CCS Oncology - Imminent closure, bankruptcy, FBI investigation

[Lamount]

why aren't you submitting 25/5 rectal as SBRT tho?

It also predates 3D planning and lacks a stereotactic frame (lest someone invoke Leksell)

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[RickyScott]

why aren't you submitting 25/5 rectal as SBRT tho?

I tried once and got denied by evercore

 

[thesauce]

I tried once and got denied by evercore

Same. Denied by Evilcore for SBRT for a 5-fraction breast. No rationale, just “we don’t consider it that”

 

[medgator]

I tried once and got denied by evercore

Same. Denied by Evilcore for this and 5-fraction breast. No rationale, just “we don’t consider it that”

The same people that won't let you bill 3D for anything palliative, even if you contour at least 2 OARs and generate a dvh. Instead they pay you a "complex" code which is worth 3-4 figures less regardless of the work you actually did

 

[RickyScott]

Same. Denied by Evilcore for this and 5-fraction breast. No rationale, just “we don’t consider it that”

I have no issue with it. Terrible Medicare advantage plan that I was told the hospital recieves 80-90% of Medicare. Thorought we deserved something for all the effort.

 

[evilbooyaa]

Have you submitted it as sbrt ?

Yes. Thus far only had Medicare patients be APBI suitable candidates, but have a 50 something year old with private insurance I just simmed filled out pre-auth paperwork on. If I have to take IMRT x 5 fractions I will which is why I qualified as "only if insurance will allow"

why aren't you submitting 25/5 rectal as SBRT tho?

Fair point. I would not routinely do that. Same reason as Simul, where it's not pinpoint to a small target. I did a 25/5 with SIB to 40/5 to gross external iliac lymph node (with allowed heterogeneity in the LN higher) which I did submit as SBRT. Didn't hear of any issues from billing on it.

 

[Wildcat321]

To me it’s due the volume being treated. Maybe arbitrary but I think at that size I don’t think of it is sbrt - it’s not focused or pinpoint in any way. But that’s subjective

What kind of setup are you doing for ABPI? Didn't see anything specific mentioned in the manuscript.

 

[deleted1111261]

Supine, breast board, arms up, DIBH, cbct daily

 

[metallica81788]

Supine, breast board, arms up, DIBH, cbct daily

DIBH for L sided only or both?
This is what I do minus the DIBH.

 

[deleted1111261]

DIBH for L sided only or both?
This is what I do minus the DIBH.

Both. With the small margins, I think it helps. It’s what Chirag does, and if it works for him, then it works for me.

 

[evilbooyaa]

Both. With the small margins, I think it helps. It’s what Chirag does, and if it works for him, then it works for me.

What Would Chirag Do is a very reasonable treatment strategy with breast cancers.
However, I don't think DIBH is actually necessary on all APBI cases. Don't see it mentioned in Livi paper as part of their set-up either...

DIBH in L-sided breast is primarily to separate heart from chest wall contour, which thus far all of mine have been (fortunately) not inferomedial left-sided tumor beds.

 

[jondunn]

‘However, I don't think DIBH is actually necessary on all APBI cases. Don't see it mentioned in Livi paper as part of their set-up either...’

It’s not necessary but it allows you to use smaller margins than Livi

 

[CaesarRO]

Weird that this is in the CCS oncology thread.

For those of you doing Livi APBI, do you require your surgeons to put clips in the lumpectomy cavity? We've been doing Fast Forward whole breast if no clips, Livi if clips

 

[deleted1116990]

Weird that this is in the CCS oncology thread.

For those of you doing Livi APBI, do you require your surgeons to put clips in the lumpectomy cavity? We've been doing Fast Forward whole breast if no clips, Livi if clips

"Require" your surgeons to put clips in. Hah. That's funny. The surgeons I work with refuse to do it. So I wire the scar, contour the seroma, and am more generous with the contouring and margins as needed. I've got one right now that's about half the breast due to surgeon not putting in clips and a lot of uncertainty. Any bigger and I would not meet trial constraints and would go to fast-forward style approach if patient demanded 5 treatment, I agree.

