Change in IPSS w Hydrogel

[Haybrant]

We have our urologists place the hydrogel and fiducials, they have been doing it for many years and have done a great job. Recently have had some issues. Urologist and rep came down to talk to me couple weeks ago after one placement on a patient that was a very good SBRT candidate with IPSS of 4 when I spoke with him. they were concerned the hydrogel went subcapsular into the prostate bc they met a lot of resistance but werent certain, when they looked with ultrasound they ultimately didn’t feel like it did. This is their procedure note:

“Operative Findings:
Pre-op cipro. Ultrasound showed stool-filled rectum; stool manually disimpacted. 6cc of 1% lidocaine plain were injected at the skin
and mid-depth. Next, ultrasound was used to place 4 separate fiducial markers, 2 on each side of the prostate with care to aim for good distance between the markers. Then, SpaceOar was injected in standard fashion in the appropriate
plane posterior to prostate and anterior to rectum. Saline test was performed which confirmed appropriate plane but did favor the right aspect of this plane. Therefore the SpaceOar was instilled more vigorously to start to encourage even
spread. With instillation of SpaceOar it became evident that the SpaceOar was spreading evenly laterally but was favoring the prostatic apex. Therefore decision made to stop after 4cc of SpaceOar instilled so as to not put undue pressure on urethra and to prevent anterior spread of SpaceOar.”

Had patient come for sim and spoke with him. He has had more frequency and hesitance with urination. A couple times he tried to pee and nothing came out then he had to go again - has only happened twice in 2 weeks. His IPSS has gone from 4 to 11 now w frequency a 5 and incomplete emptying a 2 - these were all 0. Nocturia is a 1. TBH the gel looks ok on CT. He has an MRI scheduled tomorrow.

How worried are you by the IPSS change in light of the hydrogel placement issue. Not sure if maybe the MRI will tell me about the positioning better. Maybe it is subcapsular or it’s just a really tight space now with pressure on the urethra. Would you worry about moving forward with sbrt and transition to 28/44(?) fraction. He is unfav int risk on ADT.

---

Members don't see this ad.

 

[elementaryschooleconomics]

We have our urologists place the hydrogel and fiducials, they have been doing it for many years and have done a great job. Recently have had some issues. Urologist and rep came down to talk to me couple weeks ago after one placement on a patient that was a very good SBRT candidate with IPSS of 4 when I spoke with him. they were concerned the hydrogel went subcapsular into the prostate bc they met a lot of resistance but werent certain, when they looked with ultrasound they ultimately didn’t feel like it did. This is their procedure note:

“Operative Findings:
Pre-op cipro. Ultrasound showed stool-filled rectum; stool manually disimpacted. 6cc of 1% lidocaine plain were injected at the skin
and mid-depth. Next, ultrasound was used to place 4 separate fiducial markers, 2 on each side of the prostate with care to aim for good distance between the markers. Then, SpaceOar was injected in standard fashion in the appropriate
plane posterior to prostate and anterior to rectum. Saline test was performed which confirmed appropriate plane but did favor the right aspect of this plane. Therefore the SpaceOar was instilled more vigorously to start to encourage even
spread. With instillation of SpaceOar it became evident that the SpaceOar was spreading evenly laterally but was favoring the prostatic apex. Therefore decision made to stop after 4cc of SpaceOar instilled so as to not put undue pressure on urethra and to prevent anterior spread of SpaceOar.”

Had patient come for sim and spoke with him. He has had more frequency and hesitance with urination. A couple times he tried to pee and nothing came out then he had to go again - has only happened twice in 2 weeks. His IPSS has gone from 4 to 11 now w frequency a 5 and incomplete emptying a 2 - these were all 0. Nocturia is a 1. TBH the gel looks ok on CT. He has an MRI scheduled tomorrow.

How worried are you by the IPSS change in light of the hydrogel placement issue. Not sure if maybe the MRI will tell me about the positioning better. Maybe it is subcapsular or it’s just a really tight space now with pressure on the urethra. Would you worry about moving forward with sbrt and transition to 28 fraction. He is unfav int risk on ADT.

Well, regardless of the truth, a malpractice lawyer would easily paint a convincing picture of complications.

The safest, most conservative thing to do would be to switch to 28 (or 44) fractions.

And reconsider the routine use of the goo...

 

[medgator]

28-44 fx, no gel all day

 

[BobbyHeenan]

You need an MRI. I strongly recommend post-gel routine MRI's if you can get them (for now we do no-charge post gel MRI's and I review them carefully. I get rads involved if I suspect post placement issues like rectal wall infiltration).

