology — Radiotherapy Division — Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - André Guimaraes Gouveia
- Latin American Cooperative Oncology Group (LACOG), Brazil
- Juravinski Cancer Centre, Department of Oncology, Division of Radiation Oncology, Hamilton, ON, Canada
| | | | | | | | - Pablo Munoz Schuffenegger
- Latin American Cooperative Oncology Group (LACOG), Brazil
- Radiation Oncology Unit, Department of Hematology — Oncology, Pontificia Universidad Catolica de Chile, Chile
| | | | | | - Raúl Murillo
- Centro Javeriano de Oncología, Hospital Universitario San Ignacio, Bogota, Colombia
- Facultad de Medicina, Pontificia Universidad Javeriana, Bogota, Colombia
| | - Luis Ernesto Moreno Sánchez
- Instituto Nacional del Cáncer Rosa De Tavares (INCART), Savia Care Centro Avanzado de Radioterapia, Centro Gamma Knife Dominicano, Dominican Republic
| | - Elizabeth Gamarra-Cabezas
- Departamento de Radio-Oncología, Instituto Oncológico Nacional “Dr. Juan Tanca Marengo”
- Sociedad de Lucha Contra el Cáncer (SOLCA), Guayaquil, Ecuador
| | - Arthur Accioly Rosa
- Latin American Cooperative Oncology Group (LACOG), Brazil
- Oncoclinicas Salvador — Hospital Santa Izabel
| | - Maurício Fraga da Silva
- Latin American Cooperative Oncology Group (LACOG), Brazil
- Santa Maria Federal University, Santa Maria, RS, Brazil
- Clínica de Radioterapia de Santa Maria, RS, Brazil
| | | | - Diego Chaves Rezende Morais
- Latin American Cooperative Oncology Group (LACOG), Brazil
- Oncoclinicas Recife and Hospital Santa Águeda, Brazil
| | - Douglas Guedes de Castro
- Latin American Cooperative Oncology Group (LACOG), Brazil
- Department of Radiation Oncology, A.C. Camargo Cancer Center, Brazil
| | - Alan Dal Pra
- Latin American Cooperative Oncology Group (LACOG), Brazil
- Department of Radiation Oncology, University of Miami Miller School of Medicine, United States
| | | | - José Máximo Barros
- Latin American Cooperative Oncology Group (LACOG), Brazil
- Departamento de Radio-Oncología, Instituto Oncológico Nacional “Dr. Juan Tanca Marengo”
- Centro de Radioterapia del Hospital Universitario Austral, Argentina
| | - Tomas Merino Lara
- Department of Hematology Oncology, school of Medicine, Pontificia Universidad Catolica de Chile, Chile
| | | | - Dolores de la Mata Moya
- Latin American Cooperative Oncology Group (LACOG), Brazil
- Cancer Center — ABC Medical Center, Mexico
| | - Iván Hidalgo
- Centro Javeriano de Oncología — Hospital Universitario San Ignacio, Colombia
| | | | | | | | | | | | - Gustavo Arruda Viani
- Latin American Cooperative Oncology Group (LACOG), Brazil
- Ribeirão Preto Medical School, Department of Medical Imagings, Hematology and Oncology of University of São Paulo (FMRP-USP), Brazil
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Yu JB. The RO-APM: The Wrong Solution to the Wrong Problem. Int J Radiat Oncol Biol Phys 2022; 114:57-59. [PMID: 35964632 DOI: 10.1016/j.ijrobp.2022.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 02/03/2022] [Indexed: 11/19/2022]
Affiliation(s)
- James B Yu
- Department of Radiation Oncology, Columbia University Irving Medical Center, New York, New York.
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Batumalai V, James M. Unwarranted variation in radiation therapy fractionation. J Med Imaging Radiat Oncol 2022; 66:233-241. [PMID: 35243787 DOI: 10.1111/1754-9485.13372] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 12/06/2021] [Indexed: 01/02/2023]
Abstract
The adoption of hypofractionation across multiple tumour sites has been slow despite robust evidence. There is considerable unwarranted variation in practice, both within and between jurisdictions. This has been attributed to inconsistencies in guidelines, physician preference, lack of technology and differing financial incentives. Unwarranted variation in the use of hypofractionation has a tremendous effect on cost to both patients and the healthcare system. This places an unnecessary burden on patients and poorly utilises scarce healthcare resources. A collaborative effort from clinicians, patients, healthcare providers and policymakers is needed to reduce unwarranted variation in practice. This will improve quality of care both for patients and at broader healthcare system level.
