March, 2018


In This Issue
HDR Interstitial Brachytherapy in Recurrent Head and Neck Cancer: An Effective Salvage Option

How Do We Measure the Costs of Brachytherapy? Introducing a New Workshop at the ABS 2018 Annual Meeting

Brachytherapy Patient Safety Insights from the ASN Patient Safety - Paving the Way for Progress Series

ABS Meets with CMS Regarding Comprehensive APC 
Payment Methodology

Incorporating Social Media into Radiation Oncology
2017-2018  Board of Directors 
Catheryn Yashar, MD, FACRO, FACR
Peter F. Orio, III, DO, MS 
President Elect
Daniel G. Petereit, MD
Vice President
Ann Klopp, MD, PhD
Firas Mourtada, PhD
Steven J. Frank, MD
Chairman of the Board
David K. Gaffney, MD, PhD
Past Chairman of the Board

S ushil Beriwal, MD
Zoubir Ouhib, MS, DABR
Christopher L. Deufel, PhD
Peter J. Rossi, MD

Brachytherapy Journal: 

Membership Benefit!


The  Brachytherapy Journal may now be accessed online through the Elsevier Science website via the members-only portion of the ABS website. Members can access the journal articles quickly by clicking on the link below and logging in using your ABS username and password.



Reimbursement and Coding

The Socioeconomic Committee has created a   new member-benefit  by posting relevant brachytherapy coding and reimbursement information on the ABS website. Currently, ABS members can review the 2017 Medicare proposed rule summaries and payments to physicians, hospital outpatient departments and ambulatory surgical centers. In the coming months, the Committee will post new and revised procedure codes effective in 2017 and  frequently asked questions and answers.
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What can YOU do for the ABS?
As a Member of ABS, what 
can YOU do to Support 
Your Association?

- Recruit new members both locally and at national meetings that you attend during the year
- Contact the national office with the names of potential corporate members, potential exhibitors and sponsors, based on the various vendors that you come into contact with on an annual basis
- Participate on an ABS committee
- Submit an article for publication in Brachytherapy, the official journal of the Society
- Renew your membership each year in a timely fashion
- Submit topics and speaker suggestions for the next Annual Meeting or for a future ABS School
Welcome to the monthly communication of the American Brachytherapy Society called BrachyBlast. The BrachyBlast is somewhat informal and we welcome your feedback on issues relevant to your practice. This month's topics are,
HDR Interstitial Brachytherapy in Recurrent Head and Neck Cancer: An Effective Salvage Option, How Do We Measure the Costs of Brachytherapy? Introducing a New Workshop at the ABS 2018 Annual Meeting, Brachytherapy Patient Safety Insights from the ASN Patient Safety - Paving the Way for Progress Series, ABS Meets with CMS Regtarding Comprehensive APC Payment Methodology and Incorporating Social Media into Radiation Oncology.

Thank you,
Catheryn Yashar, MD, FACRO, FACR
Daniel G. Petereit, MD , FASTRO



We are pleased to have one of our international ABS members as our guest editor this month - Dr. Vibhay Pareek. He is a radiation oncologist at the Jupiter Hospital, in Mumbai, India, where he was trained under Dr. Rajendra Bhalavat - a pioneer in modern day image guided head and neck brachytherapy. Dr. Pareek is a brachytherapist specializing in head and neck, sarcoma, breast and gynecological malignancies. From Dr. Pareek, "The art of brachytherapy has a learning curve but once attained, can help achieve the best form of treatment available". He describes their technique and results using HDR brachytherapy for recurrent head and neck cancers.  So, a special thank you to Dr. Pareek for writing our ABS blast this month. Please e-mail me if you wish to write on a topic as we are very interested in your brachytherapy practice and expertise. Topics are completely open and include literature reviews to the specifics of your brachytherapy practice.

