By Thomas Eichler, MD, FASTRO, ASTRO Chair
After more than a decade of enjoying the prestige of being one of the most highly sought-after specialties in the medical student match process, there have been troubling signs in the past few years that something was amiss. In 2019, the number of medical students who initially matched into radiation oncology declined with multiple slots unfilled. At the time, there was speculation about whether this was an anomaly or the beginning of a trend that had been forecast years before. In 2020, the field saw a larger decline in the number of medical students who matched, coupled with an increase in the number of people who then entered the field through the Supplemental Offer and Acceptance Program (SOAP) process. In fact, radiation oncology had the highest percentage of spots filled through the SOAP of any medical specialty.
From a treatment perspective, many factors, including the decreased use of radiation for some disease sites and an increased use of hypofractionation, bring into question the long-term viability of our specialty. Despite the many positive aspects of radiation oncology, there are growing concerns about the future of the workforce. There has been an increase in the number of available trainee positions despite the apparent decline in medical student interest and concern regarding patient volume projections. These issues contribute to forecasts of declining income streams and anxieties about the future given the recently proposed ― and now delayed ― radiation oncology alternative payment model. The worrisome trend in the SOAP percentages for radiation oncology underscores some of these negative perceptions about the field among students and residency applicants, which are in turn amplified on social media platforms. Not surprisingly, many students are confused about what career path to choose and may be discouraged to pursue radiation oncology before they even truly explore it.
ASTRO leaders have sought to be forthright with our members about challenges in the field (see previous blog posts below) and ASTRO’s role in addressing them. While there are strict anti-trust principles ASTRO must abide by, the Board of Directors felt compelled to issue a definitive statement so that there is no ambiguity about our position.
ASTRO Position Statement on the U.S. Radiation Oncology Workforce
- Radiation oncology has long been a critical component of multidisciplinary cancer management, driven by clinical and scientific innovation. Recent advances in technology and our understanding of cancer biology have allowed radiation oncologists to offer more accurate and effective therapies, often in fewer total treatments than before, resulting in improved patient care. ASTRO has observed growth in residency training positions over the past two decades. With more efficient treatment delivery, fewer radiation oncologists may be needed in the coming years. Residency training positions should be reserved for those who are enthusiastic about the field and should reflect the anticipated societal need for radiation therapy services. As we prepare the next generation of radiation oncologists for independent practice, we encourage stakeholders to carefully consider these aspects affecting our specialty as they review the size and scope of their training programs.
Additionally, ASTRO acknowledges the continued need to grow and nurture diversity within the next generation of our workforce. We serve diverse peoples, and our trainees and faculty should reflect that diversity. We are committed to addressing all aspects of bias as we seek to ensure equity and inclusion within our specialty and to improve health outcomes for all our patients.
While we acknowledge that this statement will not magically solve the issues impacting the field, we do want to be clear with our current and future members about ASTRO’s stance on this critical issue. We also strive to keep the lines of communication open with all members, including our residents. We listen to and appreciate the insights and perspectives from Association of Residents in Radiation Oncology (ARRO) to better understand their perceptions and experiences. Results from a survey of the class of 2020 found that residents had an average of five job interviews, received at least two job offers and, perhaps most significantly, 89% of residents were satisfied with the offers they received. While there are some vocal naysayers on social media, the direct response from residents gives us confidence and hope about the current realities in the field.
Radiation oncology has always sought the best and the brightest minds for our field because we know it is a truly rewarding area of cancer treatment. That will not change. We have deeply meaningful interactions with our patients, curing many of their cancers, alleviating suffering and extending life. Technology continues to play a large role in the field with novel and groundbreaking synergies between radiation and systemic agents, including immunotherapeutics, and many contemporary research questions are emerging, ripe for exploration and clinical trials. The field is also expanding due to innovations in radiopharmaceuticals and theranostics, offering radiation oncologists exciting new ways in which to help patients. While the future is unpredictable, we unequivocally believe in the continued impact and relevance of our specialty going forward, and perhaps more importantly, have unshakeable faith in the dedicated professionals who have made radiation oncology fundamental in the fight against cancer.
Read previous posts:
A Commitment to the Field - Dr. Theodore DeWeese, March 10, 2020
The Residency Training Landscape, Continued - Dr. Paul Harari, May 28, 2019
The Residency Training Landscape - Dr. Paul Harari, March 20, 2019
Posted: January 5, 2021
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By Colin Whitney, ASTRO Government Relations Specialist
2020 has been a year of unavoidable changes and challenges. ASTRO’s annual Advocacy Day was no exception, as the original April event dates were canceled in early March. But with the release of the RO Model, steep cuts in the 2021 Medicare Physician Fee Schedule (MPFS) and increased prior authorization delays, ASTRO’s Advocacy team knew that the event was now more critical than ever.
