Breast APBI - SBRT or not? Discussion

[seper]

Thanks for responding and thanks for looking into it.

Is there any reason that ASTRO cannot just add SBRT as an accepted technique on the new partial breast guidelines they are about to publish?

My argument is that it would qualify as SBRT under the AAPM task group 101 definition of SBRT: “the delivery of large doses in a few fractions, which results in a high biological effective dose BED.” With appropriate imaging, machine QA and physician/physics supervision, it would also meet the characteristics of SBRT as set forth in table 1 of that paper (Benedect et al, Med Phys 2010). The link for the paper is provided below. 25-30 Gy in 5 fractions are also already considered stereotactic radiation in other disease sites such as CNS.

If ASTRO added it as an accepted technique in the new partial breast guidelines, then we would at least have a better chance of having it covered when doing a peer to peer with a private insurance.

The ultimate dream would be if that ASTRO called it SBRT in their guidelines then we could lobby for NCCN to call it SBRT in NCCN guidelines. After that we could pressure Medicare to add it as a coverable diagnosis for SBRT.


https://aapm.onlinelibrary.wiley.com/doi/epdf/10.1118/1.3438081

Why would you want to call PBI X 5 an SBRT?

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[radiation123]

Why would you want to call PBI X 5 an SBRT?

SBRT reimburses significantly more than an IMRT 5 fraction partial breast treatment.

If we use the numbers provided by Meeks et al in table 3 in the paper linked below switching to 5 fractions IMRT treatment would decrease reimbursement per patient for a 15-fraction 3D conformal plan, 15 fraction IMRT plan and a 25-fraction 3D plan by ~1,500 dollars, ~5,400 dollars, and ~5,800 dollars, respectively. In contrast a five fraction SBRT plan would change reimbursement per patient for a 15-fraction 3D conformal plan, 15-fraction IMRT plan and a 25-fraction 3D plan by ~+3,800 dollars, ~0 dollars and ~-400 dollars. Depending on the fractionation and number of breast patients seen, switching eligible patient to a 5-fraction IMRT treatment could decrease reimbursement by hundreds of thousands of dollars per provider per year. However, a 5-fraction SBRT treatment would likely cause no significant change or a slight increase in reimbursement.

https://ascopubs.org/doi/pdf/10.1200/OP.21.00298?role=tab

 

[Mandelin Rain]

Is there any reason that ASTRO cannot just add SBRT as an accepted technique on the new partial breast guidelines they are about to publish?

Obvious reason is ASTRO has moved on to case rates so those designations become somewhat meaningless with regard to reimbursement.

Unless you're doing proton PBI. Then...

Folks out here making money and breaking ribs.

 

[evilbooyaa]

Why would you want to call PBI X 5 an SBRT?

30Gy in 5 fractions to a vertebral body - SBRT
30GY in 5 fractions to a similar sized cavity in the breast - not SBRT

Why WOULDN'T you want to call PBI x 5 an SBRT?

 

[deleted1168505]

SBRT does not have 1 cm PTVs (nevermind 1 cm CTVs to cover subclinical disease).

Trying to upbill 5 fraction partial breast is the wrong way to go and will unattract unneeded attention.
Reasonable case-based payments make a lot more sense.
Put Evicore out of business.

 

[metallica81788]

Why WOULDN'T you want to call PBI x 5 an SBRT?

Margin size, no gross disease (adjuvant treatment)

I'm all for getting whatever advantage we can for our specialty, but this small goal seems a bit disingenuous with the overall history of SBRT
I understand there is no true definition of SBRT as has been discussed here many times, but PBI is not SBRT to me

 

[radiation123]

Obvious reason is ASTRO has moved on to case rates so those designations become somewhat meaningless with regard to reimbursement.

Unless you're doing proton PBI. Then...

Folks out here making money and breaking ribs.

I would argue that unless the probabilty of ROCR passing congress is ~100% and the probabilty that private insurance will rapidly adopt the case rate approach is 100% then we should pursue calling 5 fraction breast treatment SBRT.

I dont think either of the above conditions are a certainty. The safest thing would be to pursue both strategies simultaneously.

 

[RadOncDoc21]

Margin size, no gross disease (adjuvant treatment)

I'm all for getting whatever advantage we can for our specialty, but this small goal seems a bit disingenuous with the overall history of SBRT
I understand there is no true definition of SBRT as has been discussed here many times, but PBI is not SBRT to me

Also 25/5 to pelvis would be considered SBRT.

 

[radiation123]

SBRT does not have 1 cm PTVs (nevermind 1 cm CTVs to cover subclinical disease).

Trying to upbill 5 fraction partial breast is the wrong way to go and will unattract unneeded attention.
Reasonable case-based payments make a lot more sense.
Put Evicore out of business.

If the PTV expansion is a problem for you then just change your CTV expansionfrom 1.5 cm to 2 cm and your PTV expansion from 1 cm to 5 mm. In the guidelines we are discussing they already state for 5 fractions breast " PTV: 1 cm margin around CTV. For patients undergoing daily imaging, tighter margins may be considered depending on accuracy of patient setup"

SBRT does not bill higher than other widely used techniques (i.e. conventionally fractionated 3-D conformal).

