Variation in the Cost of Radiation Therapy Among Medicare Patients With Cancer.

PURPOSE: Radiation therapy represents a major source of health care expenditure for patients with cancer. Understanding the sources of variability in the cost of radiation therapy is critical to evaluating the efficiency of the current reimbursement system and could shape future policy reform. This study defines the magnitude and sources of variation in the cost of radiation therapy for a large cohort of Medicare beneficiaries. PATIENTS AND METHODS: We identified 55,288 patients within the SEER database diagnosed with breast, lung, or prostate cancer between 2004 and 2009. The cost of radiation therapy was estimated from Medicare reimbursements. Multivariable linear regression models were used to assess the influence of patient, tumor, and radiation therapy provider characteristics on variation in cost of radiation therapy. RESULTS: For breast, lung, and prostate cancers, the median cost (interquartile range) of a course of radiation therapy was $8,600 ($7,300 to $10,300), $9,000 ($7,500 to $11,100), and $18,000 ($11,300 to $25,500), respectively. For all three cancer subtypes, patient- or tumor-related factors accounted for < 3% of the variation in cost. Factors unrelated to the patient, including practice type, geography, and individual radiation therapy provider, accounted for a substantial proportion of the variation in cost, ranging from 44% with breast, 43% with lung, and 61% with prostate cancer. CONCLUSION: In this study, factors unrelated to the individual patient accounted for the majority of variation in the cost of radiation therapy, suggesting potential inefficiency in health care expenditure. Future research should determine whether this variability translates into improved patient outcomes for further evaluation of current reimbursement practices.

[Innovation and the next generation radiotherapy system].

Innovation is the key to future success for Japan that is slowly falling behind. Industries targeted by the "Abenomics" growth strategy include healthcare and medicine. Since cancer is the leading cause of death in Japan, the development of a system that can detect and treat early stage cancers will be very valuable for patient QOL and reducing health care costs. Although the effectiveness of radiation therapy for treating early stage cancer is widely recognized, there has been no system to treat small, moving tumors with sub millimeter accuracy. A project supported by NEDO develops a "Next-Generation Radiation Therapy System" that uses high energy, narrow X-rays beams that can be accurately pinpointed deep inside the body. Performance testing of a prototype system is currently underway at the National Center for Global Health and Medicine in Tokyo.

Comparative effectiveness research for prostate cancer radiation therapy: current status and future directions.

Comparative effectiveness research aims to help clinicians, patients and policymakers make informed treatment decisions under real-world conditions. Prostate cancer patients have multiple treatment options, including active surveillance, androgen deprivation therapy, surgery and multiple modalities of radiation therapy. Technological innovations in radiation therapy for prostate cancer have been rapidly adopted into clinical practice despite relatively limited evidence for effectiveness showing the benefit for one modality over another. Comparative effectiveness research has become an essential component of prostate cancer research to help define the benefits, risks and effectiveness of the different radiation therapy modalities currently in use for prostate cancer treatment.

A question of value.

Assessing the value of a new clinical technology--in this case, proton therapy--requires tough questions.

The Dose Verification System (DVS) for cancer patients receiving radiation therapy.

The Dose Verification System (DVS) is the first implantable radiation dosimeter designed for in situ measurement of dose delivered to the tissue being irradiated. The success of radiation therapy is predicated on maximizing tumor cell death and minimizing normal tissue toxicity. Tumor control increases with the delivery of appropriate radiation doses to the target area. These doses have been determined from in vitro and animal studies, which generated specific dose-response data. However, there has not been a practical system available to ensure that the appropriate dose was being delivered in situ to monitor the daily patient dose during radiation therapy. Studies have shown that dose variations can occur. Recently completed pivotal clinical studies using the DVS found a greater than 7% (positive or negative) change in cumulative dose in seven out of 36 (19%) breast cancer patients; and six out of 29 (21%) and eight out of 19 (42%) patients during large-field and boost irradiation of the prostate. The device is an important step to enable physicians to expand the concept of individualization of therapy.

Considerations of cost-effectiveness for new radiation oncology technologies.

PURPOSE: The additional equipment and personnel costs of supplying image-guided radiation therapy (IGRT) technology have caused many to question if the marginal gains in patients' health-related quality of life are worth the additional cost. Novel IGRT technologies, including cone-beam computed tomography and helical tomotherapy, provide the opportunity to study cost and effectiveness for patients. MATERIALS AND METHODS: This methodologic study proposes to evaluate the cost and effectiveness of treating conventional radiotherapy versus IGRT patients prospectively among several institutions. The cost of treating patients varies among institutions depending on personnel, equipment, and overhead costs, but the nature and quality of services provided are expected to be consistent. RESULTS: The study will track cost information at a single institution and simultaneously as the median from multiple institutions. Effectiveness measures will include both standard quality-adjusted life-year instruments completed by patients and performance status measures completed by institutional personnel. In addition, disease-specific effectiveness measures will be accommodated in the study. Each participating institution will use the same effectiveness measures to track patients with similar diseases. CONCLUSION: The resulting cost and effectiveness data will be available to investigators at any point during the study, immediately on the completion of a trial, or when statistical acceptability is achieved. These considerations are being incorporated into a high-level information model under development.