Following ASTRO’s successful virtual Annual Meeting, the team decided to move forward with a new, virtual Advocacy Day experience on November 19-20. Virtual Advocacy Day 2020 ultimately consisted of more than 50 ASTRO members and 14 ASTRO staff meeting with 94 congressional offices. In the meetings, ASTRO members were able to share the key issues facing the radiation oncology community going into 2021 and inform Congress on action they can take to protect patients and providers. To gauge the success of this new look for Advocacy Day, we posed some questions to our participants:
Q: What were your key takeaways from this year’s Advocacy Day?
Casey Chollet, MD, chair of ASTRO’s Government Relations Committee, Tennessee Oncology, PLLC, Nashville: I have been attending ASTRO Advocacy Day since 2009 and really appreciate the extraordinary effort ASTRO staff put into making our first virtual Advocacy event a success. One of my big takeaways was that the virtual format allowed for more dedicated discussion time with the congressional staff members. It was a pleasant surprise to have a full 30 minutes to really go into the details of the critical issues facing our specialty and the accompanying congressional asks; plus, there were none of the usual interruptions that come with being in D.C. Given the unique circumstances created by the COVID-19 public health emergency, this was a welcome change from the sometimes rushed in-person meetings.
Krisha Howell, MD, Fox Chase Cancer Center, Philadelphia: My key takeaways were that ASTRO continues to work with our government officials of both parties to further the issues important to our field. It is evident from this event that the ASTRO staff has made alliances and is working hard throughout the calendar year on these concerns.
Q: Why is it important to advocate for the profession?
Anish Butala, MD, resident, University of Pennsylvania, Philadelphia: As physicians, we are not only leaders of our health care teams but are also responsible for promoting the interests of our patients and society. We are privileged to care for cancer patients, which arms us with unique insights surrounding the impact of broad legislative measures on health care policy and daily clinical practice. As such, when negatively impactful legislation is identified, it is our duty to reach out to our congressional leaders to inform them of the issues at hand and advocate for meaningful change. Doing so may not only improve the administrative and financial burdens facing our field but ultimately influence the care received by each of our patients.
Q: What advice would you give to someone who wants to get engaged in advocacy?
Dr. Butala: It can be challenging to know where to begin within this complex landscape. With this in mind, initial steps might include reaching out to a peer or colleague who has engaged in prior advocacy work to obtain their guidance. Participating in the annual Advocacy Day is an additional avenue to broaden your exposure to public policy and expand your professional network. Finally, becoming involved with ASTRO Subcommittees is another important way to gain valuable experience and advocate on our profession’s behalf.
Thomas Eichler, MD, FASTRO, chair of ASTRO, VCU Health Massey Cancer Center, Richmond, Virginia: Advocacy for our patients and our specialty can take many forms, ranging from the face-to-face interactions that occur during Advocacy Day, to sending letters and contacting your state congressional delegation via ASTRO’s Advocacy Action Center. Writing to your senators and representative is a critical and meaningful way to make your voice heard in Washington. The ASTRO Advocacy team is continually updating the center to include new campaigns focused on actions that Congress can take to address the issues of greatest urgency for our community. Participating in these advocacy campaigns takes less than a minute and lets Congress know exactly how they can help to solve the pressing challenges we face.
Social media provides another easy route to jumpstart or amplify your advocacy efforts. Retweeting #ASTROAdvocacy posts and posting directly to your representative and senators is not only easy but is an effective means of keeping our issues on their radar screen.
Thank you to all our members who participated in Advocacy Day! Learn more about the key issues addressed during the congressional visits at www.astro.org/advocacy.
Posted: January 5, 2021
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By Krisha Howell, MD; Shauna Campbell, DO; Jessica Schuster, MD; and ASTRO President Laura Dawson, MD, FASTRO
ASTRO is pleased to announce the launch in the fall of a new community, ASTRO’s Gender Equity, on the ROhub.