I dont disagree regarding case rate, but I dont think that they are a sure thing. We should pursue both strategies to be safte.

 

[radiation123]

Also 25/5 to pelvis would be considered SBRT.

In the long term I would argue we should push for this as well, but I think it is a harder sell. I think we should go after low hanging fruit first.

 

[NotMattSpraker]

30Gy in 5 fractions to a vertebral body - SBRT
30GY in 5 fractions to a similar sized cavity in the breast - not SBRT

Why WOULDN'T you want to call PBI x 5 an SBRT?

ASTRO (leadership) is totally absurd when it comes to defining breast treatments for reimbursement.

This has been the case for a while. Todd has posted extensively on Twitter about how they have tied themselves in knots trying to discourage billing IMRT for years. It is not scientific, it is almost entirely political. At a high level, radiation oncologists take a really strange approach in engaging payers/medicare.

Personally, I don't think Florence-style breast treatment needs the physician presence and enhanced QA that, I guess, sort of defines SBRT. I think this is more important for CNS or lung. But I think people who want breast to be SBRT are very reasonable and I understand the argument.

Honestly, avoiding this frustrating conversation is a huge upside of case rate models to me

 

[deleted1168505]

If the PTV expansion is a problem for you then just change your CTV expansionfrom 1.5 cm to 2 cm and your PTV expansion from 1 cm to 5 mm. In the guidelines we are discussing they already state for 5 fractions breast " PTV: 1 cm margin around CTV. For patients undergoing daily imaging, tighter margins may be considered depending on accuracy of patient setup"

SBRT does not bill higher than other widely used techniques (i.e. conventionally fractionated 3-D conformal).

I dont disagree regarding case rate, but I dont think that they are a sure thing. We should pursue both strategies to be safte.

Sigh.

Definition of stereotactic body radiotherapy: Principles and practice for the treatment of stage I non-small cell lung cancer

This report from the Stereotactic Radiotherapy Working Group of the German Society of Radiation Oncology (Deutschen Gesellschaft für Radioonkologie, DEGRO) provides a definition of stereotactic body radiotherapy (SBRT) that agrees with that of ...

www.ncbi.nlm.nih.gov

SBRT is (1) a method of external beam radiotherapy (EBRT) that (2) accurately delivers a (3) high dose of irradiation in (4) one or few treatment fractions to an (5) extracranial target.

These essential components of the SBRT definition are specified in more detail below:

1. SBRT can be adequately performed with either traditional linear accelerators equipped with suitable image-guidance technology, accelerators specifically adapted for SBRT or dedicated delivery systems. Additionally, the principles of SBRT apply for both photon and particle therapy.
   YES
2. It is of fundamental importance that the entire SBRT workflow be systematically optimized and that appropriate quality assurance (QA) measures are implemented. From a clinical perspective, the term “accurate” covers disease staging; multidisciplinary discussion of the indications for SBRT; tumor site adjusted imaging with appropriate spatial and temporal resolution for target and organ at risk (OAR) definition; highly conformal treatment; image-guided patient setup; active or passive intrafraction motion management and follow-up (preferably at the treating institution). From a physics perspective, SBRT requires additional and more sophisticated QA procedures compared to conventional radiotherapy. These include system-specific end-to-end tests for both static and moving targets, as well as verification of the alignment of imaging and treatment isocenters prior to SBRT on a daily basis.
   NO. The breast is highly mobile. For this to maybe qualify you would need to track fiducials during treatment to be able to adequately reduce PTV margins.
3. Radiation doses are at least equivalent to radical doses in conventional fractionation.
   SURE
4. Radiation doses are delivered in few fractions (usually but not necessarily in a maximum of 10 fractions). Adjustment of single-fraction dose and total dose to volume and location of the target is essential.
   FINE
5. The target is accurately localized using tumor site specific imaging modalities. Simultaneously, the target needs to be spatially separated from critical OARs, without diffuse infiltration into these. Only the macroscopic target and small, immediately adjacent volumes of potential microscopic spread are treated in SBRT.
   NO. There is no macroscopic target. There is no gross disease.
   
   If you want to work to change the definition of SBRT, go for it, but it's a losing battle to argue against the above. Sorry.

 

[radiation123]

Margin size, no gross disease (adjuvant treatment)

I'm all for getting whatever advantage we can for our specialty, but this small goal seems a bit disingenuous with the overall history of SBRT
I understand there is no true definition of SBRT as has been discussed here many times, but PBI is not SBRT to me

If the PTV expansion is a problem for you then just change your CTV expansionfrom 1.5 cm to 2 cm and your PTV expansion from 1 cm to 5 mm. In the guidelines we are discussing they already state for 5 fractions breast " PTV: 1 cm margin around CTV. For patients undergoing daily imaging, tighter margins may be considered depending on accuracy of patient setup"

Stereotiactic radiation is used in the adjuvant setting very often (i.e. resected brain met, postop spine).

