Building a radiation center

[md_hopeful21]

I'm a bit of a novice but I was wondering if anyone here has ever considered building a radiation therapy center. Is this even an achievable endeavor?

Thanks for your thoughts.

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[medgator]

I'm a bit of a novice but I was wondering if anyone here has ever considered building a radiation therapy center. Is this even an achievable endeavor?

Thanks for your thoughts.

Yes it is.

Lots of practitioners/groups have done it over the years. There are corporations now that specialize in acquiring and building centers as a joint venture with physicians.

 

[mpdoc2]

Do you know the names of these corporations?

 

[medgator]

Do you know the names of these corporations?

There are several. Here are some examples

http://www.vantageoncology.com/
http://www.oncure.com/partner_with_oncure.php
http://www.21stcenturyoncology.com/about/about-introduction.aspx

 

[Gfunk6]

Also, Ion (website: http://www.ion-llc.com/index.html)

 

[md_hopeful21]

Thanks guys, I didn't know these guys exist.

Kind of a dream of mine to one day build my own center....

 

[medgator]

A couple more that come to mind...

http://www.usoncology.com/network/AboutUs
http://www.rosaoncology.com/

 

[deleted4401]

Basics: if you are solo need 1 million up front, borrow 4 million. You'll do fine of you have about 15 patients on treatment. Big risk, big reward. People still do the solo thing - there is a gal in the DC area that has two and she competes with the big boys, and well. It's a business I'd never get into. Too many ethical considerations...

 

[medgator]

You'll do fine of you have about 15 patients on treatment.

Seems a bit high, no? I think it depends on what linac you get and support staff etc. I've seen the break-even lower than that

 

[Seldon1985]

How difficult is it to get to the break even on treat number? Obv would depend on location, competition, ability to get referrals, etc. Would this be more feasible in a midwest location in an area of lower competition than, say, DC? How does this process change with CON states vs non-CON states?

 

[medgator]

How difficult is it to get to the break even on treat number? Obv would depend on location, competition, ability to get referrals, etc. Would this be more feasible in a midwest location in an area of lower competition than, say, DC? How does this process change with CON states vs non-CON states?

CON would obviously be easier, but then again, that would also restrict the number of new centers that are able to be built. Also, I'm not sure on this, but I think that for many states, the CON only applies to hospitals, and it doesn't affect the development of free-standing, independent centers.

 

[Gfunk6]

It really depends on where you are opening your center. You will maximize your chances of success by building it in an underserved area.

Having recently been in the loop for a proposed Radiation Oncology center which failed in procuring the capital costs, I can offer the following observations:

1. You have to assume that most of your patients will be treated with IMRT with daily IGRT to maximize reimbursement. Palliation and 3D plans ain't gonna cut it.
2. There are ALWAYS proposed reimbursement cuts floating around and any reasonable investor should assume that such cuts will come to pass in making their financial projections.
3. Unless you are opening a center in the middle of nowhere, you will probably need to purchase a state of the art Linac (TrueBeam, Synergy S) and these things ain't cheap. If you have no competition, you can save big bucks by buying a second hand machine.

Just like fewer and fewer people are going into true private practice Rad Onc (partnership-track, practice owns the machine and facilities), there are a vanishingly small number of Rad Oncs who have the business sense, patience, risk tolerance and cajones to actually open their own centers. Nowadays, most new centers are opened by hospital who either hire physicians as employees or have a contract with them to provide the professional component.

In residency, I would joke with my colleagues that we would all move to the middle of nowhere, purchase an ancient Linac (one step up from Cobalt really) and just treat mets. I would call it "Gfunk's house of Mets."

 

[deleted4401]

Break even closer to about 12-13, according to a presentation I went to. I was just using a better sounding number.

Problem is, no matter what, you end up facing pressures to do things you might not typically do if you didn't own the shop. From treating a bone met to 40 Gy/20 fx to using CBCT on cases that don't really need it to IMRT for palliative cases. It's not that you're a bad person for doing it. It's just natural behavior. And it's obvious that this happens, because when you train in residency at an academic center where people are typically salaried, they do much more 3D and hypofractionation. In the community, that isn't quite the case.

