Viewray‘s Demise

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Mandelin Rain said:
The derms claim they do some sort of ultrasound guided adaptive therapy
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Moved into my region. A very corporate model where national company employs the RTT and derm collects professional codes.

It was advertised in several local papers and I’m going to respond in kind. These are very low energy photon machines (50-100 kv) well below orthovoltage and in a domain where primary interaction is photoelectric (so they will be dumping excess dose into underlying bone).

Superficial Radiotherapy: Long Term Follow-Up of Highly Selected Basal and Squamous Cell Carcinomas in Skin Cancer Patients

Superficial radiotherapy (SRT) treatment for non-melanoma skin cancer has been reported to yield variable cure rates. When patients are highly selected, adequate margins of treatment are chosen, and hypofractionation is avoided, cure rates of SRT can approach that of Mohs surgery.
www.dermatoljournal.com www.dermatoljournal.com

Above is the only reasonable published series that I have seen (lots of emerging specious and borderline unethical publications coming out). I strongly suspect cosmesis is inferior to electrons and the toxicities in this series exceed anything that I have cause in similar cases in years of practice.
 
communitydoc13 said:
Moved into my region. A very corporate model where national company employs the RTT and derm collects professional codes.

It was advertised in several local papers and I’m going to respond in kind. These are very low energy photon machines (50-100 kv) well below orthovoltage and in a domain where primary interaction is photoelectric (so they will be dumping excess dose into underlying bone).

Superficial Radiotherapy: Long Term Follow-Up of Highly Selected Basal and Squamous Cell Carcinomas in Skin Cancer Patients

Superficial radiotherapy (SRT) treatment for non-melanoma skin cancer has been reported to yield variable cure rates. When patients are highly selected, adequate margins of treatment are chosen, and hypofractionation is avoided, cure rates of SRT can approach that of Mohs surgery.
www.dermatoljournal.com www.dermatoljournal.com

Above is the only reasonable published series that I have seen (lots of emerging specious and borderline unethical publications coming out). I strongly suspect cosmesis is inferior to electrons and the toxicities in this series exceed anything that I have cause in similar cases in years of practice.
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I mean cosmetic result is going to be some function of tumor factors, patient factors, and treatment factors like dose, field size, etc.

I use the orthovoltage unit in my dept, we have 100kV as the lowest energy. With good fractionation/tighter collimation, it’s a preferred modality over electrons a lot of the time for me. Electrons need a larger penumbra, and often a lot more heterogeneity, when orthovoltage is just 100% at a flat surface. The key is when to employ one over the other for best dosimetry, and having access to only one, while feasible for many tumor scenarios, leaves you lacking when another modality may be better.
 
taserlaser said:
cosmetic result is going to be some function of tumor factors, patient factors, and treatment factors like dose, field size, etc.
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taserlaser said:
Electrons need a larger penumbra
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Above all absolutely true, and I have no problem with a radonc having multiple sources and choosing which one to use.

pubmed.ncbi.nlm.nih.gov

Optimum radiation source for radiation therapy of skin cancer - PubMed

Several different applicators have been designed for treatment of skin cancers, such as scalp, hand, and legs using Ir-192 HDR brachytherapy sources (IR-HDRS), miniature electronic brachytherapy sources (eBT), and external electron beam radiation therapy (EEBRT). Although, all of these...
pubmed.ncbi.nlm.nih.gov pubmed.ncbi.nlm.nih.gov

This is a pretty good paper regarding dosimetry for low energy photons vs electrons. Keep in mind, these commercial machines are often operating in the 50-75 kv range.

There are two major dosimetric factors that bother me with low energy photon treatment.

First, you never normalize just to the surface (unless truly a lesion with zero depth, perhaps a CIS with questionable indications for treatment regardless). If you normalize at 5mm, surface dose for low energy photons is much higher, and I think this manifests as significantly more long term hypopigmentation (hard to find good references on this, this is from experience).

Second is the marked dosimetric impact of Z at low energies, resulting in crazy dose increase at bone.

I have no problem with my local derm using superficial photons for tiny lesions on fleshy areas where cosmesis not the most important. However, all of these lesions are also amenable to conservative local surgical or other management, and it is clear that they are looking to spend and recoup more to treat the same.

