What are the barriers to rad onc doing more radiopharm?

[Krukenberg]

Inspired to ponder by this NCI page: Radiopharmaceuticals Emerging as New Cancer Therapy

Rad oncs constantly complain about how we don’t have a pharma industry to fund our trials. Well here it is, and facilitated by the NCI. What are the barriers to rad onc getting into this? We should own radiation therapeutics and diversify practice, especially in the face of hypofrac. At least the last few years ASTRO has had a whole day on teaching rad oncs how to start a radiopharm practice at the annual meeting. Curious what’s stopping people out in practice.

Edit: mods feel free to move to business private forum if warranted

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[deleted605854]

Inspired to ponder by this NCI page: Radiopharmaceuticals Emerging as New Cancer Therapy

Rad oncs constantly complain about how we don’t have a pharma industry to fund our trials. Well here it is, and facilitated by the NCI. What are the barriers to rad onc getting into this? We should own radiation therapeutics and diversify practice, especially in the face of hypofrac. At least the last few years ASTRO has had a whole day on teaching rad oncs how to start a radiopharm practice at the annual meeting. Curious what’s stopping people out in practice.

Edit: mods feel free to move to business private forum if warranted

-Nuc Med turf war

-Needing shielded rooms for some dose/indications

-Inpatient responsibilities as mild as those would be

 

[Krukenberg]

-Nuc Med turf war

-Needing shielded rooms for some dose/indications

-Inpatient responsibilities as mild as those would be

Don’t know much about the shielding, but a turf war with nuc med isn’t a fair fight. We have robust clinics and referral networks with med oncs, go to tumor boards, and much more onc training than nuc med. we don’t depend on referrals from nuc med (unlike the ludicrous propositions of us giving chemo). Also for the past 20 years we’ve had an influx of smart, personable talent entering the field. Turf war shouldn’t be a barrier

 

[medgator]

Don’t know much about the shielding, but a turf war with nuc med isn’t a fair fight. We have robust clinics and referral networks with med oncs, go to tumor boards, and much more onc training than nuc med. we don’t depend on referrals from nuc med (unlike the ludicrous propositions of us giving chemo). Also for the past 20 years we’ve had an influx of smart, personable talent entering the field. Turf war shouldn’t be a barrier

It's totally region/institution dependent and rad Onc has the upper hand based on the factors you've listed

 

[FreakFlag]

Barriers may include RVU inefficiency, added overhead of radiopharm service, potential for derailing your outpatient bread & butter schedule, and punishing good deeds.

For the many private groups that collect professional only, doing Xofigo doesn't net much if I recall correctly (caveat: it's been >1 yr since I last gave Ra-223). Also our billing peeps crunched the numbers regarding professional-only oral iodine for thyroid...the numbers were tiny compared to what one can achieve with bread and butter IMRT.

Another consideration is hospitals that deliver the treatment in a collaborative anti-turf fashion, with both radonc MD and nuc/radiology MD involved. That risks derailing your radonc outpatient clinic schedule if there are delays in the nuc-med or radiology dept.

These 1-4+ hour delays can result in a lose-lose situation. Your radonc outpatient consult patients get mad at you for having to leave in the middle of their visit to staff a procedure across the hospital, and the radiopharm patient gets mad at you for being late to their already late procedure. Both patients write public negative reviews of you on Yelp and Healthgrades, and both respective referring physicians receive negative feedback about you. Also, all your subsequent outpatients that day were delayed and got mad/cancelled also.

 

[RadOncDoc21]

Literally having this turf war now at my institution. The nuc med/radiologists are digging in deep making me wonder if this is something extremely lucrative to look into more.

 

[deleted605854]

I don't know much about the reimbursement part but you have to have a favorable institutional set up.

Short distance from clinic to the place where the radionuclide is being administered.

Not on a clinic day or block that slot or something.

Nuc med is a dying specialty and I don't think they want to accelerate the process.

I think if more lucrative agents make it to the market then rad onc might be singing a different tune

 

[RadOncDoc21]

I don't know much about the reimbursement part but you have to have a favorable institutional set up.

Short distance from clinic to the place where the radionuclide is being administered.

