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In real life, they have extreme difficulty billing for it (G6001)The derms claim they do some sort of ultrasound guided adaptive therapy
In real life, they have extreme difficulty billing for it (G6001)The derms claim they do some sort of ultrasound guided adaptive therapy
Moved into my region. A very corporate model where national company employs the RTT and derm collects professional codes.The derms claim they do some sort of ultrasound guided adaptive therapy
I mean cosmetic result is going to be some function of tumor factors, patient factors, and treatment factors like dose, field size, etc.Moved into my region. A very corporate model where national company employs the RTT and derm collects professional codes.
It was advertised in several local papers and I’m going to respond in kind. These are very low energy photon machines (50-100 kv) well below orthovoltage and in a domain where primary interaction is photoelectric (so they will be dumping excess dose into underlying bone).
Superficial Radiotherapy: Long Term Follow-Up of Highly Selected Basal and Squamous Cell Carcinomas in Skin Cancer Patients
Superficial radiotherapy (SRT) treatment for non-melanoma skin cancer has been reported to yield variable cure rates. When patients are highly selected, adequate margins of treatment are chosen, and hypofractionation is avoided, cure rates of SRT can approach that of Mohs surgery.www.dermatoljournal.com
Above is the only reasonable published series that I have seen (lots of emerging specious and borderline unethical publications coming out). I strongly suspect cosmesis is inferior to electrons and the toxicities in this series exceed anything that I have cause in similar cases in years of practice.
cosmetic result is going to be some function of tumor factors, patient factors, and treatment factors like dose, field size, etc.
Above all absolutely true, and I have no problem with a radonc having multiple sources and choosing which one to use.Electrons need a larger penumbra
And backed by PE and you should see their pro forma. We are not excited about reimbursing for daily US and daily 77280Above all absolutely true, and I have no problem with a radonc having multiple sources and choosing which one to use.
Optimum radiation source for radiation therapy of skin cancer - PubMed
Several different applicators have been designed for treatment of skin cancers, such as scalp, hand, and legs using Ir-192 HDR brachytherapy sources (IR-HDRS), miniature electronic brachytherapy sources (eBT), and external electron beam radiation therapy (EEBRT). Although, all of these...pubmed.ncbi.nlm.nih.gov
This is a pretty good paper regarding dosimetry for low energy photons vs electrons. Keep in mind, these commercial machines are often operating in the 50-75 kv range.
There are two major dosimetric factors that bother me with low energy photon treatment.
First, you never normalize just to the surface (unless truly a lesion with zero depth, perhaps a CIS with questionable indications for treatment regardless). If you normalize at 5mm, surface dose for low energy photons is much higher, and I think this manifests as significantly more long term hypopigmentation (hard to find good references on this, this is from experience).
Second is the marked dosimetric impact of Z at low energies, resulting in crazy dose increase at bone.
I have no problem with my local derm using superficial photons for tiny lesions on fleshy areas where cosmesis not the most important. However, all of these lesions are also amenable to conservative local surgical or other management, and it is clear that they are looking to spend and recoup more to treat the same.
I will be concerned if they are treating substantial scalp, nose and distal extremity lesions with superficial photons however.
That they advertise groundbreaking technology (image guidance for superficial lesions) and quote ridiculous studies to support why their machine has a better cure rate than linac based treatment is farcical.
I've heard a lot of payors are flat out rejecting that now?And backed by PE and you should see their pro forma. We are not excited about reimbursing for daily US and daily 77280
Above all absolutely true, and I have no problem with a radonc having multiple sources and choosing which one to use.
Optimum radiation source for radiation therapy of skin cancer - PubMed
Several different applicators have been designed for treatment of skin cancers, such as scalp, hand, and legs using Ir-192 HDR brachytherapy sources (IR-HDRS), miniature electronic brachytherapy sources (eBT), and external electron beam radiation therapy (EEBRT). Although, all of these...pubmed.ncbi.nlm.nih.gov
This is a pretty good paper regarding dosimetry for low energy photons vs electrons. Keep in mind, these commercial machines are often operating in the 50-75 kv range.
And also we should not forget that a 2 Gy dose of 100kV photons will have the RBE of a 1.8 Gy dose of 6MeV electrons. (Although in practice everyone actively and intentionally forgets this.)I mean cosmetic result is going to be some function of tumor factors, patient factors, and treatment factors like dose, field size, etc.
I use the orthovoltage unit in my dept, we have 100kV as the lowest energy. With good fractionation/tighter collimation, it’s a preferred modality over electrons a lot of the time for me. Electrons need a larger penumbra, and often a lot more heterogeneity, when orthovoltage is just 100% at a flat surface. The key is when to employ one over the other for best dosimetry, and having access to only one, while feasible for many tumor scenarios, leaves you lacking when another modality may be better.
Electrons so easy just for that reason alone. Can clog up the machine at times but the nrc reqs are just tough in q busy practiceThanks for the ref. Been doing a lot of superficial HDR treatments over the past few years for a variety of reasons. Only downside is requirement to be present, but with hypofx not too burdensome.
I had an exact same thing happen. Derm group in town with long standing history of billing igrt on their SRT machine. …recently sent me a guy where insurance denied his whole course and demanded he be treated with me.I've heard a lot of payors are flat out rejecting that now?