I will be concerned if they are treating substantial scalp, nose and distal extremity lesions with superficial photons however.

That they advertise groundbreaking technology (image guidance for superficial lesions) and quote ridiculous studies to support why their machine has a better cure rate than linac based treatment is farcical.
 
communitydoc13 said:
Above all absolutely true, and I have no problem with a radonc having multiple sources and choosing which one to use.

pubmed.ncbi.nlm.nih.gov

Optimum radiation source for radiation therapy of skin cancer - PubMed

Several different applicators have been designed for treatment of skin cancers, such as scalp, hand, and legs using Ir-192 HDR brachytherapy sources (IR-HDRS), miniature electronic brachytherapy sources (eBT), and external electron beam radiation therapy (EEBRT). Although, all of these...
pubmed.ncbi.nlm.nih.gov pubmed.ncbi.nlm.nih.gov

This is a pretty good paper regarding dosimetry for low energy photons vs electrons. Keep in mind, these commercial machines are often operating in the 50-75 kv range.

There are two major dosimetric factors that bother me with low energy photon treatment.

First, you never normalize just to the surface (unless truly a lesion with zero depth, perhaps a CIS with questionable indications for treatment regardless). If you normalize at 5mm, surface dose for low energy photons is much higher, and I think this manifests as significantly more long term hypopigmentation (hard to find good references on this, this is from experience).

Second is the marked dosimetric impact of Z at low energies, resulting in crazy dose increase at bone.

I have no problem with my local derm using superficial photons for tiny lesions on fleshy areas where cosmesis not the most important. However, all of these lesions are also amenable to conservative local surgical or other management, and it is clear that they are looking to spend and recoup more to treat the same.

I will be concerned if they are treating substantial scalp, nose and distal extremity lesions with superficial photons however.

That they advertise groundbreaking technology (image guidance for superficial lesions) and quote ridiculous studies to support why their machine has a better cure rate than linac based treatment is farcical.
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And backed by PE and you should see their pro forma. We are not excited about reimbursing for daily US and daily 77280
 
RealSimulD said:
And backed by PE and you should see their pro forma. We are not excited about reimbursing for daily US and daily 77280
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I've heard a lot of payors are flat out rejecting that now?

I got a referral recently from one of those SRT derms for a standard bcc of the face, pt said his insurance company wouldn't cover their treatment only mine??? I wonder if the insurance companies are finally on to it
 
communitydoc13 said:
Above all absolutely true, and I have no problem with a radonc having multiple sources and choosing which one to use.

pubmed.ncbi.nlm.nih.gov

Optimum radiation source for radiation therapy of skin cancer - PubMed

Several different applicators have been designed for treatment of skin cancers, such as scalp, hand, and legs using Ir-192 HDR brachytherapy sources (IR-HDRS), miniature electronic brachytherapy sources (eBT), and external electron beam radiation therapy (EEBRT). Although, all of these...
pubmed.ncbi.nlm.nih.gov pubmed.ncbi.nlm.nih.gov

This is a pretty good paper regarding dosimetry for low energy photons vs electrons. Keep in mind, these commercial machines are often operating in the 50-75 kv range.
Click to expand...

Thanks for the ref. Been doing a lot of superficial HDR treatments over the past few years for a variety of reasons. Only downside is requirement to be present, but with hypofx not too burdensome.
 
taserlaser said:
I mean cosmetic result is going to be some function of tumor factors, patient factors, and treatment factors like dose, field size, etc.

I use the orthovoltage unit in my dept, we have 100kV as the lowest energy. With good fractionation/tighter collimation, it’s a preferred modality over electrons a lot of the time for me. Electrons need a larger penumbra, and often a lot more heterogeneity, when orthovoltage is just 100% at a flat surface. The key is when to employ one over the other for best dosimetry, and having access to only one, while feasible for many tumor scenarios, leaves you lacking when another modality may be better.
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And also we should not forget that a 2 Gy dose of 100kV photons will have the RBE of a 1.8 Gy dose of 6MeV electrons. (Although in practice everyone actively and intentionally forgets this.)
 
temujim said:
Thanks for the ref. Been doing a lot of superficial HDR treatments over the past few years for a variety of reasons. Only downside is requirement to be present, but with hypofx not too burdensome.
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Electrons so easy just for that reason alone. Can clog up the machine at times but the nrc reqs are just tough in q busy practice
 
medgator said:
I've heard a lot of payors are flat out rejecting that now?

