CCS Oncology - Imminent closure, bankruptcy, FBI investigation

[medgator]

I am not, but what says it’s isnt

- dose / fractions are sbrt
- volume is small
- Image guided
- breath hold as immobilization

What makes it not sbrt Vs sbrt ?

Agree

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[medgator]

Honestly the initial complaint is not completely terrible but the hearing committee is totally off the rails.

Yeah just read it... Wild

 

[Ray D. Ayshun]

I am not, but what says it’s isnt

- dose / fractions are sbrt
- volume is small
- Image guided
- breath hold as immobilization

What makes it not sbrt Vs sbrt ?

From a cost pov, 5 fx sbrt is equivalent to 15 fx 3d. I'd bet more work goes into apbi from a radonc pov.

 

[deleted1111261]

From a cost pov, 5 fx sbrt is equivalent to 15 fx 3d. I'd bet more work goes into apbi from a radonc pov.

Chirag wrote this up. It’s more expensive than 3D.

 

[Ray D. Ayshun]

Chirag wrote this up. It’s more expensive than 3D.

Sbrt? Could only find report that 5 fx imrt is cheaper than 15 fx 3d.

NVM, saw it alluded to at least. Maybe got my conversion factor wrong 1 sbrt = 3 imrt

 

[RickyScott]

Tangentially related... academic satellite located into my town a few years back. Over time have shared some bone met patients w/ them. They appear never to have heard of "8 gray in 1 fraction."

Meanwhile on twitter…

 

[medgator]

I heard of someone who has an inhouse PET and owns the machine. They bill globally for this. They get multiple PETs throughout treatment to “guide assessment of response”. Of course many PETs at follow up. This same person treats at 0.5 gy a day treating prostates for months to minimize side effects. Oh and the in house pharmacy brings in lots cheesy dough too.
True story folks!

Personally our field would be better off if FBI would raid all these folks and put them away. Surely they working on it.

Pet scans are so regulated these days... Can't imagine that happening anymore.

 

[thecarbonionangle]

I am not gonna get sucked into a da worst breast debate but i will briefly answer: the original paper does not call it SBRT. It seems silly to me to go check the CBCT with each treatment, do a second CBCT midway before next arc, and have physics tied up present for treatment when we all know a CBCT with good set up is all that is needed once initial set up is confirmed. This is the kind of stuff that makes us look bad and will continue to put us in crosshair of CMS. I don’t treat breast but in residency when this was done it was never SBRT.

 

[theradiator]

Updates....

Former CCS Oncology chief deemed 'danger' to patients, stripped of state medical license

The state Board for Professional Medical Conduct this month revoked the medical license of Dr. Won Sam Yi following a lengthy review of the care he provided to seven seriously

buffalonews.com

6 weeks of WBRT in a 43 yo F with previous xrt

The buried lede of this sad story is that multiple radiation oncologists (in what should be the primes of their careers) are available to work whether for Evicore or as physician reviewers for the State Medical Board.

 

[deleted1111261]

I am not gonna get sucked into a da worst breast debate but i will briefly answer: the original paper does not call it SBRT. It seems silly to me to go check the CBCT with each treatment, do a second CBCT midway before next arc, and have physics tied up present for treatment when we all know a CBCT with good set up is all that is needed once initial set up is confirmed. This is the kind of stuff that makes us look bad and will continue to put us in crosshair of CMS. I don’t treat breast but in residency when this was done it was never SBRT.

I don’t think doing an additional CBCT is what makes it SBRT. Many people don’t do multiple images for lung. Your tone is a bit accusatory. What makes this different than other forms of SBRT? It really seems to check the boxes.

 

[thecarbonionangle]

Pet scans are so regulated these days... Can't imagine that happening anymore.

Perhaps but it was for sure going on not too long ago

 

[thecarbonionangle]

I don’t think doing an additional CBCT is what makes it SBRT. Many people don’t do multiple images for lung. Your tone is a bit accusatory. What makes this different than other forms of SBRT? It really seems to check the boxes.

I hear ya!

