RO APM Dies!

[evilbooyaa]

What about if the person/place doing the EBRT is affiliated with the same practice/cancer center but at a different facility? Would that make a difference?

This, hyper-specific question, has been specified, on page 113 (comment) and page 114 (response) of https://innovation.cms.gov/media/document/specialty-care-models-rule:


"Comment: A commenter requested clarification on how RO participants will be defined if there are multiple sites of service during an episode. This commenter provided an example where a physician delivers EBRT in a freestanding setting and then chooses to deliver brachytherapy in the hospital outpatient department (HOPD) setting. This commenter asked whether the physician in this example would be considered a Dual participant such that there would be no technical component payment issued to the HOPD. This commenter suggested that CMS-5527-F 113 CMS should provide clarification regarding how these types of situations will be handled and reimbursed within the Model. "

"Response: As for the specific example the commenter presented, the freestanding radiation therapy center would be considered a Dual Participant for delivery of EBRT, and the HOPD delivering brachytherapy would bill traditional Medicare fee-for-service as described in section III.C.7. In the example described, FFS payments made to the HOPD would be considered duplicate payments during reconciliation as described in section III.C.11."

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[evilbooyaa]

Same practice participating in APM can perform both and charge APM for the first course and FFS for the second course. What is unclear to me is whether both the EBRT and brachy can or cannot be done by the same provider in the practice....

This is not correct as per my reading of the rules, see my reply above.

 

[BobbyHeenan]

This, hyper-specific question, has been specified, on page 113 (comment) and page 114 (response) of https://innovation.cms.gov/media/document/specialty-care-models-rule:


"Comment: A commenter requested clarification on how RO participants will be defined if there are multiple sites of service during an episode. This commenter provided an example where a physician delivers EBRT in a freestanding setting and then chooses to deliver brachytherapy in the hospital outpatient department (HOPD) setting. This commenter asked whether the physician in this example would be considered a Dual participant such that there would be no technical component payment issued to the HOPD. This commenter suggested that CMS-5527-F 113 CMS should provide clarification regarding how these types of situations will be handled and reimbursed within the Model. "

"Response: As for the specific example the commenter presented, the freestanding radiation therapy center would be considered a Dual Participant for delivery of EBRT, and the HOPD delivering brachytherapy would bill traditional Medicare fee-for-service as described in section III.C.7. In the example described, FFS payments made to the HOPD would be considered duplicate payments during reconciliation as described in section III.C.11."

Excuse my ignorance here, and thank you for reading this and going through it...

But is this saying that the EBRT place would have some "reconciliation" reduction of payments based upon how much FFS the brachy place collected? If so, that's a MASSIVE disencentive to refer for brachy. WE're going to be seeing wild west SBRT boosts in lieu of brachy referral or people just refusing to treat cervical cancer out in BFE because they'll recoup next no nothing once the brachy bill comes in.

 

[domestique]

Big talkers in Astro said they would seek an injunction if the APM came back dog****. It came back dog****.

 

[Irradi8or]

From my read of the final APM ruling, you should be fine with the combo EBRT + Brachy. CMS will pay APM rate to whomever gives the first course and FFS for the second. So in this setting, you (brachy) should be able to collect standard FFS.

Do you have a reference for this in the Final Rule?

Page 213: There will not be separate payment for multiple modalities in an episode that include brachy
Page 213: CMS acknowledges the billing complexity when separate RT providers and RT suppliers furnish the brachytherapy and EBRT and will address this in billing guidance provided to RO participants, but does not state that non-reconciled FFS is paid to the second provider in an episode.
Page 114: CMS confirms that in the scenario where a physician does EBRT in one setting then same physician does brachy in HOPD setting, the HOPD gets paid FFS, but those FFS payments made to the HOPD would be considered duplicate payments during reconciliation.