I got a referral recently from one of those SRT derms for a standard bcc of the face, pt said his insurance company wouldn't cover their treatment only mine??? I wonder if the insurance companies are finally on to it
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I had an exact same thing happen. Derm group in town with long standing history of billing igrt on their SRT machine. …recently sent me a guy where insurance denied his whole course and demanded he be treated with me.

I called and talked with the derm radiation therapist because I was perplexed and she said “usually they just deny the image guidance charge but on this guy they denied everything.”
 
RealSimulD said:
It’s hard to reject outright, since ASTRO guidelines suggest it as a reasonable option. The problem is that the guidelines and NCCN just make you do BED of XX, so the RXs I get sent are ridiculous for SRT. + IGRT, + daily sim. We reject all but one sim and all the igrt.
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Yeah that's why I called out to the derm office to try to figure out. I suspect it was a coding error or alternatively insurance not getting a long with this practice and pushing people away. Like I said, I heard the therapist say they very often get IGRT declines but this was the first time they had an outright denial for the whole course.
 
The ASTRO Clinical practice guidelines paper discussed fractionation schedules for electronic brachytherapy. It did not specifically address indications (so hard to know where ASTRO stands on it)

Definitive and Postoperative Radiation Therapy for Basal and Squamous Cell Cancers of the Skin: Executive Summary of an American Society for Radiation Oncology Clinical Practice Guideline - PubMed


The NCCN guidelines do not even mention electronic brachytherapy.


Two ABS Guidelines say that enrollment on clinical trial or registry is recommended and recommend against routine use

The American Brachytherapy Society consensus statement for electronic brachytherapy - PubMed

The American Brachytherapy society consensus statement for skin brachytherapy - PubMed


So I can see why insurers might balk at this treatment.
 
true though ABS’s stance applies to both from
what I understand. and NCCN guidelines similarly don’t even mention SRT
 
It seems like the practice guidelines does not specify SRT (though they state - "ELS and superficial radiation therapy may be considered synonymously and have appeared in the literature as such"

It is interesting that the ABS does not separate out SRT explicitly. The issues they describe with EBT apply to SRT ("dose calculations in tissue, lack of consensus with respect to EB dosimetry and potential increase in relative biological effectiveness with low-energy photons")

EBT (i.e. Xoft) - energies up to 50 kV that are generated electrically

SRT (i.e. Sensus) -20-30-50-70-100 kv

Orthovoltage - ~200-500 kv




So they are different but often lumped together in that they do not require shielding or NRC oversight (which would be required for HDR).
 
Yeah, again, we interpret them synonymously and broadly. I think that is the most patient and provider friendly approach.

I am uncertain why electronic brachy got the shaft.
 
RealSimulD said:
I am uncertain why electronic brachy got the shaft.
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I don't know, but it's the format that I am most leery of (SRT next).

So much of brachy is based on what has worked in the past, and you cannot choose a more inhomogeneous and superficial type of radiation than electronic brachy...so you are either just sterilizing the surface (vaginal cuff or other) or you are prescribing to depth with marked dose inhomogeneity and a super hot surface dose.

We looked into XOFT years ago, as on the surface (sic) it's an appealing format for a smaller community place to start doing their own vaginal cuff and some other indications (shielding requirements, etc.). After looking a littler deeper, we decided not to make the investment (fortunately).
 
communitydoc13 said:
We looked into XOFT years ago, as on the surface (sic) it's an appealing format for a smaller community place to start doing their own vaginal cuff and some other indications (shielding requirements, etc.). After looking a littler deeper, we decided not to make the investment (fortunately).
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but i havent miles teller GIF
 
50 kV is 50 kV regardless of how it's made..

But how it's delivered could affect things...


Anyone have a pdf link comparing the dosimetry of xoft vs sensus worth a read?
 
sirspamalot said:
50 kV is 50 kV regardless of how it's made..