 

[deleted1111261]

I am not gonna get sucked into a da worst breast debate but i will briefly answer: the original paper does not call it SBRT. It seems silly to me to go check the CBCT with each treatment, do a second CBCT midway before next arc, and have physics tied up present for treatment when we all know a CBCT with good set up is all that is needed once initial set up is confirmed. This is the kind of stuff that makes us look bad and will continue to put us in crosshair of CMS. I don’t treat breast but in residency when this was done it was never SBRT.

A lot of what you’re saying is institutional policy rather than what defines or is required for SBRT.

 

[thecarbonionangle]

A lot of what you’re saying is institutional policy rather than what defines or is required for SBRT.

Why are you not billing it if you feel strongly it is sbrt or could be?

 

[deleted1111261]

Because I honestly don’t have a good clinical and billing definition of SBRT. It is what people decide it to be, and I’d rather under bill than over bill.

 

[jondunn]

I am not, but what says it’s isnt

- dose / fractions are sbrt
- volume is small
- Image guided
- breath hold as immobilization

What makes it not sbrt Vs sbrt ?

It’s post op, homogenous dosing, not prioritizing conformality. But you are correct that it’s poorly defined

 

[Lamount]

Using an alpha beta of 3, 80 fractions of 0.5 gy a day is an EQD2 of 28. You folks do the math

I think it would be >200 fx.

 

[Lamount]

I am not, but what says it’s isnt

- dose / fractions are sbrt
- volume is small
- Image guided
- breath hold as immobilization

What makes it not sbrt Vs sbrt ?

I think there are higher requirements for IGRT QA for SBRT machines, but no reason you couldn’t just use an SBRT-approved machine.

The question is… is SBRT “indicated” for APBI?… which is entirely up to the payer.

 

[radiaterMike]

The buried lede of this sad story is that multiple radiation oncologists (in what should be the primes of their careers) are available to work whether for Evicore or as physician reviewers for the State Medical Board.

It would seem that would be the logical career path. However, if you google him, he appears to be working in Iowa. I guess if you lose your NY license another state will just hand one out.

 

[jondunn]

Chirag wrote this up. It’s more expensive than 3D.

No.

Dr. shah pub said that 5 fraction IMRT is more cost effective than 15 fraction 3D

SBRT is absolutely more expensive

 

[TheWallnerus]

the original paper does not call it SBRT. It seems silly to me to go check the CBCT with each treatment, do a second CBCT midway before next arc, and have physics tied up present for treatment when we all know a CBCT with good set up is all that is needed once initial set up is confirmed.

I don’t think doing an additional CBCT is what makes it SBRT. Many people don’t do multiple images for lung. Your tone is a bit accusatory. What makes this different than other forms of SBRT? It really seems to check the boxes.

"[T]he original paper does not call it SBRT."

@thecarbonionangle keep in mind, how many papers on "breast IMRT" there are, and ASTRO's position:

So does it really matter what the paper "calls" it? According to ASTRO, we get to call anything anything we want. Ain't that great?!

Sometimes the argument over SBRT vs not SBRT is about feelings, confidence, fear, and subjectivity versus established proscriptive rules, or even science. It's my understanding that 60 Gy in 8 fraction is called, and billed as, SBRT in foreign countries. Foreign countries like Canada. However, in America, if you do 8 fractions of 7.5 Gy per day and try to bill it as SBRT, one of two things will happen:

1) Your stupidity will be exposed and your entire department will hate you because the entire course of therapy will automatically deny upon submission to the payor because, like they say in Maine, "You can't get there from here." Every single payor, including Uncle Sam, in the U.S., has defined SBRT very precisely but broadly...​

a. Must seek to "eliminate" or "inactivate" a target...​

b. Must use image guidance, and immobilization...​

c. Must use 5 fractions or less at >=5 Gy per fraction.​

That's it.​

You meet those criteria, it's SBRT.​

2) You will be put in jail for attempting to commit fraud. (You're still stupid. And American.)​

​

But back to feelings and subjectivity. I remember ~20 years ago when the 17 Gy/2 fx lung cancer trial came out in JCO. I mean, for my money, it's one of the slickest pure RT trials in medical history. And I bet 2 (maybe 1?) Americans will have received palliative lung RT of 17 Gy in 2 fractions in 2021. And it's a phIII validated treatment. I think it didn't catch on because... it's frightening! Just like SBRT... very frightening/sphincter tightening (correlates w/ age of rad onc). I got a rad onc guy 20 miles north of me who will never, ever do SBRT (he's about 60yo) because it strikes the fear of God in him. And he has a True Beam. And that 17 Gy in 2 fractions?

