- Joined
- Mar 1, 2014
- Messages
- 111
- Reaction score
- 93
im assuming most people are with you, KHE88. not really worth arguing about at this point.
FUTURE RESIDENT, DO NOT BECOME A RADIATION ONCOLOGIST!!!
- Thread starter hbosch
- Start date
- Status
- Joined
- Jul 21, 2011
- Messages
- 532
- Reaction score
- 733
...arguing about Star Wars lightsaber lasers?
All the non RadOnc folk have no clue what you guys are arguing about, well over our heads, and its strayed far from the entertaining dialogue. Any chance we can resume the normal program so we can finish our popcorn?
All the non RadOnc folk have no clue what you guys are arguing about, well over our heads, and its strayed far from the entertaining dialogue. Any chance we can resume the normal program so we can finish our popcorn?
Last edited:
- Joined
- Dec 18, 2015
- Messages
- 3,216
- Reaction score
- 4,930
Lol re: 5 or more fields equals IMRT. At this point, we could have a "field day" (literally!) asking for paper retractions/corrections re: IMRT. When the day comes that inverse optimization is done instantaneously (and right now in many cases it takes about 30 seconds or less), I guess we're gonna be S.O.L. on getting any IMRT paid because time. Or, heaven forfend, if it's optimized too fast it won't be true IMRT.
- Joined
- Dec 18, 2015
- Messages
- 3,216
- Reaction score
- 4,930
You can too, but caveat emptor.
"CPT code 77301
Intensity modulated radiation therapy (IMRT) plan, including dose-volume histograms for target and critical structure partial tolerance specifications. (Dose plan is optimized using inverse or forward planning technique for modulated beam delivery (e.g., binary dynamic MLC) to create highly conformal dose distribution."
- Joined
- May 15, 2018
- Messages
- 723
- Reaction score
- 1,189
Dude, I never said or even came close to implying that simply using >= 5 fields in and of itself qualifies as IMRT. You are just making up lies at this point. I'm done arguing with you. You refuse to discuss the real issue (payment regarding field-in-field vs. real IMRT -- which you apparently believe are the exact same thing and should be compensated equally both technically and professionally? I don't know since you dance around it every time) and instead pick apart everything I post to try and find some technicality/semantics/gotcha strawman. It's clear we're not even on the same planet on this issue.
This exchange has been real eye opening, and if for nothing else, I thank you for that just so I know this kind of stuff is out there.
I am employed doc, and have always been told that professionally not really any difference in charges or rvu for imrt vs 3D. Actually have had some colleagues insist that 3D with cone downs is sometimes more? Usually find myself in the opposite position that something that is imrtish is actually 3D since that is all we can get approved
Last edited:
- Joined
- Dec 18, 2015
- Messages
- 3,216
- Reaction score
- 4,930
FiF is real IMRT, no straw man needed. I didn’t imply 5 or more fields was IMRT sui generis.
- Joined
- Dec 18, 2015
- Messages
- 3,216
- Reaction score
- 4,930
- Joined
- Sep 20, 2004
- Messages
- 11,747
- Reaction score
- 11,839
Interesting.... yet no one wants to bill E-COMP as IMRT in recent years. It really is confusing. What isn't confusing (except to some it seems) is how the definition of IMRT has evolved with time.
- Joined
- Sep 20, 2004
- Messages
- 11,747
- Reaction score
- 11,839
You can bill V-sims with 3D, but not IMRT. If the simple vs complex IMRT thing pushed by ASTRO had gone through, IGRT would have been bundled with IMRT on the technical side (I believe hospitals already have IGRT bundled into their technical charges), but not with 3D, so 3D would have allowed the treatment charge and an IGRT charge.
Seems like one big shell game that will be happily resolved with bundled payments one day.
- Joined
- Dec 18, 2015
- Messages
- 3,216
- Reaction score
- 4,930
I certainly don't want to equivocate, or use weasel words, or not express myself clearly. That was never my intent. I wanted to lead you into a bit of reductio ad absurdum, get you to engage in a bit of Aristotelianism, etc. We didn't get there. But so you don't further accuse me of singin' and dancin' in the rain, let me clearly state:
1) There is a huge amount of literature to back up the premise that IMRT can be forward planned and FiF in its application.
2) Intensity and fluence are essentially interchangeable in the physics of electromagnetic radiation, and any technique which alters the intensity of the radiation across a field is intensity modulated which by necessity, of course, modulates the fluence (but also vice versa).
3) CMS has defined FiF, forward planned IMRT as... IMRT (and as I mentioned, so has our literature). Whether it's "true" or "false" is your purview, but don't use your opinions as a hammer on others' heads. It hurts!
