ACRO is offering a complimentary webinar on LDR prostate brachytherapy technique"

[ACRO]

November 14, 2017
4:30PM-5:30PM CT (5:30PM-6:30PM ET)

Dr. Steven Frank, professor of radiation oncology at University of Texas MD Anderson Cancer Center, will focus on the technique of LDR brachytherapy. He will discuss changes in the technique including the increasing use of MRI for treatment planning. This webinar is the first part of a two part series on prostate brachytherapy. After the webinar, there will be a live question and answer session.

To register for this free webinar, visit our website acro,org, go to residents, webinars, and click the registration link in the webinar listing.

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[seper]

With changing reimbursement model, this procedure is IMHO on it's way out.

 

[Haybrant]

for those in hospital based practice if your practice doesn't offer it what do you do, refer out?

 

[Chartreuse Wombat]

With changing reimbursement model, this procedure is IMHO on it's way out.

Wait, what? LDR is most cost-effective treatment.

Utilizing time-driven activity-based costing to understand the short- and long-term costs of treating localized, low-risk prostate cancer. - PubMed - NCBI

Time-driven activity-based costing of low-dose-rate and high-dose-rate brachytherapy for low-risk prostate cancer. - PubMed - NCBI

What model are you talking about?

 

[medgator]

Wait, what? LDR is most cost-effective treatment.

Utilizing time-driven activity-based costing to understand the short- and long-term costs of treating localized, low-risk prostate cancer. - PubMed - NCBI

Time-driven activity-based costing of low-dose-rate and high-dose-rate brachytherapy for low-risk prostate cancer. - PubMed - NCBI

What model are you talking about?

I'm guessing he's referring to bundled/case-based reimbursement.

I think with LDR, you'll have to buy seeds/strands for every case vs HDR where you can use the machine/source multiple times and have better planning/modulation imo.

That being said, I know LDR guys are pretty hardcore about that modality and even point out that the ASCENDE trial was ldr etc

 

[evilbooyaa]

With changing reimbursement model, this procedure is IMHO on it's way out.

????

Based off ASCENDE-RT, this should be increasing in use. Of course it won't due to lack of experience and comfort with brachytherapy procedures, but that's what should happen.

 

[medgator]

????

Based off ASCENDE-RT, this should be increasing in use. Of course it won't due to lack of experience and comfort with brachytherapy procedures, but that's what should happen.

I'm guessing he's referring to HDR increasing in use. Prob more sbrt as well

Sent from my SAMSUNG-SM-N910A using SDN mobile

 

[seper]

yep, LDR vs HDR stands really poorly because someone must pick up 5K charge for seeds.

 

[Chartreuse Wombat]

yep, LDR vs HDR stands really poorly because someone must pick up 5K charge for seeds.

Um...did you read the papers? LDR has less charges/costs than HDR...HDR takes longer and OR time ain't cheap (of course maybe that is a feature not a bug)

 

[evilbooyaa]

yep, LDR vs HDR stands really poorly because someone must pick up 5K charge for seeds.

Oh, fair enough. I thought you were insinuating that brachytherapy usage in general would be decreasing. I think HDR chosen instead of LDR is not unreasonable for wider acceptance, as if you screw up HDR it's not the end of the world.

 

[medgator]

Um...did you read the papers? LDR has less charges/costs than HDR...HDR takes longer and OR time ain't cheap (of course maybe that is a feature not a bug)

Unless we are talking about an ASC (Ambulatory Surgery Center).... plus isn't there a move to "brachytherapy suites" in some of the larger hospital-based programs where anesthesia can be given?

 

[Haybrant]

So Ascende RT shows significant PSA PFS benefit in intermediate and high risk patients but a randomized trial presented at ASTRO in intermediate risk patients showed no benefit to brachy boost? Also, is brachy not just ridiculously complicated compared to IMRT. Is it wrong for me to have no interest in doing this particularly without MRI at every step of the way

 

[Chartreuse Wombat]

So Ascende RT shows significant PSA PFS benefit in intermediate and high risk patients but a randomized trial presented at ASTRO in intermediate risk patients showed no benefit to brachy boost? Also, is brachy not just ridiculously complicated compared to IMRT. Is it wrong for me to have no interest in doing this particularly without MRI at every step of the way

I think the RCT that you are referring to compared brachy alone to brachy plus external beam (RTOG 0232). No difference in efficacy but more toxicity with combo. The excess toxicity of combo is a real problem and one observed in the ASCENDE-RT trial. The brachy enthusiasts tend to neglect that part.
IMHO LDR brachy does not require MRI; the Seattle results hold up quite well and their method was not ridiculously complicated.

It is not wrong for you to have no interest but I am curious whether you discuss this option with your patients, namely LDR brachy. It might be wrong if you didn't bring up as an option and refuse to refer to someone that offers it.