My default in this situation (any gel weirdness) is to change to 28 fractions. Pump the brakes, let things clarify BEFORE you start treatment.

The gel is not benign. We've had I think 2 acute urinary retentions post gel in the past 24 months as I recall as well in our network.

I consider the gel "very optional" and I've posted about it before, I have very mixed feelings on it after initially being more enthusiastic. I don't really push it too hard now.

 

[Haybrant]

You need an MRI. I strongly recommend post-gel routine MRI's if you can get them (for now we do no-charge post gel MRI's and I review them carefully. I get rads involved if I suspect post placement issues like rectal wall infiltration).

My default in this situation (any gel weirdness) is to change to 28 fractions. Pump the brakes, let things clarify BEFORE you start treatment.

The gel is not benign. We've had I think 2 acute urinary retentions post gel in the past 24 months as I recall as well in our network.

I consider the gel "very optional" and I've posted about it before, I have very mixed feelings on it after initially being more enthusiastic. I don't really push it too hard now.

do you place it yourself? MRI is tomorrow so i can look but ya with the increased IPSS sounds like not much of an option

 

[BobbyHeenan]

do you place it yourself? MRI is tomorrow so i can look but ya with the increased IPSS sounds like not much of an option

Throughout the years I used to place it myself, then urologists took over. Other rad oncs in our network place it as well. I'd say they are all pretty experienced at it.

 

[elementaryschooleconomics]

*internal screams intensify*

 

[TheWallnerus]

I would refuse to accept a consult or irradiate anyone with SpaceOAR at this point. I would willingly kill a relationship with a urologist if he got his hackles up about that too. Like Sully said, “Can we get serious now?”

 

[BobbyHeenan]

I would refuse to accept a consult or irradiate anyone with SpaceOAR at this point. I would willingly kill a relationship with a urologist if he got his hackles up about that too. Like Sully said, “Can we get serious now?”

In my experience the urologists don't care much one way or the other. They're busy enough and the revenue isn't great for it.

Now it seems its very much patient-driven....especially if they went to *insert academic center or proton center* and I'm seeing them now for a "local" option...."well this place said they would strongly recommend the gel, why are you telling me it's optional?"

 

[JS1987]

28-44 fx, no gel all day

Okay now do 5-20 fx.

 

[evilbooyaa]

SpaceOAR isn't something that you can pause and see what's going on before making a determination of whether you can instill more or not. Any pause they did means that the gel is actively polymerizing in the needle and it's not going to go. SpaceOAR, if you're going to do it at all, needs to be a consistent, steady flow because any pause will cause the matrices to form within the insertion needle.

So, basically, idk what the **** the Urologist was doing. New grad? If you want to inject and pause and see where it goes and all that, you need to use Barrigel.

Was it a VUE? If not, why not? Then a CT sim would show where it's gone (and show up intracapsular if truly there). Sure, you can await the MRI, but it's just unnecessary.

If it was like 3-5 days and he had these symptoms I'd let it ride and see if it improves, but if it's been a couple weeks and his symptmos have not sufficiently improved, I would use your clinical judgment (despite the fact ath IPSS 11 in a vaccumm is not too high to consider SBRT) and switch him to something less acutely toxic (in terms of urinary symptoms) than SBRT, which would be either 20-44 fractions.

Silver lining - doesn't sound like rectal infiltration, which is where most of the G3+ toxicities from SpaceOAR come from!

 

[OTN]

Okay now do 5-20 fx.

Have been for years

 

[medgator]

You need an MRI. I strongly recommend post-gel routine MRI's if you can get them (for now we do no-charge post gel MRI's and I review them carefully. I get rads involved if I suspect post placement issues like rectal wall infiltration).

My default in this situation (any gel weirdness) is to change to 28 fractions. Pump the brakes, let things clarify BEFORE you start treatment.

The gel is not benign. We've had I think 2 acute urinary retentions post gel in the past 24 months as I recall as well in our network.

I consider the gel "very optional" and I've posted about it before, I have very mixed feelings on it after initially being more enthusiastic. I don't really push it too hard now.

Personally saw an elective 6 month colostomy for infection, as well as the published report from utsw regarding a pelvic exent. Not at all.

 

[medgator]

Okay now do 5-20 fx.

Quicker or better tx?

 

[OTN]

Quicker or better tx?

