By Lisa Braverman, PhD, Senior Managing Editor, ASTRO Journals

This past summer, I had the opportunity to spend a week in Finland. While the trip was mostly a vacation, I was inspired to visit a cancer treatment facility by the recent ASTROnews issue, “Personalizing the Patient Experience.” The articles about Danish and Australian centers made me wonder: What decisions were made in the design of a Finnish treatment facility, and why?

Shortly before my travels, I contacted Docrates Cancer Hospital in Helsinki and was graciously invited to visit. My time there revealed beauty, efficiency and an exceptionally well-curated cultivation of calmness.

I was first struck by how separate the patient waiting areas were from the administrative centers of the hospital. Nearly every waiting room I have visited in the United States is open concept to a fault: dozens of chairs comingle with stations to check in, check out, provide information and pay. Waiting areas were abundant in Docrates, all of which were small and intimate. The ones near windows were flooded with light; others outside infusion rooms were designed to look like living rooms. For patients seeking more privacy, cubbies with desks were provided. Walls of greenery were ubiquitous, promoting calm and obvious references to the world outside. As with nearly everywhere I visited in Finland, Docrates was noticeably quiet. Juha Kononen, MD, PhD, Chief Clinical Director of Personalized Oncology, said a quiet soundscape was intentional and “very Finnish”; having a low sound burden was meant to enhance healing and lessen the hardships of treatment.

Dr. Kononen showed me his office and vacant infusion beds. All faced the same direction: outward toward the Baltic Sea. Doctors sat with their backs to the sea, so patients could look at the water. He explained that this was done on purpose, so patients would have something nice to look at while they were undergoing treatment. The floors were wood to evoke feelings of home; stunningly detailed paintings of wildlife adorned patient room doorways in an effort to keep the mood light.

In terms of radiation therapy treatment, Dr. Kononen confirmed that the center mostly sees prostate cancer and breast cancer patients and occasionally head and neck cancer patients.

One goal of cancer treatment at Docrates is to offer highly personalized care to each individual’s disease. Dr. Kononen noted that Docrates’ approach to prostate cancer treatment, for example, is more aggressive than most. Strong emphases are placed upon understanding the tumor microenvironment and using radiopharmaceutical therapies. The center offers an in-house cyclotron in order to be able to deliver nucleotides in the most efficient way possible.

When speaking with members of the Docrates team, I was struck by everyone’s unwavering commitment to ensuring a positive patient experience. A patient’s doctor and nursing staff remain with them throughout the entirety of treatment. Schedulers empathize with patients’ time pressures and proactively work to have them seen as quickly as possible; administrative staff have medical training so they are able to answer treatment-related questions during off-hours. All of Docrates’ actions, Dr. Kononen said, are done “with the best interest of the patients at the center.”

Visiting a cancer treatment center was an extremely informative way not just to learn about RT practice outside the United States, but to learn more about Finnish culture. I hope to make such visits part of my vacation routine in the future!
 

Lisa Braverman assists with the publication of ASTRO's three scientific journals. She holds a PhD in Communication and Culture, and she enjoys interfacing with ASTRO members from all over the world.

By Cindy Tomlinson, Senior Patient Safety and Regulatory Affairs Manager

In 2022, the American Board of Radiology announced that it was terminating the Nuclear Regulatory Commission recognition of all ABR certification processes after December 31, 2023. This change is important for radiation oncologists that want to begin offering radiopharmaceuticals but have not previously offered treatments regulated by the NRC, such as brachytherapy or radiopharmaceutical therapy.

What does this change mean? Starting on January 1, 2024, any radiation oncologist who is interested in becoming an Authorized User (AU) under 10 CFR 35, Medical Use of Byproduct Material, must obtain AU status via the “alternate pathway.”

What is the “alternate pathway”? The “alternate pathway” is how radiation oncologists become AUs without using board certification to prove compliance with training and experience requirements.

Simply put, if you are not already an AU, are within seven years of completion of training, and you want to become an AU, you must have all the proper paperwork, signatures and attestations as required by either the NRC or Agreement State. Note: if you are more than seven years after completion of training, there may be additional training and experience requirements needed to obtain AU status, but the process will be the same. You will need to contact your state radiation control program (for agreement states) or the NRC (for all others).

What can I do? Current trainees should ensure that your training program maintains meticulous records, complete with preceptor attestations, and fills out both NRC form 313A (AUT) and form 313A (AUS) and provides those to you upon graduation. This information must also be accessible to you indefinitely. Also, current trainees should ask their training programs to make them an AU under their training program’s license. This will be dependent on what type of license your facility has and the structure of your training program. The first step is to discuss this with your program director, your radiation safety officer (RSO) and your radiation safety committee.

