September, 2012

Fast and Curious

By Michael J. Katin, MD

Advances in technology are credited with improving our quality of life, but, ironically, may be the means of extinguishing the livelihoods of hundreds of persons in the field of radiation oncology. As detailed in last month's column, CMS has proposed reducing the charges for many items in our field due to reassessment of the complexity and, interestingly, the speed of carrying out these techniques. Logic would say that advances that allow procedures to be done more rapidly make them more complicated. That would be logical. When logic is not involved, the number of procedures that can be done per hour is detrimental to reimbursement.

Has radiation oncology been fined for being too efficient? In fact, shouldn't this count as the most expensive speeding ticket of all time?

It has been estimated that seven per cent of the upcoming proposed CMS reimbursement cuts for radiation oncology is due to estimation of reduced treatment times for IMRT and SBRT.

Is it true that doing something faster should make it cheaper? For example, a physicist in New York wants to go to Boston on October 27, in time for ASTRO's 54th Annual meeting. She could take a bus from Pennsylvania Station at 7:30 am and arrive in Boston at 8:20 pm, only 12 hours and 50 minutes later, for $35.96. US Airways Flight 2126 from LaGuardia Airport to Logan Airport, leaving at 12 noon and arriving at 1:10 pm, 1 hour and 10 minutes later, would cost $420.00. A 2012 Honda Civic DX Coupe , selling for $15, 755, can have a top speed of 115 miles per hour (briefly), while a 2012 BMW M5, at a price of $90,695, can reach 190 miles per hour.

Is it possible that they're correct, and that it is better to take more time to do procedures? Benjamin Franklin, in Poor Richard's Almanack, described that "Haste makes waste ." The Pointer Sisters wanted someone who would take his time , although Eric Clapton, despite his nickname, was probably not that person (pop culture reference). Maybe going slowly has some advantages, but it's hard to say it's a practice that should automatically be expected to be rewarded . Regardless, there have been some instances in which trying to be rapid and efficient in the field of radiation therapy has not been good. For examples, there were the 1986 overdoses on the Therac-25 linear accelerator at the East Texas Cancer Center. At least two patients received excessive doses of electrons due to a flaw in the software such that extremely rapid data entry by a skilled therapist resulted in a "Malfunction 54." The physicist investigating this problem was not able to reproduce the situation until many efforts to maximize speed of entering prescription information into the computer. The outcome was one death, several serious injuries (at least two more, in Georgia and Washington in 1985), huge lawsuits, discontinuation of the Theratronics linear accelerator line, and, in 1991, an FDA ban on all Theratronics medical equipment .

Fortunately, similar accidents have not subsequently occurred, meaning either that the software and hardware for linear accelerators has been improved or that therapists are not as energetic as they were in 1986. It still remains that with the explosion in personal communication and social media that everything else seems to be done in a rush . Whether anyone has anything worthwhile to do otherwise, most people want to get procedures done as rapidly as possible. How often do we have to answer about the potential advantages and disadvantages of accelerated partial breast irradiation , for example?

As if to make things more difficult for us, "RapidArc" calls out for scrutiny just by its name alone! Why wasn't it called HighlyComplicatedArc? A survey of the August 1, 2012, issue of the International Journal of Radiation Oncology", Biology, and Physics shows that in just the first few pages are four advertisements for rapidity: "twice the leaves at twice the speed" (Varian); "With this much protection and speed" (Veritas); "MCO shortens planning time" (RaySearch Laboratories); and, "Auto-Segmentation with SPICE streamlines the process to just a few fast clicks" (Philips).* Are our vendors doing their best to do us in? Although everything else seems to be speeding up as much as possible, the dilemma is whether to do our best to accommodate our patients' desires, or to recognize that CMS and other entities do not recognize speed as an asset, regardless of how much effort went into being able to reduce treatment and planning times.

Maybe it's important to remember that ours is just about the only profession that charges by the procedure rather than by the hour , and the vast majority of politicians and higher-level bureaucrats come from professions in which taking longer to do something is more profitable. We need to get the message from CMS and encourage ourselves, our therapists, our nurses, and our physicists to slow down

And we hope we avoid a conflict if fast neutron therapy is ever rediscovered.

*unfortunately, no payments were received for commercial products mentioned