It is not a small goal. A large percent of breast patients ar candidates for 5 fractions breast and this number is going to increase over time. The difference in reimbursement is substanital.

The below statement is strange logic to me.

"I understand there is no true definition of SBRT as has been discussed here many times, but PBI is not SBRT to me"

If you don't have a good definition of SBRT shouldn't you advocate for the definiton that benefits you/your patients/the field the most.

Also I would argue that 5 fraction breast meets the definition set forth by the AAPM task group 101: “the delivery of large doses in a few fractions, which results in a high biological effective dose BED.” With appropriate imaging, machine QA and physician/physics supervision, it would also meet the characteristics of SBRT as set forth in table 1 of that paper (Benedect et al, Med Phys 2010). The link for the paper is provided below.

https://aapm.onlinelibrary.wiley.com/doi/epdf/10.1118/1.3438081

 

[deleted1168505]

If the PTV expansion is a problem for you then just change your CTV expansionfrom 1.5 cm to 2 cm and your PTV expansion from 1 cm to 5 mm. In the guidelines we are discussing they already state for 5 fractions breast " PTV: 1 cm margin around CTV. For patients undergoing daily imaging, tighter margins may be considered depending on accuracy of patient setup"

Do you not know the difference between a CTV and PTV?

 

[metallica81788]

Btw I don't use the trial PTVs personally I go smaller, those things are unnecessarily huge when you daily CBCT

...and the fact we are debating this re: the future of our field shows how far we've fallen and have to go. It's certainly not my hill to die on, I really don't care. It's just not SBRT to me.

 

[evilbooyaa]

SBRT does not have 1 cm PTVs (nevermind 1 cm CTVs to cover subclinical disease).

Trying to upbill 5 fraction partial breast is the wrong way to go and will unattract unneeded attention.
Reasonable case-based payments make a lot more sense.
Put Evicore out of business.

Vertebral body SBRT - 1cm CTV (or more)
Prostate SBRT - 1cm CTV (or more)

Breast SBRT w/ APBI can be a 5mm PTV margin with daily imaging. We do lung SBRT with 5mm PTV margins.

Margin size, no gross disease (adjuvant treatment)

I'm all for getting whatever advantage we can for our specialty, but this small goal seems a bit disingenuous with the overall history of SBRT
I understand there is no true definition of SBRT as has been discussed here many times, but PBI is not SBRT to me

See above re: margin size

Post-op spine SBRT still SBRT, as are multiple trials evaluating SBRT to prostate fossa for post-operative treatment including in endometrial, prostate cancers. That being said, I recognize that the lack of gross disease may be the biggest factor.

Also 25/5 to pelvis would be considered SBRT.

25/5 planned with IMRT/VMAT? Sure. Planned with 3D - probably not... We don't call 8Gy x 1 for palliation SBRT.

Sigh.

Definition of stereotactic body radiotherapy: Principles and practice for the treatment of stage I non-small cell lung cancer

This report from the Stereotactic Radiotherapy Working Group of the German Society of Radiation Oncology (Deutschen Gesellschaft für Radioonkologie, DEGRO) provides a definition of stereotactic body radiotherapy (SBRT) that agrees with that of ...

www.ncbi.nlm.nih.gov

SBRT is (1) a method of external beam radiotherapy (EBRT) that (2) accurately delivers a (3) high dose of irradiation in (4) one or few treatment fractions to an (5) extracranial target.

These essential components of the SBRT definition are specified in more detail below:

1. It is of fundamental importance that the entire SBRT workflow be systematically optimized and that appropriate quality assurance (QA) measures are implemented. From a clinical perspective, the term “accurate” covers disease staging; multidisciplinary discussion of the indications for SBRT; tumor site adjusted imaging with appropriate spatial and temporal resolution for target and organ at risk (OAR) definition; highly conformal treatment; image-guided patient setup; active or passive intrafraction motion management and follow-up (preferably at the treating institution). From a physics perspective, SBRT requires additional and more sophisticated QA procedures compared to conventional radiotherapy. These include system-specific end-to-end tests for both static and moving targets, as well as verification of the alignment of imaging and treatment isocenters prior to SBRT on a daily basis.
   NO. The breast is highly mobile. For this to maybe qualify you would need to track fiducials during treatment to be able to adequately reduce PTV margins
2. The target is accurately localized using tumor site specific imaging modalities. Simultaneously, the target needs to be spatially separated from critical OARs, without diffuse infiltration into these. Only the macroscopic target and small, immediately adjacent volumes of potential microscopic spread are treated in SBRT.
   NO. There is no macroscopic target. There is no gross disease.
   
   If you want to work to change the definition of SBRT, go for it, but it's a losing battle to argue against the above. Sorry.

Lung SBRT is frequently done using a 4DCT. If a breast was scanned on a 4DCT to assess for motion (it's really not that much!) and then planned with a seroma ITV would that satisfy? Lung SBRT at times done with breath hold technique, which is not uncommon for folks doing PBI. So either way, that can meet that criteria.

See above re macroscopic target. The target is the seroma. Small is in the eye of the beholder (see above regarding CTV).