But how it's delivered could affect things...


Anyone have a pdf link comparing the dosimetry of xoft vs sensus worth a read?
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pubmed.ncbi.nlm.nih.gov

Aspects of dosimetry and clinical practice of skin brachytherapy: The American Brachytherapy Society working group report - PubMed

Given the limited published data for skin BT, this article is a summary of the limited literature and best practices currently in use for the treatment of NMSC.
pubmed.ncbi.nlm.nih.gov pubmed.ncbi.nlm.nih.gov

Closest I’m aware of
 
evilbooyaa said:
It's going to lead to even greater worship of the computer screen in proton users.... the next logical step in protons - variable RBE without adaptation is OLD protons! Now we adapt daily so we don't have the same range uncertainty margins that we normally would use!!

Until they start necrosing brainstems and putting holes in duodenums, of course.
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We have a trial open for pancreas CA that is T3/T4 borderline or unresectable using protons to give 63 Gy in 28 fx of 2.5 Gy each. The goal is convert to operable or for definitive local control.

I wouldn't mind the ability to re-optimize based on bowel or stomach filling if something got in the way, but usually we are posterior to most of those volumes. The toxicity so far has been pretty minor for similar patients I've treated off protocol, usually in the setting of reirradiation after SBRT or 50.4 Gy progression.
 
IonsAreOurFuture said:
We have a trial open for pancreas CA that is T3/T4 borderline or unresectable using protons to give 63 Gy in 28 fx of 2.5 Gy each. The goal is convert to operable or for definitive local control.

I wouldn't mind the ability to re-optimize based on bowel or stomach filling if something got in the way, but usually we are posterior to most of those volumes. The toxicity so far has been pretty minor for similar patients I've treated off protocol, usually in the setting of reirradiation after SBRT or 50.4 Gy progression.
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Haha I have so many questions about this trial, do you have an NCT? Is it a re-irradiation trial?
 
IonsAreOurFuture said:
We have a trial open for pancreas CA that is T3/T4 borderline or unresectable using protons to give 63 Gy in 28 fx of 2.5 Gy each. The goal is convert to operable or for definitive local control.

I wouldn't mind the ability to re-optimize based on bowel or stomach filling if something got in the way, but usually we are posterior to most of those volumes. The toxicity so far has been pretty minor for similar patients I've treated off protocol, usually in the setting of reirradiation after SBRT or 50.4 Gy progression.
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I can't think of many worse places than pancreas cancer dose escalation to use proton. the whole issue you want with pancreas near the duodenum is tight conformity. Give me VMAT any day over current proton. What is the rationale for the trial? Good luck.
 
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electronic brachy (Xoft) applied for their own CPT code and failed. As far as I understand
 
A_DeMichele said:
electronic brachy (Xoft) applied for their own CPT code and failed. As far as I understand
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Actually they did get their own code. Reimburses about 250 per fraction… a lot more than superficial. Well, as long as the insurance company approves it. See LCD L35490.

IMG_0416.png
 
yesmaster said:
Departments that purchased Viewray's are going to write off $12 million?
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Seems that way if they don’t even tell you if you need Imperial or metric hex set to service it!!😂

p.s. i’m from the path board so i know a good fist f***.😉
 
Tigerstang said:
This guy is unwell, and an embarrassment to our field
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God I really don't want to "like" this post. I really don't want to reply to this post.

But...so before all this, I liked Percy. To be clear, I do not have any personal relationship with him - just that, over the years, I've read a lot of publications with his name on them, seen his talks, know people who know him, etc.

And now...this Viewray thing...

So first, he went from MD Anderson to City of Hope.

Two of the eleven PPS-exempt centers in this country.

He has ABSOLUTELY NO IDEA about how healthcare economics works for like, you know, the majority of us.

The Viewray thing is absolutely a tragedy for what it represents. Yes, the company itself, the machine itself, all of that. But on a macro level, this is unprecedented and terrifying for the "system" of RadOnc.

I just can't shake the feeling that he doesn't "get it". He's Tweeting out these impassioned, humanistic please about Viewray, and alright fine, you do you.

