Clinical Value of Prostate/Pelvic Radiation Therapy and All Body Sites

My name is Guy Jones. I’m a radiation oncologist and medical director for Oncology Nevada in Reno. I also have some clinics in several other states, including elsewhere in Nevada, in Las Vegas. It would seem like a different state, but it’s not, and Washington State, Alaska, et cetera. I want to talk about the clinical value of SGRT’s use in radiation therapy across all body sites. We are heavily pelvic, prostate specifically, but we treat all kinds of cancers and benign conditions in our clinics, and so this is used across the spectrum.

A little bit about Oncology Nevada: we are a freestanding physician-owned clinic in Reno. We have a very high-volume center where we treat anywhere between mid-60s to mid-80s on a single Varian TrueBeam, and about 70% of our cases are prostate. We have block times, they vary, but around 10 minutes. The way I got originally interested in Vision RT was when I was practicing in Washington State in the eastern side of the state. Anybody know the Tri-Cities? That’s where I’m from, that’s where I grew up, and that was my first job when I came out of training, and I was really interested in doing treatments for trigeminal neuralgia, like stereotactic ablation procedures. We had a Varian Edge at the time, and we could use a virtual cone to treat, in theory, but really it hadn’t been justified to treat trigems using a non-invasive system and with just surface guidance. So I started that program in the Tri-Cities about maybe eight years ago and treated about 100 trigems over a couple of years there. So I was really kind of surprised how much volume we had. And then we wrote up our paper for a stereotactic conference, and we were giving 90 gray in a single shot to that nerve root of the trigeminal nerve just right next to the brain stem using SGRT. And it worked. We had really essentially no toxicity and good outcomes comparable to anything else out there, CyberKnife, Gamma Knife, et cetera. So it got me really interested and confident in the technology, and so when I came to Reno, I not only deployed this at our site in Reno, but also across our other centers that I either own or am affiliated with.

There’s a lot of benefits to SGRT, and I’ll go through them in no particular order. But I’d say one of the big ones is just being able to get away from tattoos and having just markerless treatments. So it seemed like a small thing. Actually, patients do value it a lot more than you would think they do. And there’s a lot of reasons for that. There’s psychological reasons, et cetera, but it is also more accurate to not line up just on small little points, but to do it over a stretch of the body. And that’s essentially what SGRT allows you to do, specifically the Vision RT system.

So what we have found—well, not just us, but in the papers—they’ve shown that it reduces the shifts that are done. It also reduces the treatment time, and it reduces the amount of additional imaging you have to do. So, when you do your initial IGRT, you do the setup, you just don’t have to reshoot the images that often. In fact, it’s about a two-thirds decrease in the amount of re-imaging you have to do, which is something we always document, and it isn’t considered necessarily a medical event, but it’s something we keep track of, and it is important to reduce patient radiation exposure. It’s just that general ALARA principle we all talk about.

I love the way the interface is on this. And one thing I want to just back up a little bit and say is that our center, you can imagine, if we’re treating 60 to 80 patients a day on a single machine, and our manager, supervisor, therapist is in the room, the first thing they brought to me and asked, and the first thing I asked this company was, “Can we ensure that this is not going to increase our treatment times? Because we cannot reduce throughput.” You add a minute a day, you’re there for another hour and a half. You can’t do it. So it needs to be at least neutral, if not a time savings. And we put it in, and we’ve seen exactly that, which is exciting, and that’s been true across our centers. One of the things I found kind of interesting is that they removed SGRT as a reimbursable part of SBRT treatment, and yet when I gave the option to my therapist saying, “Well, we’re not going to get paid for this, so you don’t necessarily have to do it for SBRT,” they said, “No, we’re going to keep using it because we like it and it helps us set up better.” So it was kind of proof of principle. At first, it was like having to pull teeth to get them to do it, and then once they started doing it, it was like, hey, I can’t really take it away from them. So I think that shows a lot.

