Most cost effective prostate ultrasound set up.

[johnbeck]

I work in a small community practice and would like to start inserting SpaceOARs in my prostate patients. The problem is we do not have a ton of money to throw at the latest and greatest prostate ultrasound and stepper unit. It is a touch sell to administration as SpaceOARs do not reimburse well (yet)... Eventually, we would like to use the ultrasound and stepper for prostate brachy as well.

Is there an aftermarket for these things? If not, what have you purchased (with cost in mind)? Thanks in advance, guys!

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[medgator]

In some areas, there are companies who come out to your office and charge a flat fee for the ultrasound machine and accompanying technician.

Another option is try and work with your urologists? Might be a way to generate more referrals by having them do it

SpaceOAR will have its own code next year from CMS...should improve reimbursement picture

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[scarbrtj]

Anyone willing to expound on the pros/cons re: SpaceOAR. I have a ~1% rectal toxicity rate in my prostate patients with IG-IMRT. I worry the risk/benefit ratio will be too thin to see a benefit from inserting a large sized (as compared to fiducials) foreign object into the body.

 

[Mandelin Rain]

Anyone willing to expound on the pros/cons re: SpaceOAR. I have a ~1% rectal toxicity rate in my prostate patients with IG-IMRT. I worry the risk/benefit ratio will be too thin to see a benefit from inserting a large sized (as compared to fiducials) foreign object into the body.

Ask the SpaceOAR reps to give a presentation and they'll tell you it will not only eliminate the 15% rectal toxicity you're "actually" currently seeing, but also decrease urinary toxicity (somehow, by pushing the prostate anteriorly into the bladder), and will increase potency.

True story.

When they went into the potency "data" I just kind of laughed and told them they should market it in the same space as Viagra, but that I now didn't believe a single word they said.

Pro is your rectal DVH will be better.

Con is you have to implant it, and HAVE to plan on MRI. CBCTs become difficult to interpret without fiducials, so I think you need them as well. I'm assuming there are no deleterious effects of implanting a dissolving hydrogel 20 years down the road, but who the hell knows?

Best use I see for it is after a seed implant. You're in there anyway with the whole setup. Might as well just place it at that time. Maybe before SBRT, though, if you have a man willing to undergo a TRUS and needle insertion of a foreign body via the perineum prior to SBRT... why wouldn't you just put in about 24 more needles and leave behind 120 or so seeds?

FWIW, I would never begrudge someone for doing it. I just have never viewed my late rectal toxicity as an issue (knock on wood), at least not above the risk of an additional invasive procedure (anesthesia, infection, bleeding, whatever...).

 

[BobbyHeenan]

Ask the SpaceOAR reps to give a presentation and they'll tell you it will not only eliminate the 15% rectal toxicity you're "actually" currently seeing, but also decrease urinary toxicity (somehow, by pushing the prostate anteriorly into the bladder), and will increase potency.

True story.

When they went into the potency "data" I just kind of laughed and told them they should market it in the same space as Viagra, but that I now didn't believe a single word they said.

Pro is your rectal DVH will be better.

Con is you have to implant it, and HAVE to plan on MRI. CBCTs become difficult to interpret without fiducials, so I think you need them as well. I'm assuming there are no deleterious effects of implanting a dissolving hydrogel 20 years down the road, but who the hell knows?

Best use I see for it is after a seed implant. You're in there anyway with the whole setup. Might as well just place it at that time. Maybe before SBRT, though, if you have a man willing to undergo a TRUS and needle insertion of a foreign body via the perineum prior to SBRT... why wouldn't you just put in about 24 more needles and leave behind 120 or so seeds?

FWIW, I would never begrudge someone for doing it. I just have never viewed my late rectal toxicity as an issue (knock on wood), at least not above the risk of an additional invasive procedure (anesthesia, infection, bleeding, whatever...).

This has been my exact experience as well - ie reps being really over the top with benefits and my personal practice not seeing much in the way of rectal toxicity to justify it.

However, the trial data is pretty impressive (to the point that I too like the original poster am thinking about doing it or having urology do it in some case)...but I couldn't find on the trial the margins used anywhere and have not seen the protocol. Anyone have any input here?

I personally use 7 mm/4mm posterior (as how I was trained as well) with daily IGRT (typically CBCT) and see minimal rectal toxicity.

 

[nkmiami]

Anyone willing to expound on the pros/cons re: SpaceOAR. I have a ~1% rectal toxicity rate in my prostate patients with IG-IMRT. I worry the risk/benefit ratio will be too thin to see a benefit from inserting a large sized (as compared to fiducials) foreign object into the body.