Not on a clinic day or block that slot or something.

Nuc med is a dying specialty and I don't think they want to accelerate the process.

I think if more lucrative agents make it to the market then rad onc might be singing a different tune

i think that’s what I’m seeing on the horizon. Based off my experiences with rad oncs, we’ll be pushed out so it doesn’t really matter.

 

[temujim]

My understanding is the financials are a loser. Made worse by the occasional patient not showing up.

Inspired to ponder by this NCI page: Radiopharmaceuticals Emerging as New Cancer Therapy

Rad oncs constantly complain about how we don’t have a pharma industry to fund our trials. Well here it is, and facilitated by the NCI. What are the barriers to rad onc getting into this? We should own radiation therapeutics and diversify practice, especially in the face of hypofrac. At least the last few years ASTRO has had a whole day on teaching rad oncs how to start a radiopharm practice at the annual meeting. Curious what’s stopping people out in practice.

Edit: mods feel free to move to business private forum if warranted

 

[RickyScott]

Can only speak for my institution, but radiology has more sway than xrt.

 

[deleted605854]

Maybe with decreased Linac utilization, Rad Oncs will start to pick this up more especially if more agents are developed ?

 

[OTN]

Xofigo can be profitable if your practice can bill globally. RAI usually is not. Lutathera should be profitable eventually.

I'm able to deliver all the radiopharm for our practice, but at the current rate of usage it represents a very tiny slice of the overall radonc pie.

 

[RickyScott]

Maybe with decreased Linac utilization, Rad Oncs will start to pick this up more especially if more agents are developed ?

Nuc Med is only a specialty in academic centers, where it will always have this defined role. In the community, nuc med practiced by one of the radiologists and that department is usually more politically influential in most community systems.

 

[OTN]

Nuc Med is only a specialty in academic centers, where it will always have this defined role. In the community, nuc med practiced by one of the radiologists and that department is usually more politically influential in most community systems.

True, but in a multispecialty group the medoncs control the flow of patients. We have zero competition from the local radiology group in this space, and they are very large and very good. We cooperate very well with them- they do RAI for us- but we get to decide which radiopharm txs we pharm out. (Get it? Very punny, eh? I’ll see myself out.)

 

[kimplera]

i feel strongly that we should be moving aggressively to take ownership of this by demanding good dosimetry and cancer care. This could be done while feeding nucmed (SPECT) and provide more rigor and personalization to the radiopharm field.

 

[deleted605854]

i feel strongly that we should be moving aggressively to take ownership of this by demanding good dosimetry and cancer care. This could be done while feeding nucmed (SPECT) and provide more rigor and personalization to the radiopharm field.

I like your attitude

I wish all newcomers to this field were like this

 

[RadOncDoc21]

So yeah, just as I figured.

The rad techs here were basically explaining to me how the radiologists are upset about cardiology performing nuc med imaging and surgeons doing IR procedures. So my interest in radiopharmaceuticals was viewed as more of another specialist encroaching in their field.

I think it’s a smart move to get defensive and again I’m betting on this becoming something more in the future with all the new targeting agents coming out. I’m sure there is going to be more of a role for radioimmunotherapy in the future and we are going to be left behind as we focus more on the use of having more expensive shiny machines to treat with one fraction or less.

 

[MegaVoltagePhoton]

So yeah, just as I figured.

The rad techs here were basically explaining to me how the radiologists are upset about cardiology performing nuc med imaging and surgeons doing IR procedures. So my interest in radiopharmaceuticals was viewed as more of another specialist encroaching in their field.

I think it’s a smart move to get defensive and again I’m betting on this becoming something more in the future with all the new targeting agents coming out. I’m sure there is going to be more of a role for radioimmunotherapy in the future and we are going to be left behind as we focus more on the use of having more expensive shiny machines to treat with one fraction or less.

we are WAY too hard on ourselves. We have been perversely trained to think that new and shiny is **** by default. It is ALL about marketing and perception. Look at all the crap response rate branded drugs.

i guarantee a well promoted shiny radiation toy will draw customers.

we just have a love hate relationship with ourselves. Wherein we hate ourselves and love talking about it

 

[deleted605854]

we are WAY too hard on ourselves. We have been perversely trained to think that new and shiny is **** by default. It is ALL about marketing and perception. Look at all the crap response rate branded drugs.

i guarantee a well promoted shiny radiation toy will draw customers.

we just have a love hate relationship with ourselves. Wherein we hate ourselves and love talking about it

-Shiny radiation toys are good and I agree with what you said

-radiopharm is good

-radoimmunopharm is also good

-RT-IO will be great

We need to take it all if we want this field to flourish.