​

​

 

[thecarbonionangle]

Sometimes the argument over SBRT vs not SBRT is about feelings, confidence, fear, and subjectivity versus established proscriptive rules, or even science. It's my understanding that 60 Gy in 8 fraction is called, and billed as, SBRT in foreign countries. Foreign countries like Canada. However, in America, if you do 8 fractions of 7.5 Gy per day and try to bill it as SBRT, one of two things will happen:

1) Your stupidity will be exposed and your entire department will hate you because the entire course of therapy will automatically deny upon submission to the payor because, like they say in Maine, "You can't get there from here." Every single payor, including Uncle Sam, in the U.S., has defined SBRT very precisely but broadly...​

a. Must seek to "eliminate" or "inactivate" a target...​

b. Must use image guidance, and immobilization...​

c. Must use 5 fractions or less at >=5 Gy per fraction.​

That's it.​

You meet those criteria, it's SBRT.​

2) You will be put in jail for attempting to commit fraud. (You're still stupid. And American.)​

​

But back to feelings and subjectivity. I remember ~20 years ago when the 17 Gy/2 fx lung cancer trial came out in JCO. I mean, for my money, it's one of the slickest pure RT trials in medical history. And I bet 2 (maybe 1?) Americans will have received palliative lung RT of 17 Gy in 2 fractions in 2021. And it's a phIII validated treatment. I think it didn't catch on because... it's frightening! Just like SBRT... very frightening/sphincter tightening (correlates w/ age of rad onc). I got a rad onc guy 20 miles north of me who will never, ever do SBRT (he's about 60yo) because it strikes the fear of God in him. And he has a True Beam. And that 17 Gy in 2 fractions?

​

​

U gonna type out this beautiful thing yet ignore my request for 0.5 for prostate essay?

 

[Lamount]

Sometimes the argument over SBRT vs not SBRT is about feelings, confidence, fear, and subjectivity versus established proscriptive rules, or even science. It's my understanding that 60 Gy in 8 fraction is called, and billed as, SBRT in foreign countries. Foreign countries like Canada. However, in America, if you do 8 fractions of 7.5 Gy per day and try to bill it as SBRT, one of two things will happen:

1) Your stupidity will be exposed and your entire department will hate you because the entire course of therapy will automatically deny upon submission to the payor because, like they say in Maine, "You can't get there from here." Every single payor, including Uncle Sam, in the U.S., has defined SBRT very precisely but broadly...​

a. Must seek to "eliminate" or "inactivate" a target...​

b. Must use image guidance, and immobilization...​

c. Must use 5 fractions or less at >=5 Gy per fraction.​

That's it.​

You meet those criteria, it's SBRT.​

2) You will be put in jail for attempting to commit fraud. (You're still stupid. And American.)​

​

But back to feelings and subjectivity. I remember ~20 years ago when the 17 Gy/2 fx lung cancer trial came out in JCO. I mean, for my money, it's one of the slickest pure RT trials in medical history. And I bet 2 (maybe 1?) Americans will have received palliative lung RT of 17 Gy in 2 fractions in 2021. And it's a phIII validated treatment. I think it didn't catch on because... it's frightening! Just like SBRT... very frightening/sphincter tightening (correlates w/ age of rad onc). I got a rad onc guy 20 miles north of me who will never, ever do SBRT (he's about 60yo) because it strikes the fear of God in him. And he has a True Beam. And that 17 Gy in 2 fractions?

​

​

I did 17 Gy/2 for obstructing R hilar disease going to hospice… once. Now it is someone else’s turn.

 

[TheWallnerus]

U gonna type out this beautiful thing yet ignore my request for 0.5 for prostate essay?

I got it cookin'

 

[TheWallnerus]

I did 17 Gy/2 for obstructing R hilar disease going to hospice… once. Now it is someone else’s turn.

Did you bill it as SBRT?!? And are you a Nazi, racist, or both?

