How does radiation therapy fit into the treatment of oligometastatic disease

By James Yu, MD, PhD, Yale University Cancer Center

Oligometastatic disease is of increasing academic and community interest, and it has been identified by ASTRO membership as a top research priority. There are emerging imaging and diagnostic technologies that are more readily defining and detecting oligometastatic disease – making contemporary discussion of oligometastatic disease especially relevant. Radiosurgery and radiation in general are thought to be ideal non-invasive therapy for the treatment of oligometastatic disease. Improved imaging techniques are emerging to better characterize metastatic cancer and treatment response. Lastly, innovations in targeted therapy and immune therapy are arguably increasing the numbers of patients with oligometastatic disease, and they have the potential to reverse widely disseminating disease into a clinically curable, but still metastatic state. For these reasons and more, world renowned speakers will discuss the clinical and basic science research of the definition, diagnosis and treatment of oligometastatic disease during the 2019 ASTRO Research Workshop, co-sponsored with the Radiological Society of North America (RSNA).

What is Oligometastatic Disease?

Oligometastatic disease is the theorized intermediate state between localized and disseminated cancer. There is increasing interest in oligometastatic disease in both the academic and the wider cancer community, partly because of the long-term survival that can be achieved through multimodality treatment strategies for patients with oligometastatic cancer.

How can Radiation Oncology be used to improve outcomes for patients with Oligometastatic Disease?

Data are emerging that local ablative therapies (such as surgery, radiofrequency ablation and radiation therapy) can play an important role in the treatment of oligometastatic cancer, particularly in delaying disease progression and increasing survival times. Stereotactic body radiation therapy (SBRT) has rapidly emerged as an effective and less toxic tool for the treatment of lung, liver, adrenal, brain and bone metastases. The ability of modern radiotherapy techniques to deliver potentially ablative doses to numerous organ sites throughout the body has allowed for the aggressive treatment of unresectable metastases.
The clinical implications of improved treatment of oligometastatic disease are enormous and immediate. Radiation oncology should be at the forefront of the treatment of oligometastatic disease, and radiation oncology researchers should lead the charge in defining, detecting and optimally combining treatment. Focused effort is required so that we can translate current efforts of large numbers of studies with few patients to larger studies of larger impact.
The workshop will be held on June 13 and 14, 2019, at the FHI 360 Conference Center in the Dupont Circle neighborhood of Washington, DC. For more information and to register, visit the meeting website.
Posted: January 22, 2019 | 0 comments

