Radiation Breakdown: All That Glitters Is Not Gold

Neil Canavan

June 2012, Vol 3, No 4 - ACCC Annual Meeting


Baltimore, MD—Radiation technologies rank as some of the most interesting new developments. However, the advantages of these new technologies in terms of patient outcomes are sometimes elusive, and the costs of acquiring radiologic facilities—and the revenue generated by them—are increasingly coming into question.

“There’s a disconnect about how costs are going in one direction but reimbursement is going in another, and no one is really sure what to do about it,” said Andre Konski, MD, MBA, FACR, Professor and Chair, Department of Radiation Oncology, Wayne State University School of Medicine, Detroit, MI, at the 2012 Association of Community Cancer Centers meeting. The technologies in question include:

  • Intensity-modulated radiation therapy (IMRT). This technology allows for the sparing of critical anatomical structures, while at the same time facilitating the delivery of increased doses of radiation to the tumor
  • Image-guided radiation therapy. This allows for the real-time targeting of radioactive material (“seeds”) directly to the tumor site
  • Stereotactic body radiotherapy (SBRT). The use of SBRT allows for the compression of radiation treatments from as many as 6 weeks of therapy to 3 to 4 days of therapy. This technology can accurately deliver very high biologic doses, and has demonstrated high activity in some tumor types, particularly lung cancer
  • Proton therapy. This particle therapy using protons allows for targeting a confined dose within a given tumor volume. It is often used to treat prostate cancer and is considered a game changer for certain types of pediatric cancers.

Is It Cost-Effective?

All of these technologies are expensive (proton therapy facilities exceedingly so), but as expenses rise for facilities and machines, reimbursements for the related procedures decline. “As we are moving toward more hypofractionated regimens,” said Dr Konski, “we have to ask ourselves if it is really cost-effective.”

That the new technologies are more convenient for the patient is without question, having greatly reduced treatment times. However, are these new treatment modalities more effective? “Some research presented recently suggests that fewer fractions of radiation might be better for prostate cancer,” Dr Konski noted. “We’re talking about more than 30 fractions to potentially less than 5.” But the data may not necessarily translate to other tumor types, or, at the end of the day, make good business sense.

Consider a recent analysis of the cost-effectiveness of modern radiotherapy techniques in patients with locally advanced pancreatic cancer (Cancer. 2012;118:1119-1129). “They did a modeling exercise comparing historical data for the use of single-fraction SBRT for pancreatic cancer to a study performed by ECOG [Eastern Cooperative Oncology Group study 4201].”

In that study, the chemotherapy gemcitabine was compared with gemcitabine plus radiation versus gem – citabine alone, “and what they found was that there was no statistical difference in disease-free or overall survival at 36 months with the addition of SBRT,” Dr Konski said.

The analysis then considered cost, which was calculated using the 2009 Medicare fee schedule. Results showed that the expected mean costs generated by the model were gemcitabine alone, $42,900; gemcitabine/ SBRT, $56,700; gemcitabine/radiotherapy, $59,900; and gemcitabine/IMRT, $69,500 (the current standard of care in many cancer centers).

Quality-adjusted life-years (QALYs), a measure increasingly used in costbenefit analysis, were highest for gemcitabine/ SBRT at 0.77; however, this was not greatly improved from the other 2 modalities that rated an average QALY of 0.72.

“So, over the lifetime of the patient, if you look at gemcitabine/IMRT versus gemcitabine/SBRT, that’s a $12,000 difference in revenue being generated by the cancer center,” observed Dr Konski. “That’s great for the insurance companies—they save money—but for every patient you treat with SBRT, your cancer center has just registered $12,000 in potential lost revenue.”

And that is just one tumor type—pancreatic. It is likely that if you are using SBRT at all, it will be a part of the prescribed therapy for breast cancer and prostate cancer as well. How will that impact your cancer center? “We’ve shown that revenue is going to decline because of this technology,” Dr Konski said, but along with this, treatment time has been compressed. So, perhaps you are saving money on staffing? Actually, no. “You’re going to need the same dosimetrist to design the treatment plan,” Dr Konski pointed out. Short course, long course, IMRT, or SBRT—it does not matter. “And you are going to need the same physicist, because there is the same need for quality assurance. These are highly technical procedures that must be delivered correctly, and physicists do not come cheap.”

That brings the question, is the reality of needing fewer therapists for fewer procedures a wash in terms of overall cost-savings? Consider the pressure that will come from payers when they realize how much money they can save. Medicare reimbursement for a full course of 40 treatments with IMRT for prostate cancer (technical component only) is $17,888; the reimbursement rate for 26 treatments of hypofractionated radiotherapy for prostate cancer is $11,627; and the rate for 5 courses of SBRT in the same disease setting is $12,992. Therefore, the saving to Medicare is a minimum of $4896 or a maximum of $6261, depending on which advanced modality you compare with standard IMRT.

Implications for Cancer Centers And the reward for the provider in the middle of all this? Over a period of 1 year, “The potential loss of revenue to the cancer center is $325,580 for hypofractionated [radiotherapy] and $254,594 for SBRT [compared with IMRT] if 1 patient a week is treated with the alternative fractionation schedule,” Dr Konski said.

Are cancer centers going to be able to make up that lost revenue? Not if everyone is doing it. “You’re not going to make it back on volume. These things are easy to set up (except for proton facilities). In some states, there is a Cyberknife on every corner,” Dr Konski stated. With that said, he urges those who have already made the investment in the technology to be sure to advertise the advantage of abbreviated treatment times to the patient.

In almost any market, there are still centers where lengthy IMRT courses are the norm. Beyond that, however, Dr Konski urges cancer centers to think twice about buying into any additional new radiation technologies that can prove too costly.