ABR’s change puts greater onus on radiation oncologists, trainees and training programs to obtain AU status, particularly those that wish to deliver brachytherapy and radiopharmaceuticals.

More information, including links to state-specific radiation control programs and forms (where available), can be found on ASTRO’s How to Obtain AU Status webpage.

If you have any questions, please contact Cindy Tomlinson.

Learn more about radiopharmaceutical therapies in the Winter 2023 ASTROnews.

By Beth Erickson, MD, FASTRO, Chair, ASTRO Fellows Selection Committee

Do you have what it takes to be an ASTRO Fellow? We are very excited to announce the 2023 Class of ASTRO Fellows. These individuals all have one thing in common: a commitment to serving their professional organization.

The ASTRO office receives many phone calls regarding eligibility requirements to achieve ASTRO Fellowship. In this blog, I will highlight the prerequisites for consideration and also share with you what the ASTRO Fellows Selection Committee looks for in candidates worthy of holding the FASTRO designation.

Let’s start with the prerequisites:

• Typically, 15 years of ASTRO Active, International or Emeritus membership, post training, are required. However, there are instances, which I will explain later, where members are considered who are shy of the 15-year membership requirement.


• Significant service to ASTRO. Similar to other professional societies, e.g., ASCO, ABS, ACRO, an important requirement for fellowship is volunteer service. Examples of ASTRO service include committee involvement, speaking engagements at ASTRO meetings, serving as a reviewer or on the editorial board for ASTRO’s journals and participation in ASTRO’s Advocacy Day.

A few years ago, the Committee put together a points chart to help evaluate an applicant’s level of service. The question we are frequently asked is, how many points do I need to be eligible for Fellowship. The number of points is evaluated as part of the entire application package, therefore there is not a specific number. I will say, however, that 100 points is a good starting point for applicants with 15 years of membership. Applicants who are shy of the 15-year requirement (11-14 years) must have contributed an extraordinary level of service, far exceeding 100 points.

Wondering how many points you have accumulated? Log in to the ASTRO website and on your MyASTRO page you can access your FASTRO Service Transcript. Note that some of your ASTRO service may not be recorded on your transcript. That is why taking the time to thoroughly complete your Fellow application is extremely important. Staff will validate the service provided on your application and add verified service to your transcript.

Once the membership and service prerequisites are met, the Committee looks at the application and letters of nomination and support for commendable contributions in one of four pathways — research, patient care, education and leadership/service (to the field). Applicants are required to select and provide details on a primary and secondary pathway. Here’s a bit of a description of each pathway (Note: these pathways are in addition to the minimum 15 years of membership and significant service to ASTRO prerequisites):

• Research: Significant research as evidenced by grants, authorship of scientific papers, chapters or books that have been a guiding influence in the immediate or future aspects of the practice of radiation oncology.


• Patient Care: Significant contribution to patient care and clinical excellence as evidenced by improvement in the standard of practice in the management of disease.


• Education: Significant contribution to the advancement of education in the field as evidenced by participation in residency training, faculty service, extensive presentations at regional or national meetings, or providing significant mentorship to those joining or active in the field.


• Leadership/Service: Demonstration of leadership and service that has advanced the specialty as a whole. This can be in the form of extensive volunteerism, advancement of scope of practice, patient advocacy and legislative and regulatory issues. Service to medicine, including ASTRO and other societies may be considered but in the context of the total application.

Once again, let me stress the importance of thoughtfully completing the Fellow application. Earning the FASTRO designation is a distinguished honor reserved for individuals who have demonstrated a sustained, thoughtful commitment to ASTRO and the field. The Committee takes into consideration how seriously an applicant values this distinction by the quality of the application submitted.

A letter of nomination and three letters of support round out the application process. The Committee reads each letter and looks for information to substantiate the candidate’s qualifications for Fellowship.

• Letter of nomination: Only an ASTRO Fellow may nominate a candidate for ASTRO Fellow.


• Letters of support: Letters in support of a nomination must come from the following subset of ASTRO members: past or current members of the ASTRO Board of Directors, ASTRO Gold Medalists, ASTRO Fellows, and former or current chairs of radiation oncology programs. Emeritus members, except Gold Medalists, are not eligible to nominate or support.

ASTRO membership is comprised of incredible individuals who are devoted to curing patients with cancer. If the FASTRO designation was based on that alone, all members would qualify. However, the FASTRO designation is meant to recognize individuals who are devoted to ASTRO through membership, extraordinary volunteer service and engagement, in addition to accomplishments in the field.

Please join me in congratulating the 29 members of the 2023 Class of ASTRO Fellows. They join a distinguished group of 421 colleagues.

If you have any questions about the application or review process, please email or refer to information on our website.