The spirit of the responses from CMS is overwhelmingly (over)confident in their bundled payment average payment pricing methodology, where they justify that everything is bundled into average cost pricing methodology, so the prices for the national base rates plus the 90% of your historical experience already accounts for the multiple modalities. Thus, according to them, the second participant should have payment as per FFS and the first should get that portion taken out of the bundle (i.e. reconciled). We definitely need clarification around the unique multi-modal scenarios (two separate PGPs involved with two separate TINs/CCNs; what happens when brachy is done in a PPS-exempt center or center outside the RO Model but EBRT done elsewhere in the RO Model; what happens when an academic center NOT in the RO Model starts with brachy boost then patient gets EBRT in a RO Model zip code by separate PGP and TIN?). However, wouldn't be surprised if CMS ends up saying that all second providers get FFS that are ultimately reconciled from bundle. Hope that is not the case for sure. Thanks for the info!

 

[cancer_doc]

This is not correct as per my reading of the rules, see my reply above.

The impression I got from your citation was that the same provider in a practice that participates in APM cannot do both the EBRT and brachy. Good detective work, nonetheless.

On pages 324-325, it specifies whether different providers are performing the EBRT and brachy. My read was one bills APM and the other bills FFS....

"
Comment: A commenter requested clarification on billing when one physician provides EBRT and a different physician, either co-located in the same facility or in a different facility, provides brachytherapy services. The commenter wanted clarification on when the brachytherapy physician would be considered part of the RO Model and when the brachytherapy physician would be paid FFS. A commenter requested that CMS provide clarification regarding how the agency will handle a second claim for a case that has already received an episodic payment associated with a second physician who bills the brachytherapy insertion codes. The commenter stated that accommodations should be made to pay the insertion codes at the FFS rate when a second physician is involved to prevent cash flow issues that could result if the second claim were held up as part of the RO Model reconciliation process.

Response: When RT services are furnished by an RO participant and a non-participant or when the PC is furnished by more than one Professional participant or Dual participant, or when the TC is provided by more than one Technical participant or Dual participant, these scenarios would be considered duplicate services. The RO beneficiary would remain under the care of the RO participant that initiated the PC and/or TC, and in many circumstances, the duplicate RT service would be a different modality than what is furnished by the RO participant. The RO participant(s) that bills the SOE and EOE claims would receive the bundled payment and the RT provider and/or RT supplier furnishing one or more duplicate RT services would bill claims using the designated modifier or condition code to indicate that they should be paid FFS. Thus, cash flow would not be affected by this. We encourage RO participants to access forthcoming instructions for billing RT services during the Model performance period provided by CMS through the Medicare Learning Network (MLN Matters) publications, model-specific webinars, and the RO Model website."

 

[Irradi8or]

The impression I got from your citation was that the same provider in a practice that participates in APM cannot do both the EBRT and brachy. Good detective work, nonetheless.

On pages 324-325, it specifies whether different providers are performing the EBRT and brachy. My read was one bills APM and the other bills FFS....

"
Comment: A commenter requested clarification on billing when one physician provides EBRT and a different physician, either co-located in the same facility or in a different facility, provides brachytherapy services. The commenter wanted clarification on when the brachytherapy physician would be considered part of the RO Model and when the brachytherapy physician would be paid FFS. A commenter requested that CMS provide clarification regarding how the agency will handle a second claim for a case that has already received an episodic payment associated with a second physician who bills the brachytherapy insertion codes. The commenter stated that accommodations should be made to pay the insertion codes at the FFS rate when a second physician is involved to prevent cash flow issues that could result if the second claim were held up as part of the RO Model reconciliation process.

