August, 2019

IMRT (Intentionally Modified Radiation Therapy)

By Michael J. Katin, MD

On July 26 there had already been leakage, following a national tradition, of the proposed rule for the 2020 Physician Fee Schedule, which was then "placed on display at the Federal Register," as their terminology describes.

In its wisdom, CMMS has taken on the responsibility of controlling medical costs, to be done entirely based on reduction of payments for radiation oncology. This is appropriate, since radiation oncology expenditures have usually been in the range of 0.5% of the total healthcare burden. Analysis of the contribution of radiation oncology to overall cost is, amazingly, analyzed primarily by inference; for example, a June, 2019, review of 2013 Medicare expenses showed that cancer care that year was only 5% of Medicare (undoubtedly higher now) but radiation therapy accounted for only $2.2 billion out of approximately $575 billion.

In any event, change needs to start somewhere. There have been previous examples of decisions rather abruptly resulting in long-lasting changes in behavior.

1. Ugo Boncampagni was elected Pope in 1572 and took the name of Gregory XIII. Since climate change was not yet recognized as a divisive issue, the two main crises which he had to address were relations with Protestants (resolved in such ways as the St. Bartholomew's Day Massacre) and concern that holy days did not any longer seem to be occurring at the right times. This was due to the difference between days of the Julian calendar year and the solar calendar year. Scholars were assigned to determine the best way to reboot the calendar and in 1582 he decreed that the new system, named the Gregorian calendar (it was fortunate he was no longer named Ugo), was put into use. Interestingly, although it was adopted immediately by most of the Catholic world, the rest of the world took some time to go along, leading to such phenomena as to why no one was born between September 3 and 13, 1752, in New England.

2. It was some years later that another individual caused dramatic changes in the lifestyle of a substantial number of people. Throughout the 16th and 17th centuries it was recognized that witchcraft was the cause of most of society's problems, and was primarily at the end of the 17th century that persons in Massachusetts became woke to this phenomenon. It was one person who was primarily responsible for the start and end of this flurry of activity. William Phips had one of the most extraordinary lives of anyone in history. Amidst multiple adventures, what should have been one of the least eventful was his being Governor of the Massachusetts Colony. In 1692, when witchcraft became endemic in the Salem area, a Special Court of Oyer and Terminer (not to be confused with the name of a law firm) was decreed by Governor Phips, who then left the area to help secure Maine against French and Native American raids and establish a truce with the Abenaki tribe. Upon his return he learned that there had already been the execution of up to twenty persons and two dogs for witchcraft, and many more persons were being accused, including Mrs. Phips. Apparently, Governor Phips was under the spell of Mrs. Phips and decided to immediately terminate all cases and release those who were already imprisoned. He was subsequently turned into a newt.

3. At about this same time, Russian Tsar Peter (not yet Peter the Great) was making a concerted effort to learn everything about industry, particularly shipbuilding, in Europe, traveling under the pseudonym of Pyotr Mikhailov, although, since he reportedly was six feet eight inches tall, would have been about as anonymous as LeBron James. When Peter returned to Russia, he implemented policies to drag his country into the modern age, including directing nobility to shave their beards and mustaches, starting a civil service system based on merit, establishing celebration of Christmas with Christmas trees (true), and even adopting the Julian Calendar. At least a start. Russia switched to the Gregorian calendar in 1918.

4. In 1928 Kemal Ataturk declared that the Turkish language would now be written in modified Latin rather than Arabic script......and the transition was made in 5 months. Converting the USA to the metric system was started in 1975 and fairly well abandoned by 1982 with dissolution of the U.S. Metric Board. In fairness to the U.S. Metric Board, the literacy rate in Turkey at the time of the conversion was 10%, whereas most Americans knew how may ounces were in a can of Budweiser and the size of a quarter-pounder.

5. For years there has been controversy about the optimal way to fractionate radiation therapy treatments, and we were all required to know about radiobiology with the five R's of radiobiology: repair of DNA damage, redistribution of cells in the cell cycle, repopulation, reoxygenation of hypoxic tumor areas, and reimbursement. Large doses per fraction were likely to produce more normal tissue damage, and were unlikely to cause more harm to hypoxic tumors than smaller doses. This has all now been disrupted by the findings that hypofractionation appears safe and effective for treatment of many cases of breast cancer and prostate cancer and with stereotactic techniques high doses can be more safely administered than in years past. There is now also the possibility that "FLASH" radiation therapy, delivering a high dose in a very short time, might be the way to go -- and so far safe for preserving neurocognitive function in mice but with additional studies on zebrafish embryos to be done.

As illustrated above it is necessary for bold moves to be made to change human behavior and move into the future. The proposed rule recommends a "demonstration project" of having 40% of practices participate in a capitated system in which treatment of a disease diagnosis is paid by a single amount regardless of the type of treatment used. In other words, treating prostate cancer with 28 fractions would pay the same as treating with 45 fractions. Presumably flashing with one treatment would pay the same as treating with 30 fractions. While it is hard to believe that a financial factor would determine what the best course of treatment is for an individual, there might be a very few practitioners (and hospital administrators) that might possibly be influenced by this factor. Truly hard to believe. However, in the remote chance that hypofractionation might now appear more acceptable and the risk of long-term complications may seem more acceptable as well, this "demonstration project" may influence practice patterns for the new generation of radiation oncologists to be point that going back to historically-used treatment protocols may never happen. Ugo, Governor Phips, Pyotr, and Kemal would all be proud.

Asteroid 2006 QV89 Countdown: Asteroid 2006 QV89 will be impacting with or passing by Earth September 9, 2019, which, counting September 9, is 40 days from now. Plenty of time left to stock up on batteries and plywood.

BONUS: In honor of the 25 candidates seeking the Democratic Party nomination for President of the United States:

To the tune of "Waterloo "

It's getting late for the candidates for the race for 2020;
It's not that there's no one that's good, it that there are way too many for one stage.
The problem is which one to choose
It won't mean a thing if you lose
Klobuchar -- she's got Midwestern common sense
Klobuchar -- all the right moves to be President
Klobuchar -- who'd have believed she'd have gone this far
Klobuchar -- she's captured lightning in a jar
Klobuchar -- Amy's America's superstar.

Debates may help settle their fate with the policies they're making

Amy Jean won't be too extreme, with no green new deal or Medicare for all.
She's the one that you'd host at your home
Except when she eats with a comb.
Klobuchar -- break the glass ceiling once and for all
Klobuchar -- help the oppressed and tear down the wall
Klobuchar -- compassionate values will be restored
Klobuchar -- tweets will be banished forevermore
Klobuchar -- will win re-election in '24.