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Affiliation(s)
- Vikneswary Batumalai
- Collaboration for Cancer Outcomes, Research and Evaluation, Ingham Institute for Applied Medical Research, South Western Clinical School, University of New South Wales, Sydney, New South Wales, Australia.,GenesisCare, Sydney, New South Wales, Australia
| | - Melissa James
- Christchurch Oncology Service, Canterbury Regional Cancer and Haematology Centre, Christchurch, New Zealand.,Department of Medicine, Christchurch Hospital, University of Otago Christchurch, Christchurch, New Zealand
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Corrigan KL, Lei X, Ahmad N, Arzu I, Bloom E, Chun SG, Goodman C, Hoffman KE, Joyner M, Mayo L, Mitchell M, Nead KT, Perkins GH, Reed V, Reddy JP, Schlembach P, Shaitelman SF, Stauder MC, Strom EA, Tereffe W, Wiederhold L, Woodward WA, Smith BD. Adoption of Ultrahypofractionated Radiation Therapy in Patients With Breast Cancer. Adv Radiat Oncol 2022; 7:100877. [PMID: 35387420 PMCID: PMC8977907 DOI: 10.1016/j.adro.2021.100877] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Accepted: 12/01/2021] [Indexed: 11/27/2022] Open
Abstract
Introduction The first high-quality clinical trial to support ultrahypofractionated whole-breast irradiation (ultra-HF-WBI) for invasive early-stage breast cancer (ESBC) was published in April 2020, coinciding with the beginning of the COVID-19 pandemic. We analyzed adoption of ultra-HF-WBI for ductal carcinoma in situ (DCIS) and ESBC at our institution after primary trial publication. Methods and Materials We evaluated radiation fractionation prescriptions for all patients with DCIS or ESBC treated with WBI from March 2020 to May 2021 at our main campus and regional campuses. Demographic and clinical characteristics were extracted from the electronic medical record. Treating physician characteristics were collected from licensure data. Hierarchical logistic regression models identified factors correlated with adoption of ultra-HF-WBI (26 Gy in 5 daily factions [UK-FAST-FORWARD] or 28.5 Gy in 5 weekly fractions [UK-FAST]). Results Of 665 included patients, the median age was 61.5 years, and 478 patients (71.9%) had invasive, hormone-receptor-positive breast cancer. Twenty-one physicians treated the included patients. In total, 249 patients (37.4%) received ultra-HF-WBI, increasing from 4.3% (2 of 46) in March-April 2020 to a high of 45.5% (45 of 99) in July-August 2020 (P < .001). Patient factors associated with increased use of ultra-HF-WBI included older age (≥50 years old), low-grade WBI without inclusion of the low axilla, no radiation boost, and farther travel distance (P < .03). Physician variation accounted for 21.7% of variance in the outcome, with rate of use of ultra-HF-WBI by the treating physicians ranging from 0% to 75.6%. No measured physician characteristics were associated with use of ultra-HF-WBI. Conclusions Adoption of ultra-HF-WBI at our institution increased substantially after the publication of randomized evidence supporting its use. Ultra-HF-WBI was preferentially used in patients with lower risk disease, suggesting careful selection for this new approach while long-term data are maturing. Substantial physician-level variation may reflect a lack of consensus on the evidentiary standards required to change practice.
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Has Hypofractionated Whole-Breast Radiation Therapy Become the Standard of Care in the United States? An Updated Report from National Cancer Database. Clin Breast Cancer 2022; 22:e8-e20. [PMID: 34257001 PMCID: PMC8934112 DOI: 10.1016/j.clbc.2021.05.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Revised: 05/24/2021] [Accepted: 05/29/2021] [Indexed: 01/03/2023]
Abstract
INTRODUCTION/BACKGROUND We aimed to update the previous evaluation of hypofractionated whole-breast irradiation (HF-WBI) use over time in the United States and factors related to its adoption for patients undergoing a lumpectomy from 2004 to 2016. MATERIALS AND METHODS Among the patients who underwent a lumpectomy, we identified 688,079 patients with early-stage invasive breast cancer and 248,218 patients with ductal carcinoma in situ in the National Cancer Database from 2004 to 2016. We defined HF-WBI as 2.5 to 3.33 Gy/fraction to the breast and conventional fractionated whole-breast irradiation as 1.8 to 2.0 Gy/fraction. We evaluated the trend of HF-WBI use and examined factors associated with HF-WBI use using logistic regression models. RESULTS Among invasive cancer patients, the use of HF-WBI increased exponentially from 0.7% in 2004 to 15.6% in 2013 and then to 38.1% in 2016. Among patients with ductal carcinoma in situ, the use of HF-WBI has increased significantly from 0.42% in 2004 to 13.4% in 2013 and then to 34.3% in 2016. Factors found to be associated with HF-WBI use included age, patient geographical location, race/ethnicity, tumor stage, grade, treating facility type, and volume. CONCLUSION HF-WBI use in the United States has more than doubled from 2013 to 2016. Although its use is close to that of conventional fractionated whole-breast irradiation, HF-WBI is still far from the preferred standard of care in the United States. We identified several patient and facility factors that can impact the uptake of HF-WBI treatment. Microabstract Using the National Cancer Database from 2004 to 2016, we evaluated the trend of hypofractionated whole-breast radiation therapy use and factors associated with use. Use in the United States has more than doubled from 2013 to 2016, but it has not become the standard of care. We identified several patient and facility factors that impact the uptake of hypofractionated whole-breast radiation therapy treatment.
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Marta GN, Ramiah D, Kaidar-Person O, Kirby A, Coles C, Jagsi R, Hijal T, Sancho G, Zissiadis Y, Pignol JP, Ho AY, Cheng SHC, Offersen BV, Meattini I, Poortmans P. The Financial Impact on Reimbursement of Moderately Hypofractionated Postoperative Radiation Therapy for Breast Cancer: An International Consortium Report. Clin Oncol (R Coll Radiol) 2021; 33:322-330. [PMID: 33358283 DOI: 10.1016/j.clon.2020.12.008] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 11/06/2020] [Accepted: 12/08/2020] [Indexed: 12/16/2022]
Abstract
AIMS Moderately hypofractionated breast irradiation has been evaluated in several prospective studies, resulting in wide acceptance of shorter treatment protocols for postoperative breast irradiation. Reimbursement for radiation therapy varies between private and public systems and between countries, impacting variably financial considerations in the use of hypofractionation. The aim of this study was to evaluate the financial impact of moderately hypofractionated breast irradiation by reimbursement system in different countries. MATERIALS AND METHODS The study was designed by an international group of radiation oncologists. A web-questionnaire was distributed to representatives from each country. The participants were asked to involve the financial consultant at their institution. RESULTS Data from 13 countries from all populated continents were collected (Europe: Denmark, France, Italy, the Netherlands, Spain, UK; North America: Canada, USA; South America: Brazil; Africa: South Africa; Oceania: Australia; Asia: Israel, Taiwan). Clinicians and/or departments in most of the countries surveyed (77%) receive remuneration based on the number of fractions delivered to the patient. The financial loss per patient estimated resulting from applying moderately hypofractionated breast irradiation instead of conventional fractionation ranged from 5-10% to 30-40%, depending on the healthcare provider. CONCLUSION Although a generalised adoption of moderately hypofractionated breast irradiation would allow for a considerable reduction in social and economic burden, the financial loss for the healthcare providers induced by fee-for-service remuneration may be a factor in the slow uptake of these regimens. Therefore, fee-for-service reimbursement may not be preferable for radiation oncology. We propose that an alternative system of remuneration, such as bundled payments based on stage and diagnosis, may provide more value for all stakeholders.