Response: When RT services are furnished by an RO participant and a non-participant or when the PC is furnished by more than one Professional participant or Dual participant, or when the TC is provided by more than one Technical participant or Dual participant, these scenarios would be considered duplicate services. The RO beneficiary would remain under the care of the RO participant that initiated the PC and/or TC, and in many circumstances, the duplicate RT service would be a different modality than what is furnished by the RO participant. The RO participant(s) that bills the SOE and EOE claims would receive the bundled payment and the RT provider and/or RT supplier furnishing one or more duplicate RT services would bill claims using the designated modifier or condition code to indicate that they should be paid FFS. Thus, cash flow would not be affected by this. We encourage RO participants to access forthcoming instructions for billing RT services during the Model performance period provided by CMS through the Medicare Learning Network (MLN Matters) publications, model-specific webinars, and the RO Model website."

Not exactly. They state on Page 325 "these scenarios would be considered duplicate services" which means duplicate services get reconciled in the future reconciliation period, which is essentially taken out of the amount from the incorrect payment withhold (Page 454). So no, the FFS is not in addition to the bundle, it's just taken out of the bundle at a future date. That's what it appears to be at least based on the Final Rule as cited above

 

[evilbooyaa]

To the above - Duplicate services/claims is BAD in this and APM will do what it can to make sure it does not have to pay for duplicate services. The fact that two different physicians (Say RO#1 and RO#2) are billing for the same diagnosis will be something that gets reconciled. Reconciled = CMS takes money back from you. Maybe not immediately, but at some point in the future (thus cash flow not affected in regards to reimbursement of the initial bundled payment to RO #1). This is assuming that both zip codes are part of the 30% who do APM, I think?

What this means if one group is in an APM zip code and another one is not.... is to be determined.

 

[Irradi8or]

To the above - Duplicate services/claims is BAD in this and APM will do what it can to make sure it does not have to pay for duplicate services. The fact that two different physicians (Say RO#1 and RO#2) are billing for the same diagnosis will be something that gets reconciled. Reconciled = CMS takes money back from you. Maybe not immediately, but at some point in the future (thus cash flow not affected in regards to reimbursement of the initial bundled payment to RO #1). This is assuming that both zip codes are part of the 30% who do APM, I think?

What this means if one group is in an APM zip code and another one is not.... is to be determined.

Well, we need clarification on that last point, but CMS is pretty clear on page 325: these are duplicate services even "when RT services are furnished by an RO participant and a non-participant"

Thoughts?

 

[evilbooyaa]

Well, we need clarification on that last point, but CMS is pretty clear on page 325: these are duplicate services even "when RT services are furnished by an RO participant and a non-participant"

Thoughts?

You're right, missed that. But will they deduct money from a participant and give it to a non-participant FFS physician and hospital?
What if the FFS charges from hospital Y are more than the bundled payment provided to Hospital X?

 

[Irradi8or]

You're right, missed that. But will they deduct money from a participant and give it to a non-participant FFS physician and hospital?
What if the FFS charges from hospital Y are more than the bundled payment provided to Hospital X?

Yes, this is where we need more clarification. In general, CMS (I think) is saying that the RO participant gets the bundle (PC to PGP, TC to Technical Participant, PC and TC to a Dual Participant). If there's a second provider (different TIN/CCN) in that episode, that second participant is going to get FFS. In the short run, there's no impact to cash flow for either participant (bump up in cash flow for RO participant who gets the whole bundle), BUT the RO Model participant will get that amount of FFS reconciled the following year from incorrect payment amounts (or have to pay money back to CMS if amount reconciled is more than amount withheld in incorrect payments) - answers your question above.