 

[jondunn]

I did 17 Gy/2 for obstructing R hilar disease going to hospice… once. Now it is someone else’s turn.

17/2 is fantastic.

I have zero clue why people don’t do it all the time

 

[deleted1111261]

No.

Dr. shah pub said that 5 fraction IMRT is more cost effective than 15 fraction 3D

SBRT is absolutely more expensive

That’s what I said - it’s more expensive

 

[Lamount]

Did you bill it as SBRT?!? And are you a Nazi, racist, or both?

I’m sure there is a joke there that is just a little too clever for me

 

[BobbyHeenan]

I don’t have a great gestalt for why I don’t bill 30/5 APBI as sbrt other than this….

1. For most of my sbrt I allow (or like) the middle of the target to be hot to promote rapid dose fall off. Think gamma knife pituitary Rxd to a 50-60 % isodose line .
2. Highly conformal plan - look at a comformality index as part of plan evaluation . Very steep dose gradient (correlated with 1 above).
3. There are often adjacent structures that are at risk for big problems if the Rxd dose is given to them .


My 30/5 breast plans don’t really fall into those boxes.

So I bill IMRT.

I don’t necessarily think it’s wrong to bill sbrt but I don’t.

I just don’t think it meets the “spirit” of SBRT.

 

[TheWallnerus]

I just don’t think it meets the “spirit” of SBRT.

 

[TheWallnerus]

I’m sure there is a joke there that is just a little too clever for me

17/2 is by definition* SBRT by every payor.

I would assume you billed it. And I would assume you billed it as SBRT, or not SBRT.

1) If you billed it as SBRT, many people would say you committed fraud.
2) If you didn't bill it as SBRT, CMS could have you for fraudulent under-billing, enticement, etc.

So you're either an over-biller, an under-biller, or both!



* if you used CBCT or kV X-ray or VisionRT for setup

 

[jondunn]

That’s what I said - it’s more expensive

got it, thought you were saying 5 fraction imrt was more expensive.

 

[jondunn]

you can make a much better argument that Livi 30/5 is SBRT than 17/2 large field, non-conformal, palliative lung is sbrt. the 17/2 JCO trial was AP/PA.

its not sbrt, by any definition.

 

[TheWallnerus]

you can make a much better argument that Livi 30/5 is SBRT than 17/2 large field, non-conformal, palliative lung is sbrt. the 17/2 JCO trial was AP/PA.

its not sbrt, by any definition.

What if you make it conformal. Not that conformailty index has anything to do with the proper billing of SBRT, or not.

 

[jondunn]

What if you make it conformal.

what makes 17/2 sbrt more than 8/1?

why not bill sbrt for 25/5 rectal?

 

[medgator]

what makes 17/2 sbrt more than 8/1?

why not bill sbrt for 25/5 rectal?

Some people bill 25/5 for wimpy brain srt

 

[TheWallnerus]

what makes 17/2 sbrt more than 8/1?

why not bill sbrt for 25/5 rectal?

Now you've got it

To be clear, I'm playing reductio ad absurdum. But I can play it so well in regards to what is or isn't SBRT (in America, especially).

 

[Lamount]

17/2 is by definition* SBRT by every payor.

I would assume you billed it. And I would assume you billed it as SBRT, or not SBRT.

1) If you billed it as SBRT, many people would say you committed fraud.
2) If you didn't bill it as SBRT, CMS could have you for fraudulent under-billing, enticement, etc.

So you're either an over-biller, an under-biller, or both!



* if you used CBCT or kV X-ray or VisionRT for setup

Ah… and there it is.

 

[jondunn]

Some people bill 25/5 for wimpy brain srt

i have no problem with that. its clearly stereotactic technique when youre doing 25/5 for a meningioma

 

[deleted1111261]

Basically we are all saying it is what we say it is. No good definition exists. If you billed CMS sbrt for APBI, if it’s rejected, it’s on Medicare to clarify what it is. 70/10 for lung w SBRT technique should be SBRT but it’s not due to fraction number. And that is stupid. So, yeah… this field

 

[TheWallnerus]

i have no problem with that. its clearly stereotactic technique when youre doing 25/5 for a meningioma

Basically we are all saying it is what we say it is.

