Exciting Things are Happening in 2020 for ABS!

A Message From the President

NextGen Brachy

For the ABS Blast this month, I asked Dr. Lisa Singer to discuss our new ABS mentorship program, NextGen Brachy, as part of 300 in 10. Dr. Lisa Singer attended our December BOD meeting and has been developing and leading this initiative with others. The plan is to pair experienced brachytherapists and physicists with interested ABS members over one year to increase their confidence level in developing or maintaining their brachytherapy practice. This is a great opportunity for both mentors and mentees. The NextGen Brachy program has the potential to preserve and “pay it forward” the extensive brachytherapy knowledge and experience of hundreds of our ABS members and to mentor the next generation of brachytherapists. More details with be forthcoming in the next few months. Thank you to Dr. Singer for for taking the lead on this important and practical initiative.

ABS will announce two month “hands on electives” for senior radiation oncology residents at 6 to 8 institutions in the next month or so. Current PGY 3 and PGY 4 residents who are interested in brachytherapy careers are strongly encouraged to apply. To date, Dr. Brian Moran at the Chicago Prostate Center has trained 2 senior level residents - Dr. Awad Ahmed and Dr. Mark Hwang. Dr. Ahmed has already started his prostate brachytherapy practice, and Dr. Hwang plans on doing so when he completes his residency in June.

I am happy to report we submitted our grant to the ROI (Radiation Oncology Institute) last week: Increasing Access to Quality Brachytherapy For Cervical Cancer. Successful funding of this grant will accelerate 300 in 10. Our 300 in 10 team will be developing a similar budget for the parallel prostate program.

While we have reached our “registration quota” for the Big Sky Brachytherapy Summit February 14-16, there is still availability. For any radiation oncologists within driving distance of Big Sky, please consider attending. For everyone else, please check the flight schedule. Thank you to Drs. Kristin Bradley, Peter Rossi and Mitch Kamrava for developing a phenomenal program. Also, ABS is deeply grateful to our industry partners for supporting this meeting. There will be plenty of time for everyone to attend the lectures, ski and network. For our industry partners, we will be seeking your input in developing the new ABS industry advisory board.

See you at the top!

Cheers!

Daniel G. Petereit, MD, FASTRO

President

@AmericanBrachy

Forging a Path Forward with Mentorship

Lisa Singer, MD, PhD

Although brachytherapy is integral to the curative therapy of a variety of cancers, including prostate and cervical cancer ^1,2 , recent data has shown a decline in appropriate brachytherapy utilization in the United States ^3-6 . The decline is likely multi-factorial ⁷ , but radiation oncology education provides the foundation for brachytherapy expertise. In a survey of radiation oncology residents, inadequate case volume was cited by over half of respondents as a chief barrier to independent practice ⁸ . Examination of resident case logs has highlighted a decrease in interstitial cases, with only 4.5 average gynecological interstitial cases per resident per year ⁹ . And while fellowships can supplement case load, the survey highlighted that only 2% of respondents were likely or highly likely to pursue fellowships if brachytherapy independence had not been otherwise achieved ⁸ . Through the 300 in 10 initiative, the American Brachytherapy Society is committed to training the next generation of brachytherapists through a variety mechanisms, including not only fellowships, but also hands-on workshops ^10-13 , online curricula, and rotations.

Mentorship is a cornerstone of the 300 in 10 initiative, leading to the development of a new ABS mentorship program: NextGen Brachy. Through NextGen Brachy, early career radiation oncologists will be paired with experienced brachytherapists and physicists in a mentorship program for ABS members, designed to take place over at least one year. The program provides a forum for mentees to discuss challenging cases and hurdles in practice and career development with experienced mentors. To promote sustainability of the program, former mentees are encouraged to ultimately serve as mentors, and both mentors and mentees are encouraged to serve on annual meeting panels highlighting difficult cases and experiences in practice building. The program emphasizes confidentiality of mentee challenges. In addition, since physicians may transition into brachytherapy later in their careers, mentees are eligible for participation regardless of age or career stage. Our field has benefited from mentorship (Figures 1-3) and NextGen Brachy aims to expand and formalize these efforts for ABS members. The pilot for NextGen Brachy will begin later this year, with the potential to increase the program based on interest.

Even with outstanding clinical training, for new brachytherapists, challenges to practice exist, and NextGen Brach provides an opportunity to brainstorm solutions and discuss cases with experienced brachytherapists. Increased brachytherapy utilization will undoubtably require more than mentorship, but mentorship will help light the way for the next generation of brachytherapists in forging a path forward.

1. Gill BS, Lin JF, Krivak TC, et al. National Cancer Data Base Analysis of Radiation Therapy Consolidation Modality for Cervical Cancer: The Impact of New Technological Advancements. International Journal of Radiation Oncology*Biology*Physics . 2014;90(5):1083-1090. doi:10.1016/j.ijrobp.2014.07.017.