 

[CaesarRO]

Yeah require is wishful thinking. Meant more require the clips for the treatment option, to not require them to actually place them

 

[jondunn]

"Require" your surgeons to put clips in. Hah. That's funny. The surgeons I work with refuse to do it. So I wire the scar, contour the seroma, and am more generous with the contouring and margins as needed. I've got one right now that's about half the breast due to surgeon not putting in clips and a lot of uncertainty. Any bigger and I would not meet trial constraints and would go to fast-forward style approach if patient demanded 5 treatment, I agree.

this makes sense to me

ultimately all the partial breast data compiled together shows us that we are and should be more than okay treating less than the whole breast tissue, skin, and fat.

past that, use however big margins you need to, based on the situation, any tissue getting avoided is better than no tissue getting avoided.

(also should make you feel better about skimping on whole breast RT when needed)

 

[deleted1111261]

What Would Chirag Do is a very reasonable treatment strategy with breast cancers.
However, I don't think DIBH is actually necessary on all APBI cases. Don't see it mentioned in Livi paper as part of their set-up either...

DIBH in L-sided breast is primarily to separate heart from chest wall contour, which thus far all of mine have been (fortunately) not inferomedial left-sided tumor beds.

He uses much smaller margins. I think as we get out in practice, we can deviate from “exactly what study does” and make some leaps in logic.

Like people were not doing HF because “whelan didn’t study dcis” which is silly. This forum has a lot of debate on that in the past, because ROs stick to NCCN guidelines or to the letter of the study without using common sense.

Yes, Livi did not do it. For me, his study is proof it can be done, and smart people like Chirag and the good people at The other centers can refine technique.

 

[deleted1116990]

this makes sense to me

ultimately all the partial breast data compiled together shows us that we are and should be more than okay treating less than the whole breast tissue, skin, and fat.

past that, use however big margins you need to, based on the situation, any tissue getting avoided is better than no tissue getting avoided.

(also should make you feel better about skimping on whole breast RT when needed)

I have a hypothesis that you could treat essentially the whole breast to 30 Gy in 5 every other day, limit hotspot to 105%, and the patients would do fine.

At least with my experience treating breast volumes far larger than I otherwise would because the surgeons think the clips cause the patients post-operative pain, don't want to consent for a retained foreign body, or whatever other excuse they have given.

 

[jondunn]

I have a hypothesis that you could treat essentially the whole breast to 30 Gy in 5 every other day, limit hotspot to 105%, and the patients would do fine.

At least with my experience treating breast volumes far larger than I otherwise would because the surgeons think the clips cause the patients post-operative pain, don't want to consent for a retained foreign body, or whatever other excuse they have given.

Only caveat to this is the UK data but 28.5 should be fine

 

[TheWallnerus]

I have a hypothesis that you could treat essentially the whole breast to 30 Gy in 5 every other day, limit hotspot to 105%, and the patients would do fine.

I would love to get a good argument going as to whether 26 Gy in 5 fractions partial breast is valid for all 50+ yos with T1N0 favorable risk breast cancer.

 

[Ray D. Ayshun]

I would love to get a good argument going as to whether 26 Gy in 5 fractions partial breast is valid for all 50+ yos with T1N0 favorable risk breast cancer.

If you think they're going to die within the next 5 to 6 years, I think it's perfect.

 

[metallica81788]

I'm curious now as to what margins everyone is using here for 30/5 if this impacts the DIBH/non-DIBH argument

Mine are case by case, but after doing about 50 cases last year (mostly in 65yo+) I've settled into mostly 7mm CTV 5mm PTV. If cavity is not as well defined I'll revert closer to the original paper.

 

[deleted1111261]

If you think they're going to die within the next 5 to 6 years, I think it's perfect.

