Lung SBRT sans biopsy

[Ray D. Ayshun]

Probably discussed before, but there are certain instances where imaging findings and history are such that various nodule nomograms would say >95% chance a particular nodule is NSCLC. I'm wondering how often people are treating with no meat, whether there's a greater risk to biopsy than SBRT, or simply patient refusal, and how you're coding this, as in, as a clinical dx of lung cancer or as a pulm nodule. I'm also not infrequently seeing patients who had a pneumo after a nondiagnostic biopsy.

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[HolySmokes]

I treat empirically fairly often. I still code it as malignant neoplasm of LUL or whatever it may be and put the nomogram in the note showing high probability of malignancy. So far I haven't had any denials

 

[Ray D. Ayshun]

I treat empirically fairly often. I still code it as malignant neoplasm of LUL or whatever it may be and put the nomogram in the note showing high probability of malignancy. So far I haven't had any denials

I have to some degree as well. My concern to a degree isn't getting it approved up front, but having some issue on audit.

 

[medgator]

Probably half my cases at this point... I always get (and document) CT surgery or pulm input depending on who referred the pt.

We both will agree that poor fev1/pt refusal to take risk, inability to put to sleep (for ebus), or extensive lung blebbing (for CT guided bx) etc are issues for why we skipped biopsy in that case along with documentation of progression on imaging, pet findings etc.

 

[medgator]

I have to some degree as well. My concern to a degree isn't getting it approved up front, but having some issue on audit.

Haven't run into that yet

 

[RickyScott]

I think in the some of the studies up to half pts didn’t have path.

 

[communitydoc13]

Same as above. No refusals to date. Coding as clinical diagnosis of stage I lung CA. High risk on nomogram combined with confirmation of growth is enough for me in most circumstances.

I usually will not treat without biopsy based on a single date of imaging (or within weeks) even with strong PET avidity as multiple non-pathologic processes can mimic malignancy acutely.

 

[medgator]

I think in the some of the studies up to half pts didn’t have path.

Supposedly Japan they skip bx quite often and treat SBRT equal to surgery?

 

[RADONC4285]

I have to some degree as well. My concern to a degree isn't getting it approved up front, but having some issue on audit.

I think if you document what others suggested, then you're protected even if there is an audit. It's always a good idea to discuss at tumor board if possible and document "there was consensus" the nodule is most likely malignant.

 

[madchemist89]

I code as cancer, but I only treat these patients if they refuse biopsy or there is a contraindication. If it is contraindicated, I make sure it is documented as such.

 

[sirspamalot]

Audit by.. whom exactly? Your payor paid if they accepted the code. Your internal QA audit? Some magical ASTRO elf?

 

[NotMattSpraker]

I code as cancer, but I only treat these patients if they refuse biopsy or there is a contraindication. If it is contraindicated, I make sure it is documented as such.

Clinically it is very reasonable to treat without path, especially if you are using a nomogram to try to put a number on the risk of malignancy and make sure the patient is comfortable.

At my old job, we would get push back from billing unless we explicitly called it "radiographically apparent lung cancer". Now I do it by habit so I do not know if this is made up or locoregional preference or what.

I code it and stage it as early stage lung cancer.

 

[Ray D. Ayshun]

Audit by.. whom exactly? Your payor paid if they accepted the code. Your internal QA audit? Some magical ASTRO elf?

I don't even know, but it made me think of this

Can't tell if it's my filter blocking me, but it's Joe Pesci doing a "they F you at the drive thru" monologue from Lethal Weapon 2.

 

[evilbooyaa]

Don't spend your life worrying about audits. Do good, ethical, SOC stuff and leave the rest up to your preferred divine entity (or entropy).

I don't put the nomogram. I usually document growth over time, favor some spiculations in the mass rather than purely circular (for stage I NSCLC at least), PET/CT avidity x 1, and discussion of biopsy and either shared decision making with patient or multi-disciplinary discussion that biopsy is not warranted. Document risk that the nodule to be SBRT'd may not be lung cancer.

Beam on.

 

[sirspamalot]

Don't spend your life worrying about audits. Do good, ethical, SOC stuff and leave the rest up to your preferred divine entity (or entropy).

I don't put the nomogram. I usually document growth over time, favor some spiculations in the mass rather than purely circular (for stage I NSCLC at least), PET/CT avidity x 1, and discussion of biopsy and either shared decision making with patient or multi-disciplinary discussion that biopsy is not warranted. Document risk that the nodule to be SBRT'd may not be lung cancer.

Beam on.

 

[metallica81788]

Don't be a pansy, beam on
MD = make decisions

Surgeons have done worse for less

 

[OTN]

I've treated presumed NSCLC with no tissue. No problem at all, just make sure to document proper consent. I don't give a flying f at the moon about any possible audit.

 

[Ray D. Ayshun]

This is essentially an asking forgiveness not permission type thread. Just looking back at this year's sbrts and noticing about a third weren't biopsied. Partly because Pulm is now telling them to get SBRT and a biopsy probably isn't a good idea as opposed to all the things that used to happen. It's a good thing I think, just evolving and want to make sure I'm not being weird about it.

 

[seper]

Audit by whom? I code these as a malignant neoplasm of the lung and state in the note that it is clinically diagnosed. Zero risk

 

[medgator]

Pulm is now telling them to get SBRT and a biopsy probably isn't a good idea

Probably most common scenario i see. Pulm is literally referring these pts to me saying exactly that when they don't think they can ebus, feel the ptx-risk with CT guided bx is too high and know pt is too high risk to get cut. Often they have already seen these patients a few times longitudinally and have imaging to support the story

 

[Ray D. Ayshun]

Probably most common scenario i see. Pulm is literally referring these pts to me saying exactly that when they don't think they can ebus, feel the ptx-risk with CT guided bx is too high and know pt is too high risk to get cut. Often they have already seen these patients a few times longitudinally and have imaging to support the story

Yeah, it's straightforward, and I love it. I think I've already sbrtd as many lungs this year as I did last year.