So a couple of different things. You guys all know this. This is maybe not the best audience for these messages, but this is for intrafraction motion management as opposed to interfraction motion management. This isn’t setup. And that needs to be clearly documented in your medical necessity so that we’re not talking about just another IGRT. If it worked the same as IGRT, you’d just use IGRT, or you’d just use this, one or the other. But it’s two different things. One is what you’re setting up to initially, and then after that you’re going to… Are you guys hearing feedback, by the way? This is throwing me off a little bit.

Yeah. All right. I don’t really know what to do about that. Maybe step back a little bit or move up. That’s better, isn’t it? Sorry. You want me to start over? So, this is actually relevant across disease sites. So not only do we have it for prostate and pelvic… I’m still getting the feedback. Is everybody still… There’s something wrong with the electrical in this room. All right. Is it tolerable? Can we just go on with it? Okay. All right. I’ll just do that. So again, we treat a ton of prostate, we treat a ton of pelvic aside from that. We’re treating pelvic lymph nodes, and then especially for abdominal targets, frankly, I would not be comfortable without some strict motion management if I was treating SBRT pancreas. I need that for something like that. So, there are certain things where it’s just an absolute must, and it’s most important, ironically, for SBRT, which is where this code got pulled out as a separate billing code. Which is counterintuitive, but why does CMS do half what it does?

One thing to keep in mind is that we’re not—and a lot of people have talked about this—it’s like a thin line between, okay, we’re not really monitoring the tumor, we’re monitoring the surface of the body. Those are two different things. Well, it is and it isn’t. It’s a surrogate. It’s no different than when we used to set up just on the skin and then maybe had some crude imaging, old MV films, for instance, and you couldn’t see hardly anything, and you’re kind of hallucinating it. But you’re still tracking. You’re setting it up based on external anatomy. So, it’s essentially the idea that external anatomy does correlate with internal anatomy, which is common sense, but at the same time, it’s something that’s been brought up as maybe two distinct things. They are essentially one and the same. When you monitor the body, you are using that as a surrogate for the internal anatomy, and that’s the reason this works. Along with tattoo-less delivery, the reduction in the treatment times, fewer shifts, less repeat cone beams, things like that.

So again, it’s not just for positioning, it’s continuous intrafraction motion that is really what makes this important and makes you be able to give a clinical case for the billing case, which unfortunately is a reality that we all face. Again, sub-millimeter accuracy. We have reduced setup errors and less re-imaging, real-time motion tracking without immobilization, faster setup, and then the tattoo-less options. And all these things have been clinically documented. These are all peer-reviewed PubMed articles that are in my clinical justification document that I put in for every patient that we’re doing SGRT on.

The final rule that came out—well, it’s not a rule anymore. I guess this is an older slide. It is the final rule, but it’s now the current rule. This 77412, as many times as we can capture that, the better. Obviously, we all took a hit this year. This was a big mess. It’s still a big mess, and we’re sorting it out. But I would say that it definitely, in terms of Medicare CMS, that very much the SGRT fits what the spirit of this idea of why we should be able to justify 77412. But we found even most of the commercial payers, aside from a couple of problem children, the normal ones, United and Blue Cross, they are paying it. And I think we’re capturing over 90% 412 in a couple of our markets, but not all of them. So your market may vary.

The key to reimbursement on this, though, is to have any chance of it and frankly, to reduce the chance of an audit or anything like that, is you do need the clear documentation of SGRT use. And then you also need the justification through a letter of medical necessity that we upload, and that’s how we’ve been doing it for several years now. I should say, we’ve had Vision RT for maybe three years or so now. So it’s been a while, and we’re really glad we did it back then because we could get paid for it. Now, we’re just glad we have it so we’re not reduced in our current reimbursement because we’re getting so much 412.

