Don't Miss the September BrachyBlast~!

A Message From the President

ABS members should be pleased with the ongoing progress of our society at multiple levels. Thank you to Dr. Orio for an excellent summary over the last few months. To echo Dr. Orio, many of our members continue to go “above and beyond the call of duty in the name of brachytherapy”. At 3 months into my presidency, I feel blessed to have so many of you working on key issues that will have an impact for years to come.

The CMS proposal for new Radiation Oncology (RO Model) was released in July of 2019 and has caused angst for the US brachytherapy world. Dr. Orio and Dr. Thaker have collectively put in over 100 hours of their time to write the 32 page comment letter to CMS. We all owe both of them our sincere gratitude for their time and efforts. Dr. Thaker also provides other key updates and what to expect next. Please thank them when you have the opportunity.

As busy providers (physicians, physicists, nurses and others) safety is an ongoing top priority. The section by Dr. Ouhib and team discuss another preventable medical event that led to termination of a pregnancy. While all of us dread preventable medical events and making them public, this is key information that improves patient care. Thank you to Dr. Ouhib for your ongoing ABS Medical Event Project.

I spent a significant amount of time moving the 300 in 10 initiative forward during the ASTRO annual meeting. This included meeting with our 300 in 10 team, ASTRO leaders, the Radiation Oncology Institute (ROI), industry and whoever else would listen to me! While the program continues to evolve, some of the high-level talking points include significant enthusiasm and support from ASTRO, industry sponsorship once tangible benefits are finalized, funding opportunities, and additional 2-3 month fellowship options for residents in training.

Finally, registration is now open for the Big Sky Brachytherapy Summit February 14-16. Dr. Kristin Bradley (Scientific Chair,) Dr. Peter Rossi (co-chair) and Dr. Mitchell Kamrava (co-chair) have put together an outstanding meeting with superb speakers. Maintaining a vibrant brachytherapy practice and helping teams to start and/or re-invigorate their practice are key meeting objectives. Participants will receive 14 CMEs and 6-8 SA-CMEs. Dr. David Crawford, former department chair of urology at the University of Colorado, will be our keynote speaker. Dr. Crawford is a renowned urologist who will speak on “Disruptive Innovation in Prostate Cancer Treatment” and will participate in our panels. Other clinically relevant topics include gynecologic and breast brachytherapy, socioeconomics and physics. Participants will fly into Bozeman, Montana, with a 45 minute commute to Big Sky – transportation options will be available. The resort is at the base of Big Sky with immediate access to the slopes once the am sessions conclude at 11:30 AM. Big Sky is the largest ski resort in the US with levels of skiing for everyone. You and your family will enjoy of one of America’s iconic ski resorts with adjacent restaurants and shopping. As the number of registrants is limited, we encourage you to sign up as soon as you can. I predict this meeting will be discussed and remembered for years to come!

Thank you,

Daniel G. Petereit, MD, FASTRO

President

@AmericanBrachy

Chairman's Corner

Peter F. Orio, III, DO, MS

Welcome to the Chairman’s Corner of the American Brachytherapy Society’s BrachyBlast .

Many members of the organization have been going above and beyond the call of duty in the name of brachytherapy over the past few months as we manage the many facets of the changing healthcare system, and this month I would like to highlight a few big initiatives members have been working on.

As you know, CMS released a proposal for the new Radiation Oncology (RO Model) in July 2019. Following many collaborative discussions with our sister societies and months of diligent work by members of the ABS Socioeconomic Committee, on September 16th ABS submitted a comment letter to CMS, totaling an astounding 31-pages, providing them with our independent analysis and responses to their proposed alternative payment model. In the Socioeconomics Corner of the BrachyBlast this month Dr. Nikhil Thaker details for us the proposed rule as well as the society’s submitted response, which I encourage you to review. I am very proud to call myself a Brachytherapist, and to have been a part of the team that has worked tirelessly for months to dissect every detail of CMS’ proposal and provide them a thoughtful response, which we hope, will mean a bright future for brachytherapy as a treatment option for our patients. Stay tuned, we will continue to update you as information becomes available, and at this time we anticipate the Final Rule to be released sometime in November 2019.

Many members of the ABS Board of Directors participated in a fruitful discussion with the ASTRO Board of Directors at the 2019 ASTRO Annual Meeting in Chicago. Our meeting focused mainly on support for future brachytherapy training programs, because if done right and CMS is willing to listen, we have an opportunity to level the playing field for brachytherapy with the proposed RO Model and we will see an uptick in the utilization of brachytherapy soon. The group also discussed a more collaborative consensus statement process as well as the CMS proposed alternative payment model. ASTRO and ABS remain committed to working together towards a future where brachytherapy is an equally offered modality for eligible patients to consider for the treatment of their cancer and we look forward to working with them in the future.