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Affiliation(s)
- G N Marta
- Department of Radiation Oncology, Hospital Sírio-Libanês, São Paulo, Brazil.
| | - D Ramiah
- Department of Radiation Oncology, Donald Gordon Medical Centre, Johannesburg, South Africa
| | - O Kaidar-Person
- Breast Cancer Radiation Unit, Radiation Oncology Institute, Sheba Medical Center, Ramat Gan, Israel
| | - A Kirby
- Department of Radiotherapy, Royal Marsden NHS Foundation Trust, London, UK; Institute of Cancer Research, London, UK
| | - C Coles
- Department of Oncology, University of Cambridge, Cambridge, UK
| | - R Jagsi
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, USA
| | - T Hijal
- Division of Radiation Oncology, McGill University Health Centre, Montréal, Quebec, Canada
| | - G Sancho
- Department of Radiation Oncology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Y Zissiadis
- Department of Radiation Oncology, Genesis Cancer Care, Wembley, WA, Australia
| | - J-P Pignol
- Department of Radiation Oncology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - A Y Ho
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - S H-C Cheng
- Department of Radiation Oncology, Koo Foundation Sun Yat-Sen Cancer Center, Taipei, Taiwan
| | - B V Offersen
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark; Department of Experimental Clinical Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - I Meattini
- Radiation Oncology Unit, Oncology Department, Azienda Ospedaliero Universitaria Careggi, Florence, Italy; Department of Biomedical, Experimental, and Clinical Sciences "M. Serio", University of Florence, Florence, Italy
| | - P Poortmans
- Department of Radiation Oncology, Iridium Kankernetwerk, Wilrijk-Antwerp, Belgium; University of Antwerp, Faculty of Medicine and Health Sciences, Wilrijk-Antwerp, Belgium
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Hsieh K, Housri N, Haffty B, Smith B, Burt LM. Radiation Oncologists' Views on Breast Radiation Therapy Guidelines: Utilizing an Online Q&A Platform to Assess Current Views on Whole-Breast Irradiation Therapy. Clin Breast Cancer 2021; 21:408-416. [PMID: 33814285 DOI: 10.1016/j.clbc.2021.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 01/26/2021] [Accepted: 02/20/2021] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Poor adherence to the 2011 American Society for Radiation Oncology (ASTRO) evidence-based guideline on whole-breast irradiation (WBI) has been reported. We utilized theMednet to assess the views of the updated 2018 guideline among radiation oncologists (ROs). METHODS We identified 11 questions asked by community ROs on theMednet, a web-based platform, between October 27, 2014 and May 2, 2017 that were updated in the 2018 guideline. New answers provided by senior authors of the 2018 guideline, cited guidelines, and polls to survey ROs were disseminated in 3 theMednet's newsletters between March 16, 2018 and May 1, 2018. Any question with less than 60% consensus was resubmitted on October 9, 2019 and assessed on February 13, 2020. RESULTS A total of 792 ROs responded to the initial surveys. In each survey, the answer choice(s) that received the majority of the votes aligned with the 2018 guideline. The strongest consensus was for the use of hypofractionated (HF)-WBI regardless of histology (97%), followed by HF-WBI boost dose (92%), molecular subtype (90%), grade (88%), and concurrent use of trastuzumab (87%). The least consensus was for age at which HF-WBI should be offered with 53% of respondents, specifically 73% of academic ROs versus 47% of community ROs (P = .001), agreeing with the guideline. The re-submitted survey 19 months later showed 77% of 287 new respondents now agreed with the guideline regarding age. CONCLUSION The majority of ROs concur with the 2018 WBI guideline in theMednet surveys, with better agreement among academic ROs than community ROs for certain components of the guideline. Further research into the different practice patterns may optimize patient care.
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Affiliation(s)
- Kristin Hsieh
- Columbia University Vagelos College of Physicians and Surgeons, New York City, NY
| | - Nadine Housri
- Department of Therapeutic Radiology, Yale University School of Medicine and Yale Comprehensive Cancer Center, New Haven, CT.
| | - Bruce Haffty
- Department of Radiation Oncology, Rutgers Robert Wood Johnson Medical School and the Cancer Institute of New Jersey, New Brunswick, NJ.
| | - Benjamin Smith
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX.
| | - Lindsay M Burt
- Department of Radiation Oncology, University of Utah Huntsman Cancer Institute, Salt Lake City, UT.
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Williams VM, Kahn JM, Thaker NG, Beriwal S, Nguyen PL, Arthur D, Petereit D, Dyer BA. The Case for Brachytherapy: Why It Deserves a Renaissance. Adv Radiat Oncol 2021; 6:100605. [PMID: 33723523 PMCID: PMC7940781 DOI: 10.1016/j.adro.2020.10.018] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2020] [Revised: 09/16/2020] [Accepted: 10/13/2020] [Indexed: 01/22/2023] Open
Abstract
The recent global events related to the coronavirus disease of 2019 pandemic have significantly changed the medical landscape and led to a shift in oncologic treatment perspectives. There is a renewed focus on preserving treatment outcomes while maintaining medical accessibility and decreasing medical resource utilization. Brachytherapy, which is a vital part of the treatment course of many cancers (particularly prostate and gynecologic cancers), has the ability to deliver hypofractionated radiation and thus shorten treatment time. Studies in the early 2000s demonstrated a decline in brachytherapy usage despite data showing equivalent or even superior treatment outcomes for brachytherapy in disease sites, such as the prostate and cervix. However, newer data suggest that this trend may be reversing. The renewed call for shorter radiation courses based on data showing equivalent outcomes will likely establish hypofractionated radiation as the standard of care across multiple disease sites. With shifting reimbursement, brachytherapy represents the pinnacle in hypofractionated, conformal radiation therapy, and with extensive long-term data in support of the treatment modality brachytherapy is primed for a renaissance.
