Impact of USPTF Guidelines on Rad Onc

[SKR]

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The USPTF has recommended against PSA screening for prostate cancer. They recently recommended for low-dose CT for lung cancer screening. What impact, if any, will these guidelines have on radiation oncology practice in the future? Have the PSA guidelines impacted your practice already? Love to hear your thoughts.

 

[Gfunk6]

PSA guidelines are largely irrelevant to Rad Oncs as the majority of PSA screening is done by PCPs and, to a lesser extent, urologists. Nobody argues with following PSA after curative therapy to verify biochemical response. However, I will tell you that there is widespread discontent of USPTF guidelines from patient and physician groups and I think they will be (mostly) ignored. If these guidelines are implemented, I would assume we see less early stage prostate cancer, meaning less treatment, and less revenue. This may not necessarily be a bad thing for the patient population, but you have to accept that we will miss the window for cure in a few aggressive cases.

Low-dose CT for lung cancer screening is huge. If we are able to identify patients with Stage I/II lung cancer, we can potentially treat them with SBRT or lobectomy and avoid chemotherapy entirely. Also cure rates are obviously superior when treating earlier stages.

Added: If we start performing low-dose CT scans then we can claim that this new technology tripled our cure rates!! 😀

 

[medgator]

If it's anything like their breast guidelines, I don't anticipate much in the way of changes

Insurance companies and Medicare didn't change their policies for coverage after those guidelines came out.

Patients didn't change their behavior either
http://m.huffpost.com/us/entry/3112397

I think the LDCT lung guidelines will eventually change practice, particularly once insurance actually starts paying for that screening exam 😉

 

[honger]

Lung screening ought to increase detection of early lung cancers, most of which would end up getting surgical resection. These patients would otherwise have ended up with locally advanced/metastatic cancer at the time of diagnosis, so revenue wise it probably isn't the best for radiation oncologists. Way better for high-risk patients given the huge mortality benefit. It will be interesting to see if many of these patients end up developing new lung primaries and how those might be managed.

 

[RadOncDoc21]

Lung screening ought to increase detection of early lung cancers, most of which would end up getting surgical resection. These patients would otherwise have ended up with locally advanced/metastatic cancer at the time of diagnosis, so revenue wise it probably isn't the best for radiation oncologists. Way better for high-risk patients given the huge mortality benefit. It will be interesting to see if many of these patients end up developing new lung primaries and how those might be managed.

Don't we have to include Thoracic surgeons in the billing for SBRT as well? I thought I saw that somewhere in the new medicare billing (along with a decrease in reimbursements).

 

[radiaterMike]

Don't we have to include Thoracic surgeons in the billing for SBRT as well? I thought I saw that somewhere in the new medicare billing (along with a decrease in reimbursements).

There is a billing code that reimburses a thoracic surgeon or pulmonologist for their role in planning (akin to a neurosurgeon for SRS). Their involvement is not necessary though, and billing for their services would not subtract from the radiation oncology billing codes.

 

[Tanner]

I would assume we see less early stage prostate cancer, meaning less treatment, and less revenue. This may not necessarily be a bad thing for the patient population, but you have to accept that we will miss the window for cure in a few aggressive cases.

Seeing less low-risk prostate cancers and high-risk diseases at the time of diagnosis may not necessarily mean less treatment and less revenue. You may get to treat more with combined modality: ADT + IMRT, or postprostatectomy RT. You never know.

 

[deleted4401]

I think everyone's prostate numbers are down (from what I've seen/heard). It makes sense - there are a lot of patients who shouldn't be getting screened that are not getting screened, which is good for the general population, but bad for our revenues. I think more so than screening, the more current issue is active surveillance, which people are definitely recommending more often (particularly in academic centers, I don't think it's picked up in the community). The NCCN recommendation that selected women be recommended to be treated with hypofractionation for breast cancer is also directly affecting revenues (16 fx instead of 30-33 fx). Again, for many women, it is definitely the right call, we have good evidence for it. NCCN and ASTRO also push single fraction palliation for bone mets and more and more physicians are recommending it. There are two trials in rectal cancer that show that 25 Gy/5 fx may be as effective as 50.4 Gy/28fx with chemo, especially in those patients with tumors that would be resectable with LAR without downstaging (interesting how those are never mentioned, but we have one sh***y trial to hang our hats on for pancreatic cancer and it's still talked about in tumor boards).

Soo... anyway, these are all good things for patients, but hurts our bottom line, and maybe portends a move towards capitation. I hate that it even comes into our heads, but that's the thing. If there is more treatment/more revenue, it's adopted immediately. If it's less treatment/less revenue, it takes a lot longer to be adopted or it's the standard "with this fractional size, who knows what the late toxicity will be? (even after 10 years of follow up!)"

 

[Gfunk6]

Soo... anyway, these are all good things for patients, but hurts our bottom line, and maybe portends a move towards capitation. I hate that it even comes into our heads, but that's the thing. If there is more treatment/more revenue, it's adopted immediately. If it's less treatment/less revenue, it takes a lot longer to be adopted or it's the standard "with this fractional size, who knows what the late toxicity will be? (even after 10 years of follow up!)"

This rings very, very true with me. If revenue from a proposed intervention is less than the current standard, then it is sometimes amazing the song and dance radiation oncologists will perform to avoid the lower-reimbursed treatment under the pretense of, "well, we still need long-term data." However for IMRT/protons, there is a push for immediate implementation and any thought of producing category I evidence via a randomized trial would be "unethical" due to "proven dosimetric superiority."