Características principales de la gestión clínica en los servicios de Radioterapia Oncológica / The mot important characteristics of Clinical Management in Radiotherapy Oncology Units

Los autores señalan que el establecimiento de un completo cuadro de mando con índices de medida de actividad en su conjunto, es esencial para un correcta gestión clínica en Oncología Radioterápica. Hacen hincapié en que es imprescindible disponer de una serie exhaustiva de mecanismos de control en todo el proceso para asegurar una pronta detección de cualquier error que pudiera producirse (AU)

According to the authors of this paper, the establishment of a full management system able to gauge its overall activity rate is essential to proper clinical management in Radiotherapy Oncology. The authors stress the need to establish a comprehensive control mechanism throughout the entire process in order to ensure early detection of any possible errors (AU)

Intensity modulated radiation therapy--the shape of things to come?

Over the past century, the field of radiation oncology has seen tremendous technological advances. Some of these advances relate to biomedical accomplishments, while many are directly related to those achieved in computing and information technology. For example, developments in radiation treatment planning systems are intimately connected to progress in all of computing, and have culminated in the ability of radiation oncologists to accurately plan even the most complex therapy. Treatment machines, themselves tooled with embedded computer chips and processors, have evolved from rigid monstrosities to highly flexible, compact, machines capable of moving with robotic-like precision. The addition of multi-leaf collimators to these treatment machines has added yet another dimension to the picture. The ability to coordinate the fine motor movements of these collimators along with the coarser movements of the machine itself has required a level of control not possible manually. Computers again have provided a solution, and the result was not just a new means of directing the radiation beam, but a revolution in how radiation itself was delivered Intensity Modulated Radiation Therapy. Now, Intensity Modulated Radiation Therapy (IMRT) is practiced in hundreds of radiation oncology departments worldwide. The administration process, which challenges the most sophisticated computer planning and treatment control systems, requires not just proficient technical support, but also a dedicated administrative infrastructure. The payoff, however, promises to be big. Preliminary clinical outcome reports suggest that significant reductions in toxicity will be achievable, making increased control rates more likely. In addition, favorable CMS reimbursement changes make it probable that the technology will spread rapidly throughout the radiation oncology community. Studies are ongoing to help identify the most appropriate use of the therapy. Ultimately, IMRT is likely to become a readily available treatment for use in select cases.

Guide to clinical use of electronic portal imaging.

The Electronic Portal Imaging Device (EPID) provides localization quality images and computer-aided analysis, which should in principal, replace portal film imaging. Modern EPIDs deliver superior image quality and an array of analysis tools that improve clinical decision making. It has been demonstrated that the EPID can be a powerful tool in the reduction of treatment setup errors and the quality assurance and verification of complex treatments. However, in many radiation therapy clinics EPID technology is not in routine clinical use. This low utilization suggests that the capability and potential of the technology alone do not guarantee its full adoption. This paper addresses basic considerations required to facilitate clinical implementation of the EPID technology and gives specific examples of successful implementations.

Off-line verification of the day-to-day three-dimensional table position variation for radiation treatments of the head and neck region using an immobilization mask.

Variation in the table height position for 175 treatments of 167 patients was calculated as a measure for day-to-day set-up precision in 2063 treatment sessions and resulted in a median standard deviation of 1 mm. The median standard deviations of table longitudinal and lateral position were 3 and 5 mm, respectively.

Physician resource utilization in radiation oncology: a model based on management of carcinoma of the prostate.

PURPOSE: To develop a methodology to estimate the comparative cost of physician time in treating patients with localized prostate cancer, using as an example two-dimensional (2D) vs. three-dimensional (3D) conformal irradiation techniques, and to illustrate how current cost-accounting techniques can be used to quantify the cost of physician time and effort of any treatment. METHODS AND MATERIALS: Activity-based costing, a recent innovation in accounting, widely recommended for estimating and managing the costs of specific activities, was used to derive physician resource utilization costs (actual cost of the physician services and related support services consumed). RESULTS: Patients treated with 3D conformal irradiation consume about 50% more physician time than patients receiving 2D conventional radiation therapy. The average professional reimbursement for the 3D conformal irradiation is only about 26% more than for the 2D treatment. Substantial variations in cost are found depending on the total available physician working hours. In an academic institution, a physician working 40 hours a week would have to spend an average of about 60% of available time on clinical services to break even on a 2D treatment process and over 74% of available time on clinical work to break even on a 3D treatment process. The same physician working 50 hours a week would have to spend an average of about 48% of available time on 2D clinical services and about 60% of available time on 3D clinical work to break even. Current Medicare reimbursement for 3D treatment falls short of actual costs, even if physicians work 100% of a 50-hour week. Medicare reimbursement for 2D barely allows the department to break even for 2D treatments. CONCLUSIONS: Costs based on estimates of resource use can be substantially under- or overestimated. A consistent language (method) is needed to obtain and describe the costs of radiation therapy. The methodology described here can help practitioners and researchers more accurately interpret actual cost information. Future use of such cost-estimation methodologies could provide consistent and comparable costs for negotiations with health care providers and help assess different treatment strategies.

