Trends in Radiation Oncology

The practice of radiation oncology is advancing rapidly, but even as the technology evolves, it is the power of partnership that is key to improving care. Novel collaboration with radiology, payers and the patients themselves are changing the way treatments are delivered.

Bridging the gap: Radiology and radiation oncology

Imagine a patient with early stage lung cancer. The tumor is inoperable because of a risk for pulmonary compromise due to the patient’s long smoking history and underlying emphysema. There are a couple options: The patient could have stereotactic body radiation therapy (SBRT) in multiple sessions over a several week period or the patient could undergo an outpatient thermal ablation. The former strategy costs about three times that of the latter.

All things being equal, the cost-effective strategy would seem to be the way to go, but due to a rift between the specialties of radiology and radiation oncology, the most efficient and cost-effective treatments are not always used, according to Damian E. Dupuy, MD, director of tumor ablation at Rhode Island Hospital and a professor of diagnostic imaging at the Warren Alpert Medical School of Brown University in Providence, R.I.

“It was kind of us versus them, and we were fighting over—people are still fighting over—these patients,” says Dupuy. “That type of siloing mentality is probably not the best patient care.”

The rift grew when the two groups split in the 1970s when people realized the specialties were evolving so rapidly it was becoming too much information for one person to learn. Diagnostic radiology was primarily concerned with imaging and some procedures such as biopsies, while radiation oncology dealt with treatment. Now, however, diagnostic radiology is becoming more involved in cancer care and treatment, specifically with targeted treatments using ablation or embolic agents. These treatments are competing with radiation therapies, says Dupuy.

But they don’t have to. Instead, the treatments offered by the different specialties could be seen as complementary, a point Dupuy underlined when he presented the Annual Oration in Diagnostic Radiology as part of the RSNA 2013 Opening Session. In that lecture, Dupuy referenced the words of Anthony L. Zietman, MD, MBBS, a professor of radiation oncology at Harvard Medical School. Zietman said the strength of radiation oncology is in irradiating the microbes of small volume disease, while most ablative technologies are suited to handle larger tumors but don’t address microscopic disease. It’s possible to combine the strengths of both specialties and utilize embolization or ablation along with radiation.

Dupuy says that even the higher energy hyperfractionated techniques of SBRT can’t effectively treat bigger tumors that are radiation resistant due to a low oxygen environment in their centers. “All of the radiation oncologists know this, but because they tend to be competing with the interventional radiologists for some of these other patients, there’s not this collaborative feel.”

Moreover, it makes sense for the specialties to pool resources such as scanners under one department that works together clinically and administratively, as well as collaborates on research.

As imaging practice and the accountable care movement evolves, it will be important to maintain a focus on collaboration and a search for the most efficient treatments. Dupuy says that in many cases when performing a biopsy for diagnosis, an ablation can be conducted in the same sitting. “So you can actually cut costs even more. You can do a one-stop biopsy and ablate. If you have to put a needle in, why not just ablate it at that time?”

Teaming with patients

Like collaboration between specialties, better coordination between provider and patient can produce benefits for care, even in a specialty like radiation oncology that’s typically very paternalistic. It’s true that radiation oncology is very complex, requiring a multidisciplinary team, extensive technical planning and a tailored approach, but there are still decisions on which patients can provide input, says Neha Vapiwala, MD, associate professor of radiation oncology at the Hospital of the University of Pennsylvania.

For instance, in situations where two doses have been verified to be effective, a patient may prefer to have a higher per-day dose but delivered in fewer treatments. There also are questions about medications to manage treatment side effects. “There are areas lacking clear answers that one is better than the other, so you might go with patient preference and let the patient hear the pros and cons and determine that way,” says Vapiwala.

This mindset of collaborating with patients led to a study of shared decision making published by Vapiwala and colleagues March 19th in Cancer. They surveyed more than 300 patients undergoing definitive radiotherapy about their level of perceived control over treatment.

Results showed that 31.3 percent of patients said they experienced shared decision making, and those who did had statistically significantly more positive feelings about their treatment and overall satisfaction. Of those who perceived shared decision making, 84.4 percent reported high satisfaction, compared with 71.4 percent of those who didn’t feel they shared in the decision-making process.

For those who wanted more control over their treatment but did not receive it, Vapiwala says there was increased anxiety, depression and fatigue. There’s not enough evidence to state cause and effect, but it’s worth further study, she says.

The researchers also found that even patients who said they didn’t want control over their treatment reported being happier if they experienced shared decision making. “That really highlights the fact that you can’t necessarily assume, based on…how engaged [patients] seem, that they’ll just go along with whatever I say and I don’t have to involve them,” says Vapiwala. “You might still gain some benefit in explaining it. The patient will be happier and potentially more compliant.”

Vapiwala acknowledges the challenges of a busy schedule. Most physicians would likely prefer to include the patient and improve satisfaction, but there’s a time crunch and there’s no reimbursement for spending extra time talking things over with patients. The study, she says, highlights the fact that it doesn’t take an inordinate amount of time to make a patient feel included. In the end, the effort will be worth it to boost satisfaction scores on which hospitals are increasingly being judged.

“You can’t live in this bubble where you just treat and don’t have expectations of keeping patients happy,” says Vapiwala.

Pricing problems

For any treatment, somebody is going to have to agree to foot the bill. When it comes to a novel treatment like proton therapy, that can be a sticky proposition. Proton therapy targets an escalated dose to the tumor while decreasing radiation to normal tissues in an effort to control side effects and complications. It also allows for re-treatment of tumors after recurrences. But the devil is in the dollar signs. According to the Centers for Medicare and Medicaid Services, Medicare paid more than $1,100 per day of proton therapy treatment in 2013 at the few centers in the U.S. where it is conducted. There is limited evidence demonstrating clinical benefits, which has other payers shying away from coverage.

The result is a Catch-22, says Justin E. Bekelman, MD, an assistant professor of radiation oncology at the Perelman School of Medicine at the University of Pennsylvania and physician at the Abramson Cancer Center. Without the evidence, payers are concerned, but with no coverage to support randomized controlled trials, the evidence can’t be gathered. “It’s incumbent on providers of proton therapy to generate the evidence to demonstrate that the novel benefits we believe may translate into clinical benefits actually do.”

Bekelman’s suggestion for a solution is “reference pricing,” a relatively new model that would establish standard prices for both types of treatment. The more expensive proton therapy would be covered at rates currently paid for standard intensity-modulated radiation therapy under Medicare, Medicaid and most insurance plans. This would ease the concerns of payers while allowing the treatment to actually be used in trials.

“I don’t see any downside—and there isn’t a concern about safety. This is an FDA-approved treatment,” says Bekelman. He adds that under reference pricing, providers are absorbing the financial costs of delivering proton therapy at a reduced rate. If it turns out that proton therapy’s benefits are supported by trials, this investment would be worth it to have developed the evidence and to justify a price premium in the future.

In an article written with colleague Stephen M. Hahn, MD, for the Journal of Clinical Oncology, Bekelman highlights the success University of Pennsylvania Health System has had with a reference pricing agreement with large insurers in the region. It was implemented in 2010, and now, each day, more than 100 patients are treated at Penn Medicine’s Roberts Proton Therapy Center.

“This seems like a reasonable approach in this era of cost constraint and also uncertainty about clinical benefits,” says Bekelman. So far, the partnership has worked out well, giving patients access to new technology and demonstrating responsibility to payers.

Novel pricing, along with the lessons from Dupuy, Vapiwala and colleagues, also provide examples of collaboration improving care in radiation oncology.