By Laura Thevenot, ASTRO Chief Executive Officer
You might have heard some rumors over the past few months that ASTRO is making some changes to our Annual Meeting. You may even have been contacted to give your feedback on the meeting, whether it was to participate in a focus group or take a survey. We’ve taken an in-depth look at our Annual Meeting with a goal of transforming it into an indispensable experience not only for our members, but for anyone involved in cancer treatment.
While the ASTRO Annual Meeting is a successful, well-attended event, we need to evolve to keep pace with newer learning styles and a changing audience. In addition, the pace of change in radiation oncology and cancer treatment overall has greatly accelerated, and we felt it was time to reengineer the Annual Meeting to meet the needs of our audience. Here is a sampling of suggestions we received from attendees:
- Provide more innovative, forward-thinking information, with session formats to match.
- Offer a less packed schedule – with more time to connect with the content and colleagues.
- Allow for opportunities to solve problems collaboratively.
- Provide wrap up sessions with key points for attendees to take back to their practices.
- Present a more comprehensive look at cancer care, incorporating interdisciplinary approaches.
- Make the Exhibit Hall more of an educational hub, with interactive experiences.
What’s new in 2019? Innovate, Collaborate: Transform!
ASTRO 2019 will be the beginning of a three-year transformation of our Annual Meeting. Here are some of the exciting changes we have planned this year:
- An all-new format for the Presidential Symposium, based around the provocative question: “Curing Metastatic Disease with Radiotherapy — Myth or Reality?”, with an Oxford-style debate, followed by facilitated break-out sessions, and the opportunity to continue the discussion on various subtopics in the Innovation Hub with “Table Talks.” We will be asking for your input on this — stay tuned for more information on how to provide feedback, as well as more details on the Symposium coming from our president, Dr. Ted DeWeese, in next week’s blog post.
- A new focus on wellness throughout the meeting, with a special luncheon, more healthy food options available throughout the day, Sunrise Yoga and more free time in the schedule, giving you a chance to relax, reflect and connect with old and new friends.
- An inspirational closing session on Wednesday, “Cancer Breakthroughs: Takeaways from the Major 2019 Oncology Meetings,” that will highlight the big takeaways from the meeting along with an overview of the advances from the past year in multidisciplinary cancer treatment.
What’s on tap for 2020 and beyond?
In the past we have positioned the ASTRO Annual Meeting as “the premier radiation oncology scientific event in the world.” We are still that event, but we have the potential to be so much more. With curated content, a warmer, more inviting environment, a focus on debate, discussion and collaboration, along with the top practice-changing science, we can provide a cohesive and unifying experience for the entire cancer care community. We are working on plans to move the meeting in this new direction over the coming years, and we welcome your feedback and suggestions as these plans take shape.
Radiation oncology is at the intersection of humanity and technology. ASTRO’s Annual Meeting can be the place where the best of the oncology community connects to advance cancer care, improve patient outcomes, and inspire and renew providers.
New Grants Aim to Individualize Radiotherapy by Improving Patient Experiences and Outcomes
By Gita Suneja, MD, MS, ROI Research Committee Chair
The Radiation Oncology Institute is excited to announce new funding awards to four research teams who will be working to personalize radiation therapy for cancer patients. We received a record number of applications, highlighting the strong enthusiasm and ongoing work in this area of radiation oncology research. The following teams were selected for the ROI Personalized Radiation Therapy research awards.
Minimizing Cardiac Toxicity for Lung Cancer Patients Carmen Bergom, MD, PhD, and El-Sayed Ibrahim, PhD, and their team at the Medical College of Wisconsin will conduct a pilot study to determine whether cardiac MRI can be used to detect early, non-symptomatic damage to the heart in lung cancer patients treated with radiation therapy. They will measure associations between delivered cardiac dose and subclinical cardiac damage, as well as test whether biomarkers associated with cardiac dysfunction correlate with the damage to the heart. Eventually, this information could be used to prevent and manage the effects of radiation to the heart by personalizing treatment plans to minimize cardiac toxicity and improve long-term outcomes for lung cancer patients.