As many of you know, we have been working tirelessly over the past 18 months to increase awareness of brachytherapy as a treatment option for many cancers, and we are simultaneously working hard to provide practitioners the opportunity to strengthen their brachytherapy skillsets. As part of this initiative, the 2019 HDR/LDR Prostate Scholarship Workshop will be held November 1-2 in Denver, Colorado. The planning committee has been working to design a school which will allow for 30 teams of practicing Radiation Oncologists/Physicists/Dosimetrists/Urologists to learn in a hands-on setting from international experts in HDR and LDR prostate brachytherapy in a small group. We hope you are registered, and we see you there!

Thank you,

Peter F. Orio III, DO, MS

Chairman of the Board

@AmericanBrachy

@peter_orio

ABS Medical Event Project

Medical Event case 0006- Feedback and Corrective Actions

Panagiota Galanakou, Graduate Student, Florida Atlantic University

Sarah Wisnoskie, PSMMP

Zoubir Ouhib MS FACR FABS FAAPM

As promised in case 0006 posted in the June Brachyblast, we are eager to present the feedback (corrective and preventive measures) that we have collected from several colleagues (medical physicists and radiation oncologists). As a reminder to readers, case 0006 related to a patient receiving iodine (I-131) for ablation of residual thyroid tissue. Hours after the delivery of the treatment, a positive pregnancy test result was received by the delivering licensee. The patient terminated the pregnancy.

IMMEDIATE (SHORT TERM) ACTIONS

CORRECTIVE

Prior to delivery of a radioisotope, the female patient should be informed at time of consultation about the radiation effects (with details) on the fetus should they become pregnant shortly before or after the treatment. This might include recommendation of a pregnancy test which should be performed as close as possible to the treatment date.

In addition, other practical solutions (when possible) should also be discussed by the AU.

Perhaps liability should also be discussed in case of any undesirable outcome to the newborn directly associated with the treatment itself.

The consent form signed by the patient should inform them of the possible effects of radiation to a fetus.

PREVENTIVE

The licensee should be made aware of all lab orders the referring physician made prior to treatment that are relevant to the recent pregnancy test (and results) and should be part of the checklist and the timeout procedure.

Every effort should be done to ensure that all patients (use of an interpreter when needed) fully understand this safety issue and its consequences.

Treatment should not be performed when feedback and results remain questionable.

While it might difficult to envision all scenarios, every effort should be made to provide the patients with all viable options to minimize such a risk.

Female patients less than 55 years old who have a uterus should have typical risk counseling and have a serum pregnancy test either the day before or in morning of the thyroid ablation. Urine test could also be considered because of its rapid results but caution should be used for false negative cases. Women with 55< age(years) <65 with a uterus should be counseled about risks and offered the pregnancy test. They are usually forthcoming about menopausal status as well as sexual practices/status. Any practices which yield anything beyond a zero risk of pregnancy (e.g. abstinence) yields a pathway towards the pregnancy test as stated above. Stated menopausal status by patients might be risky as well so the AU might defer to the pregnancy test.

All patients who are of potential childbearing age, which should be defined, should have serum pregnancy testing performed before administration of radio iodine. In this era of assisted reproduction technology, this needs to be strictly adhered to at ages where pregnancy is not usually expected. Preparation of these patients with thyroid carcinoma generally consists of administration of thyrogen, and generally administered a therapeutic dose of 50-150 mCi of I-131. Institutions should have a policy applicable to different ages and menopausal status.

LONG TERM ACTIONS

Institutional policy regarding premenopausal and postmenopausal women should be well established and updated on a regular basis.

_____________________________________________________________________________

Institution policy regarding mandatory pregnancy tests for women with a uterus of childbearing age prior to treatment with a radio-isotope should be in place and executed in the form of a checklist items and the timeout procedure

We would like to thank Tamara Weiss MD and John Schallenkamp MD, Rashmi K Benda MD for their valuable feedback.

We encourage our readers to continue to submit their ideas to [email protected] as there may have been preventive and corrective actions we did not identify. Be sure to check out next month's BrachyBlast where we will present Case 0007.

New item to all users: if you think you have an interesting near miss or an actual medical event that you would like to share with us please send it to [email protected] . We will be happy to evaluate it and provide you and the rest of the brachytherapy community with some feedback (short term preventive/corrective and long term actions). We ask you not to send the name of the institution and the individuals involved in the case. Please provide us with information related to the” when, how, where”, etc. Your contact information (which will remain confidential) is needed for follow up questions and clarification only.