I think the actual injection of spacer oar should be defined as Grade 1-2 toxicity.

 

[Gfunk6]

Our Rad Oncs only use SpaceOAR in cases with high-risk of rectal toxicity like h/o Crohn's/UC.

Agree with VMAT + high-def MLCs we see pretty minimal rectal toxicity even with hypofractionation.

 

[Haybrant]

Any more people using SpaceOAR recently? Do you absolutely have to do MRI after for planning? The reps claim you can CT 24-48 hours after insertion and you can make out the gel in that short time frame - the pictures they provided did make it seem possible to see the gel on CT in that time frame (airpockets in the gel) but not after. Our urologists want to place it and we're interested in building some experience before considering SBRT in the future. Thanks

 

[Gfunk6]

Now that Medicare covers SpaceOAR we are starting to use it more and more. Like you, we are on the cusp of implementing SBRT prostate which will certainly cause SpaceOAR utliziation to take off.

 

[Haybrant]

Now that Medicare covers SpaceOAR we are starting to use it more and more. Like you, we are on the cusp of implementing SBRT prostate which will certainly cause SpaceOAR utliziation to take off.

Thanks Gfunk. So You guys getting planning MRI for all EBRT patients with spaceOAR?

 

[Gfunk6]

Yes

 

[Reaganite]

Any more people using SpaceOAR recently? Do you absolutely have to do MRI after for planning? The reps claim you can CT 24-48 hours after insertion and you can make out the gel in that short time frame - the pictures they provided did make it seem possible to see the gel on CT in that time frame (airpockets in the gel) but not after. Our urologists want to place it and we're interested in building some experience before considering SBRT in the future. Thanks

I've had cases where the gel was very clear on CT. In other instances it was impossible to delineate. I always get MRI. Make sure you tell your uros not to do it on patients with contraindications to MRI! It's happened to me twice this month, and basically the procedure was a waste because I couldn't make out gel vs. prostate.

 

[Haybrant]

I've had cases where the gel was very clear on CT. In other instances it was impossible to delineate. I always get MRI. Make sure you tell your uros not to do it on patients with contraindications to MRI! It's happened to me twice this month, and basically the procedure was a waste because I couldn't make out gel vs. prostate.

Good call, very important! So within the 24-48 window there are cases you can’t tell on CT? Or were all those cases ones where it was after that window.

 

[RickyScott]

Look, I initially rejected space oar as BS, along the lines of protons, but it is actually a great way to motivate urologists to send patients in a hospital employed model. Our department buys the space oar, their department gets to bill the 4000 for the combined code....(more than proffesional fee on prostatectomy?

 

[medgator]

Look, I initially rejected space oar as BS, along the lines of protons, but it is actually a great way to motivate urologists to send patients in a hospital employed model. Our department buys the space oar, their department gets to bill the 4000 for the combined code....(more than proffesional fee on prostatectomy?

Fiducials also. I find fiducials to be far more efficient than daily cbct for machine throughout plus it keeps the urologists involved (when they want to place them, sometimes they don't)

 

[BobbyHeenan]

Fiducials also. I find fiducials to be far more efficient than daily cbct for machine throughout plus it keeps the urologists involved (when they want to place them, sometimes they don't)

My urology referring docs could care less about fiducials and at times are downright negative about them. They're relatively XRT friendly, but really don't like doing fiducials it seems for whatever reason.

 

[medgator]

My urology referring docs could care less about fiducials and at times are downright negative about them. They're relatively XRT friendly, but really don't like doing fiducials it seems for whatever reason.

Yup... it's really odd to me actually. It's a quick and easy procedure if they already have the TRUS and they can bill for the u/s and placement. I end up doing them (and giving ADT) when the urologists aren't interested

 

[cancer_doc]

Yup... it's really odd to me actually. It's a quick and easy procedure if they already have the TRUS and they can bill for the u/s and placement. I end up doing them (and giving ADT) when the urologists aren't interested

Payment for fiducial placement in freestanding clinics is poor. they barely break even for the basic markers, and lose $$ if they place Calypsos. The 55876 code pays the same whether you place 3 or 6 markers. Thus most independent urologists come out barely ahead, so most don't see it as worth their while to place them, unless they own a piece of the IMRT revenue.....

