September 2018

The Cancer Epidemic: How the IAEA helps Countries with Nuclear Techniques

By May Abdel-Wahab, MD, PhD, FASTRO
The increasing cancer burden places great pressure on health care systems and leaders worldwide to provide effective solutions, even when the resources to diagnose and treat these conditions may be scarce. Even in high-income countries, the increasing number of cancer cases is presenting significant challenges for countries, their leaders and health care providers. To assist in these efforts, the International Atomic Energy Agency’s (IAEA) Programme in Human Health aims to provide a comprehensive approach to the prevention, diagnosis and treatment of cancer in four main areas of support: nutrition; radiology and nuclear medicine for diagnosis; radiation oncology for treatment; medical physics, dosimetry and quality assurance.
Recent years have witnessed rapid advances in radiotherapy techniques, including intensity-modulated radiation therapy, image-guided radiation therapy, stereotactic radiotherapy, tomotherapy, new brachytherapy and unsealed-source techniques and proton and heavy ion therapy, all of which have one goal in common: treating patients more efficiently, effectively and safely. The IAEA supports these and other treatment techniques in several ways:
Training and education
Supporting the initial education and training of radiotherapy professionals, such as medical physicists, radiation therapy technologists and radiation oncologists, as well as supporting the continuing education and training of previously trained professionals to update or expand their knowledge and skills is a priority. The lack of qualified professionals is one of the main obstacles preventing the needed modernization and expansion of radiotherapy services in the developing world. Adequate human resource planning is essential and must accompany government investment in equipment.
The IAEA supports long-term and short-term fellowships, education and training workshops, such as contouring workshops, as well as virtual education platforms such as the Human Health Campus, an educational and resources website for health professionals, and AfroNET, a virtual tumor board for professionals in the African region. In addition, the IAEA supports the implementation of new master’s programs, such as the medical physics program at the University of Trieste and the radiation oncology program in Chile.
Research programs
The IAEA fosters the exchange of scientific and technical information. Coordinated research projects allow researchers across the globe to access a platform of quality clinical research, where a full range of projects (from pre-clinical to phase III trials, health economics trials, patterns of care studies and cost-analysis research) can be discussed and actions planned. Funding research to improve health globally allows answers to research questions of relevance that would be difficult to address otherwise. A broad range of research has been supported, including randomized trials in bone metastases, liver radiosurgery, head and neck and other sites.
Coordinated research projects are instrumental to build capacity in research in IAEA member states while also providing opportunities for scientists and institutions to conduct more strategic research.
Support of new radiotherapy and nuclear medicine centers in countries
Assessing and supporting the significant global radiotherapy needs and transferring nuclear technology to developing countries is one of the core IAEA activities. The IAEA has contributed to filling the gaps in access to technologies and education in the fields of nuclear medicine, diagnostic imaging and radiotherapy, contributing in this way to saving lives and improving quality of life across the socioeconomic spectrum.
The IAEA also maintains the Directory of Radiotherapy Centres (DIRAC), an online registry of radiotherapy centers worldwide and the world’s only database on radiotherapy resources containing radionuclide and high-energy radiotherapy machines.
Quality assurance and safety
The IAEA contributes to quality assurance and patient safety in radiotherapy and publishes reports and guidelines on quality assurance programs and quality control procedures to support high quality, safe and effective radiotherapy. These documents provide general guidance for the implementation of quality management systems, and several national radiation safety regulations and laws are based or include elements of this documentation.
The IAEA develops internationally harmonized codes of practice and guidelines for dosimetry and quality assurance, as well as recommendations for best practices, and provides guidance to member states for their implementation. Access to teletherapy, brachytherapy and diagnostic imaging at the IAEA Seibersdorf complex in Austria plays an important role in ensuring quality radiotherapy worldwide through access to training, audits and calibration. These activities play a key role in establishing and disseminating best practices for the safe, secure and effective use of radiation in the diagnosis and treatment of cancer.
The dosimetry laboratory provides services to countries to assure that treatment devices can be safely operated in clinical use. Since 1969, the IAEA/World Health Organization (WHO) TLD postal dose quality audit service has been operating to validate the calibration of radiation beams in developing countries. In addition, in 1976, the IAEA, together with the WHO, established a Network of Secondary Standards Dosimetry Laboratories, with the aim of improving the accuracy in radiation dosimetry and assure a traceable route for national dosimetry standards.
How the IAEA supports these and other global cancer initiatives will be the topic of this year’s keynote speech at ASTRO’s 60th Annual Meeting by Yukiya Amano, Director General of the International Atomic Energy Agency.
For more information, please visit www.IAEA.org and the Human Health Campus website.
Dr. Abdel-Wahab is director of the Division of Human Health in the Department of Nuclear Sciences and Applications with the  International Atomic Energy Agency in Vienna, Austria.
Posted: September 26, 2018 | 0 comments

Are restrictive coverage policies the greatest challenge facing U.S. radiation oncologists?

