Imaging costs for Medicare cancer patients on the rise

[News]

A study in the Journal of the American Medical Association analyzed data from Medicare cancer patients to determine the change in imaging use for this group.

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[gdpawel]

The current issue of Oncology News International (June 2010, V 19, No 6) quotes a Duke University study of the use of high-tech cancer imaging, with one representative finding being that the average Medicare lung cancer patient receives 11 radiographs, 6 CT scans, a PET scan, and MRI, two echocardiograms, and an ultrasound, all within two years of diagnosis. A study co-author (Dr. Kevan Schulman) asks: "Are all these imaging studies essential? Are they all of value? Is the information really meaningful? What is changing as a result of all this imaging?"

Why is it that oncologists are so accepting of high tech, expensive imaging studies, yet so reluctant to consider the use of cell culture diagnostic tests? For one thing, clinical trials virtually always have time to disease progression as a primary endpoint. Without the imaging studies, one can't get accurate time to progression data. So these are tests performed for the benefit of drug companies seeking new drug approval, for clinical investigators seeking contracts and publications, and for clinicians seeking an easy way to make clinical decisions (and, occasionally, seeking income enhancement).

In the absence of information provided by cell culture testing, oncologists have complete freedom to choose between a myriad of drug regimens. The proven basis on which they make these selections, by and large, is on the benefit a given regimen provides to the oncologist (or academic institution). Cell culture testing threatens this freedom of choice. There's absolutely nothing in it for the oncologist or academic medical center (unlike, for example, imaging studies).

[gdpawel]

Physicians tend to settle on the smallest amount of tumor tissue possible, often with a fine needle aspirate that collects just a few cells, for biopsy analysis. Larger bore needles (tru-cut) are needed to perform core biopsies or even remove entire lymph nodes, so that they can collect enough "live" tissue to more reliably determine the histologic and molecular features of a cancer. Imaging technologies cannot substitute for the biologist's thorough examination of the features of a cancer cell.

I am not a proponent of "diffuse" radiation therapy. So the high energy proton beam, which is a "focused" radiation technique, is appealing to me, although at a more expensive approach. Accuracy is the key to effective radiation treatment with minimal collateral damage (the same as for chemotherapy treatment).

But, is the proliferation of proton beam outpacing evidence? Proton therapy still requires manual beam attenuation and there is no integrated feedback. I understand that better technology is being developed to eliminate the need for manual beam attenuation and promoting 3D control, but it's five years or so away.

Brian Baker is an executive of Regents Health Resources, which helps hospitals and physicians develop and manage their medical imaging services. He was interviewed for Community Oncology. He said that "if you look at cancer trends worldwide and then estimate proton beam therapy use based on today's indications, the world market opportunity is only around a total of 250 units. That need will likely change as proton beam adopts some of the automation technologies."

Baker says that "a four-gantry proton therapy center costs as much as a small hospital ($125 million). The cost of proton beam equipment alone is well over $50 million." Proton beam is reimbursed at $25,000 (on average) per patient. And Medicare increased reimbursement. It's also worth noting that the physics behind a 900-ton synchrocyclotron getting those protons close to the speed of light may need as much as a city block of real estate.

Baker agreed that $125 million for a proton beam unit is a big pill to swallow for something whose capabilities are still being discovered. However, he pointed out that a patient with cancer in the spine may mean the difference between surviving as a quadriplegic, having received radiation therapy, and surviving to live a normal life, having received proton beam therapy.

With the high cost of all this technology and the return on investment considerations, how does the private practitioner compete? His point is to share, not only the risk, but the potential opportunity in the technology.

He says he is "seeing more and more requests for partnerships and joint ventures, which can work very well if people are realistic about their expectations and goals. Partnerships can be structured in many different ways depending on the practice's needs and the legal considerations."