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Affiliation(s)
- Vonetta M. Williams
- Department of Radiation Oncology, University of Washington, Seattle, Washington
| | - Jenna M. Kahn
- Department of Radiation Oncology, Oregon Health & Science University, Portland, Oregon
| | - Nikhil G. Thaker
- Department of Radiation Oncology, Arizona Oncology, Tucson, Arizona
| | - Sushil Beriwal
- Department of Radiation Oncology, UPMC Hillman Cancer Center, Pittsburgh, Pennsylvania
| | - Paul L. Nguyen
- Department of Radiation Oncology, Dana-Farber/Harvard Cancer Center, Boston, Massachusetts
| | - Douglas Arthur
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, Virginia
| | - Daniel Petereit
- Department of Radiation Oncology, Monument Health Cancer Care Institute, Rapid City, South Dakota
| | - Brandon A. Dyer
- Department of Radiation Oncology, University of Washington, Seattle, Washington
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Mechanisms of radiation-induced endothelium damage: Emerging models and technologies. Radiother Oncol 2021; 158:21-32. [PMID: 33581220 DOI: 10.1016/j.radonc.2021.02.007] [Citation(s) in RCA: 57] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 02/04/2021] [Accepted: 02/05/2021] [Indexed: 12/24/2022]
Abstract
Radiation-induced endothelial/vascular injury is a major complicating factor in radiotherapy and a leading cause of morbidity and mortality in nuclear or radiological catastrophes. Exposure of tissue to ionizing radiation (IR) leads to the release of oxygen radicals and proteases that result in loss of endothelial barrier function and leukocyte dysfunction leading to tissue injury and organ damage. Microvascular endothelial cells are particularly sensitive to IR and radiation-induced alterations in endothelial cell function are thought to be a critical factor in organ damage through endothelial cell activation, enhanced leukocyte-endothelial cell interactions, increased barrier permeability and initiation of apoptotic pathways. These radiation-induced inflammatory responses are important in early and late radiation pathologies in various organs. A better understanding of mechanisms of radiation-induced endothelium dysfunction is therefore vital, as radiobiological response of endothelium is of major importance for medical management and therapeutic development for radiation injuries. In this review, we summarize the current knowledge of cellular and molecular mechanisms of radiation-induced endothelium damage and their impact on early and late radiation injury. Furthermore, we review established and emerging in vivo and in vitro models that have been developed to study the mechanisms of radiation-induced endothelium damage and to design, develop and rapidly screen therapeutics for treatment of radiation-induced vascular damage. Currently there are no specific therapeutics available to protect against radiation-induced loss of endothelial barrier function, leukocyte dysfunction and resulting organ damage. Developing therapeutics to prevent endothelium dysfunction and normal tissue damage during radiotherapy can serve as the urgently needed medical countermeasures.
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Boyce-Fappiano D, Ning MS, Thaker NG, Pezzi TA, Gjyshi O, Mesko S, Anakwenze C, Olivieri ND, Guzman AB, Incalcaterra JR, Tang C, McAleer MF, Herman J, Ghia AJ. Time-Driven, Activity-Based Cost Analysis of Radiation Treatment Options for Spinal Metastases. JCO Oncol Pract 2020; 16:e271-e279. [DOI: 10.1200/jop.19.00480] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE: Several treatment options for spinal metastases exist, including multiple radiation therapy (RT) techniques: three-dimensional (3D) conventional RT (3D-RT), intensity-modulated RT (IMRT), and spine stereotactic radiosurgery (SSRS). Although data exist regarding reimbursement differences across regimens, differences in provider care delivery costs have yet to be evaluated. We quantified institutional costs associated with RT for spinal metastases, using a time-driven activity-based costing model. METHODS: Comparisons were made between (1) 10-fraction 3D-RT to 30 Gy, (2) 10-fraction IMRT to 30 Gy, (3) 3-fraction SSRS (SSRS-3) to 27 Gy, and (4) single-fraction SSRS (SSRS-1) to 18 Gy. Process maps were developed from consultation through follow-up 30 days post-treatment. Process times were determined through panel interviews, and personnel costs were extracted from institutional salary data. The capacity cost rate was determined for each resource, then multiplied by activity time to calculate costs, which were summed to determine total cost. RESULTS: Full-cycle costs of SSRS-1 were 17% lower and 17% higher compared with IMRT and 3D-RT, respectively. Full-cycle costs for SSRS-3 were only 1% greater than 10-fraction IMRT. Technical costs for IMRT were 50% and 77% more than SSRS-3 and SSRS-1. In contrast, personnel costs were 3% and 28% higher for SSRS-1 than IMRT and 3D-RT, respectively ( P < .001). CONCLUSIONS: Resource utilization varies significantly among treatment options. By quantifying provider care delivery costs, this analysis supports the institutional resource efficiency of SSRS-1. Incorporating clinical outcomes with such resource and cost data will provide additional insight into the highest value modalities and may inform alternative payment models, operational workflows, and institutional resource allocation.