4) Your mental rigidity re: "true" IMRT and lack of a historical "long view" is a problem in our field (and evidently for our trainees). E.g., I could say "Dr. Ehrlich invented chemotherapy," and while you could say "Incorrect!" you could also say "Yes."
Last edited:
- Joined
- Sep 20, 2004
- Messages
- 11,747
- Reaction score
- 11,839
- Joined
- May 15, 2018
- Messages
- 723
- Reaction score
- 1,189
For anyone reading these past 40 posts or so who is not a rad onc or just starting training, med student, etc, and are wondering what the heck we are arguing about...
Basically there is (remarkably) disagreement as to what constitutes "IMRT," and the reason for this is that IMRT treatments have higher price tags.The problem is that the M term in IMRT, modulation, can be loosely interpreted. Technically, anything you move in front of a photon beam modulates it. In this sense, virtually every treatment we give anybody is IMRT. However, just because you have modulated the beam in some fashion DOES NOT make it IMRT. True IMRT, if you are being honest in the proper spirit of the term, is a very specific and complex technique requiring very specific machinery and software to deliver radiation with the goal of "dose painting" the target such that high doses are deposited in the target (tumor) regions and low doses go to the normal tissues, which have limits as to how much dose they can receive. An example of a true IMRT treatment is creating a hemispherical protected dose region around the spinal cord in head and neck cancer or the rectum in prostate cancer. To do this, multiple beams (5 or more) coming in at different angles, or arcs where the radiation is delivered through a continuous range of angles are used, each delivering a different radiation pattern such that they are all summed up to create these highly conformal dose paintings. This CANNOT be done using only two parallel opposed beams, such as tangential fields used for breast cancer treatments. Field-in-field (or tissue compensation) is a term used for tangential breast cancer treatments to describe a technique used to improve dose homogeneity. When you treat the breast using 2 tangent fields, you often end up with areas in the breast where the dose is much higher than the prescribed dose. In order to lower these "hot spots" you can add a briefly delivered extra field, at the same angle, where these hotspots are blocked. This technique DOES NOT carve dose away from the heart. In order to do that, you need to use the much more complicated "breast IMRT" techniquem which is compensated at a higher rate due to its commensurate complexity. Field-in-field is a treatment technique that modulates the beam, but it IS NOT "breast IMRT" simply because it modulates the beam.
It is, in the opinion of many, inappropriate (at the least) to bill tangential breast treatments using the field-in-field technique or tissue compensation as "breast IMRT." In some uncommon cases, true breast IMRT can be advantageous (e.g., bilateral lumpectomy bed boosting, bilateral PMRT, etc.), but typically it results in extra low dose to the lung and carries a higher risk of target under-dosing due to difficulty with breast immobilization. Hence the ASTRO recommendation to not routinely use a more complicated and expensive treatment when it may actually be providing no clinical advantage and perhaps even detriment.
Before this thread, I had never met anyone attempting to call field-in-field "breast IMRT" except when discussing historical evolution of the term. Breast IMRT should only mean one thing if you are being honest about the issue and not trying to jump to semantics and technicalities surrounding the vague meaning of "modulation" in the term in order to justify a higher treatment reimbursement (which you will notice, everyone is curiously tip-toeing around while simultaneously trying to claim FiF and breast IMRT are the same thing - cognitive dissonance much?). If you really are going to be honest about this issue, then you need to discriminate between breast IMRT and FiF -- the easiest way, which most do in my experience (at academic centers so I'm nobody cares!), is just to use these two terms. But if you really want to latch on the IMRT term, then call it "forward planned-IMRT," "simple IMRT," "psuedo-IMRT," or use some other qualifier as many do. At the very least, put it in god-damned quotation marks. But apparently it is anathema to even attempt to suggest that field-in-field is anything other than full-blown inverse-optimized OAR-sparing dose-painted multiangle field IMRT! Quotation marks are are hinting it might be just a little bit different (it's actually a lot different), and that's just not OK!
For more reading and a very different view than what has been presented here, read the commentary by Lawrence Marks on this issue:
https://www.practicalradonc.org/article/S1879-8500(13)00132-X/fulltext
Key excepts:
"Many have labeled “field-in-field” forward-planned breast treatment as “IMRT.” While such plans do technically modulate beam intensities, they lack many other essential features of “traditional IMRT.” We believe it is more accurate to refer to this as “tissue compensation,” a related but different concept."