But to then implore the UNITED STATES GOVERNMENT to intervene?????

This is notable, to me, because he's not your "average" RadOnc. He's Vice Chair at CoH. That's a position that has power. People will listen, or at least take note.

To have someone in a position of authority at a PPS-exempt center publicly advocating for government intervention in one of the most expensive pieces of capital equipment in modern medicine...just...no. No. Tagging the POTUS Twitter account. No.

As always: while I don't personally engage in MR-linac therapy, I want the technology to continue to exist. And it does. Just not this company's version of it. We all know that adaptive RT is currently being exploited by big academic centers in ways that most of us can't do. It will bring the Eye of Sauron. It always does.

But if you do stuff like this, similar to randomly proposing novel reimbursement legislation - stop inviting scrutiny! You're not helping! None of this is helpful!
 
Would a judge having their own biased opinion count as someone having influence? Granted, I hate insurance companies but there needs to be some guidance as to when certain modalities are appropriate.

Let’s face it, our “leaders” suck. Speaking of them, where is our ASTRO president hiding these days?


“It is undisputed among legitimate medical experts that proton radiation therapy is not experimental and causes much less collateral damage than traditional radiation,” wrote Scola, a US District Court judge for the Southern District of Florida. “To deny a patient this treatment, if it is available, is immoral and barbaric.”
 
RadOncDoc21 said:
Would a judge having their own biased opinion count as someone having influence? Granted, I hate insurance companies but there needs to be some guidance as to when certain modalities are appropriate.

Let’s face it, our “leaders” suck. Speaking of them, where is our ASTRO president hiding these days?


“It is undisputed among legitimate medical experts that proton radiation therapy is not experimental and causes much less collateral damage than traditional radiation,” wrote Scola, a US District Court judge for the Southern District of Florida. “To deny a patient this treatment, if it is available, is immoral and barbaric.”
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“…causes much less collateral damage than traditional radiation.”
[citation needed]
 
courts will always follow public opinion
 
I'll tell what little I know... Most of this is rumor mill level information.

The remaining assets of ViewRay were bought by a holding group with a generic name.

The founder of ViewRay who remained heavily involved throughout the company's history, Jim Dempsey, is heavily involved in this.

What I've heard is that the goal is to re-hire all the technical and medical people who used to be in the company. They will move forward again with service, construction of systems, upgrades, etc.

The new company plans to operate privately without much of the old leadership picked up by being a public company that were not medical people. I suspect they created large cost burdens, and I can see how poor decisions at that level could have led to the financial disaster at Viewray.

More to come, I'm sure...
 
Neuronix said:
I'll tell what little I know... Most of this is rumor mill level information.

The remaining assets of ViewRay were bought by a holding group with a generic name.

The founder of ViewRay who remained heavily involved throughout the company's history, Jim Dempsey, is heavily involved in this.

What I've heard is that the goal is to re-hire all the technical and medical people who used to be in the company. They will move forward again with service, construction of systems, upgrades, etc.

The new company plans to operate privately without much of the old leadership picked up by being a public company that were not medical people. I suspect they created large cost burdens, and I can see how poor decisions at that level could have led to the financial disaster at Viewray.

More to come, I'm sure...
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Have you heard anything about centers that shut down their systems? Are they bringing them back up now?

I wonder how many of the private investors are radiation oncologists.

It makes me a little uncomfortable how emotional some of the physicians are about this machine, but Im happy it's back in play. I wonder if the private investors are also going to fund the randomized pancreas trial that was planned! Would be awesome.
 
Neuronix said:
I'll tell what little I know... Most of this is rumor mill level information.

The remaining assets of ViewRay were bought by a holding group with a generic name.

The founder of ViewRay who remained heavily involved throughout the company's history, Jim Dempsey, is heavily involved in this.

What I've heard is that the goal is to re-hire all the technical and medical people who used to be in the company. They will move forward again with service, construction of systems, upgrades, etc.

The new company plans to operate privately without much of the old leadership picked up by being a public company that were not medical people. I suspect they created large cost burdens, and I can see how poor decisions at that level could have led to the financial disaster at Viewray.

More to come, I'm sure...
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Uh

Yikes.
 
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