 

[medgator]

Payment for fiducial placement in freestanding clinics is poor. they barely break even for the basic markers, and lose $$ if they place Calypsos. The 55876 code pays the same whether you place 3 or 6 markers. Thus most independent urologists come out barely ahead, so most don't see it as worth their while to place them, unless they own a piece of the IMRT revenue.....

Even after billing for the fiducials themselves? That's a different code I thought

 

[Reaganite]

Look, I initially rejected space oar as BS, along the lines of protons, but it is actually a great way to motivate urologists to send patients in a hospital employed model. Our department buys the space oar, their department gets to bill the 4000 for the combined code....(more than proffesional fee on prostatectomy?

There is no kickback issue in this scenario?

 

[medgator]

There is no kickback issue in this scenario?

How? They're doing the procedure and billing for it, as long as the gel isn't bundled in with that code.

Now if it is....

 

[Reaganite]

How? They're doing the procedure and billing for it, as long as the gel isn't bundled in with that code.

Now if it is....

Pretty sure it is...

 

[RickyScott]

How? They're doing the procedure and billing for it, as long as the gel isn't bundled in with that code.

No because everyone is employed. it really shouldnt matter what cost center it comes out of. Urologists just get the RVUS, but numbers make their department look good. Hospital keeps all proffesional and technical fees. In private practice, if I buy the stuff for 2.0k and someone else bills for it, that is a different story...because I am basically giving a 2k inducement. I know of one academic center where this has really caught on and I suspect for this reason.

 

[cancer_doc]

Even after billing for the fiducials themselves? That's a different code I thought

Yes. The fiducial marker code is different from the procedure charge (55876). The code does not differentiate between gold seeds, visicoils, Calypso transponders, etc, and the reimbursement to an ASC or physician office is much lower that what is paid to a hospital. The procedure charge is chump change.

 

[medgator]

No because everyone is employed. it really shouldnt matter what cost center it comes out of. Urologists just get the RVUS, but numbers make their department look good. Hospital keeps all proffesional and technical fees. In private practice, if I buy the stuff for 2.0k and someone else bills for it, that is a different story...because I am basically giving a 2k inducement. I know of one academic center where this has really caught on and I suspect for this reason.

Yes. The fiducial marker code is different from the procedure charge (55876). The code does not differentiate between gold seeds, visicoils, Calypso transponders, etc, and the reimbursement to an ASC or physician office is much lower that what is paid to a hospital. The procedure charge is chump change.

Once again shows how things are stacked in favor of hospital-owned radiation

 

[RickyScott]

Once again shows how things are stacked in favor of hospital-owned radiation

yes and no. In a large employed, hospital setting, urologists are always going to be heavily incentivized to operate because 1) spending time with the robot is what they love to do- I know plenty who would happily rope in homeless/charity cases if the hospital would let them. (and need to get cases for residents) 2) that maximizes RVUS.

Private practice/ freestanding centers, can offer urologists chance to be an operating partner/employee like 21c that kicks back significant revenue to them. NEJM - Error, or what probably happens in some markets: frank under the table, bribery

 

[cancer_doc]

You are missing the point. Payment to hospital is generally disproportionately higher compared to outpatient/freestanding centers for the exact same procedure or RT treatment.

 

[seper]

But in a hospital you have to compete hard with crazy employed urologists robotisizing everything... I've been there.

 

[medgator]

But in a hospital you have to compete hard with crazy employed urologists robotisizing everything... I've been there.

If you have a hospital tumor board, you at least get a crack at it.... Not happening in PP unless patients look you up or the urologists own a piece.

 

[RickyScott]

You are missing the point. Payment to hospital is generally disproportionately higher compared to outpatient/freestanding centers for the exact same procedure or RT treatment.

That is absolutely true.

 

[Gfunk6]

If you have a hospital tumor board, you at least get a crack at it.... Not happening in PP unless patients look you up or the urologists own a piece.

Or unless you own the urologists

 

[medgator]

Or unless you own the urologists

More like the group does? Or everyone owns as piece? Having an independent multi-specialty group is the most viable way forward imo, with integrated ownership of linacs, imaging etc and even lab/path in some cases

 

[Gfunk6]

More like the group does? Or everyone owns as piece? Having an independent multi-specialty group is the most viable way forward imo, with integrated ownership of linacs, imaging etc and even lab/path in some cases

Precisely, that was tongue in cheek. We have an independent multi-specialty group which Urologists are a part of. We own multiple linacs, PET/CT scanners, MRI units, lab, chemo infusion, real estate, etc.