"IMRT is a nonspecific, overly simple term. Considering tangential breast fields, wedges can be considered “one dimensional intensity modulators” as they vary beam intensity in 1 direction orthogonal to the central ray.
"Calling field-in-field tangential radiation beams (or other means of modulating simple tangents) “IMRT” results in unjustifiably high reimbursements that our society cannot afford."
"We certainly are not the first to raise these concerns."
"The IMRT limited to tangent fields improves dose homogeneity and decreases toxicity, but this is essentially tissue compensation by another name. In our opinion, this should not be billed as IMRT at current reimbursement levels."
"As IMRT becomes more routinely adapted, our field should work to create a more rational coding structure that better reflects the efforts and expense of different types of IMRT, including “tangent-field breast IMRT.”
"However, “breast IMRT” via tangent fields appears to provide no sparing of these normal tissues beyond that achievable with simpler
methods (eg, shaping the deep border of the tangents and/or using gating to displace the heart away from the breast)."
Basically there is (remarkably) disagreement as to what constitutes "IMRT," and the reason for this is that IMRT treatments have higher price tags.The problem is that the M term in IMRT, modulation, can be loosely interpreted. Technically, anything you move in front of a photon beam modulates it. In this sense, virtually every treatment we give anybody is IMRT. However, just because you have modulated the beam in some fashion DOES NOT make it IMRT. True IMRT, if you are being honest in the proper spirit of the term, is a very specific and complex technique requiring very specific machinery and software to deliver radiation with the goal of "dose painting" the target such that high doses are deposited in the target (tumor) regions and low doses go to the normal tissues, which have limits as to how much dose they can receive. An example of a true IMRT treatment is creating a hemispherical protected dose region around the spinal cord in head and neck cancer or the rectum in prostate cancer. To do this, multiple beams (5 or more) coming in at different angles, or arcs where the radiation is delivered through a continuous range of angles are used, each delivering a different radiation pattern such that they are all summed up to create these highly conformal dose paintings. This CANNOT be done using only two parallel opposed beams, such as tangential fields used for breast cancer treatments. Field-in-field (or tissue compensation) is a term used for tangential breast cancer treatments to describe a technique used to improve dose homogeneity. When you treat the breast using 2 tangent fields, you often end up with areas in the breast where the dose is much higher than the prescribed dose. In order to lower these "hot spots" you can add a briefly delivered extra field, at the same angle, where these hotspots are blocked. This technique DOES NOT carve dose away from the heart. In order to do that, you need to use the much more complicated "breast IMRT" techniquem which is compensated at a higher rate due to its commensurate complexity. Field-in-field is a treatment technique that modulates the beam, but it IS NOT "breast IMRT" simply because it modulates the beam.
It is, in the opinion of many, inappropriate (at the least) to bill tangential breast treatments using the field-in-field technique or tissue compensation as "breast IMRT." In some uncommon cases, true breast IMRT can be advantageous (e.g., bilateral lumpectomy bed boosting, bilateral PMRT, etc.), but typically it results in extra low dose to the lung and carries a higher risk of target under-dosing due to difficulty with breast immobilization. Hence the ASTRO recommendation to not routinely use a more complicated and expensive treatment when it may actually be providing no clinical advantage and perhaps even detriment.
Before this thread, I had never met anyone attempting to call field-in-field "breast IMRT" except when discussing historical evolution of the term. Breast IMRT should only mean one thing if you are being honest about the issue and not trying to jump to semantics and technicalities surrounding the vague meaning of "modulation" in the term in order to justify a higher treatment reimbursement (which you will notice, everyone is curiously tip-toeing around while simultaneously trying to claim FiF and breast IMRT are the same thing - cognitive dissonance much?). If you really are going to be honest about this issue, then you need to discriminate between breast IMRT and FiF -- the easiest way, which most do in my experience (at academic centers so I'm nobody cares!), is just to use these two terms. But if you really want to latch on the IMRT term, then call it "forward planned-IMRT," "simple IMRT," "psuedo-IMRT," or use some other qualifier as many do. At the very least, put it in god-damned quotation marks. But apparently it is anathema to even attempt to suggest that field-in-field is anything other than full-blown inverse-optimized OAR-sparing dose-painted multiangle field IMRT! Quotation marks are are hinting it might be just a little bit different (it's actually a lot different), and that's just not OK!
For more reading and a very different view than what has been presented here, read the commentary by Lawrence Marks on this issue:
https://www.practicalradonc.org/article/S1879-8500(13)00132-X/fulltext
Key excepts:
"Many have labeled “field-in-field” forward-planned breast treatment as “IMRT.” While such plans do technically modulate beam intensities, they lack many other essential features of “traditional IMRT.” We believe it is more accurate to refer to this as “tissue compensation,” a related but different concept."