Daniel G Petereit, MD, FASTRO

Catheryn Yashar, MD, FACRO FACR


HDR Interstitial Brachytherapy in Recurrent Head and Neck Cancer: An Effective Salvage Option
Dr. Vibhay Pareek, Radiation Oncologist, DNB, MBBS
Jupiter Hospital, Mumbai, India
Background for Reirradiation:
While there have been many advances in the management of head and neck malignancies, approximately 20-50% of patients are diagnosed with a loco-regional recurrence within the first two years. Surgical salvage is the major treatment modality, but is possible in only 20% of patients leading to an overall 5-year survival between 20 - 30% [1]. Re-irradiation using external beam radiation therapy (EBRT) can lead to severe local toxicities. High-dose-rate brachytherapy (HDR-BRT) can achieve a high dose directly to the target volume and provides the advantage of a rapid dose fall-off, thereby, allowing for sparing of normal tissues. HDR-BRT offers significant advantages over conventional LDR brachytherapy by reducing the concerns of radiation safety for the staff during hospitalization, and provides the clinician with a greater control over the dose distribution by using computer optimized dwell times within the individual catheters. With HDR-BRT, dosimetrically equivalent or superior outcomes compared to LDR brachytherapy for gynecological tumors and other locations have been achieved [2].
Techniques for HDR Brachytherapy in Reirradiation:
The implant procedure is performed under general anesthesia. A nasogastric tube is placed for feeding during treatment. A straight stainless-steel needle is introduced through the sub-mental skin with respect to the site, and traversed through the floor of mouth or implanting organ, exiting at the other end of operative bed. As needed, subsequent needles are passed next to the first one with respect to the number of lines and planes in order to keep the interval distance between14-16 mm for optimal target coverage. A plastic catheter is threaded through each needle followed by removal of the needle while leaving the catheter in place. The number of catheters varies according to the target dimensions. The plastic catheters are placed in the operative bed as near parallel as possible at 14 to 16 mm intervals, taking care of peripheral fall-off with a security margin of 10 mm in all directions about the target, using the modified technique. The catheters are held to the skin exit points with plastic buttons. This implantation technique was used for the various HNC sites [3]. After the implant procedure, all patients undergo a computed tomography (CT) scan with a slice thickness of 3 mm for three-dimensional (3D) treatment planning. The prescribed dose is in the range of 3.5-4.5 Gy per fraction, depending on the site and status of the disease. The implant tubes are removed after the planned BRT doses were delivered. Total dose (EBRT/BRT) is kept within tolerance levels and has been assessed by estimating biologically equivalent doses (BED). The dose with radical BRT is 40.5Gy and the dose with BRT boost is 27Gy.
Results in our series:
In our series of twenty-five patients treated for reirradiation in recurrent head and neck malignancies, the median survival calculated for patients who underwent reirradiation with HDR-BRT at 1 and 2-year overall survival was 77% and 68% respectively with a median follow-up of 25 months. The local control rates calculated at 1 and 2-year follow up were 84% and 75%, respectively. The median time to development of recurrence was 9 months and observed more frequently with larger tumor implants and more common in the EBRT + BRT arm compared to radical BRT (2 year LCR 62% vs 85%; p<0.02). Similarly, the disease specific survival was 74% and 67% respectively at 1 and 2-year follow up. Most of the toxicities noted were Grade I/ II and only 2% grade III toxicity noted in the form of taste alteration. No Grade IV toxicities were noted among the patients. Taste alteration (Grade I and II - 25% and 12%) and xerostomia (Grade I and II - 12% and 4%) were the common toxicities noted. The other significant toxicities noted were dysphagia (Grade I and II - 8% and 3%), persistent hoarseness (Grade I and II - 3% and 0%) and fibrosis (Grade I and II - 5% and 3%). The cumulative incidence of Grade I and II toxicities at 2-years were 12% and 8% respectively.

Recent Guidelines:
The latest report by GEC-ESTRO has reported on the role of HDR-BRT as a salvage option in reirradiation in the head and neck malignancies [4]. For patients ineligible for surgical salvage, brachytherapy is an acceptable option provided the CTV coverage is adequate, and there is no significant bone invasion, fistula or limited life expectancy. Brachytherapy in previously full course irradiated regions needs to follow the same principles as primary brachytherapy with strict dose and volume constraints.Additionally, interstitial brachytherapy can play an important role in the treatment of lymph node recurrences of head and neck cancer. Using image-guided interstitial HDR-BRT for re-irradiation of recurrent lymph node metastases of head and neck cancer, local control probabilities in the range of approximately 60-70% have been published.
Re-irradiation of recurrent head and neck cancer is a therapeutic challenge. HDR-BRT is a viable alternative to surgery and radical EBRT. Our results using HDR Interstitial Brachytherapy demonstrated excellent local control with acceptable toxicities in diverse treatment settings. This technique offers dosimetric, radiation safety, and patient comfort advantages.