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Affiliation(s)
| | - Matthew S. Ning
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Todd A. Pezzi
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Olsi Gjyshi
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Shane Mesko
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | | | | | | | - Chad Tang
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Mary F. McAleer
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Joseph Herman
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Amol J. Ghia
- The University of Texas MD Anderson Cancer Center, Houston, TX
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13
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Mitchell AP, Rotter JS, Patel E, Richardson D, Wheeler SB, Basch E, Goldstein DA. Association Between Reimbursement Incentives and Physician Practice in Oncology: A Systematic Review. JAMA Oncol 2020; 5:893-899. [PMID: 30605222 DOI: 10.1001/jamaoncol.2018.6196] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Importance Significant controversy exists regarding whether physicians factor personal financial considerations into their clinical decision making. Within oncology, several reimbursement policies may incentivize physicians to increase health care use. Objective To evaluate whether the financial incentives presented by oncology reimbursement policies affect physician practice patterns. Evidence Review Studies evaluating an association between reimbursement incentives and changes in reimbursement policy on oncology care delivery were reviewed. Articles were identified systematically by searching PubMed/MEDLINE, Web of Science, Proquest Health Management, Econlit, and Business Source Premier. English-language articles focused on the US health care system that made empirical estimates of the association between a measurement of physician reimbursement/compensation and a measurement of delivery of cancer treatment services were included. The Risk of Bias in Non-Randomized Studies of Interventions tool was used to assess risk of bias. There were no date restrictions on the publications, and literature searches were finalized on February 14, 2018. Findings Eighteen studies were included. All were observational cohort studies, and most had a moderate risk of bias. Heterogeneity of reimbursement policies and outcomes precluded meta-analysis; therefore, a qualitative synthesis was performed. Most studies (15 of 18 [83%]) reported an association between reimbursement and care delivery consistent with physician responsiveness to financial incentives, although such an association was not identified in all studies. Findings consistently suggested that self-referral arrangements may increase use of radiotherapy and that profitability of systemic anticancer agents may affect physicians' choice of drug. Findings were less conclusive as to whether profitability of systemic anticancer therapy affects the decision of whether to use any systemic therapy. Conclusions and Relevance To date, this study is the first systematic review of reimbursement policy and clinical care delivery in oncology. The findings suggest that some oncologists may, in certain circumstances, alter treatment recommendations based on personal revenue considerations. An implication of this finding is that value-based reimbursement policies may be a useful tool to better align physician incentives with patient need and increase the value of oncology care.
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Affiliation(s)
- Aaron P Mitchell
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jason S Rotter
- Department of Health Policy and Management, University of North Carolina Gillings School of Global Public Health, Chapel Hill
| | - Esita Patel
- Cecil G. Sheps Center for Health Services Research, Chapel Hill, North Carolina
| | - Daniel Richardson
- Cecil G. Sheps Center for Health Services Research, Chapel Hill, North Carolina.,Department of Hematology/Oncology, University of North Carolina at Chapel Hill School of Medicine.,Lineberger Comprehensive Cancer Center, Chapel Hill, North Carolina
| | - Stephanie B Wheeler
- Department of Health Policy and Management, University of North Carolina Gillings School of Global Public Health, Chapel Hill.,Cecil G. Sheps Center for Health Services Research, Chapel Hill, North Carolina.,Lineberger Comprehensive Cancer Center, Chapel Hill, North Carolina
| | - Ethan Basch
- Department of Health Policy and Management, University of North Carolina Gillings School of Global Public Health, Chapel Hill.,Department of Hematology/Oncology, University of North Carolina at Chapel Hill School of Medicine.,Lineberger Comprehensive Cancer Center, Chapel Hill, North Carolina
| | - Daniel A Goldstein
- Department of Health Policy and Management, University of North Carolina Gillings School of Global Public Health, Chapel Hill.,Davidoff Cancer Center, Rabin Medical Center, Petach Tikvah, Israel
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14
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How public health services pay for radiotherapy in Europe: an ESTRO–HERO analysis of reimbursement. Lancet Oncol 2020; 21:e42-e54. [DOI: 10.1016/s1470-2045(19)30794-6] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Revised: 11/01/2019] [Accepted: 11/04/2019] [Indexed: 12/19/2022]
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15
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Peer Influence on Physician Use of Shorter Course External Beam Radiation Therapy for Patients with Breast Cancer. Pract Radiat Oncol 2019; 10:75-83. [PMID: 31785370 DOI: 10.1016/j.prro.2019.11.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Revised: 10/31/2019] [Accepted: 11/06/2019] [Indexed: 11/22/2022]
Abstract
PURPOSE Social contagion among physicians may affect the dissemination of innovative and high-value cancer care. We applied social contagion theory to investigate the role of physician peer influence on the use of short courses of external beam radiation therapy (EBRT) for patients with breast cancer. METHODS AND MATERIALS Using a cohort of Medicare beneficiaries with breast cancer, we constructed physician peer groups based on patient-sharing relationships. Outcomes were a patient's receipt of (1) moderately hypofractionated adjuvant EBRT after breast-conserving surgery and (2) short-course palliative EBRT for bone metastases. Using a longitudinal design, we used mixed-effects logistic regression to examine the association between physician peer group rate of short-course EBRT in 2011 to 2012 (T1) and patients' receipt of short-course EBRT in 2013 to 2014 (T2). RESULTS During T2, a total of 17,248 patients received adjuvant therapy (32.3% moderately hypofractionated) from 3235 physicians in 1202 physician peer groups. Compared with patients treated within peer groups in which no moderately hypofractionated adjuvant EBRT was used in T1, patients treated by a physician in a peer group with higher T1 use of moderately hypofractionated adjuvant EBRT were more likely to receive moderately hypofractionated adjuvant EBRT in T2 (adjusted odds ratio = 2.03; 95% confidence interval, 1.62-2.54, vs adjusted odds ratio = 2.61; 95% confidence interval, 2.04-3.35, for peer groups where 21%-46% and 47%-100% of radiation oncologists used moderately hypofractionated adjuvant EBRT in T1, respectively, compared with peer groups with no use of moderately hypofractionated adjuvant EBRT). In contrast, there was no significant relationship between T1 peer group use and T2 receipt of short-course palliative EBRT for bone metastases. CONCLUSIONS Physician peer groups significantly influenced use of short-course EBRT in adjuvant therapy but not in palliative therapy for patients with breast cancer.
