By William Hartsell, MD, FASTRO, Chair, ASTRO Health Policy Council and Howard Sandler, MD, MS, FASTRO, Chair, ASTRO Government Relations Council

On April 28, 2021, President Joe Biden declared in his State of the Union address a commitment to “end cancer as we know it,” a goal ASTRO strongly supports. Sadly, three months later, the Centers for Medicare and Medicaid Services (CMS) unveiled two policy proposals that threaten to end radiation oncology as we know it. ASTRO was prepared for the possibility of Medicare payment cuts and is rolling out a comprehensive advocacy strategy to combat these flawed policies.

Medicare is planning a draconian double whammy for radiation oncology payments starting in 2022, with significant payment cuts totaling $300 million under the Medicare Physician Fee Schedule ($140 million) and Radiation Oncology Model ($160 million). ASTRO believes these cuts contradict the president’s anti-cancer goals as well as initiatives to advance health equity. Instead, these excessive cuts will jeopardize cancer patients’ ability to receive state-of-the-art care close to home. ASTRO is disturbed that practices treating rural and underserved populations will be hit hardest, limiting their ability to provide critical services to their patients and possibly forcing patients to travel long distances for treatment.

The facts are grim. If the Physician Fee Schedule cuts are finalized, payments to radiation oncology will have plummeted by 25% since 2012. The cuts proposed for 2022 for radiation oncology are among the highest of any medical specialty, with some key services dropping by as much as 22%. This follows on radiation oncology revenues dropping by 8% in 2020, according to an American Medical Association analysis, as clinics now try to recover while treating patients with more advanced disease that require more complex and costly treatments.

Meanwhile, the Radiation Oncology Model (RO Model) discount factor payment cuts are out of step with other alternative payment models and will put practices that are required to participate in jeopardy. Combined, the constant, year-after-year threats to clinics’ financial viability and out of control administrative burden will further contribute to burnout among physician staff.

ASTRO is sounding the alarm on the impact these cuts will have on cancer patient care. ASTRO’s Health Policy Council and Government Relations Council leadership, in concert with the ASTRO Board of Directors, is focused on dramatically scaling back the cuts stemming from both the fee schedule and RO Model and has developed an advocacy plan of action. The multipronged advocacy strategy will be in high gear through the end of the year and likely beyond. It’s important that members know some of the key features of that strategy so they can actively participate in stopping the cuts.

ASTRO is directly engaging President Biden and White House officials, with the goal of applying significant pressure on CMS to reverse course. In July, ASTRO sent a strong letter to President Biden and his senior staff and is following up with high-level meetings on the collective threats of the RO Model and fee schedule cuts. ASTRO already has secured numerous media reports highlighting for Biden Administration leadership the severity and impact of the payment cuts, and more public relations outreach is in the works.

ASTRO’s health policy team is engaged in extensive policy and data analysis to identify changes that must be made to the RO Model and fee schedule to protect access to radiation therapy. We’re working closely with partners in the House of Medicine on official comment letters to influence CMS.

To further influence the regulatory process, ASTRO’s government relations team is reaching out to congressional champions to contact CMS and demand changes that finally correct the RO Model and hold radiation oncology harmless from fee schedule payment shifts unrelated to radiation oncology. ASTRO has been working with legislators in the event congressional oversight is needed, and this initiative jumpstarted during Advocacy Day in late July when 100 ASTRO members met with 160 congressional offices on the proposed cuts.

ASTRO members should be on the lookout for action alerts in the coming weeks that will encourage radiation oncology team members to directly engage in grassroots efforts to urge members of Congress to support the specialty against the cuts. But there’s no need to wait, as senators and representatives are in their home states and districts for August recess and looking to meet with their constituents ― you!

ASTRO advocacy volunteers and staff will spend the next several months aggressively executing this strategy, recognizing it will be a great challenge to force CMS to change course. Therefore, ASTRO is preparing for the potential that legislative relief will be necessary before the end of the year.

For every aspect of the advocacy strategy, ASTRO is working closely with a committed group of radiation oncology stakeholders representing health professionals, patients, hospitals, office-based clinics, device manufacturers and more. We appreciate the hard work and support of our members and partners, as a unified and devoted team is essential for success against this dire threat.