Enhancing Patient Experience and Reducing Anxiety Using Virtual and Augmented Reality Platforms David Byun, MD, and his team at New York University School of Medicine will take on a new project that will explore whether the application of virtual and augmented reality platforms during consultation visits could better increase patient knowledge about radiation therapy, reduce anxiety, and improve the quality of their overall treatment experience. Dr. Byun’s CurieUx (Curie User eXperience) mixed reality patient education software is designed to include a novel virtual reality 360° tour of simulation and treatment rooms for patients to explore, as well as interactive virtual disease-specific anatomy models to help physicians personalize their verbal explanation of each patient’s diagnosis and treatment. To measure the efficacy of the intervention, Dr. Byun and his team will conduct a feasibility study, followed by a prospective trial, to determine whether using the CurieUx platform would help reduce patient anxiety and improve their overall treatment experience.
Customizing Patient-Physician Communication Daniel Golden, MD, MHPE, and Ritu Arya, MD, at the University of Chicago are focused on improving communication between patients with cancer and their physicians by developing a personalized discussion guide that explains external beam radiotherapy in an easy-to-digest format. With the grant from the ROI, Dr. Golden, Dr. Arya and their partners at the Institute of Design at the Illinois Institute of Technology will build upon their existing collaboration to create three new guides in the “Communicating the External Beam Radiotherapy Experience” (CEBRE) series that are tailored for patients with breast, lung and prostate cancer. The guides will be written at the sixth-grade level and provide understandable information unique to the patient’s disease site and treatment process in a graphic narrative format. Patients, caregivers, medical and non-medical staff will be involved in the development of the site-specific CEBRE guides to ensure a human-centered design process with key stakeholder input.
Individualizing Radiation Treatments for Pancreatic Cancer Patients Adam Wolfe, MD, PhD, and Terence Williams, MD, PhD, at The Ohio State University have discovered a molecular signature made up of microRNAs that could predict which patients with pancreatic cancer are at high-risk for local-regional recurrence following surgery. One of these microRNAs shows promise to help identify the pancreatic cancer patients who might benefit most from radiation therapy. With the ROI grant, Dr. Wolfe and his team will validate whether the molecular signature can predict for local-regional recurrence in an independent dataset using samples from two other institutions. They will also use cell and mouse models to examine if microRNA-296 increases cell death following radiation. Together, these two aims will improve patient selection for radiotherapeutic management of pancreatic cancer.
The future of the field is bright! We look forward to sharing more about each of these projects with you this month in honor of May being National Cancer Research Month. Be sure to follow us on Twitter, Facebook or LinkedIn to get all of the latest news on these and other research projects in our portfolio.
A look back at the 2018 ASTRO Annual Meeting Presidential Symposium
By: Sanjay Aneja, MD; Michael Dominello, DO; Tim Lautenschlaeger, MD, PhD; Marc Mendonca, PhD; Stephen Shiao, MD, PhD, on behalf of the Promoting Science through Research and Training (PSRT) subcommittee of the ASTRO Science Council
Last October, nearly 11,000 radiation oncologists, residents, physicists, dosimetrists, nurses, industry representatives, other staff and students attended ASTRO’s 60th Annual Meeting. The Presidential Symposium centered around the overall meeting theme of “Translating Discovery to Cure,” with a decidedly forward-looking slate of topics. The Symposium was organized into four sessions, each with a unique theme. With planning well underway for this year’s Annual Meeting and a full slate of exciting research to be presented, we wanted to look back at the 2018 symposium and what the themes raised mean for the field.
Theme 1) Immunotherapy
Dr. Silvia Formenti opened the immunotherapy session with a nod to the past, reminding us that the critical role of the immune system in regulating the response to radiation was recognized more than 40 years ago and that many preclinical models later, we have finally begun to see those primordial seeds bear fruit. She described how early work with anti-CTLA-4 in murine models culminated in a successful human trial of anti-CTLA-4 (ipilimumab) and radiation in non-small cell lung cancer (Formenti et al. Nat Med 2018).