 

[RSAOaky]

I do it very often. We discuss at our tumor boards that this is likely malignant, we discuss that it is either amenable to biopsy or high risk of biopsy, a discussion is then had with the patient regarding the risks and benefits of biopsy, and most of them refuse. I then see them in consultation and discuss the pros and cons. I document something like this:

We discussed that Mrs. XYZ has a progressively enlarging and PET avid lung mass which, given her significant smoking history, is highly suspicious for malignancy. She understands that without a biopsy there is no way to know for certain that this represents a primary lung cancer, and that as often as 20% of the time lesions with a high index of suspicion turn out to be something other than the expected pathology, including benign diseases or diseases that may be managed differently. She understands that in agreeing to pursue treatment, she acknowledges that there may be side effects of treatment incurred with no benefit.

 

[Burt Radnolds]

If they don't have to, then we don't. They do recommend wedge or intraoperative sampling in these instances prior to lobectomy (if going that route), but SBRT is just a functional wedge anyways...

 

[TheWallnerus]

We discussed that Mrs. XYZ has a progressively enlarging and PET avid lung mass which, given her significant smoking history, is highly suspicious for malignancy

A “bittersweet” offshoot of smoking rates plummeting is that relying on a PETs over time and clinical info will offer lower positive predictive values for non small cell lung cancer.

 

[madchemist89]

A “bittersweet” offshoot of smoking rates plummeting is that relying on a PETs over time and clinical info will offer lower positive predictive values for non small cell lung cancer.

We can always depend on you to offer a ray of sunshine 🌞.

 

[Fpg1245]

A “bittersweet” offshoot of smoking rates plummeting is that relying on a PETs over time and clinical info will offer lower positive predictive values for non small cell lung cancer.

I thank all my lung patients for smoking.

 

[medgator]

I thank all my lung patients for smoking.

 

[salubalu]

If you do not want to biopsy but want to add cost to the healthcare system you can get Nodify testing. A blood test that gives a risk of malignancy. No I do not own stock...

Nodify Lung®: Nodule Risk Assessment | Biodesix

Nodify Lung testing consists of blood-based proteomic tests designed to help providers quickly and confidently decipher the risk of malignancy of a lung nodule.

www.biodesix.com

 

[RSAOaky]

A “bittersweet” offshoot of smoking rates plummeting is that relying on a PETs over time and clinical info will offer lower positive predictive values for non small cell lung cancer.

As a glass half full kind of guy. The flipside is that my cure rate for benign lung nodules is 100% and that makes my patients very happy!

 

[evilbooyaa]

A “bittersweet” offshoot of smoking rates plummeting is that relying on a PETs over time and clinical info will offer lower positive predictive values for non small cell lung cancer.

So?

What matters is the percentage of time that empiric SBRT works.

Empiric SBRT works more frequently when what you are radiating is NOT cancer.

You're gonna do the Empiric SBRT regardless of baseline levels of smoking in the patient popoulation of the US as a whole, because this is patient-centered, PRECISION medicine.

So the less smokers there are, the more false positive PETs you treat, and the better patients do. Win/Win/Win.

 

[TheWallnerus]

So?

What matters is the percentage of time that empiric SBRT works.

Empiric SBRT works more frequently when what you are radiating is NOT cancer.

You're gonna do the Empiric SBRT regardless of baseline levels of smoking in the patient popoulation of the US as a whole, because this is patient-centered, PRECISION medicine.

So the less smokers there are, the more false positive PETs you treat, and the better patients do. Win/Win/Win.

Ha. Your logic doesn’t work if we consider irradiating normal lung because of a non malignant condition a “win.” Win for rad onc maybe but not the patient. To follow this logic to… its logical conclusion, all newly radiographically diagnosed lung nodules should be SBRT’d. Now. Today.

 

[communitydoc13]

As a glass half full kind of guy. The flipside is that my cure rate for benign lung nodules is 100% and that makes my patients very happy!

Not willing to go this far. Pretty sure I've radiated some benign nodules and caused "treatment related changes" on f/u imaging that could be confused for progression and resulted in expensive PET imaging, or unnecessary biopsy, or at least patient anxiety.

Yes, none of the benign nodules that I have likely radiated died from cancer arising from that benign nodule.

 

[evilbooyaa]

Ha. Your logic doesn’t work if we consider irradiating normal lung because of a non malignant condition a “win.” Win for rad onc maybe but not the patient. To follow this logic to… its logical conclusion, all newly radiographically diagnosed lung nodules should be SBRT’d. Now. Today.

Agreed if you take it to the extreme (who said anything about that?). But, for an individual patient who otherwise has a nodule that meets criteria based on our current understanding of 'empiric SBRT' (not bending the rules to make something else count), then the patient, who thinks he has an 80% chance of having cancer, is re-assured.

There are many a nodule that are large on CT and not bright on PET and those don't get treated so there is a process that we have, and we can stop being our own worst enemy trying to proactively poke holes in the process simply for self-flagellation purposes.

 

[sirspamalot]

At some point, we have to stop the madness right? I say we go the other direction: if it looks suspicious, it looks delicious.. for SBRT.

 

[Ray D. Ayshun]

At some point, we have to stop the madness right? I say we go the other direction: if it looks suspicious, it looks delicious.. for SBRT.

No meat? No? Treat!

It's all a matter of punctuation.

 

[TheWallnerus]

No meat? No? Treat!

It's all a matter of punctuation.

Eats shoots and leaves