By Jennifer Jang, ASTRO Communications

The Survivor Circle is celebrating its 20th year in recognizing patient organizations. The Survivor Circle Grant is one of ASTRO’s ways of giving back to the cancer community, and grantees are announced during the ASTRO Annual Meeting. Last year at the 64th Annual Meeting in San Antonio, ASTRO had the privilege to provide a $10,000 Survivor Circle Grant for two Texas-based organizations, ThriveWell Cancer Foundation and Breast Cancer Resource Center (BCRC). ASTRO followed up with both organizations to learn more about how the grants provided tangible aid since last fall.

To start, ThriveWell Cancer Foundation, is dedicated to finding the cure for cancer by funding cancer research, providing patient support and offering programs to improve the quality of life for patients and their families. Founded in 2007, ThriveWell furthers their mission by providing the following services in the San Antonio and Bexar County community:

• Patient assistance: ThriveWell Cancer Foundation provides patients with financial assistance to offset the costs associated with their medical care, as well as treatment related transportation and lodging assistance.
• Diva&Dude: Diva&Dude is a fitness and nutrition program offering a variety of exercise classes and nutritional counseling for cancer patients and survivors, provided at no charge.
• Cancer research: ThriveWell Cancer Foundation supports local investigators who conduct cutting-edge research in the fight against cancer.

ThriveWell Cancer Foundation specifically used the Survivor Circle grant to expand their Patient Assistance Program, which now serves record numbers of patients in their community. The grant has been used to help 10 cancer patients pay for their radiation treatment co-payments. ThriveWell paid those patients’ co-payments, up to $1,000 each, which allowed them to fully comply with their treatment plan.

The Breast Cancer Resource Center (BCRC) was the other Survivor Circle grantee. Most recently, BCRC shared that their Patient Navigation program is as strong as ever in providing guidance and education to people diagnosed with breast cancer in central Texas. BCRC provides support to clients with monthly support groups, online forums and their Compass Crew program for health and wellness. Because clients have become more comfortable with virtual gatherings, that has been their most recent format, but they plan to offer in-person meetings as well in hopes of clients being more comfortable with that format. Last November, BCRC hosted a retreat for their metastatic clients and 18 attended, with activities like jewelry making, aromatherapy and body movement. It was a time for them to celebrate each other, have fun and also visit with the patient navigators.

BCRC used the Survivor Circle grant to support their patient navigators, who are critical to the mission of empowering those affected by breast cancer with personalized support and compassion.

BCRC has been providing services for over 28 years in Central Texas. In 2022, they served over 1,200 clients. They provided over 7,600 hours of patient navigation and resolved 94.5% of all clients’ needs. Over their 28 years, they have supported thousands of women who have been diagnosed with breast cancer. Unfortunately, some clients have a recurrence or progression of their breast cancer. At any point, whether it has been one year or 10 years, they can access BCRC’s services whenever they need them. BCRC’s impact is to ensure any woman or man who has been diagnosed with breast cancer has the support to navigate through their initial diagnosis, treatment and into survivorship specifically equipped with the knowledge and care they need to lead the life they want for as long as they can.

ThriveWell Cancer Foundation and BCRC have used their funds to enhance their impact. This October, ASTRO will award two $12,500 grants to Breast Cancer Angels and Cancer Support Community Los Angeles during the Annual Meeting in San Diego as we celebrate 20 years of the grant program! The program is an opportunity for support organizations from the host state of California to advance their initiatives and receive recognition in the ASTRO community. For questions about the grant, contact Beth Bukata.

By Geraldine Jacobson, MD, MBA, MPH, FASTRO, ASTRO Chair; Connie Mantz, MD, FASTRO, Health Policy Council Chair; and Catheryn Yashar, MD, FASTRO, Health Policy Council Vice-chair

On June 23, ASTRO’s Board of Directors approved pursuing legislation to create a new Radiation Oncology Case Rate (ROCR) payment program under traditional Medicare, which would:

• Change radiation oncology payment from per fraction to per patient.
• Reverse decade-long declines in Medicare payments.
• Usher in a new era of stable payments, higher quality care, and reduced disparities.

ROCR represents a bold initiative to reverse disastrous Medicare payment trends. ASTRO believes ROCR is our best chance to secure long-term rate stability and continue to deliver cutting-edge care to patients close to home. ASTRO is seeking feedback on ROCR with the goal of securing broad support from the radiation oncology community before advancing this legislative proposal in Congress.

Background:

Medicare spends less on all radiation oncology treatments than it spends on just three top cancer drugs; yet radiation oncologists treat more than twice the number of beneficiaries. Despite its high value, radiation oncology has faced more payment cuts than nearly all other specialties through a combination of direct cuts and policy proposals that shift resources from specialty care to primary care. More cuts are likely to come.

