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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

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
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
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
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
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
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
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
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
Professional Radiation Oncology Revenue from Cyberknife SRS

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


radiation oncologists reimbursement
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
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
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
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
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
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
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
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.