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Working Together: How to Build a Radiosurgical Center and Partnership. Sandra Vermeulen, M.D. Seattle Cyberknife Center at Swedish Cancer Institute Seattle, WA. Swedish Cancer Institute: Background. Radiation oncology providers for 7 facilities in Puget Sound area:

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Working Together: How to Build a Radiosurgical Center and Partnership

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Working Together: How to Build a Radiosurgical Center and Partnership

Sandra Vermeulen, M.D.

Seattle Cyberknife Center


Swedish Cancer Institute

Seattle, WA

Swedish Cancer Institute: Background

  • Radiation oncology providers for 7 facilities in Puget Sound area:

    • Swedish Hospital at First Hill

    • Swedish Providence Campus

    • Seattle Prostate Institute

    • Northwest Hospital

    • Valley Medical Center

    • Highline Hospital

    • Stevens Hospital

  • 15 radiation oncologists treat 220 external beams patients per day, and perform 600+ brachytherapy and 300+ Gamma Knife procedures per year

Seattle Cyberknife: Driving Force

  • Private Medical Investment Group:

    • Assessed a need in Seattle area

    • Approached regional hospitals and medical groups

      • Intent to partner with prominent neurosurgical and radiation oncology groups

    • Swedish Hospital logical partner choice:

      • Largest oncology provider in the region

      • Large neurosurgical and radiation oncology services

Swedish Radiation Oncology Physician Group: Decision Process for Participation

  • Stereotactic Radiosurgery: is there a need?

    • Do clinical studies support hypofractionated, stereotactic treatment?

    • Are there sufficient patients to justify the device?

  • IGRT Platforms: is the Cyberknife the best?

    • How about Trilogy, Synergy, Tomotherapy?

  • Financial Analysis: does it make sense?

    • What physician resources are required, and what reimbursement will be realized?

Stereotactic Radiosurgery:Is there a need?

  • GammaKnife experience proved efficacy of cranial SRS; frameless systems allow fractionation

  • For extra-cranial SRS, literature review showed clinical efficacy in:

    • Spine

    • Head and neck

    • Lung

    • Liver & pancreas

    • Previously radiated sites

  • Population of the region, and size of Swedish network sufficiently large to justify SRS unit

The World of Image-guided RT:Is the Cyberknife the best?

  • Few people really understand the differences in platforms

    • Slow dose-rate limits throughput

    • Swedish Hospital had Elekta Synergy S Unit, and will be clinical/research development site

  • Advantages of Cyberknife over other platforms:

    • Cyberknife only image-guided platform with real-time target correction capability

    • Only device with model to track respiratory motion

    • Greater degree of targeting freedom theoretically yields superior dose delivery


Financial Analysis: Does it make sense for radiation oncology group?

  • What did radiation oncologist using CK say?

    • Amazing technology, excellent clinical outcomes

    • Enormous amount of work

    • Reimbursement was awful

    • “Just say no”, unless additional compensation given

  • Financial per formas: hospital versus professional

Projected Hospital Revenue from CK Center

A successful CK center breaks even in year two, and can bring in 1-2 million/yr in 4 - 5 years

Professional Radiation Oncology Revenue from Cyberknife SRS

Ratio of revenue for equal workext beam : CK 3 : 1


Radiation Oncologists’ Reimbursement

  • Why so poor?

    • SRS management codes (77427, 77431) not yet reimbursed for extra-cranial treatments

    • Radiation oncology billing historically weighted heavily towards weekly management fees

    • Treatment planning codes undervalued relative to work effort required

    • Treatment planning effort can be shifted to surgeon (CPT code 61793), increasing patient load

      • Shift in mindset: must be comfortable having other disciplines participate in contouring and planning

Planning the Treatment Center

  • Stand-alone center?Association with existing radiation oncology facility allows

    • Efficiencies in office space

    • Efficiencies in staffing

  • Physical space: hire architects experienced in medical construction

    • Corridors need to accommodate gurneys?

    • Bathrooms, dirty & clean utilities, etc…

Assigning Staff:Cyberknife is Complex, New Technology

  • Uncertainty at every step:

    • Indication for treatment are evolving

    • Treatment protocols are not well defined

    • Every patient requires justification with insurance company

    • Multidisciplinary treatment requires education and participation of numerous MDs and staff

    • Numerous steps require coordination

    • Fiducial placements – require IR – currently their work is not reimbursed

    • Treatment planning processes (CT requirements, MR fusion) are unique, require forethought


  • Hire motivated, smart staff, preferably with experience in radiation oncology

    • Assign a manager to oversee the project

    • Physicists are expensive and hard to find

    • An organized, efficient RN or coordinator, is needed that can multi-task well

    • Assign a technologically savvy, high-performing therapist

Plan in Advance!

  • Have manager and staff members in each domain trained through Accuray

  • Have staff members (MD, physicist, RN, therapist) proactively plan office requirements

    • Office supplies

    • Examining room equipment and supplies

    • Patient charts

    • Treatment equipment

    • Physics QA requirements

Educate Ancillary Departments

  • Develop written CT and MR imaging protocols:

    • For CT: slice thickness, pitch, # images, center, patient position, contrast agents

    • For MRI: location and size of matrix, scanning interval, sequence, contrast agents

  • Interventional radiology crucial for fiducial placement

    • Meet with MDs, radiology office manager to explain program

    • Reimbursement is a problem – but other diagnostic studies can off –set their time

    • Explain detailed requirements of fiducial placement


  • Regional Medicare intermediary initially not paying professional fees for extra-cranial SRS

  • Will this be treatment be reimbursed?

    • Meet with medical director, present literature

  • Other carriers may be reluctant to pay:

    • Meet with medical directors in advance

    • Be prepared to justify treatment with literature

    • Write letters of medical necessity

Educate Your Referral Base

  • Market to physicians:

    • Relationships with referring doctors

    • Presentations at tumor boards, grand rounds, etc…

      • At local hospitals and regional facilities

    • Open house

    • Direct informational mailings

  • Market to community:

    • Local media – papers, television

    • Website

Clinical Considerations

  • Extra-cranial SRS is new and few have experiencing training

  • Well-established treatment guidelines don’t exist

  • Follow-up and complication data on hypofractionated body SRS is limited

To Determine Clinical Guidelines

  • Attend the Cyberknife Society meetings

  • Read the literature – CK Society has a good reference list

  • Review radiobiology

  • Talk with other CK Society members

  • Amount of information is overwhelming, so assign disease sites to different doctors:

    • Agree on guidelines for each disease site/stage

    • If there is no literature on a treatment approach, submit formal protocol to your hospital IRB

  • Consider gathering data on dosing, toxicity, and clinical outcomes to guide future treatments


  • Realize enormous work effort required to start center and treat CK patients

  • MDs should evaluate in advance the financial implications of participating

  • Hire best available staff, preferably with radiation oncology experience

  • Get trained and organized in advance

  • Pro-active involvement & education of:

    • Insurance companies

    • Ancillary services (intervention radiology)

  • Uncharted clinical waters: physicians do your homework, and cautiously write protocols/guidelines.


Cyberknife is a marvelous technology, that offers non-invasive treatment instead of surgery, or pain relief instead of morphine, or hope when before there was none.

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