  1. Gregoire V, Lefebvre JL, Licitra L, Felip E, ESMO Guidelines Working Group. Squamous cell carcinoma of the head neck: EHNS-ESMO-ESTRO clinical practice guideline for diagnosis, treatment and follow-up. Ann Oncol 2010;21:184-6.
  2. Donath D, Vuong T, Shenouda G, et al. The potential uses of highdose-rate brachytherapy in patients with head and neck cancer. Eur Arch Otorhinolaryngol 1995;252:321-324.
  3. Bhalavat RL, Laskar S, Saple MP et al. Technique for interstitial brachytherapy of carcinoma of the tongue. J Brachytherapy Int 1998; 14: 179-183.
  4. GEC-ESTRO ACROP recommendations for head & neck brachytherapy in squamous cell carcinomas: 1st update - Improvement by cross sectional imaging based treatment planning and stepping source technology GEC-ESTRO Head & Neck Working Group, Martinez-Monge R., Budrukkar A.
  5. , et al. (2017) Radiotherapy and Oncology, 122 (2), pp. 248-254


Brachytherapy Patient Safety Insights from the ASN Patient Safety - Paving the Way for Progress Series
  Timothy N. Showalter, MD, MPH
University of Virginia
The French Nuclear Safety Authority (ASN) publishes an educational bulletin on patient safety in radiation therapy, Patient Safety - Paving the Way for Progress, that may be helpful for practicing brachytherapists and is freely available online. 1 Issues of the bulletin have provided feedback about radiation events over the past few years that may be of particular interest to ABS members. 2,3 In this month's ABS Patient Safety Corner, I will review information from selected ASN reports, and interested readers are encouraged to visit the ASN webpage for additional details.
During 2013-2014, the ASN was informed of 23 radiation safety events in HDR and PDR brachytherapy (compared to 403 events in external beam radiation therapy during the same period). Patient identification errors were reported, with two different situations: selecting Patient B's treatment file while Patient A was in the treatment room and Patient B responding to the call for Patient A to walk to the treatment area. The reversal of two treatment channels during catheter connection for HDR brachytherapy was also reported. Migration of a treatment catheter position during HDR brachytherapy treatment planning and delivery was noted. 2
Most of the above errors represent factors that can be addressed with institutional time-outs, checklists and provider double-checks. They provide useful examples of potential errors that could happen, and it is worth confirming that one's institutional policies and checklist can identify these potential errors before they affect patient care. Patient identification and catheter connections can be double checked for confirmation by multiple staff members and including in institutional safety checklists. The potential of applicator and catheter movement during brachytherapy planning and treatment should be considered during the entire brachytherapy process, with external fixation and monitoring performed whenever possible.
The ASN provided detailed information about one particular event that involved a jammed source during HDR brachytherapy 3 that is worth being aware of as a potential occurrence. In this event, an HDR brachytherapy source did not retract into the afterloader. The alarms functioned appropriately and the source remained jammed despite activation of the emergency stop control. Within a total of 3 minutes, the team manually withdrew the applicator and source from the patient. It was determined that the source was jammed at the junction between applicator and the transfer tube.
The jammed HDR source event provides a real-world example of an even that highlights the importance of preparing to execute emergency procedures that include the emergency stop control, the afterloader source retraction handle, and manual withdrawal of the applicator. This story may provide brachytherapy teams with the inspiration needed to transform annual radiation safety training sessions from hypothetical discussions to a hands-on simulation modeled after a real event.

The ASN webpage is a potentially useful resource for additional education material on patient safety in brachytherapy.
2.  French Nuclear Safety Authority (ASN). Pulsed Dose-Rate and High Dose-Rate Brachytherapy. 2015.
3.  French Nuclear Safety Authority (ASN). Jammed source in high-dose-rate brachytherapy. 2014.