By Laura A. Dawson, MD, FASTRO, ASTRO President

I’d like to continue to share insights with you about ASTRO 2021. Today, I’ll be focusing on the Presidential Symposium. The theme is Advancing Person-Centered Care Through Innovation — innovating for clinically meaningful benefits that matter to patients. While this is innate in what we do, we sometimes don’t aim high enough or consider the patient perspective as well as we should. Let’s ask patients what matters to them.

The symposium will open on Sunday, October 24, with an introduction by me to be followed by Dr. Shekinah Elmore, who will eloquently discuss innovating with compassion. Then the session “Harnessing Scientific Innovation to Improve Person-Centered Care,” moderated by Dr. Curtiland Deville and Dr. Kristy Brock, will have a cast of world-class speakers discussing artificial intelligence, innovations in radiation delivery and imaging, ultra-high dose rate/FLASH, advanced imaging for bioadaptive radiotherapy, patient-centered radiopharmaceutical therapy and personalizing radiation therapy using molecular biomarkers. A patient advocate will help us put these inspiring talks in context.

The second session focuses on how digital health improves patient outcomes and experiences. We’ll hear from human factors engineer, Dr. Jen Horonjeff who will talk about patients and crowdsourcing. Next, Dr. Debra Schrag, a medical oncologist leader in patient reported outcomes and measurements will discuss PROMs and PREMs as the true north — why/when/how. Dr. Edmondo Robinson will discuss reducing disparities with digital innovations. Then, Dr. Ale Berlin will highlight how he helped move in-person health visits to digital health visits at a large cancer center over just a few weeks in response to COVID-19. A panel will follow, discussing how to make user-friendly changes quickly and how to innovate equitably, using advances in digital health. Dr. Nitin Ohri will share how he’s implemented wearables (e.g., Fitbits) in the radiation oncology clinic. How can we use these tools to improve patient experiences and outcomes?

Session three asks what are some of the potential future applications of radiation therapy that may expand the role of radiation therapy and improve patient outcomes? Radiation replacing surgery, for example for liver cancer — while we aren’t there yet, there is potential. Dr. Jinsil Seong will delve into this topic. This session will keep us thinking. How can we use radiation therapy in new settings with the goal of cure? How do we get there? A talk by Dr. Chandan Guha will discuss innovative targeting of the immune system and microenvironment, for example using radiation as a vaccine. Dr. David Palma will look into the future of oligometastases SBRT, beyond three, 10 and even more metastases. In another talk, Dr. Stuart Burri will challenge us to rethink pre-operative radiation therapy. Dr. Yaacov Lawrence will share how to treat the celiac plexus with SBRT to improve cancer pain. Again, a patient advocate will provide their important perspective.

The final session will be entertaining and educational. How do we best obtain evidence for new applications of radiation therapy? Traditionally we’ve use randomized clinical trials. Can trials be more efficient and equitable? Can we learn from clinical real-world data that is searchable and inclusive of patients who are not eligible for trials? A lively debate on randomized clinical trials versus real world data will be moderated by Dr. Sue Yom and Dr. Gita Suneja. Four speakers will offer points/counterpoints for randomized clinical trials versus real world data, and Jill Feldman, a lung cancer patient advocate and survivor, will provide her thoughts on this challenging topic. This will be an engaging and interesting opportunity for audience input.

The Presidential Symposium will highlight exciting advances in radiation technologies and teams who can successfully deliver high-precision treatment, keeping the goal on where we want to be and what outcomes matter to patients. Let’s elevate our specialty beyond delivery of high-tech treatment together to advance person-centered care. I hope this provides you with some sessions to look forward to during the Presidential Symposium. If you aren’t yet registered, I encourage you to learn more and make plans now to join us in person or virtually for the Annual Meeting. The Presidential Symposium will be available as part of the Digital XP programming. If there are other topics you’d like to learn more about, I invite you to drop me a note.

Learn more about ASTRO 2021 from my first blog: Embracing Change: Advancing Person-Centered Care at ASTRO 2021

By Laura A. Dawson, MD, FASTRO, ASTRO President

Not only am I embracing change, but I’m stepping outside of my comfort zone as I write my first blog post about ASTRO 2021, our Annual Meeting. I was so pleased to announce on July 8 that registration and housing have opened. We’re back in person in Chicago, and I can’t wait to see you there, as we start to step out of our “COVID hibernation.” If you’re unable to travel to the meeting, we’ve added a virtual option called Digital XP. And we’re also offering risk-free registration through September 30, so you can take advantage of early-bird registration rates (see registration fees and policies on the meeting website for more information). I encourage you to learn more about the meeting and make plans to participate!