Huh ?

 

[Ray D. Ayshun]

Huh ?

Just a standard breast is the worst response.

 

[deleted1111261]

Mine are case by case, but after doing about 50 cases last year (mostly in 65yo+) I've settled into mostly 7mm CTV 5mm PTV. If cavity is not as well defined I'll revert closer to the original paper.

tricky !

I contour clips + seroma and add 2.5cm for PTV26 and 1.5cm for PTV30

It’s 2cm / 1 cm ctv, edit then 0.5cm for PTV then edit for PTVeval

 

[deleted1111261]

Just a standard breast is the worst response.

Is there something I’m missing about 26/5 leading to death early or bad cosmetic outcomes ?

 

[evilbooyaa]

He uses much smaller margins. I think as we get out in practice, we can deviate from “exactly what study does” and make some leaps in logic.

Like people were not doing HF because “whelan didn’t study dcis” which is silly. This forum has a lot of debate on that in the past, because ROs stick to NCCN guidelines or to the letter of the study without using common sense.

Yes, Livi did not do it. For me, his study is proof it can be done, and smart people like Chirag and the good people at The other centers can refine technique.

Fair, although I feel comfortable shrinking margins even without DIBH. I'm not saying it's wrong to do DIBH, just not sure it's mandatory.

tricky !

I contour clips + seroma and add 2.5cm for PTV26 and 1.5cm for PTV30

It’s 2cm / 1 cm ctv, edit then 0.5cm for PTV then edit for PTVeval

(Clips + Seroma) + 1cm to CTV, edit, then 0.5 for PTV, crop for PTV eval, which is PTV30.

I'm not sure of utility of adding additional volume going to 26Gy? If just preference then cool, but I wonder how much it would affect ability to get ipsi breast V15 < 50% or minimizing contralateral breast dose in certain anatomical scenarios?

 

[deleted1111261]

Fair, although I feel comfortable shrinking margins even without DIBH. I'm not saying it's wrong to do DIBH, just not sure it's mandatory.



(Clips + Seroma) + 1cm to CTV, edit, then 0.5 for PTV, crop for PTV eval, which is PTV30.

I'm not sure of utility of adding additional volume going to 26Gy? If just preference then cool, but I wonder how much it would affect ability to get ipsi breast V15 < 50% or minimizing contralateral breast dose in certain anatomical scenarios?

26/5 was good enough for the whole breast. So, 30/5 is an automatic boost and we know cosmetic outcome is fine with it.

15/50 isn’t hard to meet. It’s that 1 Gy contra breast that’s hard. But it’s not a big deal if point dose is higher than that as long as low volume.

 

[communitydoc13]

I'm not saying it's wrong to do DIBH, just not sure it's mandatory.

I'm sure its not necessary. Its a patient by patient thing. My therapists will tell me in the wrong pt DIBH extends treatment time lots and their level of confidence in positioning over course of treatment is less than with free breathing. The protocol margins are are fine for me and falloff gives you an additional 3-4 mm to 26 Gy. The trial tells us what it tells us. That doing it a certain way works well with a low risk group and 10 year f/u.

Also not sure CBCT necessary. Trial did both but with breast position you typically have to shift table to cbct and then shift back. Is this really better than orthogonal kvs in treatment position with well visualized clips? I don't know.

 

[Ray D. Ayshun]

Is there something I’m missing about 26/5 leading to death early or bad cosmetic outcomes ?

No, things look pretty much equivalent for 5 or 6 years, or at least probably no more than 33% worse.

 

[deleted1116990]

I'm curious now as to what margins everyone is using here for 30/5 if this impacts the DIBH/non-DIBH argument

Mine are case by case, but after doing about 50 cases last year (mostly in 65yo+) I've settled into mostly 7mm CTV 5mm PTV. If cavity is not as well defined I'll revert closer to the original paper.