I think it's feasible to do it still, but things could change in a heartbeat and I'd be too risk averse to try it.

S

 

[medgator]

but things could change in a heartbeat and I'd be too risk averse to try it.

Agree with this (unless I was in a decent-sized area in the middle of nowhere)

 

[Palex80]

From treating a bone met to 40 Gy/20 fx to using CBCT on cases that don't really need it to IMRT for palliative cases. It's not that you're a bad person for doing it. It's just natural behavior. And it's obvious that this happens, because when you train in residency at an academic center where people are typically salaried, they do much more 3D and hypofractionation. In the community, that isn't quite the case.

I 'd like to make a point here regarding IMRT for palliative cases.

IMRT for palliative cases has often been critisized by many, with the argument "why avoid normal tissue late toxicity and keep the patient longer on the table, if you can do it with 3D (or even 2D)?"

Many of us forget, that IMRT can indeed limit acute toxicity in numerous cases. For example when you are treating pelvic bone metastasis and have to treat over the iliosacral joint into the ilium conformal 3D-techniques often result into the 90-95% isodose encompassing large volumes of small bowel. This can often be avoided by the use of IMRT and can limit acute symptoms during and shortly after treatment for the patient.
The palliative patients are the most fragile patients we are treating. They may not live long enough to experience late effects of our treatment, but if you can spare them from excessive acute toxicity with IMRT during the last weeks and months of their lives, then we should do it.

Furthermore, with rotational sliding window IMRT the on-table-time has significantly decreased (and with TrueBeam even more), thus keeping the palliative patient on table for a longer time than with conformal 3D is not even a valid argument any longer.

 

[medgator]

I 'd like to make a point here regarding IMRT for palliative cases.

IMRT for palliative cases has often been critisized by many, with the argument "why avoid normal tissue late toxicity and keep the patient longer on the table, if you can do it with 3D (or even 2D)?"

Many of us forget, that IMRT can indeed limit acute toxicity in numerous cases. For example when you are treating pelvic bone metastasis and have to treat over the iliosacral joint into the ilium conformal 3D-techniques often result into the 90-95% isodose encompassing large volumes of small bowel. This can often be avoided by the use of IMRT and can limit acute symptoms during and shortly after treatment for the patient.
The palliative patients are the most fragile patients we are treating. They may not live long enough to experience late effects of our treatment, but if you can spare them from excessive acute toxicity with IMRT during the last weeks and months of their lives, then we should do it.

Furthermore, with rotational sliding window IMRT the on-table-time has significantly decreased (and with TrueBeam even more), thus keeping the palliative patient on table for a longer time than with conformal 3D is not even a valid argument any longer.

Where you practice, is IMRT reimbursed significantly higher than 3DCRT/2D? That's the crux of the controversy for IMRT in borderline situations. I have a feeling that if and when IMRT reimbursement reaches the level of 3DCRT reimbursement in the US, many of these controversies will get the volume turned down (similar to the protons vs photons debate).

Also, as you alluded to, table time for IMRT can be much longer for multiple fields. In a palliative situation where a patient has significant pain or dyspnea (in a lung case), are you really buying that much of a benefit via IMRT?

 

[deleted4401]

At 20 Gy/5 Fx treating large volume mets in lumbosacral and iliac regions I have never seen significant toxicity. A loose BM? Well, they are on opiates and probably welcome it. It's way below tolerance for late toxicity, and I can't fathom doing it. Agree to disagree...

 

[medgator]

At 20 Gy/5 Fx treating large volume mets in lumbosacral and iliac regions I have never seen significant toxicity. A loose BM? Well, they are on opiates and probably welcome it. It's way below tolerance for late toxicity, and I can't fathom doing it. Agree to disagree...

I feel the same.