So then major questions arise like:

1) What if that second participant was a PPS-exempt cancer center and what if they have sky high FFS rates (like MDACC)? PPS-exempt centers were not part of the creation of a baseline national base rate, and the unit rates for the national base rates are from PFS/OPPS. Even if a chosen RO model center was consistently sending their cases for brachy boost to a PPS-exempt center in the baseline period, were all of those higher FFS costs captured accurately in their historical costs? It would certainly make someone think about sending to lower cost secondary participant

2) What if a non-participant does the brachy boost first (like UCLA, MSKCC, and few others do), but then a RO model participant starts the EBRT? Technically, the RO Model includes all costs for 90 days after 77261-77263, but this would seem to get triggered by RO Model partipant, which would NOT include previous FFS brachy boost the academic did. Thus, would the brachy boost not get reconciled as those costs didn't fall within the 90 days after RO participant triggered the bundle? Assume the monitor for the RO Model would keep track of these situations

3) Any many, many other complex situations that arise in the real world where multi-modal, complex cancer care is needed, but not explicitly covered in this bundled model

 

[Irradi8or]

Helpful website in case you want to check to see if you're in the RO Model or look at the Zip codes, cities, counties, and states in the model:

Bayta Systems Disclaimer

www.bayta.us

 

[metallica81788]

And with how much IO costs compared to RT, if CMS made this rule to apply to med onc/IO, imagine how much they would really save despite perseverating over the pennies they save with RT...

But it's a CHANCE TO LIVE LONGER how dare you take that away or make people pay for it

 

[scarbrtj]

CMS to push back radiation oncology model after industry blowback

Agency administrator Seema Verma said a six-month delay will be formalized via upcoming rulemaking because "more time is needed to prepare."

www.medtechdive.com

 

[Chartreuse Wombat]

CMS to push back radiation oncology model after industry blowback

Agency administrator Seema Verma said a six-month delay will be formalized via upcoming rulemaking because "more time is needed to prepare."

www.medtechdive.com

Sad that ASTRO is referred to as a trade group rather than a scientific society.

 

[medgator]

Sad that ASTRO is referred to as a trade group rather than a scientific society.

Urorads and supervision fights probably didn't help their image

 

[cancer_doc]

Not exactly. They state on Page 325 "these scenarios would be considered duplicate services" which means duplicate services get reconciled in the future reconciliation period, which is essentially taken out of the amount from the incorrect payment withhold (Page 454). So no, the FFS is not in addition to the bundle, it's just taken out of the bundle at a future date. That's what it appears to be at least based on the Final Rule as cited above

Uggh, good catch. This is going to be a sh&t show if they actually do not clarify this in the final implementation.

 

[Lamount]

Not to inject politics, but Biden wins, might there be another chance to stop APM? It seems like the RO APM is going to be relatively small potatoes in the broader healthcare budget concerns... and I wonder if a Biden administration would be comfortable dramatically reducing spending a major modality of cancer treatment.

 

[Chartreuse Wombat]

Not to inject politics, but Biden wins, might there be another chance to stop APM? It seems like the RO APM is going to be relatively small potatoes in the broader healthcare budget concerns... and I wonder if a Biden administration would be comfortable dramatically reducing spending a major modality of cancer treatment.

Who knows? Lots can change in the next few months. It appears that ASTRO is making a push to delay implementation. I work in a large academic practice with between 5 and 10 centers. Some are within the health system framework and some are outside the framework with individual contracts to provide professional service. Some of our practices are in (and some are out). I am incredulous that CMS would give us less than 4 months to figure this all out in the midst of a pandemic that has already changed the way we work. I hope that enough radiation oncologists make their voices heard and we can somehow delay implementation (but I am not optimistic)

 

[seper]

Doesn’t it only affect straight Medicare patients (always a minority)?

 

[Chartreuse Wombat]

Doesn’t it only affect straight Medicare patients (always a minority)?

Two points-
Commercial insurance often follows CMS
Medicare for all....

 

[medgator]

Not to inject politics, but Biden wins, might there be another chance to stop APM? It seems like the RO APM is going to be relatively small potatoes in the broader healthcare budget concerns... and I wonder if a Biden administration would be comfortable dramatically reducing spending a major modality of cancer treatment.

Yes, very possible imo. Azar was a big pharma swamp crony who probably doesn't see the value of RO and originally proposed APM.

 

[OTN]

Two points-
Commercial insurance often follows CMS
Medicare for all....