 

[medgator]

i have no problem with that. its clearly stereotactic technique when youre doing 25/5 for a meningioma

You're being incredibly subjective

 

[jondunn]

You're being incredibly subjective

I mean it fits every single criteria except dose. fixation, image guidance, live presence, incredible conformality, high heterogeneity, critical structures. what else do you need?

the diff between that and 25/5 rectal goes without saying.

 

[TheWallnerus]

live presence, incredible conformality, high heterogeneity

What if I do it remotely/non-live, my conformality index is non-incredible, and my Dmax is 107%?

 

[jondunn]

What if I do it remotely/non-live, my conformality index is non-incredible, and my Dmax is 107%?

im not arguing there isnt some cognitive dissonance to some of this, but if youre looking at the spectrum of not sbrt to full on SBRT, 25/5 rectal doesnt cut it compared to many of these other things.

 

[RickyScott]

im not arguing there isnt some cognitive dissonance to some of this, but if youre looking at the spectrum of not sbrt to full on SBRT, 25/5 rectal doesnt cut it compared to many of these other things.

I have tried in the past and failed to get preauth for sbrt 5 gy x 5 rectal. I figured we only get 90% of Medicare from this advantage plan, so why should the hospital not get something reasonable for the treatment.

 

[TheWallnerus]

im not arguing there isnt some cognitive dissonance to some of this, but if youre looking at the spectrum of not sbrt to full on SBRT, 25/5 rectal doesnt cut it compared to many of these other things.

I have tried in the past and failed to get preauth for sbrt 5 gy x 5 rectal. I figured we only get 90% of Medicare from this advantage plan, so why should the hospital not get something reasonable for the treatment.

We are a country divided. On race, on politics, on masking, on vaccines, on what is/isn't IMRT, on what is/isn't SBRT. WHO WILL UNITE US.

 

[TheWallnerus]

Im sure lord wallrus can write us a thesis on the radbio of treating prostates 0.25-0.5 a day. How would you do it if you were asked lord wallrus?

In this calc, we will completely eliminate time corrections from consideration. This may actually be reasonable for very slowly dividing, very large Tpot tumors.

There is, kind of, radiobiological clinical precedent of very small fraction prostate radiotherapy: that’s brachytherapy. If we assume that I-125 has a half life of 60 days, and thus has a useful life of ~90 days, we can break the 145 Gy Rx dose into 90 days of TID doses of 0.5Gy per “fraction,” which comes out to 135 Gy. That is to say, I can enforce a radiobiological similarity between brachy 145 Gy using I-125 and 90 continuous days of 0.5 Gy per fraction, three-times-a-day RT (like CHART in lung) w/ 8h interfraction intervals, and the clinical outcomes should be very similar.

I already pre-established I’m ignoring time.

If that’s the case, we can just say 270 fractions of 0.5 Gy. Again, completely ignoring time, we can break this into 0.5 Gy per day/fraction over 54 weeks.

Therefore, we could maybe run a rational trial of 270 fractions of 0.5 Gy/day over 54 weeks vs e.g. 81 Gy/45 fractions over 9 weeks. Interestingly, the alpha/beta that would make these two regimens similar is: 1.45.

And as we all know, a prostate alpha/beta of 1.45 is quite a very reasonable and nice result that we actually just “accidentally” derived by trying to adjust very long fractionation to be normative w/ brachy and 81/45. Unfortunately, we would predict late tissue effects to be 20 to 25% higher w/ 135 Gy over 54 weeks. The reimbursement per patient w/ 270 fractions would be beyond the dreams of avarice.

 

[elementaryschooleconomics]

17/2 is fantastic.

I have zero clue why people don’t do it all the time

I would also like to throw my vote behind 17/2.

Also 10/1.

Also the 0/7/21 regimen (8Gy each treatment).




But what I really took away from this thread: 8Gy x 1 = SRS...

Is it SRS? Is it SBRT? Is it complex isodose? It's like pornography - I know it when I see it.

 

[medgator]

But what I really took away from this thread:

FL AZ CO California and Texas have nothing on upstate NY in terms of physician over fractionation and shenanigans. The hearing committee report is probably the most egregious thing I've ever heard of in our field and I've heard of some crazy stuff over the years. It's a wonder they didn't throw the guy in jail