I'm very upfront with patients about SBRT vs hypofractionation vs conventional fractionation and how the trade off is a little more toxicity for length of treatment. The data isn't complicated, and I've found that with good consultation patients are easily able to weigh those trade-offs in their mind and select the treatment most appropriate for them.

I've also found that, after a careful review of the data, they also agree with me that The Goo isn't necessary.

 

[metallica81788]

I've also found that, after a careful review of the data, they also agree with me that The Goo isn't necessary.

Most will decline The Goo once you mention even a remote possibility of a rectal abscess or anything similar (and we all know the possibility is far from remote)

 

[BobbyHeenan]

Most will decline The Goo once you mention even a remote possibility of a rectal abscess or anything similar (and we all know the possibility is far from remote)

I have seen this as well over the years.

I wish I had a better handle on the number or % chance that happens. In the clinical trials it ws basically never, but post trial MAUDE and other reports suggest it's certainly not zero.

I wish I could confidently say the gel drops your absolute risk of late rectal bleeding around X%, but you then accept an X% chance of a major problem from the gel.

So many confounders (margins on the trials, etc) make filling out those X's tough.

 

[OTN]

I have seen this as well over the years.

I wish I had a better handle on the number or % chance that happens. In the clinical trials it ws basically never, but post trial MAUD and other reports suggest it's certainly not zero.

I wish I could confidently say the gel drops your absolute risk of late rectal bleeding around X%, but you then accept an X% chance of a major problem from the gel.

So many confounders (margins on the trials, etc) make filling out those X's tough.

Doesn't make sense to swap a small chance of a minor problem with a slightly smaller chance of a major problem.

 

[BobbyHeenan]

Doesn't make sense to swap a small chance of a minor problem with a slightly smaller chance of a major problem.

I've personally come around to that conclusion as the years have gone by it seems.

I wish I knew what that "slightly smaller chance" number is, but the case reports give me so many bad feelings...combine that with some close calls I caught on post gel MRI and here I am...

 

[drowsy12]

the proton folks require the gel, from what I understand.

 

[medgator]

the proton folks require the gel, from what I understand.

With all that potentially added toxicity, no brainer.... also conventional fx

 

[TheWallnerus]

the proton folks require the gel, from what I understand.

Logistically this gets tough for them. They need the gel for rectal safety purposes, but with the gel the IMRT versus proton comparison plans (often times necessary for insurance approval) look too equal.

 

[Mandelin Rain]

All this talk of the maddening futility of proton therapy jogged my memory on this thread where I called the 2023 government relations electee a "proton protector" which was met with some derision, including by her on X.

Election Results

I ended with this.

I will admit, I know nothing about her other than the company that pays her has a vested interest/partnership with a struggling company within the proton industry.

Maybe she'll push for pay parity and inclusion in APM. Maybe lightning bolts will shoot from my butt.

Anyone remember how ROCR ended up shaking out in 2023? Protons and photons equal?

 

[elementaryschooleconomics]

All this talk of the maddening futility of proton therapy jogged my memory on this thread where I called the 2023 government relations electee a "proton protector" which was met with some derision, including by her on X.

Election Results

I ended with this.

Anyone remember how ROCR ended up shaking out in 2023? Protons and photons equal?

See THIS is why I love the internet - it's easy to bring receipts!

(disclaimer: you must care about receipts)

(disclaimer: this fact not valid as AI takes over the Dead Internet)

 

[NotMattSpraker]

All this talk of the maddening futility of proton therapy jogged my memory on this thread where I called the 2023 government relations electee a "proton protector" which was met with some derision, including by her on X.

Election Results

I ended with this.

Anyone remember how ROCR ended up shaking out in 2023? Protons and photons equal?

Problem is, swap her out with basically anyone else and it would be the same.

Anyone unwilling to be an "ASTRO protector" is excluded from ASTRO. Any unwilling to be excluded from ASTRO is pretty quiet.

 

[evilbooyaa]

All this talk of the maddening futility of proton therapy jogged my memory on this thread where I called the 2023 government relations electee a "proton protector" which was met with some derision, including by her on X.

Election Results

I ended with this.

Anyone remember how ROCR ended up shaking out in 2023? Protons and photons equal?

Idk, I stand by my criticism mostly. I just don't have high expectations of ASTRO creating something that benefits anyone besides them. PP free standing love ROCR because it evens the playing field in terms of site neutrality.

 

[elementaryschooleconomics]

Idk, I stand by my criticism mostly. I just don't have high expectations of ASTRO creating something that benefits anyone besides them. PP free standing love ROCR because it evens the playing field in terms of site neutrality.