How to raise the profile of radiation oncology, one ASTRO member at a time

By Rosalyn Morrell, MD, Committee on Health Equity, Diversity and Inclusion
More than 100 years after it debuted as a mainstream cancer treatment, radiation oncology is still somewhat of an unknown specialty to the general public, and even to other medical specialties. Even over the course of my own career (14 years), I have been consistently surprised at the high number of misconceptions and general lack of awareness about radiation therapy and its benefits and effectiveness in treating cancer. 
When patients hear the word “oncologists,” they typically think of our medical oncology colleagues. Or, when they hear “radiation oncologist,” they confuse us with radiologists.  Many patients have presented to my clinic with an inaccurate understanding about the treatments and side effects. Oftentimes, their primary source of information has been anecdotal evidence passed on by family and friends or information gleaned from the internet. In fact, it has been reported that approximately 72 percent of people research health-related information on the internet.1 However, we all know the internet can be a notoriously unreliable source of health data.
As for our internal medicine resident colleagues, in a recent article published in the Red Journal, 93 percent of polled internal medicine residents stated that they did not receive radiation oncology training during their medical school training. Furthermore, only 26 percent reported knowing when to consult radiation oncology for a patient with a new cancer diagnosis.2
Additionally, we know that lack of awareness among other medical specialties, especially primary care physicians, can have an impact on patient care.2 More frequently than ever before, primary-care providers are taking a more active role in the care of the cancer patient, referring them to oncology specialists and participating in survivorship care. Yet many of them report uncertainty about the benefits of radiation therapy and a lack of understanding regarding when patients should be seen by a radiation oncologist.2,3
This lack of awareness about radiation oncology can lead to or exacerbate disparities in the quality of patient care and survival rates across many segments (e.g., racial/ethnic, geographic or socio-economic) and even the economic bottom line for radiation oncology practices.4,5 Patients may not be referred to a radiation oncologist at all, or may be referred in later stages of their disease or only for palliative treatment.6
Since 2003, ASTRO has been actively conducting research assessing patient perception of our field. Over the years, that perception has not changed much.7 Now, work is underway at ASTRO to raise positive awareness and the profile of radiation oncology in treating cancer. Most recently, ASTRO’s Board of Directors has made raising the profile of radiation oncology a part of their strategic plan.     
On an organizational level, this will be impactful, but we should also be asking what each of us can do in our day-to day activities to raise awareness of radiation oncology. Three areas that we as practitioners could be addressing in our own practices are:
1. How do we educate our primary-care physician colleagues and other specialists about our field?
2. How can we raise the level of knowledge and awareness of radiation therapy in our patient populations?
3. How can we get more positive stories and awareness about radiation oncology into mainstream media and the general public?
So, how might we do that? Below are a few activities and best practices that have been employed by myself and others in their own practices to help raise positive awareness of radiation oncology.
  • For primary-care physicians and other medical specialties:
    • Arrange face-to-face visits with primary-care physicians and other specialists.
    • Provide their offices with educational literature about radiation therapy for referring physicians and to give to their patients (browse ASTRO’s patient education resources).
    • Participate in physician networking groups.
    • Host open houses at your practice.
    • Start a radiation oncology journal club or tumor board.
    • Partner with other specialists for disease-specific community events.
  • For our local community patient populations:
    • Give talks or seminars to community groups, churches and other organizations.
    • Promote or sponsor cancer awareness and education seminars.
    • Attend or sponsor support groups.
    • Promote or sponsor cancer screenings.
    • Sponsor and participate in cancer-related community outreach events.
  • For the general population:
    • Offer to give interviews on local radio or television.
    • Create an informative and educational website.
    • Post testimonials on a blog or website.
    • Promote cancer prevention on social media.
    • Start a blog.
    • Write a book. 
These are just a few ideas to initiate the conversation regarding awareness of our field.  I urge you to sponsor or support activities in your own communities to raise positive awareness of radiation oncology. Your patients will be healthier, happier and have a brighter future.
Please tell us in the comments what you are doing that can help raise the profile.
1.  Bibault JE, Katz MS, Motwani S et al.  Social Media for Radiation Oncologists: A Practical Primer.  Advances in Radiation Oncology. 2017;2: 277-280.
2. Shaverdian N, Yoo SM, Cook, R et al. Gaps in Radiotherapy Awareness: Results from an Educational Multi-institutional Survey of US Internal Medicine Residents.  Int J Radiat Oncol Biol Phys. 2017; 98:1153-1161
 3. Samant R, Malette M, Tucker T.  Radiotherapy Education Among Family Physicians and Residents.  Journal of Cancer Education. 2001;16:134-138.
4. Park H, Decker RH.  Disparities in Radiation Therapy Delivery: Current Evidence and Future Directions in Head and Neck Cancer. Cancers of the Head and Neck. 2016;1:1-5
5.  Rueth NM, Lin HY, Bedrosian I, et al.  Underuse of Trimodality Treatment Affects Survival for Patients With Inflammatory Breast Cancer: An Analysis of Treatment and Survival Trends From the National Cancer Database.  J Clin Oncol. 2014;32: 2018-2024
6. Zaorsky NG, Shaikh TA, Handorf EA. A National Assessment of Medical School Knowledge in Radiation Oncology and Comparison to Primary Care and Radiation Oncology Attending Physicians. Int J Radiat Oncol Biol Phys 2014;90:S601-602.
7. ASTROnews, Spring 2014; p14-20