*EDIT* - Good point from @radiation123 about post-op SRS being stereotactic. Target is the cavity. It's stereotactic. Same as breast SBRT. Target is the tumor cavity.

 

[deleted1111261]

ASTRO (leadership) is totally absurd when it comes to defining breast treatments for reimbursement.

This has been the case for a while. Todd has posted extensively on Twitter about how they have tied themselves in knots trying to discourage billing IMRT for years. It is not scientific, it is almost entirely political. At a high level, radiation oncologists take a really strange approach in engaging payers/medicare.

Personally, I don't think Florence-style breast treatment needs the physician presence and enhanced QA that, I guess, sort of defines SBRT. I think this is more important for CNS or lung. But I think people who want breast to be SBRT are very reasonable and I understand the argument.

Honestly, avoiding this frustrating conversation is a huge upside of case rate models to me

there is no actual rule about doctor being present for sbrt ...

 

[evilbooyaa]

Do you not know the difference between a CTV and PTV?

One can do 1cm CTV and 5mm PTV for PBI with daily image guidance without issue.

 

[deleted1168505]

Lung SBRT is frequently done using a 4DCT. If a breast was scanned on a 4DCT to assess for motion (it's really not that much!) and then planned with a seroma ITV would that satisfy? Lung SBRT at times done with breath hold technique, which is not uncommon for folks doing PBI. So either way, that can meet that criteria.

See above re macroscopic target. The target is the seroma. Small is in the eye of the beholder (see above regarding CTV).

Maybe if you could create an ITV this way, although this raises interesting planning questions of how to account for motion into air.
If your surgeons are routinely leaving seromas significant enough to be your GTV, that's unfortunate.
Regardless, this is the wrong way to fight the battle of declining reimbursement for breast treatment.

 

[deleted1111261]

Sigh.

Definition of stereotactic body radiotherapy: Principles and practice for the treatment of stage I non-small cell lung cancer

This report from the Stereotactic Radiotherapy Working Group of the German Society of Radiation Oncology (Deutschen Gesellschaft für Radioonkologie, DEGRO) provides a definition of stereotactic body radiotherapy (SBRT) that agrees with that of ...

www.ncbi.nlm.nih.gov

SBRT is (1) a method of external beam radiotherapy (EBRT) that (2) accurately delivers a (3) high dose of irradiation in (4) one or few treatment fractions to an (5) extracranial target.

These essential components of the SBRT definition are specified in more detail below:

1. SBRT can be adequately performed with either traditional linear accelerators equipped with suitable image-guidance technology, accelerators specifically adapted for SBRT or dedicated delivery systems. Additionally, the principles of SBRT apply for both photon and particle therapy.
   YES
2. It is of fundamental importance that the entire SBRT workflow be systematically optimized and that appropriate quality assurance (QA) measures are implemented. From a clinical perspective, the term “accurate” covers disease staging; multidisciplinary discussion of the indications for SBRT; tumor site adjusted imaging with appropriate spatial and temporal resolution for target and organ at risk (OAR) definition; highly conformal treatment; image-guided patient setup; active or passive intrafraction motion management and follow-up (preferably at the treating institution). From a physics perspective, SBRT requires additional and more sophisticated QA procedures compared to conventional radiotherapy. These include system-specific end-to-end tests for both static and moving targets, as well as verification of the alignment of imaging and treatment isocenters prior to SBRT on a daily basis.
   NO. The breast is highly mobile. For this to maybe qualify you would need to track fiducials during treatment to be able to adequately reduce PTV margins.
3. Radiation doses are at least equivalent to radical doses in conventional fractionation.
   SURE
4. Radiation doses are delivered in few fractions (usually but not necessarily in a maximum of 10 fractions). Adjustment of single-fraction dose and total dose to volume and location of the target is essential.
   FINE
5. The target is accurately localized using tumor site specific imaging modalities. Simultaneously, the target needs to be spatially separated from critical OARs, without diffuse infiltration into these. Only the macroscopic target and small, immediately adjacent volumes of potential microscopic spread are treated in SBRT.
   NO. There is no macroscopic target. There is no gross disease.
   
   If you want to work to change the definition of SBRT, go for it, but it's a losing battle to argue against the above. Sorry.

This is fun!!

1. yes

2. not as mobile as you'd think; georgetown has done some work treating definitively (not great outcomes, but showed feasibility. The lower lung is more mobile than your average breast. First time I did APBI, I did a bunch of CTs. It made me very comfortable with shrinking PTV to 0.5cm

3. Yes

4. Yes.

5. Post brain met SRS is not SRS? What about positive margin tx for pancreas (this is reported in the literature, I'm listed as an author on a few, lol)? Micro vs macro is made up. This Imma disregard.

Take $$ out of the equation, take reimbursement out of the equation. 30/5 to the cavity is SBRT.

 

[deleted1168505]

One can do 1cm CTV and 5mm PTV for PBI with daily image guidance without issue.

The post was advocating for simply changing your CTV to 1.5 cm to keep the total expansion at 2 cm. I have seen marginal recurrences even with the 2 cm total margins beyond clips. I am generous with my countouring beyond clips. I would not do this.