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Moderate hypofractionation and stereotactic body radiation therapy in the treatment of prostate cancer. Urol Oncol 2019; 37:619-627. [DOI: 10.1016/j.urolonc.2019.01.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Revised: 01/02/2019] [Accepted: 01/13/2019] [Indexed: 01/03/2023]
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17
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Nejati M, Razavi M, Harirchi I, Zendehdel K, Nejati P. The impact of provider payment reforms and associated care delivery models on cost and quality in cancer care: A systematic literature review. PLoS One 2019; 14:e0214382. [PMID: 30951536 PMCID: PMC6450626 DOI: 10.1371/journal.pone.0214382] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Accepted: 03/12/2019] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES To investigate the impact of provider payment reforms and associated care delivery models on cost and quality in cancer care. METHODS Data sources/study setting: Review of English-language literature published in PubMed, Embase and Cochrane library (2007-2019). Study design: We performed a systematic literature review (SLR) to identify the impact of cancer care reforms. Primary endpoints were resource use, cost, quality of care, and clinical outcomes. Data collection/extraction methods: For each study, we extracted and categorized comparative data on the impact of policy reforms. Given the heterogeneity in patients, interventions and outcome measures, we did a qualitative synthesis rather than a meta-analysis. RESULTS Of the 26 included studies, seven evaluations were in fact qualified as quasi experimental designs in retrospect. Alternative payment models were significantly associated with reduction in resource use and cost in cancer care. Across the seventeen studies reporting data on the implicit payment reforms through care coordination, the adoption of clinical pathways was found effective in reduction of unnecessary use of low value services and associated costs. The estimates of all measures in ACO models varied considerably across participating providers, and our review found a rather mixed impact on cancer care outcomes. CONCLUSION The findings suggest promising improvement in resource utilization and cost control after transition to prospective payment models, but, further primary research is needed to apply robust measures of performance and quality to better ensure that providers are delivering high-value care to their patients, while reducing the cost of care.
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Affiliation(s)
- Mina Nejati
- The Cancer Institute at Imam Khomeini Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Moaven Razavi
- The Schneider Institutes for Health Policy at the Heller School of Brandeis University, Waltham, MA, United States of America
| | - Iraj Harirchi
- The Cancer Institute at Imam Khomeini Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Kazem Zendehdel
- The Cancer Institute at Imam Khomeini Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Parisa Nejati
- Rasoule-Akram Hospital, Iran University of Medical Sciences, Tehran, Iran
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Johnstone PA, Peneguy S, Showalter TN, Yu JB. The case for radiotherapy in a Value based environment. Rep Pract Oncol Radiother 2019; 24:200-203. [PMID: 30833828 PMCID: PMC6384322 DOI: 10.1016/j.rpor.2019.01.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Revised: 10/30/2018] [Accepted: 01/27/2019] [Indexed: 12/25/2022] Open
Abstract
AIM Describe the Value proposition for radiotherapy (RT) in the United States. BACKGROUND In the United States since 2005, two forces have worked to decrease RT cost per patient: Federal changes in reimbursement and hypofractionation of treatment courses. We theorize that these have driven stable reimbursement in the context of increasing technology of intensity modulation (IMRT) and image guidance (IGRT). This phenomenon provides increasing Value of the discipline to patients and systems. MATERIALS AND METHODS We searched the Medicare Physician/Supplier data for Program Payments per Person with Utilization for 2000 through 2016. This involves two databases: Enrollment Database (EDB) for 2000-2012 and Common Medicare Enrollment (CME) since 2013. RT payments to individual patients accessing services were retrieved. RESULTS Taking into account the change of calculation algorithm used by CMS in 2013, costs per patient were similar in 2012 and 2003, and 2016 and 2013. CONCLUSIONS In the United States, stabilizing costs in the face of increasing work, better outcomes, and decreased toxicity contributes to increasing RT value over the past 10 years.
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Affiliation(s)
- Peter A.S. Johnstone
- Department of Radiation Oncology, Moffitt Cancer Center & Research Institute, Tampa, FL, United States
- Department of Heath Outcomes & Behavior, Moffitt Cancer Center & Research Institute, Tampa, FL, United States
| | - Susan Peneguy
- Department of Radiation Oncology, Moffitt Cancer Center & Research Institute, Tampa, FL, United States
| | | | - James B. Yu
- Yale Cancer Center, New Haven, CT, United States
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19
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Kerstiens J, Johnstone GP, Johnstone PAS. Proton Facility Economics: Single-Room Centers. J Am Coll Radiol 2018; 15:1704-1708. [PMID: 30158085 DOI: 10.1016/j.jacr.2018.07.020] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Revised: 07/09/2018] [Accepted: 07/20/2018] [Indexed: 11/25/2022]
Abstract
OBJECTIVE We have previously described the central nature of simple cases for financial feasibility of proton beam therapy centers-especially four- to five-room centers. In the 5 years since that publication, such construction has slowed drastically, and smaller, single-room projects are in vogue. We now seek to show under what circumstances a single-room system is optimally financially viable. MATERIALS AND METHODS A "standard" construction cost and debt for a single gantry system of $40 million was presumed, with 75% of the construction funded through standard 20-year financing. We then modeled a statistical analysis, deriving the optimal case mix required daily to cover construction and debt service costs. RESULTS We previously published that a single gantry treating only complex patients would need to apply 85% of its treatment slots simply to service debt, though it would cover its debt treating 4 hours of simple patients. As the business model has changed, debt maintenance, profit and operational costs have somewhat reduced the business case for adding a large number of simple patients. Debt maintenance is possible with as little as 13% of daily patients for a 40% Medicare case mix, but these numbers are critically sensitive to continued patient throughput. CONCLUSIONS Even in a single-room system, reducing overall debt, using tax-exempt financing, and having a case load emphasizing simple, private payer patients is paramount to fiscal health of the facility. Unused capacity is a huge risk if insufficient patients are available.