"IMRT is a nonspecific, overly simple term. Considering tangential breast fields, wedges can be considered “one dimensional intensity modulators” as they vary beam intensity in 1 direction orthogonal to the central ray.
"Calling field-in-field tangential radiation beams (or other means of modulating simple tangents) “IMRT” results in unjustifiably high reimbursements that our society cannot afford."
"We certainly are not the first to raise these concerns."
"The IMRT limited to tangent fields improves dose homogeneity and decreases toxicity, but this is essentially tissue compensation by another name. In our opinion, this should not be billed as IMRT at current reimbursement levels."
"As IMRT becomes more routinely adapted, our field should work to create a more rational coding structure that better reflects the efforts and expense of different types of IMRT, including “tangent-field breast IMRT.”
"However, “breast IMRT” via tangent fields appears to provide no sparing of these normal tissues beyond that achievable with simpler
methods (eg, shaping the deep border of the tangents and/or using gating to displace the heart away from the breast)."
- Joined
- Dec 18, 2015
- Messages
- 3,216
- Reaction score
- 4,930
Larry Marks decided what's IMRT--"In our opinion, this should not be billed as IMRT at current reimbursement levels"--so I concede. You've made your point. Larry's opinion is prima facie evidence I'm wrong. No controversy, no disagreements, no debate. You say: "...multiple beams (5 or more) coming in at different angles... This CANNOT be done using only two parallel opposed beams, such as tangential fields used for breast cancer treatments... In order to lower these 'hot spots' you can add a briefly delivered extra field, at the same angle, where these hotspots are blocked. This technique DOES NOT carve dose away from the heart." Now while the literature says tangential 2-field forward planned breast IMRT can carve dose away from the heart, I am 100% prepared to say you are correct and vast swaths of our literature and science and rad oncs and physicists are wrong.
In 2003, Steve Webb said Anders Brahme was the only guy on the planet who knew what IMRT was in 1988. Now sadly I'm the only guy on the planet who knows what it isn't; and you, what IMRT isn't not.
Nah. You don't need any "machinery" per se on the simple linac at all really.
Again, I wanna be really clear, non-curious, and not tiptoe: all FiF deliveries are a form of IMRT, and any IMRT dose distribution could be independently reproduced using FiF. All FiF deliveries modulate the intensity of the delivered dose delivered through a perpendicular plane. FiF is to IMRT as Type 1 string theory is to M-theory
(The thing I find curious is your idée fixe re: 5 or more beams, as if 4 very complexly modulated beams would not be IMRT but 5 would be... that one is kinda curious I admit.)Really not remarkable at all if you think about it. And that... was my initial point... about our specialty. (And FUTURE RESIDENT DO NOT BECOME A RADIATION ONCOLOGIST UNLESS YOU WANT INANE DISCUSSIONS WHERE BILLING TALKS, SCIENCE WALKS.). I knew it (IMRT, "IMRT") would inflame passions, cause a riot, etc.
Last edited:
D
deleted18755
Don't worry, nobody is wondering (not even those passionate about this field and physics, let alone those who are not rad once or just starting training or medical students).
You guys did do an awesome job of scaring away at least a few potential medical students and residents from this field with this ridiculous back and forth, which I hope everybody realizes is not what the average radiation oncologist worries about professional or spends his time "discussing" in his freetime on ananymous internet forums (or maybe we should make them think it is so they don't go into radiation oncology, the residency spots don't fill, and in that way this discussion is on topic with regard to the original thread . . . thanks for doing your small part to decrease residency expansions!!!).
Seriously guys, not even hardcore radiation oncologists, physicists, or people who love to study languange or whatever care about what you guys are spending so much time and energy talking about.
- Joined
- Mar 14, 2002
- Messages
- 14,918
- Reaction score
- 8,865
Woah. Keep it professional and no doxxing.
Edit: I don't mean you oldking and we don't need to name names. I deleted the offending posts.
Edit: I don't mean you oldking and we don't need to name names. I deleted the offending posts.
D
deleted18755
Sorry if the tone was unprofessional (I meant to be mainly sarcastic) but seriously guys I think you made your points.
So is this!
- Joined
- Oct 10, 2011
- Messages
- 8,624
- Reaction score
- 10,698
Given how off-topic this thread has now gotten, I believe it has run its course and has officially jumped the shark with a linking of a rick-roll. Closing. If any of the stuff that was angrily discussed over the last page would like to be continued, please feel free to start a new thread.
- Status