Without clips, I use the original large margins, sometimes having to go bigger. Only difference is I don't expand PTV into lung and actually crop off chestwall a bit since I CBCT.

 

[deleted1111261]

No, things look pretty much equivalent for 5 or 6 years, or at least probably no more than 33% worse.

For the Fast study? That has 10 years follow up (weekly tx study).

 

[jondunn]

Livi also has 10 year data

its a case closed situation frankly.

 

[Ray D. Ayshun]

For the Fast study? That has 10 years follow up (weekly tx study).

Fast forward. I'm not doing 5 weeks of rt...

 

[TheWallnerus]

Livi also has 10 year data

its a case closed situation frankly.

I guess it’s always fair to hold out for 10y data. The only time I remember a breast trial’s 5y results not holding up at 10y was the old Upfront Outback trial of chemo sequencing. Iirc at 5y there was a benefit to the adjuvant chemo before RT but at ten years the curves converged and the significances favoring chemo upfront went away. Yet still to this day chemo before RT the standard of care. You might get booted out of oncology if you try to give RT before adjuvant chemo.

 

[medgator]

I guess it’s always fair to hold out for 10y data. The only time I remember a breast trial’s 5y results not holding up at 10y was the old Upfront Outback trial of chemo sequencing. Iirc at 5y there was a benefit to the adjuvant chemo before RT but at ten years the curves converged and the significances favoring chemo upfront went away. Yet still to this day chemo before RT the standard of care. You might get booted out of oncology if you try to give RT before adjuvant chemo.

Used to be ok with savi/mammosite, probably an argument to try and push with 5 fx as well, but there are some battles out there just not worth fighting

 

[deleted1111261]

I don’t know of any study where the question was strictly a radiation one where the results changed from 5 to 10 years.

 

[Lamount]

I don’t know of any study where the question was strictly a radiation one where the results changed from 5 to 10 years.

I want to say the ELIOT trial for breast **digging back into my residency pimping vault**

 

[Ray D. Ayshun]

FAST compared to 50/25, felt to be more toxic than 40/15. Livi was partial vs whole breast, so two variables. fast forward wasn't designed to detect toxicity difference with both short courses numerically worse. 40/15 vs 26/5 partial breast imrt trial powered for toxicity?

 

[deleted1111261]

40/15 partial breast seems like good option, too. Doesn’t seem to be used often. MedNet thread on it, and everyone seems to minimize its utility.

 

[TheWallnerus]

40/15 partial breast seems like good option, too. Doesn’t seem to be used often. MedNet thread on it, and everyone seems to minimize its utility.

It’s great. It’s my “de rigueur” in the older than 50, low risk crowd. They do not minimize its utility in the UK; one of their “red rose” trials and the basis of making 40/15 partial breast be their new 26/5 partial breast (and reason I wanted to start an argument about 26/5 partial breast). Hesitant to make all my 15fx be 5fx tho, as I don’t know how many breast cancer patients I can treat if I bankrupt my cancer center.

 

[evilbooyaa]

I'm sure its not necessary. Its a patient by patient thing. My therapists will tell me in the wrong pt DIBH extends treatment time lots and their level of confidence in positioning over course of treatment is less than with free breathing. The protocol margins are are fine for me and falloff gives you an additional 3-4 mm to 26 Gy. The trial tells us what it tells us. That doing it a certain way works well with a low risk group and 10 year f/u.

Also not sure CBCT necessary. Trial did both but with breast position you typically have to shift table to cbct and then shift back. Is this really better than orthogonal kvs in treatment position with well visualized clips? I don't know.

Don't really get clips anymore from my vast array of referring breast surgeons vast majority of the time so CBCT pretty necessary

 

[Palex80]

40/15 partial breast seems like good option, too. Doesn’t seem to be used often. MedNet thread on it, and everyone seems to minimize its utility.

We used to do that all the time, until Livi long-term data became available.
We still use it for patients with large PTVs / large breasts.