SBRT prostate boost

[firewicket]

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Are your centers doing SBRT prostate boost (after 50.4-54Gy to the prostate/Sv +/- lymphatics)?
Dose/fractionation?
What are your patient selection criteria?
Any specific simulation parameters?
Billing/reimbursement issues with this?

 

[radiaterMike]

Are your centers doing SBRT prostate boost (after 50.4-54Gy to the prostate/Sv +/- lymphatics)?
Dose/fractionation?
What are your patient selection criteria?
Any specific simulation parameters?
Billing/reimbursement issues with this?

SBRT as a boost is not well-supported by the literature, which is mostly retrospective

This study argues against a boost in high risk patients -- Stereotactic body radiotherapy with or without external beam radiation as treatment for organ confined high-risk prostate carcinoma: a six year study

Another study suggests the need for longer follow-up - Outcomes of hypofractionated stereotactic body radiotherapy boost for intermediate and high-risk prostate cancer

 

[Chartreuse Wombat]

Are your centers doing SBRT prostate boost (after 50.4-54Gy to the prostate/Sv +/- lymphatics)?
Dose/fractionation?
What are your patient selection criteria?
Any specific simulation parameters?
Billing/reimbursement issues with this?

Pro
https://www.practicalradonc.org/article/S1879-8500(17)30341-7/fulltext

Con
https://www.practicalradonc.org/article/S1879-8500(18)30002-X/fulltext

 

[radiaterMike]

The paper you cite as "Pro" reviews the literature but does not really advocate for SBRT boost.

"SBRT boost should ideally be validated in clinical trials. Even if it becomes evident that the results are slightly worse than HDR, SBRT is technically less complex for practitioners and may be preferable to patients."

 

[Chartreuse Wombat]

The paper you cite as "Pro" reviews the literature but does not really advocate for SBRT boost.

"SBRT boost should ideally be validated in clinical trials. Even if it becomes evident that the results are slightly worse than HDR, SBRT is technically less complex for practitioners and may be preferable to patients."

I disagree. They clearly are enthusiastic about it; essentially accepting "slightly worse" because it is easier (in the sentence you highlighted). I think the con editorial provides the appropriate context.

 

[firewicket]

So back to my original question...
I know a lot of people are doing this in the community.
Is this not the case?

 

[radiaterMike]

So back to my original question...
I know a lot of people are doing this in the community.
Is this not the case?

It may depend on what community you are in. Many insurance policies will not cover SBRT if for a boost and/or for high risk disease (you need to check you local policies).

From Evicore - "It should be noted that SBRT is defined as an entire treatment course consisting of five or fewer fractions. Thus, SBRT cannot be billed as a boost."

For the 1st time (I believe) this policy allows SBRT for high risk disease.

 

[seper]

My impression is that it is not the case.

So back to my original question...
I know a lot of people are doing this in the community.
Is this not the case?

 

[medgator]

Medicare is pretty lenient for shenanigans like protons or sbrt boost for prostate. In our area I've also heard of savi/mammosite being used and billed as a boost. Outside of that, commercial/hmo/Medicare advantage will frown on it.

In the freestanding setting in our area (first coast), sbrt for definitive prostate did not reimburse for years, even for Medicare

 

[radiaterMike]

Medicare is pretty lenient for shenanigans like protons or sbrt boost for prostate. In our area I've also heard of savi/mammosite being used and billed as a boost. Outside of that, commercial/hmo will frown on it.

In the freestanding setting, sbrt for definitive prostate did not reimburse for years, even for Medicare

"Leniency" might be an incorrect impression. Medicare can come back months or years later and say they want their $ back because the treatment was not necessary. I am no expert on this, but I don't think written policies differentiate necessity based on whether or not a facility is freestanding. It may be that a hospital-based practice negotiated with local insures (as many proton centers do).

 

[medgator]

"Leniency" might be an incorrect impression. Medicare can come back months or years later and say they want their $ back because the treatment was not necessary. I am no expert on this, but I don't think written policies differentiate necessity based on whether or not a facility is freestanding. It may be that a hospital-based practice negotiated with local insures (as many proton centers do).

Oh I agree. It's just that they won't necessarily require auth or deny payment like other payors do and I get a sense that is where most of these patients are coming from

 

[seper]

Conceptually, just like with cervical cancer, I think brachy boost should ultimately win.

 

[Palex80]

Conceptually, just like with cervical cancer, I think brachy boost should ultimately win.

Although conceptually correct, there is a difference between the two. You can cure most prostate cancer patients with EBRT only. You cannot claim the same for cervix cancer patients.