And, lest anyone forget (or not know):

There are very few freestanding practices left, private or academic (because "freestanding" has nothing to do with private/academic).

The most recent data we have, at least as far as I can tell, is from a survey ASTRO did about the pandemic's impact on RadOnc.

AT MOST, perhaps 20-25% of RadOnc practices bill as freestanding.

Of that minority...GenesisCare (21C) is the majority.

The employer of Paul Wallner and Connie Mantz.

 

[NotMattSpraker]

Idk, I stand by my criticism mostly. I just don't have high expectations of ASTRO creating something that benefits anyone besides them. PP free standing love ROCR because it evens the playing field in terms of site neutrality.

I'm sorry, what should I love about ROCR?

Honest question. I understand that a case rate model in theory could stabilize our historically unstable payments. That parts pretty straight forward. There is a lot of missing information for me to argue that I should love ROCR as proposed for that reason.

What should I love other than it is not a vaguely defined "terrible future of cuts" under CMS. Maybe. We also don't know the future of ROCR beyond a few years after implementation.

 

[medgator]

I'm sorry, what should I love about ROCR?

Honest question. I understand that a case rate model in theory could stabilize our historically unstable payments. That parts pretty straight forward. There is a lot of missing information for me to argue that I should love ROCR as proposed for that reason.

What should I love other than it is not a vaguely defined "terrible future of cuts" under CMS. Maybe. We also don't know the future of ROCR beyond a few years after implementation.

Can anyone honestly trust ASTRO at this point? I can't. Any credibility left?

Decade+ of mismanagement and (consistently) making the wrong calls to CMS

 

[elementaryschooleconomics]

Can anyone honestly trust ASTRO at this point? I can't. Any credibility left?

Decade+ of mismanagement and making the wrong calls to CMS

Well, if you go to the "Trending" page on SDN:

"Rad Onc Twitter" is consistently on the front page.

The thread has over a million views.

I don't think there's anything quite like it on the rest of SDN. Maybe the pre-med forums, but that's a different audience. I would be nearly certain it's the most popular thread for the specialty forums.

Why?

In large part, because of ASTRO.

This has been the only real place for RadOncs to come talk openly about anything since...the internet was invented?

Who knows. All I know is that this gives at least one answer to "who trusts ASTRO at this (or any) point".

Evidently, there's so little trust that a specialty of only ~5,300 docs spends so much time on an independent message board that there's a single, 5-year-old thread with well over a million views...

 

[drowsy12]

There’s way more people who read here than post here. Some part of it certainly is morbid curiosity, I agree there’s no other forum on this website like this. A lot of eyes on essentially what 30 dudes are saying lol.

 

[medgator]

There’s way more people who read here than post here. Some part of it certainly is morbid curiosity, I agree there’s no other forum on this website like this. A lot of eyes on essentially what 30 dudes are saying lol.

No other open forum around to discuss these issues. Won't show up on mednet. And Putin or the CCP would be proud of the way ASTRO handles ROHub.

Not sure if ACRO has something similar to ROHub but it could certainly fulfill that role

 

[TheWallnerus]

A lot of eyes on essentially what 30 dudes are saying lol.

The way we dudes disguise ourselves here you can't do IRL ... but it's all in service to our art!

 

[JustAdocInBox]

I don’t understand why we make prostate so complicated. Hydrogel, protons, ultra hypofrac; I used to discuss all these with my patients. Now everyone gets IMRT 20-28 fx or 39-44 fx depending on risk factors and urinary function. The efficacy and safety data is excellent. Occasionally will do an HDR boost. Patients are much less confused.

 

[Mandelin Rain]

I don’t understand why we make prostate so complicated. Hydrogel, protons, ultra hypofrac; I used to discuss all these with my patients. Now everyone gets IMRT 20-28 fx or 39-44 fx depending on risk factors and urinary function. The efficacy and safety data is excellent. Occasionally will do an HDR boost. Patients are much less confused.

 

[ramsesthenice]

ASTRO just needs to drop the pretenses and embrace what it is…American Society of ACADEMIC Radiation Oncology. Their actions and mission have very clearly and consistently defined their priorities. Its just that no one wants to admit out loud they are outright discarding the interests of a sizable portion of their constituency in favor of their own needs. But hey, as long as you have one black friend, you can't be a racist am I right?

 

[TheWallnerus]

I don’t understand why we make prostate so complicated.

Why indeed.

 

[evilbooyaa]

I'm sorry, what should I love about ROCR?