 

[seper]

So you feel that IMRT for pelvic bone mets decreases small bowel dose and that leads to improved toxicity profile. This has never been proven and unlikely to ever be. Even if your logic is correct, how many hemipelvises need to be treated with IMRT to spare one case of grade 2 diarrhea?
Also, pelvic IMRT routinely results in higher Dmax on the bowel and higher bowel volume receiving low dose (5-10 Gy). Do you have any concerns about that?

I 'd like to make a point here regarding IMRT for palliative cases.

IMRT for palliative cases has often been critisized by many, with the argument "why avoid normal tissue late toxicity and keep the patient longer on the table, if you can do it with 3D (or even 2D)?"

Many of us forget, that IMRT can indeed limit acute toxicity in numerous cases. For example when you are treating pelvic bone metastasis and have to treat over the iliosacral joint into the ilium conformal 3D-techniques often result into the 90-95% isodose encompassing large volumes of small bowel. This can often be avoided by the use of IMRT and can limit acute symptoms during and shortly after treatment for the patient.
The palliative patients are the most fragile patients we are treating. They may not live long enough to experience late effects of our treatment, but if you can spare them from excessive acute toxicity with IMRT during the last weeks and months of their lives, then we should do it.

Furthermore, with rotational sliding window IMRT the on-table-time has significantly decreased (and with TrueBeam even more), thus keeping the palliative patient on table for a longer time than with conformal 3D is not even a valid argument any longer.

 

[Palex80]

Where you practice, is IMRT reimbursed significantly higher than 3DCRT/2D? That's the crux of the controversy for IMRT in borderline situations. I have a feeling that if and when IMRT reimbursement reaches the level of 3DCRT reimbursement in the US, many of these controversies will get the volume turned down (similar to the protons vs photons debate).

We get paid a bit more for IMRT, but it's only about 10-15% more, than we would get for 3D-RT. This 10-15% are "spent" on quality assurance, plan confirmation and longer time on the table (we don't have sliding window IMRT on all our LINACs yet).

Also, as you alluded to, table time for IMRT can be much longer for multiple fields. In a palliative situation where a patient has significant pain or dyspnea (in a lung case), are you really buying that much of a benefit via IMRT?

Like I said, sliding window IMRT (RapidArc or VMAT) can be significantly faster than step-and-shoot IMRT. In fact, a slidiwn-window-IMRT can sometimes be even faster than a complicated 6 field plan for extensive palliative pelvic irradiation.

At 20 Gy/5 Fx treating large volume mets in lumbosacral and iliac regions I have never seen significant toxicity. A loose BM? Well, they are on opiates and probably welcome it. It's way below tolerance for late toxicity, and I can't fathom doing it. Agree to disagree...

We generally use 30/10 or 35/14 and I've seen nausea and diarrhea in quite a lot of patients being treated with 3D-CRT if the bowel volume get's large.
Surely 3D-CRT is vastly superior to some horrible ap/pa irradiations I've seen on films from a couple of myeloma patients from the 80s and early 90s, that came back years later for retreatment, but still: If you can do it better, why not?

 

[Palex80]

So you feel that IMRT for pelvic bone mets decreases small bowel dose and that leads to improved toxicity profile. This has never been proven and unlikely to ever be. Even if your logic is correct, how many hemipelvises need to be treated with IMRT to spare one case of grade 2 diarrhea?
Also, pelvic IMRT routinely results in higher Dmax on the bowel and higher bowel volume receiving low dose (5-10 Gy). Do you have any concerns about that?

Proving such a point is difficult and would demand a trial, a trial which probably no one would do anyway.

I picked a random image of a pelvis from the internet and drew a red PTV (just say that this patient has prostate cancer with bone mets). I attached the image below.

Now try to picture what the resulting dose distribution with a 3D-plan would be and how it may turn out to be with IMRT. What would you choose, if it was your pelvis (or the one of your dad) being treated? I would take IMRT.

That's just my opinion though.
Perhaps someone has the time to actually show a plan comparison.

 

[TarHeelRadOnc]

If breast or prostate, that volume may be best treated with radioimmunotherapy... although agree with previous posters that 30Gy/10fx using 3D planning would still be reasonably well tolerated.