Today, I’m excited to share my personal thoughts with you about the Annual Meeting and the meeting themes of “person-centered care” and “embracing change.” I will start with person-centered care, which focuses on the whole person as a unique individual, beyond their cancer diagnosis. Patients are someone’s child, friend, partner and/or parent. A person’s work and hobbies are often disrupted by a cancer diagnosis and treatment, and we are in a unique position to care for and support people during some of the most challenging times of their lives. Placing an individual at the center of their care, partnering with them and personalizing treatment based on a more holistic approach that incorporates various dimensions to well‐being, including a person's individual preferences and beliefs, is “person- centered.” This approach acknowledges physical and financial barriers to care and other determinants of health. It should lead to more compassionate care and trusting relationships with patients and their families and ultimately, can help to improve health care system efficiency and effectiveness for the whole community.

A special person-centered session at this year’s meeting will be The Science of Hope: Why and How to Approach the Most Difficult Situations in Oncology. It’s sure to be inspiring. Hope is important to patients; it’s appropriate, necessary and a critical component of quality care. In this session, we’ll cover why hope matters, the psychoneuroimmunologic basis of hope and finally, how to cultivate and sustain hope in clinical practice and in clinical trials.

No matter what scientific innovation is being discussed at the meeting, it should come back to a person-centered approach. Let’s aim high — for clinically important improvements in outcomes and experiences that matter to patients and their families. We also need to look after ourselves and have empathy for each other, as we have had different degrees of loss and burnout, especially during the past year and a half. Creating a more supportive, nimble work environment may allow us to be more accessible to patients, which should in turn improve the patient experience and outcomes, as well as caregiver satisfaction and wellness. 

The second theme is embracing change. I picked this topic because I’d like to see us be more open to new ideas and different ways of thinking to help shape the future of radiation oncology. Let’s prioritize strategies to improve diversity in our field, which will help to improve person-centered care. Be open minded when someone suggests an idea that conflicts with your own inherent biases and thoughts. Let’s think of new ways to more efficiently demonstrate the benefits of radiation therapy innovations and applications, for example, with novel pragmatic trial design and/or new ways of producing evidence.

As we think about change and the profession, we can also think about new roles and new team members. Radiation oncology is a team involving physicists, radiation therapists, engineers, other oncologists, nurses, social workers, dieticians and other health care professionals. Radiation oncologists never work in isolation. As we implement new technologies and artificial intelligence (AI), all our roles will continue to evolve, and we must continue to advocate for clinically important advances. Who should be part of the team to ensure that such change occurs in an equitable manner, reducing disparities in access to treatment and cancer outcomes?
Computer scientists who are experts in machine learning and AI are playing an increasingly important role in radiation oncology, making them an obvious new team member to radiation oncology departments. One of our Keynote speakers, Dr. Fei-Fei Li, an expert in AI and computer vision, will share her views on the future of AI in health care as part of the Digital XP program (also available to all full conference registrants).

We also can learn from human factors engineers, implementation scientists, behavioral scientists and economists. I’m excited about Dr. Dan Ariely’s Keynote that will address why people do the things they do, which is a consideration in how to provide the best care for patients, how to successfully implement innovations and how to advocate for our specialty. His book, “Predictably Irrational: The Hidden Forces That Shape Our Decisions,” focuses on the behavioral research behind decision making. I expect to gain some great insights into behavior during this address.

Dr. Wendy Dean, a social scientist, will talk about the structure of medicine and how some structural changes have led to burnout and languishing during her Keynote address. We don’t usually have a social scientist on the stage, so this will be a treat. There’s so much that they and other scientists have to offer to the field. Let’s learn from them about how to improve person-centered care. Learn more about the three Keynote speakers.

I’ve provided some background and an overview of select sessions we have planned for ASTRO 2021. I hope you’ve enjoyed learning more about what you have to look forward to this year. In my next blog post, I will share more information about the Presidential Symposium. If there are other topics you’d like to learn more about, I invite you to drop me a note or even better, talk to me in person in Chicago!

Registration is open with many options to attend “your way!”