Posted: December 11, 2018 | 2 comments

Merit-based Incentive Payment System Fourth Quarter Updates

By Randi Kudner, Senior Quality Improvement Manager
It’s difficult to keep track of all the administrative deadlines within a radiation oncology practice.  This is especially true for those practices reporting to Medicare’s Merit-based Incentive Payment System (MIPS). As we near the end of the second year of the MIPS program, there are several requirements to consider and a few items to check off the end-of-year “to do” list.
2018 Requirements
In 2018, physicians or practices must achieve 15 points to avoid the 5 percent penalty in 2020.  Small practices ( less than 16 eligible clinicians) can achieve this by choosing two medium-weight Improvement Activities, or one high-weight activity. Large practices (16 or more eligible clinicians) need four medium-weight or two high-weight activities.
In 2017, the Cost performance category was not included in MIPS; however, it was scored.  ASTRO recommends that all practices review their 2017 Feedback Report in the Quality Payment Program Portal to see whether a Cost score was provided.  If a practice received a score in 2017, it is likely they will also meet the required thresholds for 2018, when the category will be 10 percent of the final MIPS score. 
MIPS Checklist All practices can learn more on the ASTRO website or contact ASTRO directly.
Posted: December 5, 2018 | 0 comments

How do you #AnswerTheQuestion?

By Malika Siker, MD
Radiation oncology represents a small specialty in medicine, accounting for less than 1 percent of the physician workforce and graduate medical education trainees.  Although the work we do is highly rewarding, the intimate and challenging nature of our work can be isolating in both our professional and personal spheres. Reaching out and sharing experiences with colleagues has been suggested as an effective way to avoid burnout and improve wellness. However, due to our small numbers and demanding schedules, it is difficult to find avenues to regularly receive support from peers.
Social media has emerged as a tool to form meaningful connections with colleagues in this modern environment. Participating in social media has many benefits, such as facilitating the dissemination of important research and discussions of current issues in radiation oncology. Additionally, the ability to connect with others to advocate for our patients and our specialty as a whole, to network professionally and to provide encouragement and support for colleagues lure many users to this space, particularly to Twitter. It is these simple interactions that can provide the most meaning in an otherwise very noisy and lonely place.
The radiation oncology community recently explored these issues on Twitter in response to an article written by pediatric oncologist Chris Adrian, MD, in the New England Journal of Medicine. In this article, Dr. Adrian described the difficulty and complexity of answering the simple, common “cocktail party” question, “What do you do? How can you do it?” After sharing this article with the #radonc community, I asked others to share how they answer this question. The sincere, thoughtful and uplifting responses from our diverse community provided followers with much inspiration. Below are some highlights of the #radonc #AnswerTheQuestion replies:
Randall Kimple, MD, PhD: The trust our patients place in us is an honor and a privilege. We come into their lives when they are vulnerable and scared. We support them, cure some, and are always driven to do better. It drives me to find better treatments in the lab so that we can help future patients.
Matthew Katz, MD, FASTRO: Vulnerability and strength come with facing a serious illness. Our role as teacher, healer means patients and clinicians both can bring our strengths and vulnerabilities together to build trust, even in the face of uncertainty.
Kaleigh Doke, MD: We are oncologists that have the privilege of helping #cure and care for patients with #cancer using the coolest, most advanced treatments in #radiation—a treatment that’s been in existence for a century!
Lauren Colbert, MD, MS: We do it because we are eternal optimists, and even for those without a positive outcome, it is such a sacred opportunity to provide relief in the midst of pain. Wouldn’t do anything else!
Anna Lee, MD, MPH: We offer relief for the disease burden of cancer patients and provide hope so that patients can be the best version of themselves!
Drew Moghanaki, MD, MPH: We are just people helping people who are suffering and need us. About as close to God’s work as one can get.
Raphael Yechieli, MD: We help people live better each day. By offering treatment FOR people, and not just doing things TO them.
Emma Holliday, MD: We meet patients where they are. Sometimes we give them a cure, sometimes we give them hope, sometimes we give them relief from suffering, sometimes we give them peace that they have done all they could. Always we give them respect, dignity and love.
Ashley Albert, MD: We are so privileged to be able to meet patients where they are ... in their vulnerable state, facing adversities and victories. We have a means to provide cure or comfort. The gratitude of our patients pushes us all forward and motivates us to press on.
Sabin Motwani, MD: It's always a privilege when someone but especially #cancer patients entrust you with their health. They are appreciative for the little things you can do for them and for each day of life they have. They are great teachers who continue to inspire us. As radiation oncologists and lifelong learners, that is why we love to work so hard for them.
Fumiko Ladd Chino, MD: I #AnswerTheQuestion by saying that there's too much pain, grief and suffering in cancer care. Our treatments are true #precisiononcology ... tailored to each person: their risks, symptoms and anatomy. Even when we can't cure, we can improve quality of days.
Benjamin King, MD: Providing answers for the scared, physical/emotional relief from those in pain, and connecting in a disorienting time are all blessings given to us as #cancer doctors and why I choose to do #radonc every day.
Jeff Michalski, MD, MDA, FASTRO: I emphasize the positive (which is 90 percent of my clinical #radonc work). I actually #CURE patients of what were previously incurable diseases. You can't say that about diabetes (endocrinologist), multiple sclerosis (neurologist), arthritis (rheumatologist), coronary artery disease (cardologist), etc.
We invite you to join the conversations of our #radonc community on Twitter. Simply follow the #radonc hashtag to discover the current research, controversies and news in radiation oncology. Additionally, we hope that by participating in this community, your life will be meaningfully enriched by the support and encouragement of your colleagues and that you will reach and help others with your own voice.
Let us know in the comments how you #AnswerTheQuestion.
Posted: November 20, 2018 | 0 comments