 

[radiation123]

Sigh.

Definition of stereotactic body radiotherapy: Principles and practice for the treatment of stage I non-small cell lung cancer

This report from the Stereotactic Radiotherapy Working Group of the German Society of Radiation Oncology (Deutschen Gesellschaft für Radioonkologie, DEGRO) provides a definition of stereotactic body radiotherapy (SBRT) that agrees with that of ...

www.ncbi.nlm.nih.gov

SBRT is (1) a method of external beam radiotherapy (EBRT) that (2) accurately delivers a (3) high dose of irradiation in (4) one or few treatment fractions to an (5) extracranial target.

These essential components of the SBRT definition are specified in more detail below:

1. SBRT can be adequately performed with either traditional linear accelerators equipped with suitable image-guidance technology, accelerators specifically adapted for SBRT or dedicated delivery systems. Additionally, the principles of SBRT apply for both photon and particle therapy.
   YES
2. It is of fundamental importance that the entire SBRT workflow be systematically optimized and that appropriate quality assurance (QA) measures are implemented. From a clinical perspective, the term “accurate” covers disease staging; multidisciplinary discussion of the indications for SBRT; tumor site adjusted imaging with appropriate spatial and temporal resolution for target and organ at risk (OAR) definition; highly conformal treatment; image-guided patient setup; active or passive intrafraction motion management and follow-up (preferably at the treating institution). From a physics perspective, SBRT requires additional and more sophisticated QA procedures compared to conventional radiotherapy. These include system-specific end-to-end tests for both static and moving targets, as well as verification of the alignment of imaging and treatment isocenters prior to SBRT on a daily basis.
   NO. The breast is highly mobile. For this to maybe qualify you would need to track fiducials during treatment to be able to adequately reduce PTV margins.
3. Radiation doses are at least equivalent to radical doses in conventional fractionation.
   SURE
4. Radiation doses are delivered in few fractions (usually but not necessarily in a maximum of 10 fractions). Adjustment of single-fraction dose and total dose to volume and location of the target is essential.
   FINE
5. The target is accurately localized using tumor site specific imaging modalities. Simultaneously, the target needs to be spatially separated from critical OARs, without diffuse infiltration into these. Only the macroscopic target and small, immediately adjacent volumes of potential microscopic spread are treated in SBRT.
   NO. There is no macroscopic target. There is no gross disease.
   
   If you want to work to change the definition of SBRT, go for it, but it's a losing battle to argue against the above. Sorry.

your definiton proves my point.

For number 2, if you are doing partial breast radiation you should have fiducials in the breast to aid with alignment. The breast is not highly mobile after you set it up. i.e it does not move much while you are treating it. A breast target moves much less than a lung cancer in the base of the lung but that is SBRT.

For number 5, macroscopic target does not mean gross disease. macroscopic target means a target visible to the eye. A lumpectomy cavity is a macroscopic target. Stereotiactic radiation is used in the adjuvant setting very often (i.e. resected brain met, postop spine).

 

[deleted1168505]

*EDIT* - Good point from @radiation123 about post-op SRS being stereotactic. Target is the cavity. It's stereotactic. Same as breast SBRT. Target is the tumor cavity.

Intracranial fractionated SRS has always been different from SBRT.
Are you planning with non-coplanar beams and multiple couch kicks with your breast immobilized in a frame?
I guess if you want to unleash a cyberknife on a breast seroma, go for it.

I think we are trying to "make fetch happen" here. It's not a great look.

 

[deleted1111261]

I feel like this is one of those things were people will not concede. Their views are fixed.

And if that's the case here, can you imagine ASTRO being like "Ya know what, buddy, you have a point."

Too much of our psyche being tied into being right at the outset rather than reaching the truth.

 

[NotMattSpraker]

there is no actual rule about doctor being present for sbrt ...

You are right, but ASTRO codebook states direct supervision is required. My billers defer to this a lot.

My state requires physics presence at every fraction. In our group, we collectively decided that MD presence is also required.

 

[deleted1111261]

Intracranial fractionated SRS has always been different from SBRT.
Are you planning with non-coplanar beams and multiple couch kicks with your breast immobilized in a frame?
I guess if you want to unleash a cyberknife on a breast seroma, go for it.

I think we are trying to "make fetch happen" here. It's not a great look.

The beam angles and couch kicks don't better if you achieve the dosimetric goals. The old RTOG protocols said something like "you need 10-14 beams" blah blah blah. If you can make it work with 8 beams, just do it with 8.

"make fetch happen" is very condescending.

We are educated bright people with differing opinions. You think you're right. I think I'm right. That is okay! Until someone spells it out, neither you or I is the decider. (Well, actually, I am, since I do prior auth, lol)

 

[deleted1168505]

Then why even use the word stereotactic? The definition of that word alone as an adjective has nothing to do with number.

We did this to ourselves by making it about number of treatments to begin with. 36 Gy in 6 to the prostate is not stereotactic but 36.25 in 5 is? OK.

 

[deleted1111261]

Then why even use the word stereotactic? The definition of that word alone as an adjective has nothing to do with number.