Medicare for All would make these conversations about RO-APM look like child's play.

 

[medgator]

Medicare for All would make these conversations about RO-APM look like child's play.

Not sure m4a is going to be worse than nearly every payor requiring a p2p auth, telling me how many fractions to prescribe, and nearly all of them denying igrt whenever they feel like it (most breast, any Palliative etc).

Wish we had site-neutral bundles already so we could get on with it

 

[Lamount]

Not sure m4a is going to be worse than nearly every payor requiring a p2p auth, telling me how many fractions to prescribe, and nearly all of them denying igrt whenever they feel like it (most breast, any Palliative etc).

Wish we had site-neutral bundles already so we could get on with it

I was just thinking the same thing, as I am tired of justifying to evicore why I want '3D planning' to treat a large spine met. There is a reasonable way to do bundling where docs have autonomy to do the right thing for patients, are reasonably compensated, but unnecessarily complex treatments are dis-incentivized

 

[OTN]

Not sure m4a is going to be worse than nearly every payor requiring a p2p auth, telling me how many fractions to prescribe, and nearly all of them denying igrt whenever they feel like it (most breast, any Palliative etc).

Wish we had site-neutral bundles already so we could get on with it

Of course it would be worse. The goal of M4A is to create a legal monopsony in order to force providers to accept below-market rates.

 

[medgator]

Of course it would be worse. The goal of M4A is to create a legal monopsony in order to force providers to accept below-market rates.

The Canadians seem to make it work ok.... M4a doesn't eliminate the private side, in some cases, it has to outsource to them. It simply becomes another option

Medicare now isn't the most lucrative payor out there but all of us take it....

Right now, i eat the cost of igrt, or offer less effective/better treatment so that Cigna/Humana shareholders can see a better ROI

 

[Mandelin Rain]

I'm on the fence about M4A. Could be cataclysmic. Could put competition to the private market and force them to provide more value or die.

I think we're going to get shaved either way. Gotta keep the money flowing to the strongest corporate lobbies (hint: not physicians).

 

[OTN]

The Canadians seem to make it work ok.... M4a doesn't eliminate the private side, in some cases, it has to outsource to them. It simply becomes another option

Medicare now isn't the most lucrative payor out there but all of us take it....

Right now, i eat the cost of igrt, or offer less effective/better treatment so that Cigna/Humana shareholders can see a better ROI

M4A as proposed by Bernie Sanders would eliminate private insurance. This is very important to understand. M4A does not "simply become another option", it becomes the only option.

The Canadian system has to pay their docs decently because there's a huge country just south of them to where they could easily work.

 

[medgator]

M4A as proposed by Bernie Sanders would eliminate private insurance. This is very, very important to understand. M4A does not "simply become another option", it becomes the only option.

The Canadian system has to pay their docs decently because there's a huge country just south of them to where they could easily work.

I don't think the Bernie option is politically viable. Probably more the original ACA proposal where a "public" option would compete with current options. Even now with Medicare, there are multiple options where patients choose any number of "advantage" replacement plans, afaik, these are gaining in popularity and are a bigger PITA when it comes to treating them

 

[thecarbonionangle]

The best system IMO is france/germany with a mix of both private and gov insurance

 

[medgator]

The best system IMO is france/germany with a mix of both private and gov insurance

Doctors are in breadlines in France already from what i hear, but at least it's tasty baguette!

Pay me like a French doctor. You know you want to.

If you want to pay me like a French doctor, also give me the French cost of medical school and the French medical malpractice system.

www.kevinmd.com

 

[deleted605854]

-You cannot compare apples to oranges.