 

[BobbyHeenan]

My biggest complaints (and our trump card over IR or nuc med doing these things) is that in my experience, the IR or nuc med folks have little if any clue about things like survival numbers, what other systemic agents are available, life expectancy, or clinic logistics. They can't answer patient questions and make the med oncs do all of the management. They have a "clinic" sort of...but patients can see it's not the same kind of cancer clinic they get in the rad onc office.

If med onc controls the flow, your pitch to them is that you can help manage these patients in your clinic as well and take away some of their burden. You're trained in cancer and not a technician.

I can see that if you're slammed with linac patients there wouldn't be much interest in this, but if Lutathera or PSMA based treatments take off, would be nice to be involved there.

Aside - we inquired about getting Lutathera in our cancer network, but about a couple of years ago it seemed like a long shot. Any community hospital based practices out there offering this?

 

[medgator]

My biggest complaints (and our trump card over IR or nuc med doing these things) is that in my experience, the IR or nuc med folks have little if any clue about things like survival numbers, what other systemic agents are available, life expectancy, or clinic logistics. They can't answer patient questions and make the med oncs do all of the management. They have a "clinic" sort of...but patients can see it's not the same kind of cancer clinic they get in the rad onc office.

If med onc controls the flow, your pitch to them is that you can help manage these patients in your clinic as well and take away some of their burden. You're trained in cancer and not a technician.

I can see that if you're slammed with linac patients there wouldn't be much interest in this, but if Lutathera or PSMA based treatments take off, would be nice to be involved there.

Aside - we inquired about getting Lutathera in our cancer network, but about a couple of years ago it seemed like a long shot. Any community hospital based practices out there offering this?

The financials don't work imo for radiopharmaceuticals... Unless you're doing a lot of it and are billing globally (and a hawk on the billing). Different business model than trying to run Linac practice, more similar to med onc and drug margins honestly.

Completely agree with you regarding our Trump card... I do a lot of cross referral to med onc for anal, h&n and a lot of skin lately (io)

 

[RadOncDoc21]

The financials don't work imo for radiopharmaceuticals... Unless you're doing a lot of it and are billing globally (and a hawk on the billing). Different business model than trying to run Linac practice, more similar to med onc and drug margins honestly.

Completely agree with you regarding our Trump card... I do a lot of cross referral to med onc for anal, h&n and a lot of skin lately (io)

By all means, I do not want or inspire this to be part of my daily practice but I’m the type of person to change course if I see a cliff coming up in the horizon. It doesn’t mean the new course is any safer but as our great leader once asked “what do you have to lose?”

 

[kimplera]

If we can focus on the need for dosimetry due to repeated treatments and knowing what dose normal tissues receive we can perhaps claw back some of this from other's and justify increased billing over just give a dose and walk away...

 

[OTN]

My biggest complaints (and our trump card over IR or nuc med doing these things) is that in my experience, the IR or nuc med folks have little if any clue about things like survival numbers, what other systemic agents are available, life expectancy, or clinic logistics. They can't answer patient questions and make the med oncs do all of the management. They have a "clinic" sort of...but patients can see it's not the same kind of cancer clinic they get in the rad onc office.

If med onc controls the flow, your pitch to them is that you can help manage these patients in your clinic as well and take away some of their burden. You're trained in cancer and not a technician.

I can see that if you're slammed with linac patients there wouldn't be much interest in this, but if Lutathera or PSMA based treatments take off, would be nice to be involved there.

Aside - we inquired about getting Lutathera in our cancer network, but about a couple of years ago it seemed like a long shot. Any community hospital based practices out there offering this?