Surgical oncologist Dr. Jennifer Wargo told the incredible success story of immunotherapy in melanoma, particularly anti-PD-1 therapy, all while emphasizing the current challenges of employing immunotherapy including identifying biomarkers of response/toxicity and understanding immunotherapy resistance. Though biomarkers such as PD-L1 expression in tumors, intratumoral immune cell infiltrates and mutational burden have begun to emerge, these remain imperfect and imprecise. However, new biomarkers, namely the gut microbiome, were identified by her group and others as being the next frontier of both biomarker and therapeutic exploration (Gopalakrishan et al. Science 2018). Other therapeutic avenues being explored include combination therapies with immunotherapies, chemotherapy and radiation with toxicity being the key hurdle to overcome.
The final speaker, Dr. Zachary Morris, made the case for the potential of radiation as the perfect partner to immunotherapy. He showed preclinical data that demonstrated the multiple mechanisms by which radiation can interface with the immune system including reducing intratumoral immune suppression and activating inflammatory pathways to produce an anti-tumor immune response. This radiation-induced immune response could be augmented by combining it with immunotherapies, particularly checkpoint blockade (Twyman-St Victor et al. Nature 2015, Morris et al. Cancer Immunol Res 2018). The preclinical data strongly supports the notion that radiation and immunotherapy can synergize, but also highlights questions about how best to combine radiation and immunotherapy.
In sum, the potential for radiation and immunotherapy is vast, but we need to support and promote future studies to answer key issues including site selection, dose, fractionation and timing that will be critical to successfully incorporating radiation into immunotherapy paradigms.
Theme 2: Virally induced cancers
From hepatocellular carcinoma to anal cancer, to Merkel cell carcinoma, it is estimated that less than 10% of human cancers are virally induced. This statistic however does not begin to describe the morbidity and mortality of viral oncogenesis in terms of global impact. For example, cervical cancer represents the fourth most common cancer in women worldwide. Per the World Health Organization, of the estimated more than 270,000 deaths from cervical cancer every year, more than 85% of these occur in less developed regions. While we hope and expect that continued focus on vaccination, screening and decreasing HPV/HIV coinfection will improve these statistics, the current numbers are staggering.
Beyond recognizing this problem and its impact, the following questions were proposed:
- Is it clinically important to confirm a viral association and perform viral typing?
- What is the role of radiotherapy in the management of these disease processes and how is it modulated once there is a known viral association?
- Do we understand and recognize the pitfalls and limitations in our knowledge in this arena?
It was suggested that while in the past we have treated malignancy as a function of location, how might this change when we consider a viral association? For example, should one treat a p16 positive nasopharyngeal cancer like a nasopharyngeal cancer or like any other HPV related head and neck cancer?
To grow as a field, suggestions moving forward included close observation and scrutiny of the data combined with a spirit of open-mindedness, communication and collaboration.
Theme 3: Artificial Intelligence
In addition to being a focus of the presidential symposium, Artificial intelligence (AI) was prominently featured among multiple educational sessions and abstracts within the newly established Digital Health and Informatics tract. Although AI has been an established field since the 1950s, there has been a renewed focus on the applications of AI over the last five years, primarily driven by three factors:
- Increased digitization of healthcare data has provided a wealth of information which can be used to train AI algorithms to perform healthcare tasks.
- Advances in computation have allowed more ease in storing and analyzing large amounts of heterogenous digitized healthcare data.
- Advances in the methods in which we analyze data, specifically in the fields of machine learning and deep learning, have improved the ability of AI solutions to mimic human intelligence.
Dr. Kristy Brock from MD Anderson Cancer Center discussed the differences between AI, machine learning and deep learning, providing a background to AI for those who were unfamiliar. AI is a subfield of computer science which employs any rule-based learning. Machine learning is a sub-field with AI where algorithms attempt to learn from user-defined variables/features. Deep learning is a more nuanced form of AI where algorithms still learn from data, but do not require any user-defined variables and features.
