By Thomas Eichler MD, FASTRO, Immediate Past Chair; Shane Hopkins MD; Ankit Agarwal MD, MBA; Shilpen Patel MD, FASTRO

For the first time in two years, ASTRO members converged on Chicago for five days in October to celebrate the specialty, partake in educational and scientific sessions and advocate on behalf of our patients at the 63rd Annual Meeting. In the immediate aftermath, however, the Radiation Oncology Alternative Payment Model (RO Model) final rule was released, in addition to final rules for the MPFS and the HOPPS. Although cosmetic changes were made with a few modest tweaks, all three rules remain flawed, in particular the RO Model, despite relentless ASTRO advocacy and engagement with CMMI to achieve fair and predictable reimbursement. Radiation oncology stakeholders, including the American Medical Association (AMA), have weighed in and made their opposition to the rules known. ASTRO is pleased to partner with the AMA to advocate for the specialty regarding reimbursement changes associated with the RO Model.

As the AMA prepared to meet in November, ASTRO was disheartened to learn that we may lose our representation at the AMA’s House of Delegates. The “federation of medicine” includes delegations representing states and specialties, but membership in the House of Delegates requires a certain percentage of each society’s membership to also be members of the AMA. Unfortunately, ASTRO has fallen short in that measure. We are currently in a one-year probation period after which ASTRO’s voice will be silenced in the House of Delegates.

My friends, it is absolutely critical that we continue to have ASTRO delegates at the table to advocate and testify at the AMA in support of radiation oncology interests. 

As we interact with other physicians on social media, skepticism is occasionally heard regarding AMA representation for radiation oncology. More often than not, however, the person with these concerns is unaware of the advocacy routinely done by the AMA benefiting radiation oncologists without fanfare. The AMA is one of the largest lobbying groups in the country, and the value of having them go to bat for us simply can't be replaced. For example, the AMA sent a detailed letter to CMS regarding the RO Model reflecting ASTRO’s concerns, albeit with the weight of the whole of organized medicine behind it. Recall that the AMA was instrumental in combating SGR cuts for two decades until its repeal in 2015. In addition, the AMA has successfully fought insurance mergers, such as the Anthem-Cigna merger that would have cost physicians $500 million dollars in payments annually. The AMA has been a leading voice on reforming prior authorization burdens and will be representing physician interests on the upcoming S.3018 bill. In short, the Association has fought against perennial challenges to our autonomy as physicians, including scope of practice issues, with major successes benefiting every one of us, even if many of us are unaware. To the benefit of all, the AMA has also been a trusted voice in communicating scientific information about COVID-19 to the public.

In order for ASTRO to maintain their seat at the AMA table with the ability to testify and vote on the sundry concerns that affect our specialty and all of medicine, we need you to join the AMA. Please consider joining right now to keep the largest physician voice in Washington in close sync with ASTRO on radiation oncology issues. Consider your AMA dues a sound investment with a proven track record. Threats to reimbursement and physician autonomy are, and will remain, ongoing, and although the AMA is just one stakeholder, they remain the single most powerful voice advocating on behalf of all physicians. Act now: join or renew your membership today. It is imperative that ASTRO maintain their voice within the AMA House of Delegates! Please help us meet this challenge!

By Jan Dragotta, Radiation Oncology Services Director, Princeton Radiation Oncology, Astera Cancer Care

ASTRO’s annual Coding and Coverage Seminar is an excellent opportunity for those involved in the field of radiation oncology to gain more insight into CPT^® coding guidance, billing practices and the evolving challenges medical professionals face in the radiation oncology field today. As an attendee of the Coding and Coverage Seminar, I was surrounded by professional coders and billers, practice administrators and radiation oncologists who experience these same challenges every day. The ASTRO virtual Coding and Coverage Seminar allows for engagement and discussion among participants, which is invaluable, particularly as practices find themselves spread thin and unable to travel due to COVID-19. Attendees have direct access to ASTRO faculty and staff, and I was impressed with the ease with which questions were answered and dialogues transitioned to group discussions throughout the program and after.