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Affiliation(s)
| | - Gregory P Johnstone
- Oncology Clinic Foundation, Ochsner Cancer Institution, New Orleans, Louisiana
| | - Peter A S Johnstone
- Departments of Radiation Oncology and Health Outcomes & Behavior, Moffitt Cancer Center & Research Institute, Tampa, Florida.
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20
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Johnstone GP, Johnstone PAS. The Oncologist's Role in Managing Financial Toxicity. Int J Radiat Oncol Biol Phys 2018; 101:306-308. [PMID: 29726360 DOI: 10.1016/j.ijrobp.2017.11.046] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Accepted: 11/30/2017] [Indexed: 10/17/2022]
Affiliation(s)
| | - Peter A S Johnstone
- Departments of Radiation Oncology and Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, Florida.
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21
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Hunter D, Mauldon E, Anderson N. Cost-containment in hypofractionated radiation therapy: a literature review. J Med Radiat Sci 2018; 65:148-157. [PMID: 29532613 PMCID: PMC5985996 DOI: 10.1002/jmrs.273] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2017] [Accepted: 02/13/2018] [Indexed: 12/25/2022] Open
Abstract
Recent technological advances in radiation therapy have allowed for greater accuracy in planning and treatment delivery. The development of hypofractionated radiation treatment regimens is an example, and has the potential to decrease the cost per episode of care, relative to conventional treatments. Our aim was to analyse published literature on the cost-effectiveness and budgetary implications of hypofractionated radiation therapy. As such, this article will quantify the projected health care cost savings and address the optimal means of treatment delivery, associated patient outcomes, and implications arising from an increased use of hypofractionated regimens.
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Affiliation(s)
- Darren Hunter
- Department of Radiation OncologyPeter MacCallum Cancer CentreMelbourneVictoriaAustralia
| | - Emily Mauldon
- School of MedicineUniversity of TasmaniaLauncestonTasmaniaAustralia
| | - Nigel Anderson
- Department of Radiation OncologyPeter MacCallum Cancer CentreMelbourneVictoriaAustralia
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22
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Gilbo P, Potters L, Lee L. Implementation and utilization of hypofractionation for breast cancer. Adv Radiat Oncol 2018; 3:265-270. [PMID: 30202795 PMCID: PMC6128038 DOI: 10.1016/j.adro.2018.04.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Revised: 03/28/2018] [Accepted: 04/01/2018] [Indexed: 12/13/2022] Open
Abstract
Purpose Hypofractionation (HF) of whole breast irradiation has become a standard treatment regimen because randomized trials continue to demonstrate equivalence in survival and local control compared with conventional fractionation. In 2011, the American Society for Radiation Oncology (ASTRO) adopted clinical guidelines on the proper selection of HF. Nevertheless, utilization remains lower than predicted. We evaluate the effects of clinical directives that serve as default treatment decisions and prospective contouring rounds on the implementation of HF in a large, multicenter radiation oncology department. Methods and materials In 2010, we implemented consensus-driven and evidence-based clinical directives to guide treatment decisions. Five directives were available for adjuvant breast cancer treatment, including conventional fractionation and HF approaches, and were selected on the basis of disease specifics and clinical judgment. In 2012, we instituted prospective contouring rounds wherein the treating physicians presented their directive selection and patient contours for peer-review and consensus opinion. For this study, charts for patients with early stage breast cancer were reviewed. A total of 1043 cases of breast cancer were identified. Patients receiving HF were analyzed on the basis of the ASTRO 2011 guidelines and adherence to our more inclusive clinical directives. Results For the ASTRO-endorsed group (n = 685), 49% of patients received HF in 2011, and 80% received HF in 2015. For the directives-endorsed group (n = 1042), 47% of patients received HF in 2011, and 73% received HF in 2015. Conclusions HF is underutilized despite equivalent local control, superior toxicity profile, and noninferior late effects. Our study demonstrates the possibility of achieving high levels of utilization in a large, multisite, outpatient setting. Factors responsible may include default rules established through the development of consensus-based treatment directives, peer review by faculty, and strong financial leadership to implement HF when indicated. To our knowledge, this is the first example of combining both consensus-based treatment directives and prospective contouring rounds in an attempt to change practice patterns.