We did this to ourselves by making it about number of treatments to begin with. 36 Gy in 6 to the prostate is not stereotactic but 36.25 in 5 is? OK.

100% agree.
60/8 to lung is stereotactic technique.
Insurance should not dictate our language.

 

[seper]

100% agree.
60/8 to lung is stereotactic technique.
Insurance should not dictate our language.

It's not so much the insurance, but the government (CMS) who is dictating. Hard to fight that.

Also, the argument in this thread to bill PBI as SBRT in order to preserve global reimbursement. Individual Radonc's are extremely unlikely to personally benefit from that in the situation of labor over-supply. So, leave it as IMRT

 

[radiation123]

Intracranial fractionated SRS has always been different from SBRT.
Are you planning with non-coplanar beams and multiple couch kicks with your breast immobilized in a frame?
I guess if you want to unleash a cyberknife on a breast seroma, go for it.

I think we are trying to "make fetch happen" here. It's not a great look.

Couch kicks and non-coplanar beams are not a defining features of SBRT. Prostate SBRT and lung SBRT are SBRT but do not require (and often not treated with) non-coplanr beams or couch kicks.

We should advocate for adequate reimbursement. I dont think this is a bad look.

 

[radiation123]

It's not so much the insurance, but the government (CMS) who is dictating. Hard to fight that.

Also, the argument in this thread to bill PBI as SBRT in order to preserve global reimbursement. Individual Radonc's are extremely unlikely to personally benefit from that in the situation of labor over-supply. So, leave it as IMRT

If you treat with a 5 fractions IMRT plan you instead of a 5 fraction SBRT plan you will decrease reimbursement. A decreased reimbursement means a higher chance of practices/centers closing or not hiring additional staff. This directly effects the employement situation

 

[deleted1111261]

It's not so much the insurance, but the government (CMS) who is dictating. Hard to fight that.

Also, the argument in this thread to bill PBI as SBRT in order to preserve global reimbursement. Individual Radonc's are extremely unlikely to personally benefit from that in the situation of labor over-supply. So, leave it as IMRT

Medicare I think of as insurance - most Americans think of it that way. We are saying the same thing, I think. They lead the way - if Medicare says it, commercial tends to go in that direction.

 

[medgator]

there is no actual rule about doctor being present for sbrt ...

Igrt though

 

[deleted1168505]

We should advocate for adequate reimbursement.

I absolutely agree. However, I don't think trying to weasel your way through on a handful of iffy-at-best technicalities is the best way to do it, nor is it a durable solution even if it is successful in the short term.
I am sure we are all on the same page that the amount of extra labor that 30 fraction whole breast requires over 5 fraction whole breast, especially on the pro side, is minimal and nowhere near enough to justify the huge difference in reimbursement.

 

[deleted1111261]

I absolutely agree. However, I don't think trying to weasel your way through on a handful of iffy-at-best technicalities is the best way to do it, nor is it a durable solution even if it is successful in the short term.
I am sure we are all on the same page that the amount of extra labor that 30 fraction whole breast requires over 5 fraction whole breast, especially on the pro side, is minimal and nowhere near enough to justify the huge difference in reimbursement.

I don't think much of RO values things appropriately, so that is cherry picking.

Just as an example, treating a low risk prostate is waaaaaaay easier than treating a palliative head neck patient. 30/10 w/3D vs 79.2/44/IGRT - the prostate requires so little cognitively, while the head and neck is harder to plan/treat, harder to manage with regards to OTVs and follow up within the 90 days.

We can't use the metric you are saying. Sometimes, we just have to do things to maintain keeping the lights on.

 

[TheWallnerus]

If the PTV expansion is a problem for you then just change your CTV expansionfrom 1.5 cm to 2 cm and your PTV expansion from 1 cm to 5 mm. In the guidelines we are discussing they already state for 5 fractions breast " PTV: 1 cm margin around CTV. For patients undergoing daily imaging, tighter margins may be considered depending on accuracy of patient setup"

Stereotiactic radiation is used in the adjuvant setting very often (i.e. resected brain met, postop spine).

It is not a small goal. A large percent of breast patients ar candidates for 5 fractions breast and this number is going to increase over time. The difference in reimbursement is substanital.

The below statement is strange logic to me.

"I understand there is no true definition of SBRT as has been discussed here many times, but PBI is not SBRT to me"

If you don't have a good definition of SBRT shouldn't you advocate for the definiton that benefits you/your patients/the field the most.

Also I would argue that 5 fraction breast meets the definition set forth by the AAPM task group 101: “the delivery of large doses in a few fractions, which results in a high biological effective dose BED.” With appropriate imaging, machine QA and physician/physics supervision, it would also meet the characteristics of SBRT as set forth in table 1 of that paper (Benedect et al, Med Phys 2010). The link for the paper is provided below.

https://aapm.onlinelibrary.wiley.com/doi/epdf/10.1118/1.3438081

Let me challenge your premises...