-Canada does pay its physicians better than Europe as a whole. However, it varies from province to province. If you want to come close to US levels of reimbursement, then the best provinces are Ontario and Alberta. These are extraordinarily rich provinces with Ontario being the economic powerhouse of the country and Alberta having oil. Other provinces reimburse much less. But Canadian physicians are usually are not saddled with US levels of debt and Canada is not as litigious as the US. Plus, they don't have to spend hours on frivolous documentation. Meaning they see more patients. So, in effect they're seeing more patients for less money. The Ontario government has been chipping away at the reimbursement of physicians in Ontario. And physicians have zero leveraging powers since it's a single payer system. And all specialties suffer together with this system.

-I cannot speak to the systems in Germany or France except that even though it's a mixed system it is sensible.

-European physicians on average enjoy a much higher quality life. I remember a Dutch Neurosurgery attending telling me that if he were paged during his lunch break for anything except an emergency there would be hell to pay. Their culture is much different. They make time to take in what life has to offer, smell the roses and all.

 

[elementaryschooleconomics]

It would be fascinating to see what would happen in this country if we kept the same cost of undergrad/med school, same work hours and culture, same legal issues and documentation requirements...and went to a single payer system with all physician salaries drastically reduced. People will always want to "be a doctor", but I have a sneaking suspicion that quality and numbers of applications to medical school would fall off a cliff.

 

[thecarbonionangle]

Maybe some people would select out but other countries still get plenty of smart people to go into medicine. It has prestige and social standing even with lower pay.

the argument if docs get paid “too much” is a different argument. I tend to think we don’t get paid enough, but if cuts came medicine would be ok

 

[elementaryschooleconomics]

Maybe some people would select out but other countries still get plenty of smart people to go into medicine. It has prestige and social standing even with lower pay.

the argument if docs get paid “too much” is a different argument. I tend to think we don’t get paid enough, but if cuts came medicine would be ok

True, I've been under the boot of Academic Overlords for so long now and made to feel like I'm not worth the air I breathe I forget that sometimes there's a "prestige" factor.

 

[FrostyHammer]

It would be fascinating to see what would happen in this country if we kept the same cost of undergrad/med school, same work hours and culture, same legal issues and documentation requirements...and went to a single payer system with all physician salaries drastically reduced. People will always want to "be a doctor", but I have a sneaking suspicion that quality and numbers of applications to medical school would fall off a cliff.

AKA what is happening to the rad onc applicant pool these days?

 

[thecarbonionangle]

True, I've been under the boot of Academic Overlords for so long now and made to feel like I'm not worth the air I breathe I forget that sometimes there's a "prestige" factor.

i mean another thing is society is also losing respect for us. Tons of fake news and everyone is an internet expert and knows more than doctors, plus the growing role of PAs/NPs, mega medicine walmart model. One could argue the “prestige” thing is diminishing as well, at least here in the US. AFAIK, other countries have not seen this growing PA/NP encroachment

 

[scarbrtj]

i mean another thing is society is also losing respect for us. Tons of fake news and everyone is an internet expert and knows more than doctors, plus the growing role of PAs/NPs, mega medicine walmart model. One could argue the “prestige” thing is diminishing as well, at least here in the US

"Not a physician, a trade group member" he says as he returns to plying his trade...

 

[Tigerstang]

Yes, very possible imo. Azar was a big pharma swamp crony who probably doesn't see the value of RO and originally proposed APM.

The genesis of the APM significantly precedes the current administration. Can we keep this to a fact based discussion and move the personal politics elsehwere?

 

[medgator]

The genesis of the APM significantly precedes the current administration. Can we keep this to a fact based discussion and move the personal politics elsehwere?

Azar Announces Mandatory Oncology Payment Model Is Coming

The announcement is an about-face from earlier efforts that scrapped a cardiac care bundled payment program originally developed during the Obama administration.

www.ajmc.com

 

[thecarbonionangle]

i mean another thing is society is also losing respect for us. Tons of fake news and everyone is an internet expert and knows more than doctors, plus the growing role of PAs/NPs, mega medicine walmart model. One could argue the “prestige” thing is diminishing as well, at least here in the US. AFAIK, other countries have not seen this growing PA/NP encroachment

The genesis of the APM significantly precedes the current administration. Can we keep this to a fact based discussion and move the personal politics elsehwere?