The Facts:

• Medicare has cut RadOnc payments by more than 20% over the last 10 years.
• Practice costs are rising, as equipment and staff are getting more expensive.
• More Medicare beneficiaries are receiving radiation therapy.
• The current payment system penalizes the use of shorter treatment regimens.
• The CMS RO Model failed due to excessive payment cuts and administrative burden.

Without stable payments, access to care and quality will suffer and the field will struggle.

Radiation therapy is primed to make great gains for cancer patients, but the current Medicare payment system is prohibiting the investments necessary to achieve those goals. ASTRO refuses to let the status quo of cuts and failure of the RO Model stand in the way of radiation oncologists who are committed to providing greater value to their patients. The specialty needs to look forward and act now.

ASTRO has invested significant time and resources in developing this new Medicare payment system for radiation oncology. Developed by ASTRO’s Health Policy Council physician leaders from various practice settings and with the help of expert consultants, the ASTRO Board approved ROCR as a proposal in June after numerous versions were evaluated and analyzed.

Several practices, including private practices (freestanding and hospital based) and academic centers, modeled ROCR using the tool linked below and determined ROCR was favorable in comparison to expected Medicare fee-for-service payments.

Why ROCR?

Because it:

• Addresses the instability of the current payment systems;
• Aligns financial incentives with clinical guidelines;
• Ensures use of quality assurance and improvement standards;
• Reduces disparities by helping underserved patients initiate, access and complete treatments;
• Uses a more simplified approach than the CMS RO Model;
• Unifies payment that levels the playing field across care delivery settings;
• Updates payments annually based on medical inflation trends.

ROCR has precedent in past payment reforms for capital intensive health care services, such as End Stage Renal Disease, which is paid on a prospective basis.

ROCR Ins and Outs

• All radiation oncology practices participating in Medicare.
• Professional and technical services paid under Medicare physician fee schedule and hospital outpatient prospective payment system for 15 common cancer types.
• External beam modalities and associated services.
  • Conventional, IMRT, SRS, SBRT

• Services delivered in inpatient hospitals, ASCs, PPS-exempt cancer hospitals.
• Medicare Advantage and commercial insurance payments.
• New Technology and Services (without Cat 1 CPT codes).
  • i.e., Adaptive RT
• Services without national Medicare prices.
  • Proton therapy, surface guidance
• Lower volume services.
  • Protons, brachytherapy, radiopharmaceuticals

Excluded technology and services potentially eligible for inclusion in future years.

How does ROCR work?

1. Payment rates and RVUs are derived from “M code” case rates published by Medicare in 2022 for technical and professional payments for 15 cancer types.
   1. ASTRO’s consultants validated the accuracy of these unified payment rates.
   2. Half of the payment will be paid at the start of the radiation treatment.
   3. Final payment will be made at the end of the course of treatment.
2. Applies annual inflationary payment updates.
   1. Professional payments updated by the Medicare Economic Index.
   2. Technical payments updated by the Hospital Inpatient Prospective Payment System market basket update.
3. Applies a savings adjustment, which is phased in over five years. 
   1. Savings adjustment would reduce Medicare radiation oncology spending by slightly more than $200 million over five years, which is about 1% of total Medicare spending on radiation oncology each year or about $17,500 per practice, per year.
   2. Savings are needed for Congress to even consider ROCR.
   3. Savings are primarily derived from technical payments.
      1. ASTRO estimates ROCR’s level of savings to be less than what is likely to happen if current payment and hypofractionation trends continue.
4. Provides a Health Equity Achievement in Radiation Therapy (HEART) payment of $500 per patient to technical payments to cover transportation services for underserved patients.
   1. Triggered by using a standardized screening question and billing code.
5. Provides a technical payment incentive to earn/maintain practice accreditation, which is well accepted by radiation oncology clinics for assessing and improving quality of care.
   1. First three years, accredited practices receive a .5% positive payment adjustment.
   2. After three years, practices would receive a -1.0% adjustment for lack of accreditation.
6. Applies geographic adjustments and the federally mandated cut of 2%, per current law.

What’s next?

Practices are encouraged to use the modeling tool to compare payments under ROCR to trended fee-for-service payments. Tell us how your practice would perform under ROCR.

• Keep in mind that the tool does not account for additional expected Medicare payment cuts under the fee schedule and the continued impact of increasing hypofractionation on technical revenues.

Review the full ROCR report, technical analysis and modeling tool. We want to hear from you — please send us your feedback via email to Health Policy.

Read the draft letter to Congress and if you agree with ROCR, indicate your practice or organizational support by filling out this form.