Applications of AI within radiation oncology are already present in auto-segmentation programs, image reconstruction and image classification. We can expect even more AI driven solutions within radiation oncology which will attempt to improve outcome prediction and bottlenecks in practice workflows.
Theme 4: Liquid biopsies and cancer care
Blood-based circulating tumor DNA (ctDNA) testing is routinely used in patients with advanced solid tumors for mutation detection to establish eligibility for certain targeted therapies. Use of these tests can often avoid invasive tissue biopsies and its spatial heterogeneity issues. While the percentage of tumor DNA in the blood of patients with widely metastatic disease is often 10% or greater, tumor DNA is less reliably picked up in the blood of patients with early stage cancers using current detection approaches. However, as introduced by Dr. Park and expertly narrated by Drs. Rosenfeld and Diehn, there are many potential applications for ctDNA testing in patients with non-metastatic disease, including cancer screening, therapy response monitoring and recurrence monitoring.
As assay technology improves, some of these applications are expected to become feasible and ready for clinical evaluation. Efforts by the speakers’ laboratories have demonstrated approaches to create ever more sensitive ctDNA assays that soon might approach the levels of performance potentially useful for early stage patients. For example, exploiting the slight size differences of ctDNA versus other cell-free DNA in blood can significantly enrich for ctDNA, which in turn reduces sequencing cost and allows for deeper analysis.
Research demonstrated that ctDNA based minimal residual disease determination after completion of therapy is highly prognostic in many solid tumors, including nasopharyngeal, non-small cell lung, breast, pancreas and colon cancer. Presented unpublished data suggests that ctDNA assessment during radiation therapy might be of prognostic significance, which could be used for adaptive radiation therapy in the future.
Overall, liquid biopsy technology has great promise and new applications are likely to be developed for patients with non-metastatic disease in the near future, several of which might be of relevance to the radiation oncologist. Prospective studies are needed to establish clinical utility and more research is necessary to further develop technologies for the most challenging applications.
The 2018 ASTRO Annual Meeting Presidential Symposium highlighted areas of rapid change and opportunity for radiation oncology. As we move through 2019, we look forward to assessing the progress and impact of these four areas on daily radiation oncology practice and seeing the latest research presented at ASTRO’s 61st Annual meeting in Chicago.
Stay tuned for a series of blogs featuring the exciting changes coming to the 2019 Annual Meeting and Presidential Symposium!
By Vivek Kavadi, MD
"Honestly, why do you need prior authorization for my cancer treatment? It is not elective!" This comment from one of our radiation patients represents the frustrations of many patients across the country. As vice-chair of the Payer Relations Subcommittee (PRC), I frequently receive complaints from ASTRO members about the negative effects that the prior authorization process has on their practice and their patients. In the recent ASTRO Prior Authorization Survey, an overwhelming majority of respondents reported that their patients experience delays in care. Nearly three quarters of these radiation oncologists also said that their patients regularly express concern over these delays.
I work in a cancer center where the radiation treatment area is in the same location as chemotherapy infusion. This provides for seamless coordination and patient convenience. However, when prior authorization for radiation is delayed, treatment with chemotherapy is also delayed. Combined modality treatment requires a lot of coordination. Radiation is daily and many infusions last several days. We often like to start both treatments on a Monday or Tuesday. Recently, treatment starts have become very unpredictable. It is not a rare circumstance where delays of one to two weeks occur due to prior authorization issues.
This issue remains at the forefront for radiation oncologists and the entire house of medicine, which led to ASTRO signing on to the Consensus Statement on Improving the Prior Authorization Process. The Consensus Statement outlines five areas for improvement for prior authorization programs. One area, the message of Transparency and Communication Regarding Prior Authorization, is extremely resonant in our current environment. Prior authorization requirements and rationale must be easily accessible to providers and patients. Perhaps most important, is the area discussing Continuity of Patient Care that emphasizes that prior authorization should not interrupt appropriate medical services, potentially causing harm and distress to patients.
