Working Together: How to Build a Radiosurgical Center and Partnership

1. Working Together: How to Build a Radiosurgical Center and Partnership Sandra Vermeulen, M.D. Seattle Cyberknife Center at Swedish Cancer Institute Seattle, WA

2. 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

3. 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

4. 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?

5. 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

6. 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

7. Cyberknife

8. 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

9. 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

10. Professional Radiation Oncology Revenue from Cyberknife SRS Ratio of revenue for equal workext beam : CK 3 : 1 (!)

11. 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

12. 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…

13. 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

14. Staffing • 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

15. 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

16. 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

17. Insurance • 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

18. 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

19. 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

20. 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

21. Summary • 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.

22. Conclusion 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.