SRT-100 and SRT-Vision - Standard of Care?

[Solodyn]

Hi. I am trying to get an idea on what would be an appropriate way to administer SRT

SRT is a controversial modality (due to billing codes etc). It is hard to find some sort of standards

I know that "SRT-100" units used to make bank with people billing all kinds of radiation oncology codes. It is now standardized to 77401 which puts it at ~$25 per treatment by medicare. With all simulation, it comes out to be $1000 a tumor.

Now Sensus is coming out with NEW "SRT-100 VISION" with ultrasound build in. The manufacturer is suggesting derm to use ultrasound guidance and bill additional $300 per treatment. This brings the treatment to $7500 per tumor.

For me this seems like an abuse as I don't see how additional Ultrasound imaging with SRT-100 Vision will improve outcome. However that is what manufacturer are suggesting us to do.

I certainly would like to know what everyone's thoughts are. I know SRT has its place. I want to know how people are using it responsibly. I would like know if the Ultrasound Imaging is the new standard of care or just a new way to squeeze more cash.

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[doctalaughs]

Hi. I am trying to get an idea on what would be an appropriate way to administer SRT

SRT is a controversial modality (due to billing codes etc). It is hard to find some sort of standards

I know that "SRT-100" units used to make bank with people billing all kinds of radiation oncology codes. It is now standardized to 77401 which puts it at ~$25 per treatment by medicare. With all simulation, it comes out to be $1000 a tumor.

Now Sensus is coming out with NEW "SRT-100 VISION" with ultrasound build in. The manufacturer is suggesting derm to use ultrasound guidance and bill additional $300 per treatment. This brings the treatment to $7500 per tumor.

For me this seems like an abuse as I don't see how additional Ultrasound imaging with SRT-100 Vision will improve outcome. However that is what manufacturer are suggesting us to do.

I certainly would like to know what everyone's thoughts are. I know SRT has its place. I want to know how people are using it responsibly. I would like know if the Ultrasound Imaging is the new standard of care or just a new way to squeeze more cash.

My question is what exact subset of tumors do you propose/recommend to use this on, and what percentage of your patients have these tumors?

I personally would guess/ estimate I could only ethically recommend this modality for less than 1% of my skin ca patients... so I'm not buying the machine even if I could make more money off it. I haven't heard a good evidence-based argument to the contrary but I'm all ears.


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[Solodyn]

The day of using SRT as a cash cow is over when they change up the codes to limit the treatment to 77401. This happened in 2016. That pays only $22 a fraction per medicare. With one simulation, the total treatment cost for 12 fractions on 1 skin cancer is only about $700. This pays not much more than excision and less than Mohs surgery. Reason I am looking into the treatment modality is not for profit motive.

I was commenting on the new practice of some physician using SRT-100 Vision and bill simulation for every fraction because of use of the Ultrasound Imaging. I don't know if it is the new standard of care. I believe the problem with SRT right now is it lacks the standards of care.

Looking at some of the clinical results, I think it will be hard for me not to provide it to some of my patients. It is hard to justify doing Mohs on the nose of a 95 years old nursing home patients. I have more of those than I care to count. My Mohs volume has increased during the past 5 years to a point where I cannot keep up with treating all cancers on a timely manner. I do need an alternative treatment option.

SRT is a valid treatment modality and it is evidence-based. I am not sure why anyone would think otherwise.

 

[MOHS_01]

Plenty of reason to think otherwise; XRT of any form should be second line therapy for any surgically amenable tumor. Some thought should be given to the chronic disease nature of NMSC (as opposed to distinct episodes of care), through which lens XRT becomes less attractive relatively quickly.

I would like to be able to offer it for scalp and anterior shins in elderly patients with horrific field cancerization, but I'm afraid that the current practitioners have poisoned this well so badly to the point that it is difficult to defend broadly.

...also, I would guard against playing coy with reimbursements and profit strategy...revenue =/= profit... and most anyone with an iota of understanding would see through that relatively quickly.

I'm waiting for CMS clawbacks... that will make for an interesting day.

 

[asmallchild]

I would like to be able to offer it for scalp and anterior shins in elderly patients with horrific field cancerization, but I'm afraid that the current practitioners have poisoned this well so badly to the point that it is difficult to defend broadly.

I'll actually get pushback from patients on this thanks to the (ab)use of XRT by other physicians in my area.

 

[doctalaughs]

The day of using SRT as a cash cow is over when they change up the codes to limit the treatment to 77401. This happened in 2016. That pays only $22 a fraction per medicare. With one simulation, the total treatment cost for 12 fractions on 1 skin cancer is only about $700. This pays not much more than excision and less than Mohs surgery. Reason I am looking into the treatment modality is not for profit motive.