We're a community freestanding center-based practice, and we haven't been able to make Lutathera work yet, either. I'm still hopeful we'll figure it out, though. My surg oncs are clamoring for it.

 

[medgator]

We're a community freestanding center-based practice, and we haven't been able to make Lutathera work yet, either. I'm still hopeful we'll figure it out, though. My surg oncs are clamoring for it.

I believe the logistics lend themselves better to hospital based places with mo/infusion centers nearby

 

[BobbyHeenan]

We're a community freestanding center-based practice, and we haven't been able to make Lutathera work yet, either. I'm still hopeful we'll figure it out, though. My surg oncs are clamoring for it.

I'm hospital based in a pretty big network (6 chemo/rads hospital based facilities), and when I inquired about 18 months ago I was told "not soon" by the company with regard to rolling out in our system.

I haven't looked into it recently.

 

[medgator]

I'm hospital based in a pretty big network (6 chemo/rads hospital based facilities), and when I inquired about 18 months ago I was told "not soon" by the company with regard to rolling out in our system.

I haven't looked into it recently.

The lutathera reps have been wining and dining us hard, but the logistics are insane. Have to infuse nephro protective amino acids, anti emetic etc before the drug and then fluids i think, plus they need their own space and bathroom, whole process basically kills at least half the day and requires RSO/physicist to be tied up.

 

[xrt123]

Myself and my partner have done >150 lutathera injections and we were early adopters as we have a practice where we are partnered with medoncs. We had a large cohort of patients with low grade neuroendocrine tumors slowly progressing on lanreotide within the medical oncology practice. Therefore we knew we would have >20 patients (>80 injections) the minute we had the program running. Logistics are hell and it doesn't make sense to do if you don't do alot of them. It's not financially beneficial for us compared to the hospital system. We work close with nuc med and they get reimbursed for all the Gallium scans and we are starting to talk about calculating dosimetry to kidney since this could predict toxicity and allow for retreatment. We are hoping this parlays into further radiopharmaceuticals as there are multiple under investigation for different disease sites. Patients benefit from our clinic as Nuc med has no real clinic. We are getting labs on them, checking for CHF, kidney injury, reviewing the gallium pet scans with patients, assessing response and working with medonc for timing of lanreotide. A lot of effort goes into the clinical side and I think as clinicians we do a better job than most NucMeds or IR would do. Also we have found about 10-15% of these patient will need palliative EBRT before or after. When PSMA based mesothelin based or other radiopharmaceuticals are approved we will have a setup that allows for economy of scale and hope it will be more profitable and less time consuming. I think it is a worthwhile to get involved as we are cancer doctors who specialize in radiation and have a license to handle radiation. I have always believed you do what you can to expand your referral base and this is one of the few growth opportunities for new indications in our field.

As a side note, it is professionally rewarding because the patients tend to do pretty well and we have had good results with lutathera.

 

[Tigerstang]

The lutathera reps have been wining and dining us hard, but the logistics are insane. Have to infuse nephro protective amino acids, anti emetic etc before the drug and then fluids i think, plus they need their own space and bathroom, whole process basically kills at least half the day and requires RSO/physicist to be tied up.

Exactly why I am not doing it

 

[radonc17]

Hi all,

Great discussion above. I noticed recently that our ACGME mins for unsealed sources/radiopharm recently increased from 6 to 8.

In this recent Red Journal article, there seemed to be some interest in expanding RO scope via unsealed sources/radiopharm, but there is minimum formal info on current usage, barriers etc

I've designed this ≤5 min survey to assess the above.

I realize this is unconventional request, but I was hoping you could help out by taking the survey

https://collaborate.tuftsctsi.org/redcap/surveys/?s=FJTA37N4CP

Sincerely,

Mudit Chowdhary

 

[ramsesthenice]

These 1-4+ hour delays can result in a lose-lose situation.