How Do We Measure the Costs of Brachytherapy? Introducing a New Workshop at the ABS 2018 Annual Meeting
 Nikhil Thaker, MD
Arizona Oncology Associates
How do we measure the costs of brachytherapy? How do we code and bill for brachytherapy procedures and how much are we reimbursed for these procedures? How much does brachytherapy actually cost to deliver? How will changes in reimbursement models, like bundled payments, affect brachytherapy?
These seemingly simple questions, unfortunately, have far from simple answers! The vast majority of training programs, from medical schools to residency/fellowship programs to academic/community centers, do not formally train physicians on the basics of running a medical practice and the necessary billing/coding, finance, cost accounting, and health policy knowledge needed to be successful in today's changing healthcare landscape.
If you've ever been interested in learning more about these topics, then we're looking forward to introducing to you a new Workshop at this year's ABS 2018 Annual Meeting. In this Workshop, we will cover several major business topics that are essential for brachytherapy physicians, physicists, and staff. In the first part of the workshop, we will provide an overview of coding and billing in brachytherapy, will define what a relative value unit (RVU) is and how many RVUs we get for common procedures, and we will also describe our current process of creating, valuating, and updating these codes. You'll have an opportunity to solidify this knowledge through hands-on examples where we will walk-through the processes of billing/coding for common brachytherapy procedures, like prostate and cervical brachytherapy.
In the second part of the workshop, we will introduce an innovative cost accounting tool called time-driven activity-based costing (TDABC). TDABC is a unique tool that can be used to measure the actual costs of delivering care [1] . Rather than using charges or RVUs to estimate the "cost" of delivering care, TDABC instead measures the cost of resources (like personnel, equipment, facilities) that are required to deliver care [2, 3]. The amount that we get paid to deliver care is not necessarily the amount that it costs us to actually deliver that care. For the majority of brachytherapists, delivering a brachytherapy procedure typically means needing to be out of the clinic, less time to see new or existing patients, and at times more physician effort than other types of treatments. So how much exactly does brachytherapy cost?  We will help answer this question through an introduction to the basics of TDABC and will provide a framework that you can use at your own institutions to conduct these analyses.
After this Workshop, you will feel more comfortable with these essential topics and will have a better understanding of the cost of brachytherapy. We'll also touch upon how shifting reimbursement paradigms, like bundled payments, may affect brachytherapy in the future [4, 5] . The Workshop will be at the 2018 ABS Annual Meeting on Friday June 8th from 4:15pm to 6:15pm, and we hope to see you there!
1. Thaker, N.G., et al., Defining the Value Framework for Prostate Brachytherapy Using Patient-Centered Outcome Metrics and Time-Driven Activity-Based Costing. Brachytherapy. 14: p. S13.
2. Kaplan, R.S. and S.R. Anderson, Time-driven activity-based costing. Harv Bus Rev, 2004. 82(11): p. 131-8, 150.
3. Kaplan, R.S., et al., Using time-driven activity-based costing to identify value improvement opportunities in healthcare. J Healthc Manag, 2014. 59(6): p. 399-412.
4. Thaker, N.G., P.F. Orio, and L. Potters, Defining the value of magnetic resonance imaging in prostate brachytherapy using time-driven activity-based costing. Brachytherapy. 16(4): p. 665-671.
5.  Porter, M.E. and R.S. Kaplan, How Should We Pay for Health Care? Working Paper. 2015.


O n behalf of the American Brachytherapy Society, we look forward to welcoming you to the Annual meeting of the ABS in San Francisco on June 7-9th. The theme of our meeting this year is "Celebrate Brachytherapy: Educative, Motivate, Innovate". Each of the sessions at the meeting will highlight new developments in brachytherapy, including imaging, insertion techniques, treatment planning, workflow, reimbursement and a focus on transitioning these new technologies into practice.
Highlights Include:  
  • 9 Live Self-Assessment Module Sessions, included in your registration fee!
  • Keynote Address by Tom Kelley, Best-Selling Author and Global Leader in Innovation in Technology and Healthcare
  • Advanced Imaging in Prostate Cancer
  • Debate on Role of SBRT vs. Brachytherapy in Prostate CA
  • Frontiers in Gynecologic Brachytherapy
  • Managing Sexual Side Effects of Brachytherapy
  • Brachytherapy Suite Workflow Optimization
  • Perspectives on Changes in Brachytherapy Reimbursement
  • Overview of Recent Medical Events and Updates on Proposed Regulations
  • Contouring and Planning Sessions in GYN, GU and Skin Brachytherapy
  • ePoster Sessions with Dedicated Time for Discussion with Meeting Attendees
  • Exhibit Hall Presentation of Brachytherapy Devices from 25 vendors
Come early and register for the Pre-Physics Workshop: Modern & Sophisticated vs Simple & Efficient:Why Not Have Both? This full day workshop will cover the cutting edge topics that relates todays work flow while keeping tomorrow's technology in mind. Specific anatomical sites (GYN and Prostate) will be discussed in detail by a panel of experts. Hear the latest use of IGRT in brachytherapy, the best use of optimization engines, updates on TG 303, and much more. Most exciting, there will be an interactive panel round table with clinical experts, audience and industry experts, where the future of our field will be discussed.
We hope to see you in San Francisco in June!
Catheryn Yashar, MD
President, ABS
Ann Klopp, MD
2018 Scientific Program Chair
Brett Cox, MD
2018 Scientific Program Vice Chair



