Prostate biopsy and Rad Onc

[bachiraki]

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Dear SDN Rad Onc comminity,

Thanks a lot for your wonderful inputs, I have benefited a lot over the years!

My hospital admin has asked me if I can get credentialed for doing Prostate biopsy.
They would like to send prostate patients directly from PCPs to Rad Onc for further work up, staging and management to counter a Urorad group in town.

Are Rad Oncs eligible to do prostate biopsy? Do you know any Rad Onc doing Prostate Biopsy?
If so do anyone know credentialing requirements for doing prostate biopsy?

What are the legal risks associated with accepting responsibility of performing prostate biopsies?

Thanks a lot!

 

[medgator]

Dear SDN Rad Onc comminity,

Thanks a lot for your wonderful inputs, I have benefited a lot over the years!

My hospital admin has asked me if I can get credentialed for doing Prostate biopsy.
They would like to send prostate patients directly from PCPs to Rad Onc for further work up, staging and management to counter a Urorad group in town.

Are Rad Oncs eligible to do prostate biopsy? Do you know any Rad Onc doing Prostate Biopsy?
If so do anyone know credentialing requirements for doing prostate biopsy?

What are the legal risks associated with accepting responsibility of performing prostate biopsies?

Thanks a lot!

Hope you know how to manage prostatitis.

 

[OTN]

I would refer to IR for MRI-guided prostate bx. Good data for that.

 

[deleted774703]

Dear SDN Rad Onc comminity,

Thanks a lot for your wonderful inputs, I have benefited a lot over the years!

My hospital admin has asked me if I can get credentialed for doing Prostate biopsy.
They would like to send prostate patients directly from PCPs to Rad Onc for further work up, staging and management to counter a Urorad group in town.

Are Rad Oncs eligible to do prostate biopsy? Do you know any Rad Onc doing Prostate Biopsy?
If so do anyone know credentialing requirements for doing prostate biopsy?

What are the legal risks associated with accepting responsibility of performing prostate biopsies?

Thanks a lot!

Interesting they asked you. I personally would decline since I have no idea how to do it and no opportunity to learn. Good luck!

 

[deleted774703]

I would refer to IR for MRI-guided prostate bx. Good data for that.

Is it possible to do this, but make it to where Rad Onc has to be present for billing 😉

 

[BobbyHeenan]

I think the hospital would be better off hiring a super radiation friendly urologist if that's the end game. Or maybe a part time semi-retired guy (our practices best referrals come from end of career urologists that don't seem to want to operate).

However, there is some precedent, as I believe there are rad oncs out there who do prostate biopsies...or I have at least heard it as hearsay. More urology practices are switching to trans perineal too...

If you've got a set up to do spaceOAR, you can do prostate biopsies with some training IMO.

With that said, I'd have to be motivated to jump into the biopsy game.

 

[OTN]

I think the hospital would be better off hiring a super radiation friendly urologist if that's the end game. Or maybe a part time semi-retired guy (our practices best referrals come from end of career urologists that don't seem to want to operate).

However, there is some precedent, as I believe there are rad oncs out there who do prostate biopsies...or I have at least heard it as hearsay. More urology practices are switching to trans perineal too...

If you've got a set up to do spaceOAR, you can do prostate biopsies with some training IMO.

With that said, I'd have to be motivated to jump into the biopsy game.

There are radoncs who do prostate bx for sure.

If I were employed by a hospital, though, I would probably just let IR do it. Hospital won't care how their charges get there, you'll see increased RVUs via treating more prostate, and the IR docs should be pretty good at it, which would help the pt.

 

[medgator]

I think the hospital would be better off hiring a super radiation friendly urologist if that's the end game. Or maybe a part time semi-retired guy (our practices best referrals come from end of career urologists that don't seem to want to operate)..

I've seen hospitals do exactly that. Makes the most sense to me

 

[bachiraki]

Thanks a lot everyone for your input, I will talk to my hospital IR guys.

 

[scarbrtj]

Dear SDN Rad Onc comminity,

Thanks a lot for your wonderful inputs, I have benefited a lot over the years!

My hospital admin has asked me if I can get credentialed for doing Prostate biopsy.

Credentialing is a bear. You almost certainly can't get credentialed unless you have had some "training" and done a few biopsies. Imagine what it would take to get a urologist credentialed to do external beam radiation in the hospital e.g.

They would like to send prostate patients directly from PCPs to Rad Onc for further work up, staging and management to counter a Urorad group in town.

That should go over great.

Are Rad Oncs eligible to do prostate biopsy? Do you know any Rad Onc doing Prostate Biopsy?
If so do anyone know credentialing requirements for doing prostate biopsy?

Eligibility and credentialing are two different things. With a medical license, you are eligible to practice medicine and surgery in your state. For example, family practice docs deliver babies, do some minor surgeries, etc. An ENT might do a dental extraction or two during an oral cancer surgery even though an ENT is not a dentist. So, yeah, you're eligible to do anything. But that's not credentialing. Insurance companies may not pay for that prostate biopsy by a rad onc. Also, you'd need new malpractice insurance.

What are the legal risks associated with accepting responsibility of performing prostate biopsies?

"So in summary your honor, my client who lost his penis due to severe Fournier's gangrene as a devastating complication of prostate biopsy, was harmed at the hands of this careless physician with no training in urology whatsoever. How much does a penis cost? Well, it's priceless your honor. The penis is priceless."

 

[Mandelin Rain]

"So in summary your honor, my client who lost his penis due to severe Fournier's gangrene as a devastating complication of prostate biopsy, was harmed at the hands of this careless physician with no training in urology whatsoever. How much does a penis cost? Well, it's priceless your honor. The penis is priceless."