We are transitioning to a more "collaborative specialty" model which is a nice way of saying we have initiated a slow hostile take over. The logistical considerations can't be stressed enough. Nuc med is like brachy or other procedural things. Without sufficient volume its not worth the hassle. Reimbursement is ok but not outstanding. If you can set it up to have a dedicated afternoon or 2 where you do these back to back it can be worth it. If its haphazardly thrown in here and there it is generally more trouble than it is worth. Just my two copper Lincolns

 

[OTN]

We are transitioning to a more "collaborative specialty" model which is a nice way of saying we have initiated a slow hostile take over. The logistical considerations can't be stressed enough. Nuc med is like brachy or other procedural things. Without sufficient volume its not worth the hassle. Reimbursement is ok but not outstanding. If you can set it up to have a dedicated afternoon or 2 where you do these back to back it can be worth it. If its haphazardly thrown in here and there it is generally more trouble than it is worth. Just my two copper Lincolns

I've found value in doing it just to continue to reinforce that even though we are "just" a private practice, we can still offer nearly all XRT services to patients. Same reason I do TBI and TSET - these certainly take the cake for "amount of work for dollars received" ratio.

 

[RickyScott]

We are transitioning to a more "collaborative specialty" model which is a nice way of saying we have initiated a slow hostile take over. The logistical considerations can't be stressed enough. Nuc med is like brachy or other procedural things. Without sufficient volume its not worth the hassle. Reimbursement is ok but not outstanding. If you can set it up to have a dedicated afternoon or 2 where you do these back to back it can be worth it. If its haphazardly thrown in here and there it is generally more trouble than it is worth. Just my two copper Lincolns

Tough to "collaborate" in most large systems unless you are powerful department. Usually in big enough hospital system, there is a radiologist who spends a considerable amount of time on nucs and radiology department wont take kindly to sharing with others.

 

[dieABRdie]

We are transitioning to a more "collaborative specialty" model which is a nice way of saying we have initiated a slow hostile take over. The logistical considerations can't be stressed enough. Nuc med is like brachy or other procedural things. Without sufficient volume its not worth the hassle. Reimbursement is ok but not outstanding. If you can set it up to have a dedicated afternoon or 2 where you do these back to back it can be worth it. If its haphazardly thrown in here and there it is generally more trouble than it is worth. Just my two copper Lincolns

We do all the radiopharm in our area simply because no one else does it. If someone else wanted to do it.... we would gladly give it up. As OTN said its nice to do just as a more complete oncology service.

 

[FrostyHammer]

Hi all,

Great discussion above. I noticed recently that our ACGME mins for unsealed sources/radiopharm recently increased from 6 to 8.

In this recent Red Journal article, there seemed to be some interest in expanding RO scope via unsealed sources/radiopharm, but there is minimum formal info on current usage, barriers etc

I've designed this ≤5 min survey to assess the above.

I realize this is unconventional request, but I was hoping you could help out by taking the survey

https://collaborate.tuftsctsi.org/redcap/surveys/?s=FJTA37N4CP

Sincerely,

Mudit Chowdhary


View attachment 328939

I'm sure your survey is fine in terms of quality but do send it to red journal, which publishes even the poorest quality survey papers these days.

 

[Reaganite]

Haven't read through all the responses admittedly but radiopharm can be very expensive and many hospitals wouldn't let u do it even if u wanted to. I tried to administer xofigo at a community hospital back in the day and they refused to purchase the isotope.

 

[ramsesthenice]

Tough to "collaborate" in most large systems unless you are powerful department. Usually in big enough hospital system, there is a radiologist who spends a considerable amount of time on nucs and radiology department wont take kindly to sharing with others.

No doubt. We took advantage of our unique situation. Tight research collaborations with nuc med and radiology in terms of newer thernagnostic agents got us in the door. Then attrition started to affect nuc med staffing and nature took its course. Hence why I put the word collaborate in quotations. No one is ever just going to cede their turf to someone else if it is still producing revenue.

 

[radonc17]

Great discussion! - @ramsesthenice @Reaganite @dieABRdie @RickyScott @OTN

Can I shamefully request for you to add your responses in the survey 🙂

@FrostyHammer - you made me LOL

 

[RickyScott]

Great discussion! - @ramsesthenice @Reaganite @dieABRdie @RickyScott @OTN

Can I shamefully request for you to add your responses in the survey 🙂

@FrostyHammer - you made me LOL

I did and appreciate role you are playing trying to expand xrt.