As someone who has attended the Coding and Coverage Seminar, I can speak to how highly interactive and informative the sessions are. The ASTRO faculty involved in the seminar included subject matter experts who write ASTRO’s Coding Resource, which serves as a textbook for the seminar and benchmark for best practice. It is a wonderful opportunity to engage in conversations and interact on coding issues, with a heavy emphasis on the clinical process of care. Case studies are presented on intensity-modulated radiation therapy, brachytherapy, proton beam therapy and stereotactic radiosurgery/stereotactic body radiation therapy for a variety of disease sites. These studies are a great tool for discussion and help attendees learn how to apply their newfound coding knowledge and provide specific coding guidance related to each scenario.

The seminar is a wonderful way to not only understand how to correctly use the CPT codes for radiation oncology, but to also understand some background information on the process of code development and valuation. Specific coding changes that are set to occur in the new year are discussed, and attendees can ask questions and gain clarity on this complex subject, helping practices avoid coding and billing errors. Faculty of the Coding and Coverage Seminar genuinely enjoy the opportunity to engage with attendees and help them navigate some of the more complex nuances of radiation oncology coding.

Additional topics covered during the seminar include sessions on the RO Model and Merit-based Incentive Payment System (MIPS), payer policy changes and other hot topics impacting the field of radiation oncology.  It’s a day well worth spending with ASTRO! I would encourage anyone with a responsibility for coding and those who want to learn more in order to grow within their profession to register for the upcoming December 11 event. An added bonus is that the electronic and hard copy versions of the ASTRO Radiation Oncology Coding Resource is included with your registration, an invaluable reference both during and after the program.

By Yun Rose Li, MD, PhD, Parul Barry, MD, and Adrianna Masters, MD, PhD

While many women scientists and physicians made critical contributions that paved the path to modern day advances in radiation oncology, few were recognized for their work. Perhaps one of the most well-known pioneers in the field of radiation oncology is a woman: Marie Curie, recipient of two Nobel Prizes for her extensive work on radioactivity and the discovery of radium.

But aside from Marie Curie, most of her contemporaries received little acknowledgment. For example, Lise Meitner, an Austrian-Swedish physicist, helped discover the element protactinium-231 and described the process of nuclear fission (Sime, 1996). Her work demonstrating that uranium atoms split when bombarded with neutrons allowed for the later development of nuclear energy and nuclear bombs. For her contributions, she was nominated for the Nobel Prize in chemistry and physics 48 times, though she never received the award.

Another example is Margaret Cleaves, who in the early 1900s was one of an estimated 20 physicians (the only female) to have access to radium for clinical purposes and ultimately became the first to use radium in gynecology to treat cervical cancer (Aronowitz, Aronowitz, & Robison, 2007). She was heavily criticized and was largely dismissed by other physician colleagues. At that time, not only were educational opportunities and access to postgraduate training for women extremely limited, but society placed strict limitations on the role of women as physicians and leaders in medicine.

It was not until the demands created by WWI and WWII that broader access to medical/graduate education and career opportunities, aside from those that were traditionally seen as “feminine” roles, were made available to women. Often considered to be a founder of nuclear medicine, Edith Quimby studied the medical effects of radiation and dose limiting side effects with the application of radioactive isotopes in the treatment of thyroid disease, brain tumors and other cancers during her time at Memorial Hospital for Cancer and Allied Disease in New York (Linton, 2012). In 1954, she became the first female president of the American Radium Society and was the recipient of the Janeway Medal of the American Radium Society, the Gold Medal of the Radiological Society of North America and the Gold Medal from the American College of Radiology.

Other important women who made contributions to radiation oncology include Chien-Shiung Wu, also known as the First Lady of Physics. Wu, a Chinese American particle and experimental physicist, worked on the Manhattan Project and played an important role in the advancement of nuclear and particle physics. Despite their successes, very few women obtained faculty positions and even fewer chaired departments during the mid-1900s. One example was Ruth Guttman, who became the director of the Department of Radiotherapy at Columbia University from 1955 to 1976. Other notable examples include Florence Chu, who was the chair of Radiotherapy at Memorial hospital 1976-1984, and Anna Hamann, who at the end of a long career, became the director of radiation therapy at Evanston Hospital, although she never attained a full professorship. These women and many other women physicians and scientists overcame tremendous challenges and faced persecution and hostility in order to pursue their dreams to advance the field of radiation oncology and radiation physics.