ABS Meets with CMS Regarding Comprehensive APC 
Payment Methodology
The ABS in conjunction with ACR, ASTRO and AAPM met with CMS officials on February 26th to discuss concerns regarding the Comprehensive Ambulatory Payment Classification (C-APC) payment methodology and its impact to brachytherapy and stereotactic radiation therapy reimbursement under the Medicare Hospital Outpatient Prospective Payment System (HOPPS).  President-elect Peter Orio III, DO, MS represented the ABS.
CMS defines a C-APC as a classification for the provision of a primary service and all adjunctive services and supplies provided to support the delivery of the primary service. CMS continues the C-APC payment policy methodology of including all covered outpatient department services on a hospital outpatient claim reporting a primary service that is assigned to status indicator "J1 or "J2." Under this policy, CMS calculates a single payment for the entire hospital stay, defined by a single claim, regardless of the date of service span.
Meeting participants explained that radiation oncology requires component or serial coding to account for the multiple steps that comprise the process of care (consultation; preparing for treatment; medical radiation physics, dosimetry, treatment devices and special services; radiation treatment delivery; radiation treatment management; and follow-up care management).  Adding that cancer treatment is complex, as patients are often treated concurrently with different modalities of radiation therapy for different disease sites and often at different sites of service. Participants explained that the existing C-APC methodology does not account for these complexities and fails to capture appropriately coded claims, resulting in distorted data leading to inaccurate payment rates that jeopardize access to certain radiation therapy services.  
Dr. Peter Orio explained that brachytherapy catheter/applicator insertion and treatment delivery take place on the same date of service or different dates of service, with delivery spanning a range of dates, single or multiple insertions, single or multiple HDR treatments per insertion, and different levels of complexities in planning and delivery. He advised CMS that these complexities make traditional clinical APCs the most accurate and appropriate way to pay separately for these services under HOPPS. 

The Medicare HOPPS proposed rule will be published in late June/early July. We hope that meeting discussions and follow-up data provided to CMS will prompt changes to the C-APC payment methodology for these services in 2019. 


Help us spread the word.   We are now on Twitter!
Chirag Shah, MD
Cleveland Clinic
The Social Media Committee represents a new American Brachytherapy Society committee and began its work in earnest during 2017. The committee is chaired by myself (@CShahMD), and members include Jacob Scott, MD, PhD (Cleveland Clinic, @CancerConnector), Matthew Ward, MD (Southeast Radiation Oncology Group, @MCWardMD), Miriam Knoll, MD (Mountainside Medical Center, @MKnoll_MD), and Brett Cox, MD (Northwell Health, @brettcoxmd).

Some of the important questions facing this committee have emerged and I will attempt to address each.

"What is the role of social media in the American Brachytherapy Society?"

The role of social media for the social is multi-faceted with the major roles being 1) to inform the radiation oncology community about American Brachytherapy Society events, meetings, educational sessions, 2) to educate physicians, physicists, residents/students, patients, and advocates about brachytherapy and emerging data/techniques, 3) to promote society initiatives/commitees and highlight society policy statements, and 4) to highlight publications from Brachytherapy, the journal of the society. The American Brachytherapy Society Twitter handle (@AmericanBrachy) will be used for much of this and will grow in its output.

"How can social media be used to reach groups including physicians, physicists, residents/students, patients, and advocates?"

In light of the differences in the populations who we are looking to reach, different strategies will be used in conjunction with different social media techniques. For physicians and physicists, techniques will include dissemination of information from ABS meetings and the Annual Meeting in particular through the use of Twitter, live videos, and physician oriented chats and Q&A sessions. For residents/ students, social media will be used to engage residents in brachytherapy and also to help facilitate education, with an emphasis on brachytherapy technique. Finally, with respect to engaging patients and advocates, the committee will look to reach out to patient groups in order facilitate coordinated events including patient-physician chats, lay summaries of key brachytherapy techniques, and posts that highlight new data summarized for patients.

"Is there value to the American Brachytherapy Society engaging in social media?"

Engaging in social media is a commitment by the society and its leaders. While we are in the beginning stages of the committee, we believe the value in these initiatives is present and we will look to provide objective metrics to the value of social media in the months and years to come.

The American Brachytherapy Society Annual Meeting will be in held in San Francisco, California in June, 2018. A session dedicated to social media is planned with key thought and social media leaders including invited speaker Drew Moghanaki, MD. Additionally, the session will include time dedicated to showing individuals how to set up social media accounts, how to use Twitter, and time for questions. For those 
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Membership Committee Participation

The ABS Membership Committee is looking for volunteers for regional membership recruitment efforts - if you are interested please contact committee chair  Jarek Hepel .