 

[medgator]

Proving such a point is difficult and would demand a trial, a trial which probably no one would do anyway.

I picked a random image of a pelvis from the internet and drew a red PTV (just say that this patient has prostate cancer with bone mets). I attached the image below.

Now try to picture what the resulting dose distribution with a 3D-plan would be and how it may turn out to be with IMRT. What would you choose, if it was your pelvis (or the one of your dad) being treated? I would take IMRT.

That's just my opinion though.
Perhaps someone has the time to actually show a plan comparison.

If breast or prostate, that volume may be best treated with radioimmunotherapy... although agree with previous posters that 30Gy/10fx using 3D planning would still be reasonably well tolerated.

Yup. Obliques would keep much of the dose off the bowel.

 

[seper]

You know, I am not sure if I would ever choose IMRT based on this image. 3D plan using 3 wedged fields, opposed obliques being heavily weighted, should look very nice.

Proving such a point is difficult and would demand a trial, a trial which probably no one would do anyway.

I picked a random image of a pelvis from the internet and drew a red PTV (just say that this patient has prostate cancer with bone mets). I attached the image below.

Now try to picture what the resulting dose distribution with a 3D-plan would be and how it may turn out to be with IMRT. What would you choose, if it was your pelvis (or the one of your dad) being treated? I would take IMRT.

That's just my opinion though.
Perhaps someone has the time to actually show a plan comparison.

 

[Palex80]

You know, I am not sure if I would ever choose IMRT based on this image. 3D plan using 3 wedged fields, opposed obliques being heavily weighted, should look very nice.

So, I am home and only got Microsoft Paint here, but you are proposing something like this, I presume (see attachment)?
2 opposite fields (green) heavily weighted with wedges and a third field (blue) coming in from something like 320°, right?
If you want to have a decent coverage of the PTV, you are going to end up with the 85-90% isodose in the yellow marked area, which is small bowel.
This is the area, where IMRT can perform better in my opinion, that's all I am saying.

 

[deleted4401]

Right- dosimetrically it's better. I don't disagree, and I don't think most people would. As far as clinically, for one, there is no good evidence; for two, I don't imagine you can lower the toxicity more in a statistically significant fashion, when it is so low to begin with.

In a world where money/resources/time are unlimited, I'm with you - a dosimetric advantage is enough for me to choose IMRT. In the real world, I think it's a misallocation of resources.

 

[Gfunk6]

In a world where money/resources/time are unlimited

Or in a world where we get case-based reimbursement . . .

 

[deleted4401]

Well, with case-based, the physician does the cheapest thing, because she/he gets to keep the rest? I.e., if you get $2500 for a bone met, why do 30 Gy in 10 Fx, when you can do a one a done? That's why with Kaiser, I have no qualms doing Canadian fx for breast cancer.

 

[Palex80]

Well, with case-based, the physician does the cheapest thing, because she/he gets to keep the rest? I.e., if you get $2500 for a bone met, why do 30 Gy in 10 Fx, when you can do a one a done? That's why with Kaiser, I have no qualms doing Canadian fx for breast cancer.

Perhaps a stupid question:
Why is IMRT standard in prostate RT in the US and pretty much everybody does it?


In Europe 3D-CRT for prostate cancer is still standard in many clinics, as long as you don't treat the lymphatics.

 

[medgator]

Perhaps a stupid question:
Why is IMRT standard in prostate RT in the US and pretty much everybody does it?


In Europe 3D-CRT for prostate cancer is still standard in many clinics, as long as you don't treat the lymphatics.

Single-institution studies that show better a rectal toxicity profile than 3DCRT. But anecdotally, I have heard that a good 6-field 3D plan can do a pretty good job. I think H&N is really the most solid place for IMRT (and CNS/GI to a lesser degree).

 

[Gfunk6]

Well, with case-based, the physician does the cheapest thing, because she/he gets to keep the rest?.

SimulD, have you become a cynic??

Even as Radiation Oncologists, we sometimes do the right thing even if it won't make us as much money.

 

[deleted4401]

Sorry - I mean "cost-effective" not cheap, ha ha.