As part of the message of the 62nd Annual Meeting, Global Oncology: Radiation Therapy in a Changing World, we realize many of the physical and ideological barriers once separating people in health care and in the workplace — geography, language, culture, time zones — have been diminished in part due to technology.1 ASTRO recognizes, however, that despite these technological advances, there are striking disparities which manifest throughout time and virtual space. At the same time, the COVID-19 pandemic has highlighted structural inequities in health care, with disparities in people marginalized by race, age, socioeconomic status and gender becoming more apparent and inhibiting the collective goals of our field. Among them, diverse challenges exist unique to women in health care and individuals stymied by gender stereotyping. During the pandemic, women and health care workers with caregiving responsibilities are having increasing domestic demands. Already, a widening gender gap in academic productivity during the pandemic is being seen.2
In surveying the future landscape of radiation oncology, ASTRO Chair Thomas Eichler, MD, FASTRO, acknowledged in 2019 that the greatest asset to our field is our members.1 This remains true in 2020. It is through our members that the ASTRO Gender Equity Community seeks to connect, provide resources and offer a platform for women and others interested in gender equity to exchange ideas within the field of radiation oncology.
The Gender Equity Community was conceived with the recognition that a smaller percentage of female medical students are choosing radiation oncology as their preferred career. Additionally, a paucity of radiation oncology leadership positions are currently occupied by women. The objective of the Gender Equity Community on the ROhub is to designate this space as a resource for ASTRO members to safely pose questions, raise concerns and foster support to achieve the above goals. We hope it will also provide an opportunity for networking and mentorship.
Within the first week of its rollout, the forum engaged in discussion about the persistently low matriculation of female medical students selecting radiation oncology and the need to have women in leadership roles to help address this disparity. Female leaders are needed to not only mentor medical students but also to guide other females into leadership roles. Other apt discussion topics opened on the forum at this time include sharing individual stories and improving ASTRO member gender demographic data.
We are thrilled to have this virtual space to provide constructive discussion of these and related issues for a positive contribution to our physicians’ careers and wellness.
We are planning many discussions and will be writing monthly blog posts and posing questions both here on the blog and in the ROhub community.
Join us on the ROhub and answer: How can the ROhub Gender Equity community best work for you as a forum to facilitate discussion, disseminate resources and enable networking?
How to Participate:
The Gender Equity Community welcomes all ASTRO members. To enroll, a member can go to the ROhub on the ASTRO website at rohub.astro.org:
- Sign in at the top right corner button.
- From there, a menu will appear under the header space.
- Second from the left is “Communities.”
- Select “All Communities” to see all communities open to you or in which you are currently enrolled. Communities are organized alphabetically.
- Scroll to “Gender Equity Network/Community.”
- At the far right of the row is a blue button that can be selected to “Join.”
Operational details are as follows:
Enrolled members may post and read the other posts within the community. Prior to posting, the submitted comment will be reviewed by a moderator to ensure our Society’s professionalism is maintained and to confirm that no parties would individually be harmed by anything posted within the community. Submitted comments will be posted within 24 to 48 hours of submission.
1. Eichler TJ. Join us in 2020 for ASTRO’s 62nd Annual Meeting in Miami Beach. ASTRO Daily News. 2019;2;Sept 15-16:16.
2. Andersen JP, Nielsen MW, Simone NL, et al. Covid-19 medical papers have fewer women first authors than expected. ELife. 2020;9:e58807.
This article originally appeared in ASTRO Daily News, a publication of the ASTRO Annual Meeting.
Posted: December 15, 2020
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By Diane Kean, ASTRO Communications Manager
ASTRO Member-in-Training Mutlay Sayan, MD, was recently recognized as a 2020 STAT Wunderkind. Nominated by his mentor, Salma Jabbour, MD, Dr. Sayan was selected among thousands of nominees to join the honored group of “the most impressive doctors and researchers on the cusp of launching their careers, but not yet fully independent.” ASTRO recently sat down with Dr. Sayan and Dr. Jabbour to learn more about Dr. Sayan’s research, their mentorship and what lies ahead.
Dr. Sayan spent the first 11 years of his life on a family farm in a small village in Turkey, having no formal education and not knowing how to read or write. His father’s sudden cancer diagnosis launched the family to a new life in Istanbul, where all members of the family, including Dr. Sayan and siblings, worked in a factory to support their father’s cancer treatments. Persistence drove Dr. Sayan to fight for a position at the local school, where, at the age of 13, he began his formal education. As Dr. Jabbour stated in her nomination letter, “Dr. Sayan’s life and career demonstrate his commitment to taking maximum advantage of the opportunities that have been granted to him.” Fast forward 20 years and Dr. Sayan is now in his last year of residency in radiation oncology at Rutgers Cancer Institute of New Jersey.
“After witnessing my father’s illness and premature death, it became my ambition to treat cancer,” said Dr. Sayan. “It was his treatment that first introduced me to radiation therapy. I was impressed by the opportunity that radiation afforded to personalize treatment for each patient.”