Radiation Oncology Reimbursement Reminders (RORR), Fall 2018

By Jessica Adams, ASTRO Health Policy Analyst
In addition to providing resources to assist practices in submitting accurate claims for reimbursement, ASTRO is actively working with payers on coverage and payment issues. Recently, we received questions regarding reimbursement for radium-223 dichloride (Xofigo) and CMS’ Targeted Probe and Educate program. The following Radiation Oncology Reimbursement Reminder is drawn from our many coding and reimbursement resources to help practices properly bill for this treatment.
What is the appropriate treatment planning code to use for the delivery of radium-223 dichloride (Xofigo)?
Complex radiation treatment planning (CPT code 77263) is used when the radiation oncologist performs the cognitive work associated with treatment planning and the service meets the definition of complex. The use of radium-223 dichloride meets the criteria for billing CPT code 77263.
What criteria do recovery audit contractors (RACs) use under CMS’ Targeted Probe and Educate (TPE) program?
CMS requested that RACs use National Coverage Determinations (NCDs) when performing an audit, as these determinations are more consistent than Local Coverage Determinations, which vary by Medicare Administrative Contractor.
ASTRO members and their practices should be familiar with the following NCDs:  
Members should also review ASTRO’s Coding Guidance regarding simulation and intensity-modulated radiation therapy (IMRT) planning. The  Office of the Inspector General (OIG) issued a report that found that Medicare overpaid U.S. hospitals an estimated $21.5 million between 2013 and 2015 for simulation (77280, 77290) when performed as part of IMRT planning (77301).
Finally, we have an example of a private payer relieving some administrative burden for radiation oncology practices. Anthem recently removed several Radiation Therapy procedures from their prior authorization list. As of early August, Stereotactic Radiosurgery (SRS), IMRT Planning, IMRT multi-lead collimator (MLC) device and IMRT Treatment Delivery codes no longer require prior authorization. These procedures are all included in ASTRO’s Model Policies, which outline correct coverage policies for radiation oncology services.
We hope that this guidance helps radiation oncology practices as they navigate billing issues. Do you have billing questions or any other common billing pitfalls? Let us know in the comments, or attend ASTRO’s third Coding and Coverage Seminar, taking place December 7-8. Registration is open and filling up fast!

To purchase ASTRO’s Coding Resource, which includes information on updated CPT codes, visit our website. Or, if you’ve already purchased the Resource, you may access it by logging in to your MyASTRO account and clicking on Virtual Meetings/Products under My Resources.
Posted: November 7, 2018 | 0 comments

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