When I do 5 fraction breast, I do it IMPORT-LOW (intensity modulated partial organ RT) style with 2-field opposed mini-tangents ("The results of FAST-Forward were planned to be taken together with those of IMPORT LOW, which had the same control regimen of 40 Gy in 15 fractions to the whole breast and, therefore, are applicable to partial-breast radiotherapy"). To me, two-field (IMRT) tangents, just because the MUs per tangent are higher, are not SBRT. Will I have to go multi-field to "bump up" into $BRT? Will 8 Gy/1 fx bone met become SBRT?

Also, again, EBM-wise, not a single PBI trial has defined PBI as SBRT, just IMRT.

Tough hill to climb. I'm swayable though.

 

[evilbooyaa]

Maybe if you could create an ITV this way, although this raises interesting planning questions of how to account for motion into air.
If your surgeons are routinely leaving seromas significant enough to be your GTV, that's unfortunate.
Regardless, this is the wrong way to fight the battle of declining reimbursement for breast treatment.

1. Could do virtual flash like how we do for vulvar planning.
2. I mean it's not necessarily a super big one but it's big enough. Too big makes patients poor candidates for PBI so it's a balance. Leaving fiducials permanently in a breast to faciliate APBI or some monstrostity like a biozorb is unfortunate.
3.

Love it when Rad Oncs fight against increasing reimbursement.

Intracranial fractionated SRS has always been different from SBRT.
Are you planning with non-coplanar beams and multiple couch kicks with your breast immobilized in a frame?
I guess if you want to unleash a cyberknife on a breast seroma, go for it.

I think we are trying to "make fetch happen" here. It's not a great look.

Non-coplanar beams are not necessary to call something SRS/stereotactic. SRS can be planned with 2 coplanar beams and will produce an overall similarly effective and toxic plan most of the time. Not saying it's wrong to do the non-coplanar and couch kicks but not necessary.

It's not so much the insurance, but the government (CMS) who is dictating. Hard to fight that.

Also, the argument in this thread to bill PBI as SBRT in order to preserve global reimbursement. Individual Radonc's are extremely unlikely to personally benefit from that in the situation of labor over-supply. So, leave it as IMRT

Increased professional RVUs of 5Fx SBRT compared to 5Fx IMRT which will help those who get paid on a $/RVU basis, which is overwhelmingly likely to be > 50% of Rad Oncs at this point.

 

[deleted1111261]

Wallnerus

You’re going at it backwards - letting the article say what the treatment is.

The treatment is what it is, regardless of what people name it after that wards

 

[evilbooyaa]

Let me challenge your premises...

When I do 5 fraction breast, I do it IMPORT-LOW (intensity modulated partial organ RT) style with 2-field opposed mini-tangents ("The results of FAST-Forward were planned to be taken together with those of IMPORT LOW, which had the same control regimen of 40 Gy in 15 fractions to the whole breast and, therefore, are applicable to partial-breast radiotherapy"). To me, two-field (IMRT) tangents, just because the MUs per tangent are higher, are not SBRT. Will I have to go multi-field to "bump up" into $BRT? Will 8 Gy/1 fx bone met become SBRT?

Also, again, EBM-wise, not a single PBI trial has defined PBI as SBRT, just IMRT.

Tough hill to climb. I'm swayable though.

Don't think 2 field mini-tangents would fall into 'highly conformal'.

Partial arc VMAT looks much better, trust me!

 

[TheWallnerus]

Couch kicks and non-coplanar beams are not a defining features of SBRT. Prostate SBRT and lung SBRT are SBRT but do not require (and often not treated with) non-coplanr beams or couch kicks.

We should advocate for adequate reimbursement. I dont think this is a bad look.

Love it when Rad Oncs fight against increasing reimbursement.

FWIW, I ran a back-of-envelope simulation for Medicare global payment rate for 5-fx breast IMRT vs SBRT: (EDIT... other regimens added)

IMRT 5fx: $5663.24

IMRT 5fx "adaptive": $14989.00

SBRT 5fx: $8590.76*

IMRT 15fx: $11066.2

3D 15fx: $7271.37

3D 33fx: $14588.38

A daily IG-IMRT nets about $500, a daily SBRT about $1000; these are just national payment rates and a few localities can vary substantially.

So @radiation123 maybe the real thing to do is just charging daily IMRT plans. Which actually reimburse more than a SBRT fraction. The provisions against a daily IMRT plan (inchoate, or not any?) are even probably more debatable versus the provisions for what is/isn't SBRT?

*77301 for planning
All IMRT assumes daily 77014

 

[TheWallnerus]

Don't think 2 field mini-tangents would fall into 'highly conformal'.

Partial arc VMAT looks much better, trust me!

Technically I have no randomized data to support VMAT at 26 Gy/5 fx ... which is my 5-fraction PBI Rx. Of course don't hit me with the technicality that there is no randomized data for 26 Gy partial breast

 

[NotMattSpraker]

FWIW, I ran a back-of-envelope simulation for Medicare global payment rate for 5-fx breast IMRT vs SBRT: (EDIT... other regimens added)

IMRT 5fx: $5663.24

IMRT 5fx "adaptive": $14989.00

SBRT 5fx: $8590.76*

IMRT 15fx: $11066.2

3D 15fx: $7271.37

3D 33fx: $14588.38

A daily IG-IMRT nets about $500, a daily SBRT about $1000; these are just national payment rates and a few localities can vary substantially.