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Affiliation(s)
- Philip Gilbo
- Department of Radiation Medicine, Northwell Health, Hofstra Northwell School of Medicine, Lake Success, New York
| | - Louis Potters
- Department of Radiation Medicine, Northwell Health, Hofstra Northwell School of Medicine, Lake Success, New York
| | - Lucille Lee
- Department of Radiation Medicine, Northwell Health, Hofstra Northwell School of Medicine, Lake Success, New York
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Gupta A, Ohri N, Haffty BG. Hypofractionated whole breast irradiation is cost-effective-but is that enough to change practice? Transl Cancer Res 2018; 7:S469-S472. [PMID: 30123739 DOI: 10.21037/tcr.2018.03.20] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Affiliation(s)
- Apar Gupta
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey
| | - Nisha Ohri
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey
| | - Bruce G Haffty
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey
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Yu JB. Hypofractionated Radiotherapy for Prostate Cancer: Further Evidence to Tip the Scales. J Clin Oncol 2017; 35:1867-1869. [DOI: 10.1200/jco.2017.72.7016] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- James B. Yu
- James B. Yu, Yale School of Medicine, New Haven, CT
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25
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Pan HY, Jiang J, Shih YCT, Smith BD. Adoption of Radiation Technology Among Privately Insured Nonelderly Patients With Cancer in the United States, 2008 to 2014: A Claims-Based Analysis. J Am Coll Radiol 2017; 14:1027-1033.e2. [PMID: 28408078 DOI: 10.1016/j.jacr.2017.02.040] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Revised: 02/17/2017] [Accepted: 02/21/2017] [Indexed: 12/25/2022]
Abstract
Despite enthusiasm for advanced radiation technologies, understanding of their adoption in recent years is limited. The aim of this study was to elucidate utilization trends of conventional radiation, intensity-modulated radiotherapy (IMRT), brachytherapy, proton radiotherapy, stereotactic body radiotherapy (SBRT), and stereotactic radiosurgery (SRS) using a large convenience sample of irradiated patients with cancer identified from private insurance claims in the United States. The unit of analysis was a claim corresponding to a fraction of delivered radiotherapy from 2008 to 2014. Each claim was assigned a disease site on the basis of the diagnosis code and a radiation technology on the basis of the procedure code. In 2014, conventional radiation and IMRT constituted 56% and 39% of all radiation treatment claims, respectively, while brachytherapy constituted 2%, proton radiotherapy 1%, SBRT 1%, and SRS <1%. Compared with the first quarter of 2008, the proportional contribution of conventional radiation and brachytherapy to all radiation claims each decreased by 16% in the fourth quarter of 2014. In contrast, proportional contribution increased by 32% for IMRT, 83% for proton radiotherapy, 124% for SRS, and 309% for SBRT. Prostate cancer constituted 60% of all proton claims in 2008 but declined to 37% by 2014. SBRT was used to treat a variety of disease sites, most commonly primary lung (25%), prostate (12%), secondary bone (9%), and secondary lung (9%), in 2014. In this claims-based analysis of younger patients with private insurance, conventional radiation and IMRT were the most commonly used technologies from 2008 to 2014, while SBRT showed the most robust growth over the study period.
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Affiliation(s)
- Hubert Y Pan
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jing Jiang
- Department of Health Services Research, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Ya-Chen Tina Shih
- Department of Health Services Research, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Benjamin D Smith
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas; Department of Health Services Research, University of Texas MD Anderson Cancer Center, Houston, Texas.
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Boero IJ, Gillespie EF, Hou J, Paravati AJ, Kim E, Einck JP, Yashar C, Mell LK, Murphy JD. The Impact of Radiation Oncologists on the Early Adoption of Hypofractionated Radiation Therapy for Early-Stage Breast Cancer. Int J Radiat Oncol Biol Phys 2016; 97:571-580. [PMID: 28126306 DOI: 10.1016/j.ijrobp.2016.11.009] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2016] [Revised: 10/19/2016] [Accepted: 11/08/2016] [Indexed: 11/19/2022]
Abstract
PURPOSE Despite multiple randomized trials showing the efficacy of hypofractionated radiation therapy in early-stage breast cancer, the United States has been slow to adopt this treatment. The goal of this study was to evaluate the impact of individual radiation oncologists on the early adoption of hypofractionated radiation therapy for early-stage breast cancer. METHODS We identified 22,233 Medicare beneficiaries with localized breast cancer that was diagnosed from 2004 to 2011 who underwent breast-conserving surgery with adjuvant radiation. Multilevel, multivariable logistic models clustered by radiation oncologist and geographic practice area were used to determine the impact of the provider and geographic region on the likelihood of receiving hypofractionated compared with standard fractionated radiation therapy while controlling for a patient's clinical and demographic covariates. Odds ratios (OR) describe the impact of demographic or clinical covariates, and the median OR (MOR) describes the relative impact of the individual radiation oncologist and geographic region on the likelihood of undergoing hypofractionated radiation therapy. RESULTS Among the entire cohort, 2333 women (10.4%) were treated with hypofractionated radiation therapy, with unadjusted rates ranging from 0.0% in the bottom quintile of radiation oncologists to 30.4% in the top quintile. Multivariable analysis found that the individual radiation oncologist (MOR 3.08) had a greater impact on the use of hypofractionation than did geographic region (MOR 2.10) or clinical and demographic variables. The impact of the provider increased from the year 2004 to 2005 (MOR 2.82) to the year 2010 to 2011 (MOR 3.16) despite the publication of long-term randomized trial results in early 2010. Male physician and radiation oncologists treating the highest volume of breast cancer patients were less likely to perform hypofractionation (P<.05). CONCLUSIONS The individual radiation oncologist strongly influenced the likelihood of a patient's receiving hypofractionated radiation therapy, and this trend increased despite the publication of long-term data showing equivalence to standard fractionation. Future research should focus on physician-related factors that influence this decision.
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Affiliation(s)
- Isabel J Boero
- Department of Radiation Medicine and Applied Sciences, University of California, San Diego, La Jolla, California
| | - Erin F Gillespie
- Department of Radiation Medicine and Applied Sciences, University of California, San Diego, La Jolla, California
| | - Jiayi Hou
- Department of Radiation Medicine and Applied Sciences, University of California, San Diego, La Jolla, California
| | - Anthony J Paravati
- Department of Radiation Medicine and Applied Sciences, University of California, San Diego, La Jolla, California
| | - Ellen Kim
- Department of Radiation Medicine and Applied Sciences, University of California, San Diego, La Jolla, California
| | - John P Einck
- Department of Radiation Medicine and Applied Sciences, University of California, San Diego, La Jolla, California
| | - Catheryn Yashar
- Department of Radiation Medicine and Applied Sciences, University of California, San Diego, La Jolla, California
| | - Loren K Mell
- Department of Radiation Medicine and Applied Sciences, University of California, San Diego, La Jolla, California
| | - James D Murphy
- Department of Radiation Medicine and Applied Sciences, University of California, San Diego, La Jolla, California.
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