So the things I put in my letter of medical necessity, my documentation of medical necessity, are that it’s utilized again for intrafraction motion. So again, to separate it from IGRT, that surface tracking is being used as a surrogate for internal target positioning. And I do say things like, if somebody coughs, fidgets, or any otherwise adjusts, these are things that you want to just have that in there spelled out as some reasons we would want to use this. That there is beam held. The automatically part, that’s going to be interesting whether there’s any clarification on whether it has to be automatically held or whether you can just set a tolerance and watch it. Right now, it doesn’t seem to matter, and based on some discussions with some of the higher-ups in ASTRO leadership, they didn’t think that it necessarily needed to be automatically integrated. And so except for one of our sites, we haven’t really been doing that. But just something to say, “Hey, the tolerance should be X amount.” Document that in your letter and in the simulation setup note, and then you should be good to go. And then you want to say that it’s required to maintain treatment accuracy and reduce the dose to OARs. That’s the whole point to this, is that you’re hitting the right spots and not hitting the things that don’t need to be hit. And then it allows reduction of PTV margin along that same idea.

For daily treatment documentation, this one’s nice because it’s essentially been done for us. Vision RT has an integration with ARIA, and it shows up in your offline review checks. So same place the IGRT images are popping up, there’s a form that’s automatically showing that we used SGRT that day. So it’s just one extra click of a button for each patient every day. It takes no time at all. So this was nice in that before the therapists were having to upload each individual one, fill out a form for each individual one, now it’s all just done automatically. So if you do get this system, I highly recommend you get the ARIA integration. And I don’t know if it’s available for the other—Is it like Mosaic too and others? I don’t even know. But it is? Okay, I’m getting a nod, so I think it is available for the others.

So the billing pitfalls, the things you absolutely need to make sure are not in your documentation are that you aren’t using the SGRT just for setup. In fact, we say not just for setup, using for intrafraction motion. Make sure that sentence is in there. You want to say that you’re beam-on monitoring. Again, a lot of that’s done for us through the ARIA integration, but it’s still just make sure it’s in your letter of medical necessity. You want to say some defined tolerances. Everybody’s going to say something different. You want to have, again, the statement of medical necessity uploaded alongside your clinical treatment plan and then, again, have it in ARIA somewhere permanently in case you ever get come back and get audited.

So again, the ARIA integration we talked about has made this really, really easy. You can see it’s just right up in the offline review on the bottom. It’s just one extra thing. Instead of an image, it pops up a document, just sign it. And this records all those things we were just talking about that need to be recorded.

Couple of things when you first integrate it, and like I said I did, whenever I bring something forward, and the therapists are really busy at our center. Most centers I know of, they’re really busy, and so these are things you’re going to have to… What we did is we just kind of found a champion therapist amongst the group and just said, “Hey, are you interested in this technology?” And she said, “Yeah, this sounds great.” And we just said, “Will you help us roll this out?” And she became kind of like a lead of this technology, and she’s been to a couple of the conferences and had a great time. But this is going to require some buy-in from the therapists, and you have to just let them know at first this is going to be a little frustrating, but then pretty quickly you’re going to get used to it. And I will offer our sites if there is any of your therapists that want to come take a look at how this is used in a high-volume center. I know Laura’s happy to have them at Reno. We’re happy to have them down in Vegas or any of our other sites if that would be something that would be helpful. Just let me know.

So the system QA does require some calibration. There’s some initial setup learning curve as there is with any technology. And then you need to make sure that integration and the ARIA documentation is going through, so there’s just an extra paperwork step that they need to at least make sure is in there. Fortunately, they don’t have to upload it manually like they used to. But again, it’s decreased treatment times across our center, which ultimately is something that they’ve valued, being able to get out a little bit earlier than before. And also we know we’re doing a little bit better for the patients as well.

So in conclusion, this is an active motion management system. It’s clinically validated, widely adopted, a lot of PubMed studies on it. Not just this technology, but a lot, but they’re all pretty similar. Supports precision, safety, and efficiency. Over 300 studies growing adoption. It used to be, I forget what, I think it was first used in the brain, and then over the next five or 10 years, it’s been now considered medically necessary for all body sites, including pelvis, and that’s in the peer-reviewed literature. And it gives us not only time savings but supply savings, staff savings, and then allows us to increase our throughput and provide a better quality of life for our patients and our staff. So really happy. I think this has been a big success story for our clinics.

 

 

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