So @radiation123 maybe the real thing to do is just charging daily IMRT plans. Which actually reimburse more than a SBRT fraction. The provisions against a daily IMRT plan (inchoate, or not any?) are even probably more debatable versus the provisions for what is/isn't SBRT?

*77301 for planning
All IMRT assumes daily 77014

Haha clever but it would be incredibly hard to justify a daily adaptive plan for breast.

In my experience, the adaptive plan has to improve dosimetry off the original sim plan otherwise you dont use it and it is not billed. If centers are just billing out plans regardless, that is nuts.

 

[RickyScott]

Haha clever but it would be incredibly hard to justify a daily adaptive plan for breast.

In my experience, the adaptive plan has to improve dosimetry off the original sim plan otherwise you dont use it and it is not billed. If centers are just billing out plans regardless, that is nuts.

they most certainly are

 

[evilbooyaa]

Technically I have no randomized data to support VMAT at 26 Gy/5 fx ... which is my 5-fraction PBI Rx. Of course don't hit me with the technicality that there is no randomized data for 26 Gy partial breast

Oof I just do the 30/5 PBI but you do you

 

[evilbooyaa]

Haha clever but it would be incredibly hard to justify a daily adaptive plan for breast.

In my experience, the adaptive plan has to improve dosimetry off the original sim plan otherwise you dont use it and it is not billed. If centers are just billing out plans regardless, that is nuts.

An adaptive plan *almost always* improves the dosimetry compared to the initial plan.

Whether tha tmakes a difference clinically is the real question.

And the answer is, depends on the location.

Said as someone who has used and evaluated the potential benefit of daily adaptation with Ethos.

 

[Ray D. Ayshun]

There's a trial doing 26/5 pbi so it's fine to do it. Whens the last time a breast radiation trial didn't result in being able to use whichever arm you'd like?

 

[NotMattSpraker]

An adaptive plan *almost always* improves the dosimetry compared to the initial plan.

Whether tha tmakes a difference clinically is the real question.

And the answer is, depends on the location.

Said as someone who has used and evaluated the potential benefit of daily adaptation with Ethos.

Not in my experience, but I wasnt a GI specialist. Thoracic is really unpredictable. Retroperitoneal lesions too. I've treated a few sarcomas and don't think I ever adapted.

Ive also covered GI cases where the anatomy was so unfavorable that even adaptive didn't help very much.

I suppose there is also subjective decision making. There had to be real space between the original and adaptive DVH for me to approve the adaptation. If they overlapped, I wouldn't do it. That seems shady, and you're adding time on the machine for the patient with unnecessary QA.

If they made a plan and I threw it out, Im not sure if they still dropped a planning charge or not. It seems no, we dont charge for comparison plans for insurance. I would think?

 

[evilbooyaa]

Not in my experience, but I wasnt a GI specialist. Thoracic is really unpredictable. Retroperitoneal lesions too. I've treated a few sarcomas and don't think I ever adapted.

Ive also covered GI cases where the anatomy was so unfavorable that even adaptive didn't help very much.

I suppose there is also subjective decision making. There had to be real space between the original and adaptive DVH for me to approve the adaptation. If they overlapped, I wouldn't do it. That seems shady, and you're adding time on the machine for the patient with unnecessary QA.

If they made a plan and I threw it out, Im not sure if they still dropped a planning charge or not. It seems no, we dont charge for comparison plans for insurance. I would think?

When we were trialing adapting prostate without billing, even if the plan was like 5% better coverage we picked the adapted. And it was almost always 2-5% better.

But it's just not clinically better so we stopped adapting prostate. Well aware that folks are though.

I am going to break this 'Breast APBI - SBRT or Nah?' discussion into its own thread though to avoid going too off-topic with the premise of the previous thread congratulating Sameer Keole.

 

[SneakyBooger]

APBI is SBRT.

 

[radiation123]

I absolutely agree. However, I don't think trying to weasel your way through on a handful of iffy-at-best technicalities is the best way to do it, nor is it a durable solution even if it is successful in the short term.
I am sure we are all on the same page that the amount of extra labor that 30 fraction whole breast requires over 5 fraction whole breast, especially on the pro side, is minimal and nowhere near enough to justify the huge difference in reimbursement.

I think we may just have to agree to disagree. In this thread we discussed two different official definitions of SBRT one provided by me and one you provided yourself. If given with appropriate supervision, imaging etc 5 fraction breast would meet the requirments of those definitions. I wouldnt characterize this as "weasel your way through on a handful of iffy-at-best technicalities". I would classify it as clearly meets definiton of SBRT and something we should advocate for.

I am not opposed to other methods to equilize payment such as case rates, but I have no idea how likely it is for that to pass, when it would pass, and how soon private insurers would copy it if it did pass. In my mind the safest route would be to call 5 fractions breast radiaion SBRT and also advocate for other payment reform.