 

[OTN]

Great discussion! - @ramsesthenice @Reaganite @dieABRdie @RickyScott @OTN

Can I shamefully request for you to add your responses in the survey 🙂

@FrostyHammer - you made me LOL

Sure, no problem

 

[ramsesthenice]

I've found value in doing it just to continue to reinforce that even though we are "just" a private practice, we can still offer nearly all XRT services to patients. Same reason I do TBI and TSET - these certainly take the cake for "amount of work for dollars received" ratio.

TBI in a private practice? Someone call the cops. This guys a murderer!

Sounds like a fair calculation to me. ROI calcs always need to take into account direct and indirect returns.

Great discussion! - @ramsesthenice @Reaganite @dieABRdie @RickyScott @OTN

Can I shamefully request for you to add your responses in the survey 🙂

@FrostyHammer - you made me LOL

Sure.

 

[radonc17]

Thank yall so much! - @ramsesthenice @OTN @RickyScott

 

[medgator]

Thank yall so much! - @ramsesthenice @OTN @RickyScott

Just filled out the survey.... Our billing people have to be like hawks when it comes to reimbursement on the freestanding side for xofigo. Can easily be a money loser if you aren't on top of the payors. It's the same struggle med oncs deal with all the time when prescribing five figure systemic therapy on a monthly basis

Still not offering lutathera, the logistics don't work outside of a hospital imo and really ties up the physics/nursing staff

 

[radonc17]

Just filled out the survey.... Our billing people have to be like hawks when it comes to reimbursement on the freestanding side for xofigo. Can easily be a money loser if you aren't on top of the payors. It's the same struggle med oncs deal with on a regular basis when prescribing five figure systemic therapy on a monthly basis

Still not offering lutathera, the logistics don't work outside of a hospital imo and really ties up the physics/nursing staff

thank you @medgator!

 

[RickyScott]

Just filled out the survey.... Our billing people have to be like hawks when it comes to reimbursement on the freestanding side for xofigo. Can easily be a money loser if you aren't on top of the payors. It's the same struggle med oncs deal with on a regular basis when prescribing five figure systemic therapy on a monthly basis

Still not offering lutathera, the logistics don't work outside of a hospital imo and really ties up the physics/nursing staff

Exactly, one denial and you are screwed. Also late payment of 90 days on 50000$, you are loosing out on some interest.

 

[elementaryschooleconomics]

Just filled out the survey.... Our billing people have to be like hawks when it comes to reimbursement on the freestanding side for xofigo. Can easily be a money loser if you aren't on top of the payors. It's the same struggle med oncs deal with all the time when prescribing five figure systemic therapy on a monthly basis

Still not offering lutathera, the logistics don't work outside of a hospital imo and really ties up the physics/nursing staff

Man, Lutathera is quite the ordeal, I was surprised at how much time such a simple treatment takes

 

[medgator]

Man, Lutathera is quite the ordeal, I was surprised at how much time such a simple treatment takes

It's like giving radioactive chemo honestly... Hydration, anti emetics, nephroprotectants etc. If you don't have a busy beam practice, it may make sense, but not for those of us that do

 

[Krukenberg]

I think this is a good space for rad oncs to occupy/take over. Glad the survey is being done to better understand. There is a trial of adjuvant Lu177-PSMA for resected high risk prostate cancer. If it pans out, it’s an example of the expanded business these theranostics could bring. What I’m afraid of is if it takes off and none of us has the infrastructure to deliver the agents, we could be left behind.

 

[medgator]

I think this is a good space for rad oncs to occupy/take over. Glad the survey is being done to better understand. There is a trial of adjuvant Lu177-PSMA for resected high risk prostate cancer. If it pans out, it’s an example of the expanded business these theranostics could bring. What I’m afraid of is if it takes off and none of us has the infrastructure to deliver the agents, we could be left behind.

It won't replace external volume that is going away/de-fractionating. Plus financially, it can be a mess. These aren't cheap drugs

 

[RadOncDoc21]

It won't replace external volume that is going away/de-fractionating. Plus financially, it can be a mess. These aren't cheap drugs

That we know of... I have no clue what the future holds but some RT is still better then no RT. At the rate we’re going we will be delivering one fraction or less to everything.