Cost benefit of emerging technology in localized carcinoma of the prostate.

PURPOSE: In a health care environment strongly concerned with cost containment, cost-benefit studies of new technology must include analyses of loco-regional tumor control, morbidity, impact on quality of life, and financial considerations. METHODS AND MATERIALS: This nonrandomized study analyzes 124 patients treated with three-dimensional conformal radiation therapy (3D CRT) and 153 with standard irradiation (SRT) between January 1992 and December 1995, for histologically proven adenocarcinoma of prostate, clinical Stage T1 or T2. Mean follow-up is 1.4 years. Three-dimensional CRT consisted of six or seven coplanar oblique and lateral and, in some patients, AP fields designed to treat the prostate with a 1 to 1.7 cm margin. SRT consisted of 120 degrees bilateral arc rotation. Total doses to prostate were 67 to 70 Gy when pelvic lymph nodes were irradiated or 68.4 to 73.8 Gy when prostatic volume only was treated; dose per fraction was 1.8 Gy. Patients were interviewed weekly for severity of 12 acute intestinal and urinary pelvic irradiation side effects (0 to 4+ grading). Time and effort for 3D RTP and daily treatment with 3D CRT and SRT were recorded. Dose-volume histograms (DVHs) were calculated for gross tumor volume, planning target volume, bladder, and rectum. Actual reimbursement to the hospital and university was determined for 41 3D CRT, 43 SRT, and 40 radical prostatectomy patients treated during the same period. RESULTS: Average treatment planning times (in minutes) were: 101 for 3D conformal therapy simulation, 66 for contouring of target volume and sensitive structures, 55 for virtual simulation, 39 for plan preparation and documentation, 65 for physical simulation, and 20 for approval of treatment plan. Daily mean treatment times were 19 min for 3D CRT with Cerrobend blocking, 16 with multileaf collimation, and 10 with bilateral arc rotation. Dosimetric analysis (DVHs) showed a reduction of 50% in volume of bladder or rectum receiving doses higher than 65 Gy. Acute side effects included dysuria, moderate difficulty in urinating, and nocturia in 25-39% of both SRT and CRT patients; loose stools or diarrhea in 5-12% of 3D CRT and 16-22% of SRT patients; moderate proctitis in 3% of 3D CRT and 12% of SRT patients (p = 0.01). Chemical disease-free survival (prostate-specific antigen < or =2 ng/ml) at 3 years was 90% with 3D CRT and 80% with SRT (p = 0.01). Average initial treatment reimbursements were $13,823 (3D CRT), $10,864 (SRT), and $12,250 (radical prostatectomy). Average total treatment reimbursement and projected cost of management of initial therapy failures per patients were $15,173, $16,264, and $16,405, respectively. CONCLUSIONS: Three-dimensional CRT irradiated less bladder and rectum volume than SRT; CRT initial reimbursement was 28% higher than SRT and 12% higher than radical prostatectomy. Because of projected better local tumor control, average total cost of treating a patient with 3D CRT or radical prostatectomy is equivalent to cost of SRT. Treatment morbidity was lower with 3D CRT. Our findings reflect an overall benefit with 3D CRT as a new promising technology in treatment of localized prostate cancer. Dose-escalation studies may enhance its efficacy and cost benefit.

Investigating the potential of three-dimensional treatment planning.

3-D treatment planning has received a great deal of attention in the radiation therapy community over the last several years. This new technology makes use of the continuous improvements in computer hardware and graphics capabilities, along with major improvements in treatment planning software, to provide a fully three dimensional simulation of the patient, radiation beams, and dose distributions which are used for radiation therapy of various cancers. With these capabilities, the physician and treatment planner may now optimize the radiation beams used to treat the patient much more effectively than in the past, when only a limited description of the patient, beams, and doses was available. This paper describes several of the new capabilities of these 3-D planning systems, some research studies which are currently being performed to evaluate the usefulness of the new technology, and finally some of the costs associated with its implementation.