Dude Trump crony Azar is to blame.

 

[elementaryschooleconomics]

Dude Trump crony Azar is to blame.

If a politician wanted to make a claim that they cut oncology-specific Medicare spending without adversely affecting the bottom line of the pharmaceutical companies, this is the mechanism to achieve that.

 

[Tigerstang]

I'm not sure how long many of you have been in this field, but I know I was having talks about bundled payments with payors and CMS 10 years ago. A little historical perspective, for whatever its worth.

 

[elementaryschooleconomics]

I'm not sure how long many of you have been in this field, but I know I was having talks about bundled payments with payors and CMS 10 years ago. A little historical perspective, for whatever its worth.

That's definitely true! I personally find it odd that this gets slammed into place in September of an election year after practices took a huge financial and structural/organizational hit a few months ago due to a global pandemic. It might not be politically motivated, but I'm not sure what isn't politically motivated in America anymore.

 

[Lamount]

I'm not sure how long many of you have been in this field, but I know I was having talks about bundled payments with payors and CMS 10 years ago. A little historical perspective, for whatever its worth.

Bundled payments could have been done well. This wasn’t.
...and it is objectively concerning that the architect of THIS effort at APM was initiated by an HHS secretary with ties to pharma at a time of record expenditure on immunotherapy

You can say that APM has been years in the making... but you can’t tell us, with a straight face, the way this was implemented isn’t at least a little suspicious.

 

[scarbrtj]

Everybody realizes what’s going to happen in a lot of body sites right. Under APM, 1-3 fx will be the new 5 fx (or the new 25+ fx). Look for single fraction low risk prostate schedules. In theory, and all the clinical data predicts this, there’s no radiobiological reason all prostates can’t be treated in one fx. And there’s no reason we couldn’t recreate TARGIT (single fx breast) with MV beams postop. There’s nothing special about intraop except you’ve got crap energy that won’t reach deep so you have to “shine” it right into the tumor cavity.

 

[OTN]

Everybody realizes what’s going to happen in a lot of body sites right. Under APM, 1-3 fx will be the new 5 fx (or the new 25+ fx). Look for single fraction low risk prostate schedules. In theory, and all the clinical data predicts this, there’s no radiobiological reason all prostates can’t be treated in one fx. And there’s no reason we couldn’t recreate TARGIT (single fx breast) with MV beams postop. There’s nothing special about intraop except you’ve got crap energy that won’t reach deep so you have to “shine” it right into the tumor cavity.

Toxicity could be a reason prostates couldn't be treated in one fraction. Remember how annoyingly small the therapeutic window for RT can be?

 

[thecarbonionangle]

I think for me like looking at big picture, if revenues drop in a hypothetical practice, it could lead to everyone taking a paycut and keeping their jobs or senior guys just cutting off the younger people. Some young will be eaten, guaranteed. The job situation will not be good=breadlines of unemployment and undermployment, lowering of locums market pay to very low due to desperation and oversupply. Unless there is some radical new path to allow retraining or expansion to give systemic agents the rad oncs will not have any options than to do another residency or leave clinical medicine. We simply have too many people.

 

[FrostyHammer]

Everybody realizes what’s going to happen in a lot of body sites right. Under APM, 1-3 fx will be the new 5 fx (or the new 25+ fx). Look for single fraction low risk prostate schedules. In theory, and all the clinical data predicts this, there’s no radiobiological reason all prostates can’t be treated in one fx. And there’s no reason we couldn’t recreate TARGIT (single fx breast) with MV beams postop. There’s nothing special about intraop except you’ve got crap energy that won’t reach deep so you have to “shine” it right into the tumor cavity.

I know a reason...it's called rectal (or bladder) toxicity.