Honest question. I understand that a case rate model in theory could stabilize our historically unstable payments. That parts pretty straight forward. There is a lot of missing information for me to argue that I should love ROCR as proposed for that reason.

What should I love other than it is not a vaguely defined "terrible future of cuts" under CMS. Maybe. We also don't know the future of ROCR beyond a few years after implementation.

I thought you are hospital employed?
I was unclear - I mean free standing PP (like people who own technical) which doesn't benefit from hospitals getting paid more than free standing for the same services. Site neutrality (for photons).

And to further clarify - SOME PP. Not all the PPs. Just some.

 

[evilbooyaa]

ASTRO just needs to drop the pretenses and embrace what it is…American Society of ACADEMIC Radiation Oncology. Their actions and mission have very clearly and consistently defined their priorities. Its just that no one wants to admit out loud they are outright discarding the interests of a sizable portion of their constituency in favor of their own needs. But hey, as long as you have one black friend, you can't be a racist am I right?

I mean.... we're discussing why someone from Tennessee Oncology and two folks from 21C (Wallner/Mantz) are leading the charge of ROCR. None of them are academic

 

[ramsesthenice]

I mean.... we're discussing why someone from Tennessee Oncology and two folks from 21C (Wallner/Mantz) are leading the charge of ROCR. None of them are academic

I don't want to have a political discussion, but this is a textbook part of an autocratic takeover. You are correct, they are not academic but as we have discussed numerous times we don't live in an academic vs PP world anymore. But that is still how much of the outside world sees it. And these guys are technically private so they must represent the interests of the little guy right? Labels mean nothing when balanced against action.

 

[medgator]

I don't want to have a political discussion, but this is a textbook part of an autocratic takeover. You are correct, they are not academic but as we have discussed numerous times we don't live in an academic vs PP world anymore. But that is still how much of the outside world sees it. And these guys are technically private so they must represent the interests of the little guy right? Labels mean nothing when balanced against action.

Proton exemption perfect example. Lots of protons with big players on both sides of that divide

 

[elementaryschooleconomics]

I don't want to have a political discussion, but this is a textbook part of an autocratic takeover. You are correct, they are not academic but as we have discussed numerous times we don't live in an academic vs PP world anymore. But that is still how much of the outside world sees it. And these guys are technically private so they must represent the interests of the little guy right? Labels mean nothing when balanced against action.

I would HOPE this doesn't lead to a political discussion, unless people want to delve into the actual political science of regulatory issues in structured society....

(it's me, I want to talk about actual political science divorced entirely from current events)

 

[NotMattSpraker]

I thought you are hospital employed?
I was unclear - I mean free standing PP (like people who own technical) which doesn't benefit from hospitals getting paid more than free standing for the same services. Site neutrality (for photons).

And to further clarify - SOME PP. Not all the PPs. Just some.

I am and 20% of my pay isn't even for being a Rad Onc! Suck on that Sameer.

Im really am genuinely curious to hear from someone that is PP, not on the ASTRO board or in a committee, and likes ROCR. I want to understand more about the upside because the ASTRO people can never explain it.

Site neutrality is a big part of the current push across medicine happening at CMS. There is a bill out to give freestanding a big raise and evaluate the benefits/harms of the lack of site neutrality. It seems somewhat well received, but don't know as much about that as others. If that passes, then what is the upside?

Just put us back in to radiology already, free us from these nuts.

 

[RickyScott]

ASTRO just needs to drop the pretenses and embrace what it is…American Society of ACADEMIC Radiation Oncology. Their actions and mission have very clearly and consistently defined their priorities. Its just that no one wants to admit out loud they are outright discarding the interests of a sizable portion of their constituency in favor of their own needs. But hey, as long as you have one black friend, you can't be a racist am I right?

In reality, they don’t represent most of those in academics either, just the chairs and some very senior faculty. Junior and midlevel faculty stuck in malignant departments with no prospect of promotion, raises, or lateral mobility have Astro to thank.

 

[TheWallnerus]

Just put us back in to radiology already, free us from these nuts.

#RescindOrResign
#DeezRadOncNuts

 

[ramsesthenice]

midlevel faculty stuck in malignant departments with no prospect of promotion, raises, or lateral mobility have Astro to thank.

Those departments exist but they are certainly not the norm. Im not going to publicly name departments but if anyone wants to PM me I can do it. Better yet, take a look yourself. One of the first things anyone looking into an academic position should do is look at the faculty directory for the department. If you see white and gray-haired assistant professors, som' wrong. During interviews, you need to ask detailed questions about expectations for promotion and how things like satellite coverage or other "departmental service commitments" factor in.