By Jessica Adams, CCA, ASTRO Health Policy Analyst

In the 2018 Member Survey, 48 percent of private practice radiation oncologists and 38 percent of academic/university system radiation oncologists said restrictive coverage policies are one of the greatest challenges they faced in their practices. The complaints that ASTRO’s Payer Relations Committee (PRC) has received from members in 2018 indicate that coverage policies and prior authorization are only becoming more challenging, which is why ASTRO devotes significant advocacy efforts in this area.

As part of ASTRO’s Health Policy Council, the PRC actively works to address payer coverage policy issues to ensure appropriate coverage for radiation oncology patients. PRC regularly reviews and comments on Medicare and private payer policies, including educating payers using ASTRO Model Policies, which contain up-to-date coverage recommendations. In recent months, ASTRO’s PRC has addressed:

Rectal spacers: Over the past two years, ASTRO advocated for coverage of rectal spacers as an effective tool for reducing rectal toxicity associated with treatment for prostate cancer. Many private payers and the majority of Medicare Administrative Contractors (MACs) responded positively to our advocacy. National Government Services (NGS) is the only MAC that considers rectal spacer not medically necessary. ASTRO, the American College of Radiology and American Brachytherapy Society have urged NGS to reconsider its position. NGS appears unwilling to change its decision, but we will continue to emphasize how this restriction will negatively impact prostate cancer patients to encourage NGS to reclassify the procedure.
Radiosurgery: ASTRO also engaged with MAC Noridian after they announced plans to crosswalk payment rates for robotic radiosurgery codes G0339 and G0340 to CPT codes 77372 and 77373, citing the G codes deletion in the 2014 Medicare Physician Fee Schedule (MPFS). This proposal would have resulted in a reduction in reimbursement by as much as 60 percent for the G codes. ASTRO, along with other stakeholder groups, petitioned Noridian to reconsider, and, in July, Noridian modified its decision and announced that it would cut rates for the G codes by 20 percent effective July 1, 2018, and postpone any additional reductions indefinitely.
Image-guided radiation therapy (IGRT): Aetna still requires practices to bill CPT code 77387 Image-guided radiation therapy, which is a carrier priced code. In the fall of 2017, PRC wrote Aetna to accept the image guidance codes recognized in the MPFS, including CPT codes 77014, G6001, G6002 and G6017. Aetna has stated that, though it is permissible per CPT to bill these codes, they feel it is more appropriate to bill 77387-26. However, Aetna acknowledges the reimbursement impact and recommends that practices contact them regarding a rate review. ASTRO’s PRC issued steps practices may take to perform a rate review, if appropriate. PRC continues to urge Aetna to update their intensity-modulated therapy radiation (IMRT) policy to align with the ASTRO model policy and to recognize 77014, G6001, G6002 and G6017.  
Prior Authorization: In May, Radiation Oncology Benefit Manager eviCore released updated 2018 Radiation Therapy Clinical Guidelines. EviCore, utilized by many private payers to perform prior authorization and other duties, considered post-operative stereotactic radiosurgery (SRS) not medically necessary. ASTRO advocated that post-operative SRS is superior to observation alone in terms of local control, and superior to whole brain radiation therapy (WBRT) in terms of preservation of cognitive function. Based on ASTRO’s comments, eviCore modified their coverage policy on the use of for post-operative SRS brain metastases, effective August 1, 2018.
ASTRO encourage members to reach out to PRC when experiencing struggles with payers. For more information regarding ASTRO PRC efforts to address payer issues, including copies of letters and payer guidance, see the ASTRO website. Attend the 2019 Radiation Oncology Coding and Reimbursement Update during ASTRO’s Annual Meeting for more in-depth information on payer coverage issues that impact the field of radiation oncology. ASTRO is also hosting its third Coding and Coverage Seminar on December 7-8. This is another great opportunity to learn the ins and outs of radiation oncology coding and coverage. Registration is open and filling up fast!
Posted: September 11, 2018 | 0 comments

ASTRO’s palliative thoracic guideline update recommends the use of concurrent chemotherapy for some patients