Socioeconomics Corner

Nikhil Thaker, MD

Dear Colleagues,

It has already been a very busy year for the Socioeconomic Committee (SEC)! As many of you know, CMS released a proposal for a new Radiation Oncology (RO Model) in July 2019, and the majority of brachytherapy procedures are included in the proposal. Dr. Peter Orio and I provided introductory remarks on this Model in last month’s BrachyBlast Chairman’s Corner.

Each month, I will highlight some of the major socioeconomics issues impacting brachytherapy. These topics will include:

1) Updates on the RO Model and impact on brachy

2) Updates on the 2020 MPFS Rule

3) Updates on the 2020 HOPPS/ASC Rule

4) Updates to CPT/HCPCS codes for brachy

5) Highlights of pertinent socioeconomic studies on brachy

In this month’s Socioeconomics Corner, I’ll provide a brief update regarding CMS’ RO Model proposal. On 9/16/19, the ABS submitted a 32-page comment letter to CMS detailing ABS’ analysis and recommendations ( link to the letter ). Impressively, 329 letters have been submitted to CMS regarding the RO Model, and several of them address key issues regarding brachytherapy.

Within our comment letter, the ABS is pushing for fair and appropriate payment for all brachytherapy services, including brachytherapy as a monotherapy or as a combination modality with EBRT. According to the current proposal, there are several clinical scenarios where brachytherapy, when delivered before, during, or after EBRT, may not be adequately reimbursed. The ABS is recommending two possible solutions:

1. Allow brachytherapy to trigger a second RO Model bundle (with a separate PC and TC payment) when delivered before, during, or after EBRT for cervical cancer within a single 90-day episode

2. Allow brachytherapy to be reimbursed as FFS when delivered before, during, or after EBRT within a single 90-day episode

The ABS is also recommending the creation of a modifier to acknowledge episodes of brachytherapy boosts, so that those episodes are more fairly reimbursed by CMS (as per one of the mechanisms above) and the episode does not count as a “duplicate RT service” that would require reconciliation of payments in the future. The ABS also strongly recommends removal of brachytherapy radioactive sources from inclusion in the Model, which is the current policy in the fee-for-service environment. We have also emphasized the need to create specific clinical business rules to ensure that CMS is not using palliative/partial episodes to calculate the National Base Rates for definitively treated disease sites.

Furthermore, ABS’ comment letter also goes into detail on many other aspects of the Model that will impact all of radiation oncology, including issues surrounding data integrity of CMS’ database, capturing quality measure data, payment of brachytherapy surgical codes, payment for new service lines and technological innovations, use of MPFS and HOPPS blends for calculating PC payments, de-emphasis of the combined adjustments and case mix adjustments on payments, an emphasis on protecting Efficient practices (such as many/most of brachytherapy practices), inclusion of the TC when calculating the advanced APM incentive payments, voluntary transition/opt-in prior to a mandatory start, among many other recommendations.

The ABS SEC will continue to collaborate with professional societies, industry, and CMS representatives to push for an RO Model that incentivizes high-value radiation therapy (like brachytherapy) and ensures access to life saving radiation therapy modalities. Please feel free to read the ABS Comment Letter here and the RO Model proposal here .

What can we expect next?

At this time, we anticipate the Final Rule to be released sometime in November 2019 (although this may be subject to change). CMS’ proposal is asking for a start date of 1/1/2020 or even 4/1/2020, but this would leave insufficient time for practices to re-tool billing/coding systems and operational workflows, and to build specific clinical infrastructure required for quality metrics and reporting requirements, among other mandatory aspects of the Model. The ABS has requested a delay until at least Apr 1, 2020 and more optimally until Jul 1, 2020, with a time period (1-2 years) to initially allow voluntary opt-in prior to a mandatory start.

Stay tuned over the next few months for more Socioeconomic Updates, and there is a lot more to come on this Model!

Nikhil G. Thaker, MD

Chair of the Socioeconomics Committee

American Brachytherapy Society

Twitter: @NGThaker_XRT

@AmericanBrachy

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NURSES WANTED

ABS Members-

We are pleased to announce that brachytherapy nursing/patient care content and resources are being created and will be available to ABS members soon on the ABS Website and at future ABS meetings. This information is intended for MDs looking for materials for their teams, brachytherapy nurses and others involved in direct patient care to become more knowledgeable and confident in their abilities to care for brachytherapy patients. Stay tuned for more information on this exciting new development!

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