I was commenting on the new practice of some physician using SRT-100 Vision and bill simulation for every fraction because of use of the Ultrasound Imaging. I don't know if it is the new standard of care. I believe the problem with SRT right now is it lacks the standards of care.

Looking at some of the clinical results, I think it will be hard for me not to provide it to some of my patients. It is hard to justify doing Mohs on the nose of a 95 years old nursing home patients. I have more of those than I care to count. My Mohs volume has increased during the past 5 years to a point where I cannot keep up with treating all cancers on a timely manner. I do need an alternative treatment option.

SRT is a valid treatment modality and it is evidence-based. I am not sure why anyone would think otherwise.

The typical 95 year old nursing home patient has an average life expectancy of about 9 months. The best option for this patient almost always is to do nothing. Once you explain the risks/benefits to the patient and family they almost universally understand. Sure, every once in a while I find a relatively healthy 95 year old or one that is really bleeding all over their pillows and annoyed by the BCC on their nose. In these cases a quick ED&C for small low risk NMSC even on a nasal tip or if larger/higher risk inject some MTX or interferon. So what if it's not cured? I'm certainly not sending them for some huge surgery (99% of the time) or repeated visits to the office for XRT where they are more likely to fall and break their hip on the way then to actually gain some meaningful benefit .

Gotta see the big picture....


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[MOHS_01]

The typical 95 year old nursing home patient has an average life expectancy of about 9 months. The best option for this patient almost always is to do nothing. Once you explain the risks/benefits to the patient and family they almost universally understand. Sure, every once in a while I find a relatively healthy 95 year old or one that is really bleeding all over their pillows and annoyed by the BCC on their nose. In these cases a quick ED&C for small low risk NMSC even on a nasal tip or if larger/higher risk inject some MTX or interferon. So what if it's not cured? I'm certainly not sending them for some huge surgery (99% of the time) or repeated visits to the office for XRT where they are more likely to fall and break their hip on the way then to actually gain some meaningful benefit .

Gotta see the big picture....


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Funny... I can do an excision - even if it requires immediate grafting, absorbable sutures, tie over bolster that can be untied by hand rather than clipping, in under 10 minutes. No dressing changes absolutely required, healed quicker with fewer episodes of bleeding. That's my preferred method, seems to cut back on the MRSA positive cultures for the open wound that the house doc always orders, clinical infection or not. To each their own, luckily I don't get a lot of those referrals.


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[username456789]

I'll actually get pushback from patients on this thanks to the (ab)use of XRT by other physicians in my area.

Could you elaborate on this a bit? Is it rad onc guys you're talking about? Or derms doing SRT or something similar?

 

[MOHS_01]

Could you elaborate on this a bit? Is it rad onc guys you're talking about? Or derms doing SRT or something similar?

Rad onc clearly won't like it, nor would other dermatologists who have witnessed others abusing it. From what I've seen, only derms are pushing the SRT form of radiation. "From patients" might be the phrase overlooked.

In smaller towns at least, patients and colleagues alike develop a sense for the character of a practice in short order; those who run people through like cattle or do everything to turn a quick buck do not remain under the radar for long. When one of these types become associated with a service, legitimate or not, that well is poisoned for anyone else looking to be second to the game -- irrespective of appropriateness of action. That is what was meant.

 

[doctalaughs]

Excluding cutaneous lymphoma I've probably sent less than a dozen patients for any form of radiation for NMSC in the last 10 years. Those usually are aggressive NMSC after surgery. There are too many other ways to treat non-aggressive NMSC that are easier and cheaper for the patient with equivalent cure-rates for me to consider it as anything but a fringe modality. Given so few cases/uses why would it make sense to invest in a machine when a radonc has way more expertise in this area?


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[asmallchild]

Could you elaborate on this a bit? Is it rad onc guys you're talking about? Or derms doing SRT or something similar?

I've referred patients to rad onc for XRT but as far as I know, they use a different technology than Census/SRT. They have an obvious conflict of interest but most of the radoncs I've spoken to don't seem very enthusiastic about the efficacy of Census/SRT.

As Mohs01 alluded to, it's more other derms pushing SRT onto patients and they catch on quick. They also hear about the super unscrupulous physicians who have been flagged for medically unnecessary radiation therapy services (e.g. Dr. Gary Marder and the United States Consent to a Final Judgement of Over $18 Million to Settle False Claims Act Allegations)

The downside is when I finally find a lesion(s) that could be treated with radiation (pretibial regions with massive field cancerization), the patients insist on a surgery-only approach.