My experiences are not unique; this issue affects us all. Last fall, more than 500 ASTRO members urged their members of Congress to sign the Roe-Bera Prior Authorization Letter, which called on the Centers for Medicare and Medicaid (CMS) to regulate Medicare Advantage plans’ use of prior authorization and ensure these requirements do not create barriers to care. PRC continues to engage with the American Medical Association and other stakeholders to reform prior authorization practices. ASTRO’s Government Relations team is working with our Hill champions to address prior authorization issues. We frequently provide updates in ASTROgrams and What’s Happening in Washington, so be sure to read those publications.
How has prior authorization impacted the way you practice? Let us know in the comments, or email email@example.com.
By Dave Adler, ASTRO Vice President of Advocacy
Radiation oncologists looking to provide their patients with local transportation services to access their clinics should closely examine a new road map for health care providers.
For rural radiation oncology patients, travelling long distances on a daily basis for weeks can often be a significant road block in completing radiation treatment regimens. Time away from work and the costs of travel quickly add up for these patients, many of whom are lower income. As part of the new ASTRO Rural Radiation Oncology Initiative, some members have asked whether providing transportation services to shuttle patients to their daily treatments constitutes a beneficiary inducement under the Anti-Kickback Statute (AKS).
As background, beneficiary inducement rules prevent providers from offering patients remuneration that they know is likely to influence the selection of a provider. While designed to protect patients and the Medicare program from abusive practices, some policymakers and providers, particularly in rural and underserved areas, expressed concern that the rules lacked street smarts and restricted access where there was a low risk of abuse.
On January 6, 2017, the Department of Health and Human Services Office of Inspector General issued new rules that codified new safe harbors and exceptions to the beneficiary inducement provisions. Thanks to the changes, a local transportation program may provide free transportation to and from health care provider appointments for established patients of a provider. According to Crowell Moring LLP, ASTRO’s outside legal counsel firm, to be protected under the safe harbor, transportation services must follow these rules of the road:
- Free or discounted transportation services may be provided to patients to travel to and from appointments with health care providers or suppliers.
- The availability of free or discounted local transportation services cannot be determined in a manner related to the past or anticipated volume or value of federal health care program business to or from an individual or entity.
- The transportation services made available cannot consist of air, luxury or ambulance transportation.
- A transportation program or the availability of transportation services cannot be publicly marketed.
- Marketing includes posting signage in public areas, including waiting rooms or lobbies of provider locations, posting online or otherwise communicating en masse the existence a transportation program or available transportation services.
- To ensure no public marketing, the availability of free or discounted transportation services should be discussed with a patient only based on a reasonable belief that the individual patient both: (1) is currently a patient of the affiliated provider, and (2) needs free or discounted transportation services to be able to keep his appointments.
- Transportation services may be made available only to established patients of the health care provider location to which they require transportation. A patient is considered “established” after he or she selects and initiates contact with a provider to schedule an appointment.
- The entity making arrangements for the transportation must also be the entity bearing the costs of the services. The cost burden cannot be shifted to a federal health care program.
- Services must be offered to patients only for the purpose of obtaining medically necessary items and services.
- A slightly less extensive set of requirements apply to a “shuttle service” that runs along a pre-established route.
- Transportation services can only be available for distances up to 25 miles in urban areas and 50 miles in rural areas.
While the rules could put some radiation oncology clinics on easy street to provide transportation services to patients, there is concern that the 50-mile restriction for rural areas will stop traffic. We’re interested in hearing from members on these issues, including:
- Are these rules right up your alley and allow your practice to provide enhanced transportation services?
- Is the 50-mile restriction a dead end for reaching patients in rural areas?
- Have you identified any innovative approaches that are the ticket to ride for providing transportation services to patients in rural areas?
Enter your response in the comment section below, we look forward to your feedback.
Before putting the pedal to the metal to offer local transportation, ASTRO members should avoid blind alleys by consulting their practice’s legal counsel to ensure compliance with the new rules and other relevant regulations.