"Of course, the challenge is how to take advantage of the new technology without interrupting patient and revenue streams. Unfortunately, there really is no easy or inexpensive answer for this yet. If your technology is too old to accept an upgrade, the only option that allows for an uninterrupted work flow is to build a new facility."

"Granted, that's expensive and complex," he says, "but it allows the new technology to be integrated, and it positions the practice for the future, while delivering better service to patients."

However, a report from the Agency for Healthare Research and Quality (AHRQ) found no evidence to support claims that cancer patients undergoing pricey proton beam radiation therapy (PRT) achieve outcomes or experience fewer side effects than patients receiving traditional photon radiation.

[Rich66]

How does Proton compare to Cyberknife?

[gdpawel]

According to John Adler, the Stanford University professor who invented the CyberKnife, it is a robotic device that treats cancer with precise, high doses of radiation. Cyberknife (stereotatic radiosurgy) in general allows a much higher dose of radiation (20-60 Gy) compared with 5-7 Gy with conventional therapy. It can be placed under CT guidance.

This kind of treatment would appear to be appropriate when there is localized disease which is considered to be inoperable. If there are a great many tumors then this technique is probably not appropriate because the disease is so widespread that no amount of treating individual tumors will halt the disease.

On the other hand, if you have a single tumor which is considered to be inoperable, or if you cannot withstand open surgery for an otherwise operable tumor, this treatment might be a real consideration. The treatment is usually given as a series of five outpatient sessions spaced anywhere from a day to a week apart depending on the situation. Side effects are said to be minimal in most cases, as is often not the case with conventional external beam radiotherapy.

I personally know a cardiothoracic surgeon who uses Cyber Knife in his repertoire of treatment options. Not everything can be done with the knife (pretty much though).

I know that is is not yet known whether Brachytherapy/Proton Beam Therapy yields better clinical outcomes than other types of radiation therapy for patients with many common cancers. In some instances, surgery and Brachytherapy/Proton Beam Therapy are used together in early stage breast cancer. It's not established that it works for more aggressive breast tumors. It is still considered new for breast cancer.

Radiation-induced necrosis can occur more commonly after Brachytherapy/Proton Beam Therapy and radiosurgery, but can also occur after conventional radiation therapy as well. I had a brother-in-law who lost his life to MDS (Myelodysplastic Syndrome), which can be caused by treatment with chemotherapy or radiation therapy. This is called treatment-related MDS or secondary MDS. He developed MDS after receiving permanent seed implants with Brachytherapy for prostate cancer treatment.

There was supposed to be a study to compare whole breast radiation to three different types of partial breast radiation: multi-catheter brachytherapy, ballon catheter brachytherapy (MammoSite) and 3-D conformal external beam radiation.

In multicatheter brachytherapy, docotrs insert hollow tubes (usually 15-20) into the tumor site. Radioactive pellets are then inserted into the tubes. They are left in the breast for a few minutes, then taken out again. The tubes themselves remain in place for the length of the treatment, which is 1-2 weeks. After seeing what radioactive pellets did to my brother-in-law, I don't know about this procedure.

Ballon catheter brachytherapy is similar but it uses only one tube with a balloon at the end. The balloon is inserted into the breast and inflated with salt water to fill the cavity left by the removal of the tumor. The radiation pellet is inserted into the center of the balloon for a few minutes at a time. This is done over the course of 1-2 weeks.

3-D conformal external beam radiation (similar to traditional radiotherapy) is delivered from outside the breast. But instead of hitting the whole breast, the beams are targeted to hit only the tumor site and a small portion of surrounding tissue.

My wife and I had already discussed if she had breast cancer, off with it. She had been the one to convince me to go surgery. She had gone surgery with all her cancers. I had one sister-in-law who had breast cancer in 1995 (one year before my wife's 24 years recurrence). She had a lumpectomy with some spot radiation to the local tumor bed. In 2007, another lesion showed up and she treated it as another primary. This time, Oncoplastic surgery, combining oncology principles with plastic surgery techniques (nothing else).