I got a referral recently from one of those SRT derms for a standard bcc of the face, pt said his insurance company wouldn't cover their treatment only mine??? I wonder if the insurance companies are finally on to it
It’s hard to reject outright, since ASTRO guidelines suggest it as a reasonable option. The problem is that the guidelines and NCCN just make you do BED of XX, so the RXs I get sent are ridiculous for SRT. + IGRT, + daily sim. We reject all but one sim and all the igrt.
I don't know, but it's the format that I am most leery of (SRT next).I am uncertain why electronic brachy got the shaft.
We looked into XOFT years ago, as on the surface (sic) it's an appealing format for a smaller community place to start doing their own vaginal cuff and some other indications (shielding requirements, etc.). After looking a littler deeper, we decided not to make the investment (fortunately).
50 kV is 50 kV regardless of how it's made..
But how it's delivered could affect things...
Anyone have a pdf link comparing the dosimetry of xoft vs sensus worth a read?
We have a trial open for pancreas CA that is T3/T4 borderline or unresectable using protons to give 63 Gy in 28 fx of 2.5 Gy each. The goal is convert to operable or for definitive local control.It's going to lead to even greater worship of the computer screen in proton users.... the next logical step in protons - variable RBE without adaptation is OLD protons! Now we adapt daily so we don't have the same range uncertainty margins that we normally would use!!
Until they start necrosing brainstems and putting holes in duodenums, of course.
We have a trial open for pancreas CA that is T3/T4 borderline or unresectable using protons to give 63 Gy in 28 fx of 2.5 Gy each. The goal is convert to operable or for definitive local control.
I wouldn't mind the ability to re-optimize based on bowel or stomach filling if something got in the way, but usually we are posterior to most of those volumes. The toxicity so far has been pretty minor for similar patients I've treated off protocol, usually in the setting of reirradiation after SBRT or 50.4 Gy progression.
We have a trial open for pancreas CA that is T3/T4 borderline or unresectable using protons to give 63 Gy in 28 fx of 2.5 Gy each. The goal is convert to operable or for definitive local control.
I wouldn't mind the ability to re-optimize based on bowel or stomach filling if something got in the way, but usually we are posterior to most of those volumes. The toxicity so far has been pretty minor for similar patients I've treated off protocol, usually in the setting of reirradiation after SBRT or 50.4 Gy progression.
NCT is a valid question but should not be answered in detail for doxing purposes.Haha I have so many questions about this trial, do you have an NCT? Is it a re-irradiation trial?
Uncle Joe needs to declare every ViewRay treatment room a disaster area
"life-saving technology"?Uncle Joe needs to declare every ViewRay treatment room a disaster area
Whoa.
Actually they did get their own code. Reimburses about 250 per fraction… a lot more than superficial. Well, as long as the insurance company approves it. See LCD L35490.electronic brachy (Xoft) applied for their own CPT code and failed. As far as I understand
Seems that way if they don’t even tell you if you need Imperial or metric hex set to service it!!😂Departments that purchased Viewray's are going to write off $12 million?
God I really don't want to "like" this post. I really don't want to reply to this post.This guy is unwell, and an embarrassment to our field
He is part of the problem. He was promoting single fraction/fly in fly out/ lung sbrt at mdacc. Race to the bottom.This guy is unwell, and an embarrassment to our field
“…causes much less collateral damage than traditional radiation.”Would a judge having their own biased opinion count as someone having influence? Granted, I hate insurance companies but there needs to be some guidance as to when certain modalities are appropriate.
Let’s face it, our “leaders” suck. Speaking of them, where is our ASTRO president hiding these days?
https://www.cnn.com/2019/05/16/health/judge-proton-beam-therapy-recusal-unitedhealthcare?cid=ios_app
“It is undisputed among legitimate medical experts that proton radiation therapy is not experimental and causes much less collateral damage than traditional radiation,” wrote Scola, a US District Court judge for the Southern District of Florida. “To deny a patient this treatment, if it is available, is immoral and barbaric.”
I don’t think politicians believe they need data to make such statements. Actually with social media, data and research is less important.“…causes much less collateral damage than traditional radiation.”
[citation needed]
Abortion?courts will always follow public opinion
“Sometimes, dead is better.”
I'll tell what little I know... Most of this is rumor mill level information.
The remaining assets of ViewRay were bought by a holding group with a generic name.
The founder of ViewRay who remained heavily involved throughout the company's history, Jim Dempsey, is heavily involved in this.
What I've heard is that the goal is to re-hire all the technical and medical people who used to be in the company. They will move forward again with service, construction of systems, upgrades, etc.
The new company plans to operate privately without much of the old leadership picked up by being a public company that were not medical people. I suspect they created large cost burdens, and I can see how poor decisions at that level could have led to the financial disaster at Viewray.
More to come, I'm sure...
UhI'll tell what little I know... Most of this is rumor mill level information.
The remaining assets of ViewRay were bought by a holding group with a generic name.
The founder of ViewRay who remained heavily involved throughout the company's history, Jim Dempsey, is heavily involved in this.
What I've heard is that the goal is to re-hire all the technical and medical people who used to be in the company. They will move forward again with service, construction of systems, upgrades, etc.
The new company plans to operate privately without much of the old leadership picked up by being a public company that were not medical people. I suspect they created large cost burdens, and I can see how poor decisions at that level could have led to the financial disaster at Viewray.
More to come, I'm sure...