Bingo. Also delay in diagnosis concerns if you miss the disease a couple times.

 

[Aphtalyfe]

If you do brachytherapy it shouldn't be hard to do or learn to do a systematic trans-perineal prostate biopsy. We would be doing them at my facility if it weren't for the likelihood of angering urology. It seems like you have the opposite problem though.

Also IR/MRI prostate biopsies are typically target lesion only and not systematic... Or at least the ones I've seen so far.

 

[RadRadRad]

I would refer to IR for MRI-guided prostate bx. Good data for that.

100% agree. Nejm paper on mri guided vs random biopsy done is compelling and should be easy sell to pcp’s...

 

[medgator]

If you do brachytherapy it shouldn't be hard to do or learn to do a systematic trans-perineal prostate biopsy. We would be doing them at my facility if it weren't for the likelihood of angering urology. It seems like you have the opposite problem though.

Also IR/MRI prostate biopsies are typically target lesion only and not systematic... Or at least the ones I've seen so far.

Isn't a standard 12 core biopsy of the bilateral prostate done transrectally? We used to place fiducials that way until space oar required the transperineal approach

 

[Reaganite]

Dear SDN Rad Onc comminity,

Thanks a lot for your wonderful inputs, I have benefited a lot over the years!

My hospital admin has asked me if I can get credentialed for doing Prostate biopsy.
They would like to send prostate patients directly from PCPs to Rad Onc for further work up, staging and management to counter a Urorad group in town.

Are Rad Oncs eligible to do prostate biopsy? Do you know any Rad Onc doing Prostate Biopsy?
If so do anyone know credentialing requirements for doing prostate biopsy?

What are the legal risks associated with accepting responsibility of performing prostate biopsies?

Thanks a lot!

I'm as aggressive as it gets when it comes to competing with hospitals, urorads, etc. for business. I've also encountered nearly every competitive scenario over the years. I've considered various ways to market to PCPs. In some cases it can work, but this is a lost cause in my opinion. It makes no sense for a PCP to send every elevated PSA to a rad onc for biopsy. I hate to even give this advice, but the hospital is better off somehow encouraging their loyal PCPs to take ownership of their cancer patients and insist they all go to you. At the end of the day, it's the PCPs patient.

 

[medgator]

I'm as aggressive as it gets when it comes to competing with hospitals, urorads, etc. for business. I've also encountered nearly every competitive scenario over the years. I've considered various ways to market to PCPs. In some cases it can work, but this is a lost cause in my opinion. It makes no sense for a PCP to send every elevated PSA to a rad onc for biopsy. I hate to even give this advice, but the hospital is better off somehow encouraging their loyal PCPs to take ownership of their cancer patients and insist they all go to you. At the end of the day, it's the PCPs patient.

Qft. I actually get referrals from specialists based on PCP preference.

Pcps will also send patients over for second opinions after the gu talks about cryo/RP etc

 

[deleted605854]

I do know a few rad onc colleagues in the magical land known as Canada who do Prostate biopsies. Mind you though, rad onc over there admits inpatients to their service and will manage the complications, if any, of said biopsies.

Canadian medical practice isn't as over encumbered with medical malpractice suits as its US counterpart. Not yet anyways.

 

[evilbooyaa]

Agree with MRI guided biopsy. You won't be able to use percent positive cores as a stratification tool without a full sextant biops FWIW.

 

[cpants]

I feel like you guys could learn the technical skills to do a biopsy, but I'm not sure this is a can of worms you want to open. Do you really want to be seeing elevated PSA consults? Many if not most elevated PSA consults do not lead to a prostate biopsy and then radiation therapy which is the concept here from the hospital admins standpoint. Many/most elevated PSA patients end up being followed for years without a cancer diagnosis or end up on active surveillance for low risk cancers.

Also, expect the local urologists to be not happy and don't expect a lot of help dealing with prostatitis, sepsis, hematuria, etc. after you start doing a lot of biopsies. Would you get admitting privileges?

 

[taserlaser]

I feel like you guys could learn the technical skills to do a biopsy, but I'm not sure this is a can of worms you want to open. Do you really want to be seeing elevated PSA consults? Many if not most elevated PSA consults do not lead to a prostate biopsy and then radiation therapy which is the concept here from the hospital admins standpoint. Many/most elevated PSA patients end up being followed for years without a cancer diagnosis or end up on active surveillance for low risk cancers.

Also, expect the local urologists to be not happy and don't expect a lot of help dealing with prostatitis, sepsis, hematuria, etc. after you start doing a lot of biopsies. Would you get admitting privileges?

To be fair, where I’m at IR does the biopsies (and especially the targeted ones) and no shade at the IR guys but I’ve never seen them admit anyone for complications.

 

[Aphtalyfe]

Isn't a standard 12 core biopsy of the bilateral prostate done transrectally? We used to place fiducials that way until space oar required the transperineal approach

Yes but most radoncs are more comfortable with transperineal procedures. Also the chance of infection is less transperineal when compared to transrectal. I think transperineal is better for anterior disease too.

 

[medgator]

Yes but most radoncs are more comfortable with transperineal procedures. Also the chance of infection is less transperineal when compared to transrectal. I think transperineal is better for anterior disease too.

Transrectal fiducial placement went a lot quicker for us, required less set up and anesthesia for the pt, but it clearly is a higher risk procedure for the pt.

Agree that the transperineal approach should feel normal if you've done a lot of brachy already