By Ehsan Balagamwala, MD, and Benjamin J. Moeller, MD, PhD

In 2011, ASTRO published a guideline on palliative thoracic radiation therapy (RT) which covered dose and fractionation for external beam radiation therapy (EBRT) and the roles of endobronchial brachytherapy (EBB) and chemotherapy given concurrently with EBRT. Pertinent to the update discussed below, the original guideline task force concluded that there was no role for concurrent chemotherapy with palliative EBRT for lung cancer. This recommendation was based on a single randomized control trial (RCT) by Ball et al., which showed improved overall response rates with concurrent chemotherapy. However, it also reported increased esophageal toxicity, as well as no improvement in overall survival, progression-free survival or symptom palliation.
ASTRO’s current guideline methodology includes periodic review of published guidelines for consideration of revision based on new data. A task force was convened in 2016 to review the palliative thoracic guideline briefly summarized above and they issued the results of this review in a guideline update published in the July-August issue of Practical Radiation Oncology. An updated literature review was performed for all three original key questions. The task force felt that the original statements on the questions of EBRT dose and fractionation, as well as those on EBB should be left intact. However, new data on the utilization of concurrent chemotherapy with palliative EBRT prompted the task force to recommend revising its guidance on this question.
For patients with stage IV lung cancer, the recommendation against concurrent chemoradiation was unchanged. However, recommendations on the palliative management of incurable stage III non-small cell lung cancer (NSCLC) were revised based on two additional RCTs published after the original guideline was released: one by Nawrocki et al., and another by Strom et al. Both of these trials had two strengths lacking in the study by Ball and colleagues: First, protocol-specified definitions of incurable stage III NSCLC (Ball et al., did not have well-defined eligibility criteria) and second, utilization of platinum-containing multiagent chemotherapy, which has been shown to have the most activity in NSCLC (Ball et al., utilized single agent fluorouracil).
With the addition of chemotherapy, both Nawrocki et al., and Strom et al., showed improvement in overall survival, albeit with increased risk of grade 3-4 toxicity (neutropenia and esophagitis) with concurrent chemoradiation. Based on these new trials, the task force recommended that a subset of patients (chemotherapy candidates, Eastern Cooperative Oncology Group performance status 0-2, and life expectancy ≥ 3 months), who are not candidates for either definitive concurrent chemoradiation or sequential chemoradiation, would benefit from concurrent chemotherapy with moderately hypofractionated RT.

In the months since this guideline was released, there has been engaging discussion via social media and scientific meetings, largely aimed at clarifying two important points:
  • How should the guideline reader define “incurable” stage III NSCLC?
  • How can the guideline reader be reassured as to the safety of concurrent chemotherapy with palliative thoracic EBRT?
Though data demonstrate that many patients with stage III NSCLC are managed with palliative intent, no validated criteria have been defined for which patients are best treated this way, which complicates clinical research done in this space. The two studies primarily informing this update used largely non-overlapping criteria for defining incurable stage III NSCLC and, therefore, could not be used as a basis for this definition. Further, developing a definition of incurability was beyond the scope of this guideline update. Therefore, we chose to leave it to the discretion of the treating physician to determine candidacy for curative therapy in this context. The recommendation to utilize concurrent chemotherapy would apply only to those stage III NSCLC patients who they have deemed incurable in their individual practices (i.e., those patients that are treated with palliative intent and will receive only palliative RT and/or chemotherapy as a part of their treatment course). 
When recommending escalating treatment intensity in the palliative care arena, treatment toxicity is an important consideration. Specific to the question of concurrent palliative thoracic chemoradiation is the risk for esophagitis. Ball et al., reported grade 3 esophagitis in 3 percent for RT alone versus 12 percent for chemoradiation (p<0.01). Nawrocki et al., did not find a statistically significant difference in risk for grade 3 esophagitis (0 percent RT versus 2 percent chemoradiation) but did find increased risk for grade 3 or 4 neutropenia with concurrent chemotherapy. Finally, Strom et al., found increased risk of grade 3 esophagitis with chemoradiation (1.5 percent versus 30 percent, p<0.01). Overall, the task force members concluded that the modest increase in the risk of acute esophagitis was outweighed by significant improvements in not only response rates and survival but also symptom control and quality of life with the addition of concurrent chemotherapy to palliative thoracic EBRT.
Finally, we applaud the investigators involved in all the referenced trials. Randomized clinical studies focused on palliative radiotherapy are relatively uncommon, partly due to the difficulties involved in conducting them. Given the prevalence of palliative care in our field and its understood value for our patients, we appreciate these efforts and encourage more investigation to further clarify these important issues.
Dr. Balagamwala served as the resident representative on the task force for this guideline; he recently completed his residency at the Cleveland Clinic, where he is now an attending physician in the Department of Radiation Oncology. Dr. Moeller chaired the update to the ASTRO guideline on palliative thoracic radiation therapy and is a member of the ASTRO Guidelines Subcommittee. He works at Southeast Radiation Oncology Group in Charlotte, North Carolina.
Posted: September 5, 2018 | 0 comments