Though many would like to believe that efforts made to address challenges faced by women in science and medicine have allowed women to break the glass ceiling in radiation oncology, there is still a lot left to do. In fact, the lack of gender diversity among radiation oncologists begins with medical school applicants and continues to widen throughout career development. Currently, women represent at least half of all medical school students but make up only 30% of applicants to radiation oncology training programs. The gender disparity widens as women progress in their careers, with leadership positions and chair positions further widening the gap: academic positions 17.4% and female chairs 11.7% (Gharzai and Jagsi 2020).

Leadership roles on editorial boards of oncology journals are another area of noticeable disparities in representation of underrepresented minorities and women. A recent abstract presented by Patel et al. reviewed 54 oncology journals and 793 board members, and there was not a single editor-in-chief position held by a minority female. At a time when COVID-19 has disproportionately affected the career development of women, who often serve as primary caretakers at home, how do we create an even ground for achieving career success? This is a pivotal time to reevaluate our measures of productivity and the metrics we use to decide on tenure or promotion. Recognizing that women in STEM in general have shown much larger interruptions in submissions to journals during this time than their male counterparts, even those with young children, the charge is with institutions and national organizations within our field to make a change to do better for women in radiation oncology.

We would argue that we need to promote diversity of not just representation and service on committees, but chairing committees, successfully applying for FASTRO status and even the Gold medalists. We reviewed the listed ASTRO Gold medalists on the website and found that since 1977 only 12% of honorees were female. The majority of the current ASTRO executive committee is female. In reviewing the chair and vice-chair positions of the councils, two of five council vice-chairs are women. Because portions of the application process for FASTRO focus on recommendations of existing recipients, leadership roles and other metrics of academic success, is this placing an undue burden on persons from underrepresented groups? We are curious to know what the success rates are for applications and if there is a way to blind applications to reduce bias.

It is important to recognize that, even though much remains to be done to level the playing ground for women in radiation oncology, our field has seen enormous contributions made by women, and more and more women are being recognized for their work. The 2021 ASTRO Gold medalists were notably both women (Colleen Lawton, MD, FASTRO, and Lori Pierce, MD, FASTRO). Moreover, Sue Yom, MD, PhD, FASTRO, who has made tremendous contributions to major societies in our field including ASTRO and American Radium Society where she is the immediate past chair, is the incoming editor-in-chief of the Red Journal.

What are some of our thoughts on increasing representation of diverse groups of people in leadership?

• Recognize the accomplishments of others and go out of your way to highlight those who may not be in a position to do it for themselves.  
• Do not assume that someone doesn’t want to serve in a leadership role, is too busy or wouldn’t want to take time away from a specific activity (raising young children, for example). Why not simply ask? 
• Offer support in a positive way that sponsors the success of others and specifically think about multiple candidates for a task or role in leadership. 
• Be thoughtful with your word choices and their impact on those around you. 
• Acknowledge the additional burden of unpaid domestic work, specifically during global pandemics, and think about ways to provide resources: Adapt to a changing environment to allow diversity of experience to enrich our culture as radiation oncologists!
• Be aware of biases, speak up when you recognize them and acknowledge when you recognize your own. Positive change cannot happen unless we do. 

Join us on the ROhub to share your thoughts and discuss: What other ways can we support diversity of leadership and diversity of thought?

And be sure to acknowledge Marie Curie on Sunday, November 7 with #WeWhoCurie day!

References: 

Aronowitz JN, Aronowitz SV, Robison RF. Classics in brachytherapy; 2007.

Gharzai LA, Jagsi R. Ongoing Gender Inequity in Leadership Positions of Academic Oncology Programs: The Broken Pipeline. JAMA Network Open 3 (3): e200691–e200691. 2020. doi:10.1001/jamanetworkopen.2020.0691

Linton O. Edith H. Quimby. Journal of the American College of Radiology, 9(6), 449. 2012. https://doi.org/10.1016/j.jacr.2011.11.020

Sime RL. Lise Meitner: A Life in Physics. University of California Press. 1996.