Dr. Sayan earned his BA and MD degrees at the University of Vermont, where he also began his research career. “There’s no greater evidence of Dr. Sayan’s commitment than in his devotion to research,” stated Dr. Jabbour in her nomination. Dr. Sayan has written and completed a clinical trial evaluating predictors of chronic fatigue in patients treated with partial brain radiation; results will emerge later this year after the last set of patient evaluations. Dr. Sayan also helped write and conduct a clinical trial of partial breast irradiation at the University of Vermont, which resulted in two important publications where Dr. Sayan is the first author.
Also, Dr. Sayan has worked with his department chair and 2020 Gold Medal recipient Bruce Haffty, MD, FASTRO, examining the acute cardiotoxicity in HER2-positive breast cancer patients treated with concurrent adjuvant hypofractionated radiation therapy and trastuzumab. The study findings demonstrate that the rate of acute cardiotoxicity in patients receiving concurrent trastuzumab and hypofractionated radiation therapy was low and was similar to the rate observed in patients receiving conventional radiation therapy. This study is important in that it clarified the safety of binding trastuzumab with adjuvant hypofractionated radiation therapy, previously a common concern for patients and oncologists.
Demonstrating his commitment to global health, Dr. Sayan is currently conducting research that examines Syrian refugees’ access to cancer therapy in Turkey. He received a grant from the ARRO-ASTRO Global Health Scholar Program for this project and spent two months in summer 2019 at the border between Turkey and Syria to collect the data.
Looking to future research endeavors, Dr. Sayan said, “While I have substantial experience with retrospective data and large databases, I envision that the next step in my career will be to advance my clinical skills through a variety of new modalities and technologies, as well as to embark on large prospective research and clinical trials. I also plan to continue pursuing research topics that incorporate quality of life outcomes.”
The value of mentorship cannot be underestimated. Dr. Jabbour and Dr. Sayan agreed that they have found the mentor-mentee relationship to provide academic fulfillment as well as friendship. They elaborated on how the mentor’s appreciation for the enthusiasm and potential of the mentee and the mentor’s guidance and support ultimately shape the trajectory of the mentee’s career. With shared goals and collaboration, the mentee benefits by improved productivity, clinical skills, medical knowledge and career preparation, for example, and both individuals benefit from the energy of this special relationship.
The STAT Wunderkinds award is sponsored by STAT News, produced by Boston Globe Media. STAT Wunderkinds are selected as the elite among the next generation of scientific leaders and include postdocs, residents and young scientists who are undertaking groundbreaking work and, as stated by STAT, “will be worth watching in the years to come.” Congratulations to Dr. Sayan! View the 2020 STAT Wunderkinds recipients.
Posted: December 1, 2020
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By Anne Hubbard, Director, Health Policy, and Bryan Hull, Assistant Director, Health Policy
Proposed Medicare payment policies set to start January 1, represent significant financial challenges for radiation oncology practices as they enter the new year, regardless of whether or not your practice is participating in the Radiation Oncology Alternative Payment Model (RO Model). Despite many practices experiencing revenue declines of 20-30% in 2020, the Centers for Medicare and Medicaid Services (CMS) is pushing ahead with massive cuts for radiation oncology and other specialties.
In August 2020, CMS issued the 2021 Medicare Physician Fee Schedule (MPFS) proposed rule effective January 1, 2021. The MPFS proposed rule includes significant cuts that will be implemented broadly across the field of medicine. Subsequently, on September 18, 2020, the Center for Medicare and Medicaid Innovation (CMMI) issued a final rule establishing a Radiation Oncology Alternative Payment Model (RO Model), effective January 1, 2021. The RO Model also includes significant payment cuts due to the payment methodology that involves discounts and withholds.
ASTRO is fighting hard to reverse these pending cuts, which are unwarranted and will potentially lead to serious access to care issues across the country. We have engaged ASTRO’s congressional champions and have contacted the highest levels of leadership within the Department of Health and Human Services to intervene. That said, ASTRO members must be aware of just how dire the consequences are for the field. Below is an overview of what practices can expect in 2021. Be forewarned, the outlook is grim.
Medicare Fee-for-Service Payments
Under fee-for-service payments, which will continue to apply to the professional component payments of those practices not participating in the RO Model, providers are paid according to patient care delivered based on the provisions of the MPFS. The Impact Table below (Table 90 of the 2021 MPFS proposed rule) shows the estimated impact on total allowed charges for radiation oncology based on the relative value unit (RVU) changes contained within the proposed rule.
The expected impact on radiation oncology is a combined reduction of 6% on payment rates for 2021. These reductions are specifically related to modifications of the Evaluation and Management (E/M) codes that create a shift in payments across all specialties resulting in a reduction to the Conversion Factor (CF) of more than 10% to comply with the statutorily mandated budget neutrality requirement.