 

[nkmiami]

The Ascende trial included pelvic xrt and hormones, and obviously included more "unfavorable" pts than rtog. It seems very possible that the ACENDE-rt could be practice changing for high risk pts. Long term, there was almost 20% biochemical difference.

Right now, I dont do brachy and have no interest in performing it as it is just abt the only thing in XRT you can really f-- up . Certainly, if you have a lot of experience, you could use preplan/no real time planning, but if I had to do it I would want every toy possible.

 

[thecarbonionangle]

Some clearly overlooked the recent entire issue by Frank and Mourtada on MRI prostate brachy in Brachytherapy. LDR is more cost effective, MRI is better.

do you guys know where the 1 year of ADT in acende-rt for HR and intermediate disease came from?

 

[radtothebone]

Some clearly overlooked the recent entire issue by Frank and Mourtada on MRI prostate brachy in Brachytherapy. LDR is more cost effective, MRI is better.

do you guys know where the 1 year of ADT in acende-rt for HR and intermediate disease came from?

The 12 month ADT was not based on much data other than the fact with brachytherapy it appears less ADT is needed due to the degree of dose escalation. The Kishan ASTRO abstract showing a CSS advantage with brachytherapy boost over RP and EBRT had something like a 9 month median duration of ADT compared to around 2 years with EBRT.

I’m one of those prostate brachytherapy zealots who is dismayed to see so little interest in the prcedure. I do prefer HDR over LDR, as it offers more conformal treatment with a favorable temporal side effect profile. However I still use both. A lot of the LDR cost efficacy advantage will be lost if we get a proven single fraction HDR dose, which will eliminate the costs of multiple implants or hospital stays. 19 to 21 Gy appears to be the right dose, but I am still using 27 GY in 2 fx until I see more follow up. Prostate SBRT will also whittle away at brachytherapy.

I offer HDR boost to all high risn patients and personally don’t see the same toxicity as ASCENDE (Oh God, I sound like a Urologist refuting the PROTECT toxicity). I do use HDR which I think has superior toxicity profiles and have very tight urethral constraints.

 

[thecarbonionangle]

it just seems like an odd study to me. You have intermediate and high risk patients in that group. You are de-escalating ADT for the high risk arm from standard 2 years to 1 year, but escalating ADT for intermediate risk from 4-6 months to 1 year? Seems to me like a lot of this wasn't based on much data?

 

[Palex80]

it just seems like an odd study to me. You have intermediate and high risk patients in that group. You are de-escalating ADT for the high risk arm from standard 2 years to 1 year, but escalating ADT for intermediate risk from 4-6 months to 1 year? Seems to me like a lot of this wasn't based on much data?

RTOG9910 showed that 4 months are sufficient and prolongation of ADT to 8 months offers no benefit in intermediate risk patients.
Bearing in mind that RTOG 9910 also delivered a suboptimal dose of RT by today's standards, 12 months of ADT in intermediate risk disease probably offer no benefit to the patient and only cause more toxicity.

 

[nkmiami]

Havent read the paper, but intermediate is very heterogenous group- pt with 10 cores Gleason (4+3), and psa rising> 2 per year may have higher risk than single core Gleason 8 vs gleason (3+ 4) in one core.

 

[seper]

Regarding cost, LDR may be cheaper than HDR for society as a whole, or for a large organization over, say a 5 years period.
But for a given RadOnc Department, charge for LDR seeds needs to be swallowed (try it), while additional HDR time costs almost nothing.

 

[Chartreuse Wombat]

Regarding cost, LDR may be cheaper than HDR for society as a whole, or for a large organization over, say a 5 years period.
But for a given RadOnc Department, charge for LDR seeds needs to be swallowed (try it), while additional HDR time costs almost nothing.

Serious question. I have performed LDR for more than 2 decades in three different institutions and have never been told that the $$ for the sources is taken from the professional revenues. In what model would the department need to "swallow" (i think you are not being literal but use the term in the sense of "be responsible for the payment of")? Seriously I don't understand. Please enlighten me.

 

[seper]

Here is my 3d attempt to explain. You decide to do prostate LDR for the first time. Before the procedure, your physicist calls the I-125 supplier and orders 60-100 seeds. The company sends you the invoice. Who pays it? I've been in this situation twice already.

 

[Chartreuse Wombat]

It is my understanding that the invoice is passed on to the insurance company who pays for it (pass through). Most cost comparisons include the cost of the sources which has fallen dramatically in the last decade.

 

[medgator]

It is my understanding that the invoice is passed on to the insurance company who pays for it (pass through). Most cost comparisons include the cost of the sources which has fallen dramatically in the last decade.

Agree... Just like when we bill for gold fiducials, we buy them for trus placement and bill insurance.

I assumed seeds worked similarly.

Intuitively I assumed a ir192 source used multiple times on multiple pts would be cheaper than a new set of seeds for each patient, as either case needs to be done under some type of anesthesia, although HDR is multiple fractions