You are also giving ASTRO too much credit. Academic centers are enormous machines which are notoriously slow to change. For some of the worst offenders, its not at the departmental level and promotion requirements are set at the level of SOM. Things like impact factor publication or grant funding minimums are antiquated and unattainable for most busy clinicians and based on the fantasy that "everyone should be held to the same standard". Fortunately, most institutions have moved away from this though it took longer than it should have.

Resistance to change at the institutional level can be a back-breaker for large academic departments. Case in point: option for at least partial remote work is something that physics and dosimetry candidates are looking for in the current market. Our institution is stuck in the mindset that "if we offer it to them, we have to offer it to everyone and we can't do that." We've all seen this movie before. This change is inevitable but we won't be able to do anything about it until we hit a critical mass and lose enough revenue to prove we have to change to compete.

 

[elementaryschooleconomics]

Those departments exist but they are certainly not the norm. Im not going to publicly name departments but if anyone wants to PM me I can do it. Better yet, take a look yourself. One of the first things anyone looking into an academic position should do is look at the faculty directory for the department. If you see white and gray-haired assistant professors, som' wrong. During interviews, you need to ask detailed questions about expectations for promotion and how things like satellite coverage or other "departmental service commitments" factor in.

You are also giving ASTRO too much credit. Academic centers are enormous machines which are notoriously slow to change. For some of the worst offenders, its not at the departmental level and promotion requirements are set at the level of SOM. Things like impact factor publication or grant funding minimums are antiquated and unattainable for most busy clinicians and based on the fantasy that "everyone should be held to the same standard". Fortunately, most institutions have moved away from this though it took longer than it should have.

Resistance to change at the institutional level can be a back-breaker for large academic departments. Case in point: option for at least partial remote work is something that physics and dosimetry candidates are looking for in the current market. Our institution is stuck in the mindset that "if we offer it to them, we have to offer it to everyone and we can't do that." We've all seen this movie before. This change is inevitable but we won't be able to do anything about it until we hit a critical mass and lose enough revenue to prove we have to change to compete.

PREACH

 

[WanderingRad3]

I am and 20% of my pay isn't even for being a Rad Onc! Suck on that Sameer.

Im really am genuinely curious to hear from someone that is PP, not on the ASTRO board or in a committee, and likes ROCR. I want to understand more about the upside because the ASTRO people can never explain it.

Site neutrality is a big part of the current push across medicine happening at CMS. There is a bill out to give freestanding a big raise and evaluate the benefits/harms of the lack of site neutrality. It seems somewhat well received, but don't know as much about that as others. If that passes, then what is the upside?

Just put us back in to radiology already, free us from these nuts.

PP and I support ROCR.
1. Will make more $ for some where I hypofx (and less $ for some where I tend to conventionally fx but overall I think that’s ok given trend to hypofx over time)
2. Minimal onerous quality reporting/No MIPS participation requirements - less stupid data reporting that doesn’t improve quality
3. Would prefer to have RO come out of FFS (see #1 and fee schedule cuts/not keeping up with inflation if ROCR can bake in inflation updates). Uncertain if this is how it will play out but prefer a legislative fix to get us out of FFS physician fee schedule spiral if we can pull it off.
4. Incentivizes combination therapy (brachy plus external) for instead of just external when justified (ROCR payment + FFS brachy). This will increase my Brachy volume.
5. New tech still protected as new CPT codes won’t be in ROCR

I did not like how they surprise rolled it out without much feedback initially but I definitely support it now.

Disclosure - I have served on Astro committees but no leadership position and wasn’t involved in ROCR development

 

[Mandelin Rain]

The twists-and-turns a thread about IPSS in the setting of hydrogel can take....

 

[NotMattSpraker]

2. Minimal onerous quality reporting/No MIPS participation requirements - less stupid data reporting that doesn’t improve quality

4. Incentivizes combination therapy (brachy plus external) for instead of just external when justified (ROCR payment + FFS brachy). This will increase my Brachy volume.

Disclosure - I have served on Astro committees but no leadership position and wasn’t involved in ROCR development

Thanks a lot! 4 surprised me, unless I guess you mean for prostate. The standard of care should incentivize people to use brachy for gyn. If reimbursement is a barrier that is news to me and that sucks!

For 2, I guess reasonable people can disagree. APEx and $12,000 every 3 years is a higher burden than MIPS. Much higher. Unless you're already accredited. We are doing this now and its a huge burden and basically our whole team feels its a waste of time.