Table 90: CY 2021 PFS Estimated Impact on Total Allowed Charges by Specialty
||Allowed Charges (mil)
||Impact of Work RVU Changes
||Impact of PE RVU Changes
||Impact of MP RVU Changes
|Radiation Oncology and Radiation Therapy Centers
Upon closer analysis, the budget neutrality adjustment results in even greater variation across radiation oncology services. For instance, CPT code 77014, Computed tomography guidance for placement of radiation therapy fields, is expected to see an 11% reduction in payment under fee-for-service billing in 2021. In addition, CPT code 77301, IMRT plan, including dose-volume histograms for target and critical structure partial tolerance specifications, is expected to see a 7% ($129.76) reimbursement cut for 2021. Of note, CMS proposed RVU increases for several key radiation oncology codes; however, the budget neutrality adjustment largely offset those increases. The table below demonstrates the impact of the CF reduction on key radiation oncology services.
||2020 National Rate
||2021 Estimated National Rate
||CT scan for therapy guide
||Radiation therapy dose plan
||Radiotherapy dose plan IMRT
||Radiation treatment aid(s)
||CT scan for therapy guide
||Radiation therapy planning
||Set radiation therapy field
||Radiation therapy dose plan
||Radiotherapy dose plan IMRT
||Radiation physics consult
||Design MLC device for IMRT
||Radiation tx management x5
||Stereoscopic x-ray guidance
||Radiation treatment delivery
||Radiation treatment delivery
||Radiation tx delivery IMRT
ASTRO is engaged in a comprehensive advocacy campaign to mitigate or postpone the expected cuts for 2021. In collaboration with a broad coalition of physician and non-physician health care provider organizations, ASTRO has urged Congress in a letter to waive the budget neutrality requirement for 2021 in any forthcoming health-related legislative package to provide relief from the reimbursement cuts associated with the MPFS updates. ASTRO’s congressional allies have also been contacted and are aware of the significant impact these cuts have on the profession. In addition to congressional action, ASTRO provided CMS with substantial comments in response to the 2021 MPFS proposed rule addressing how the budget neutrality adjustment poses a significant threat to the profession, which is already suffering significant losses as a result of the COVID-19 public health emergency (PHE). ASTRO urged CMS to use its authority under the PHE to waive the budget neutrality requirement for at least another year, allowing practices time to recuperate from significant losses already suffered in 2020.
RO Model Payment Rates for 2021
For those practices required to participate in the RO Model, it’s bad news as well. ASTRO has documented and is advocating for significant changes to the RO Model payment methodology, which layers a series of deep cuts on participants. But one aspect of the RO Model payment methodology, a “Trend Factor,” is influenced by the MPFS and Hospital Outpatient Prospective Payment System (HOPPS) and deserves greater scrutiny in light of the PFS cuts discussed above.
The Trend Factor serves as an annual update to the payment methodology by reflecting utilization and payment changes outside the Model, i.e., the MPFS and HOPPS. For 2021, the Trend Factor will use 2018 utilization data and 2021 MPFS and HOPPS data to establish an update to the RO Model payment methodology. Due to the anticipated reduction in the 2021 MPFS rates, the Trend Factor is likely to put additional undue financial strain on radiation oncology practices participating in the Model.
Practices participating in the RO Model are already subject to discount factors of 3.75% off the Professional component payment and 4.75% off the Technical component rates, as well as payment withholds for quality measures performance and incorrect payments. These reductions will be compounded by a low or potentially negative Trend Factor. This “double whammy” rate reduction is a disservice to practices that are compelled to participate in the Model, which is particularly disappointing given that the purpose of the RO Model was to establish rate stability over time. By establishing a Trend Factor that fluctuates based on the whims of the MFPS and HOPPS, CMS has effectively eroded the stability that practices thought they might be able to secure under the RO Model.
ASTRO has raised concerns regarding the RO Model’s aggressive implementation timeline and cuts with our congressional champions, as well as those at the highest levels of the Department of Health and Human Services (HHS). We are urgently seeking a delay in the RO Model’s implementation date of January 1, 2021, so that practices have more time to prepare for implementation. This will also allow for additional time to address the flaws in the payment methodology, which, as they currently stand, equate to a series of cuts on radiation oncology services.
As we enter the last quarter of 2020, a year that has been fraught with tragedy, we are bracing ourselves for further struggles in 2021, with serious potential for more financial instability. Whether your practice is in or out of the RO Model, Congress needs to hear your voice about the direct impact of these flawed policies. Go to https://www.astro.org/Advocacy/Become-an-Advocate and join the fight for the future of radiation oncology.
Posted: October 19, 2020
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