2. Morris WJ, Tyldesley S, Rodda S, et al. Androgen Suppression Combined with Elective Nodal and Dose Escalated Radiation Therapy (the ASCENDE-RT Trial): An Analysis of Survival Endpoints for a Randomized Trial Comparing a Low-Dose-Rate Brachytherapy Boost to a Dose-Escalated External Beam Boost for High- and Intermediate-risk Prostate Cancer. Int J Radiat Oncol Biol Phys . 2017;98(2):275-285. doi:10.1016/j.ijrobp.2016.11.026.

3. Han K, Milosevic M, Fyles A, Pintilie M, Viswanathan AN. Trends in the Utilization of Brachytherapy in Cervical Cancer in the United States. International Journal of Radiation Oncology*Biology*Physics . 2013;87(1):111-119. doi:10.1016/j.ijrobp.2013.05.033.

4. Glaser SM, Dohopolski MJ, Balasubramani GK, Benoit RM, Smith RP, Beriwal S. Brachytherapy boost for prostate cancer: Trends in care and survival outcomes. Brachytherapy . 2017;16(2):330-341. doi:10.1016/j.brachy.2016.12.015.

5. Petereit DG, Frank SJ, Viswanathan AN, et al. Brachytherapy: Where Has It Gone? Journal of Clinical Oncology . 2015;33(9):980–. doi:10.1200/JCO.2014.59.8128.

6. Eisenstein M. The declining art of brachytherapy. Nature . 2019;574(7780):S81-S81. doi:10.1038/d41586-019-03275-z.

7. Vu CC, Jawad MS, Krauss DJ. The Cost-Effectiveness and Value Proposition of Brachytherapy. Seminars in Radiation Oncology . 2020;30(1):87-93. doi:10.1016/j.semradonc.2019.08.007.

8. Marcrom SR, Kahn JM, Colbert LE, et al. Brachytherapy Training Survey of Radiation Oncology Residents. Int J Radiat Oncol Biol Phys . 2019;103(3):557-560. doi:10.1016/j.ijrobp.2018.10.023.

9. Shinde A, Li R, Amini A, et al. Resident experience in brachytherapy: An analysis of Accreditation Council for Graduate Medical Education case logs for intracavitary and interstitial brachytherapy from 2007 to 2018. Brachytherapy . December 2019:1-7. doi:10.1016/j.brachy.2019.10.006.

10. Rooney MK, Gunther JR, Gillespie EF, Golden DW. In Regard to Marcrom et al. Int J Radiat Oncol Biol Phys . 2019;104(1):220-221. doi:10.1016/j.ijrobp.2018.12.048.

11. Zhao S, Francis L, Todor D, Fields EC. Proficiency-based cervical cancer brachytherapy training. Brachytherapy . 2018;17(4):653-659. doi:10.1016/j.brachy.2018.03.001.

12. Singer L, Braunstein S, Klopp A, Joyner M. Development and Implementation of a Simulation-Based Educational Workshop on Gynecological Brachytherapy: Pilot Study at a National Meeting. Pract Radiat Oncol . 2019;9(5):e465-e472. doi:10.1016/j.prro.2019.05.006.

13. Singer L, Damast S, Lin L, et al. Development of a Multi-Institutional Simulation-Based Gynecologic Brachytherapy Curriculum. Int J Radiat Oncol Biol Phys . 2019;104(5):1175-1176. doi:10.1016/j.ijrobp.2019.05.023.

Figure 1. Larissa Lee with former residents and fellows Gabriela Alban, Daniele Buscariollo , and Divya Yerramilli at ASTRO.

Figure 2. Steve Frank with trainees at a hands-on prostate brachytherapy workshop.

Figure 3. Melissa Joyner and Lisa Singer preparing for a gynecological brachytherapy hands-on workshop at ABS Annual Meeting in Miami, Florida.

Figure 1

Figure 2

Figure 3

Chairman's Corner

Peter F. Orio, III, DO, MS

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

I wish you all a very Happy New Year!

The Big Sky Brachytherapy Summit is fast approaching, taking place over Presidents Day Weekend, February 14-16, 2020. Our Scientific Planning Committee, led by Dr. Kristin Bradley, Dr. Peter Rossi and Dr. Mitchell Kamrava, have developed a thoughtful agenda focused on helping participants to start and/or re-invigorate their brachytherapy practice. I hope you all enjoy this informative meeting set in a beautiful destination. I, unfortunately, will not be seeing you on the slopes as I am finishing up my recovering from Bi-Lateral Hip Replacement, but I am looking forward to catching up at the World Congress of Brachytherapy in Vienna!

To kick off 2020, following the Annual Board Meeting and Strategic Planning Summit in December, we are working to coordinate a series of brachytherapy educational pieces for use on social media. If you are interested in participating in these important endeavors to directly engage with physicians and patients, please email Melissa or see her in Big Sky!

I look forward to all that we have planned together in 2020.

Thank you,

Peter F. Orio III, DO, MS

Chairman of the Board

@ AmericanBrachy

@ peter_orio

Socioeconomics Corner

Nikhil G. Thaker, MD

Dear Colleagues,

In the first 2020 edition of BrachyBlast, we will cover a few socioeconomic topics that have impact to a broad range of brachytherapy practitioners.

RO Model Update

In October 2019, CMS released a regulatory notice regarding the Radiation Oncology Model (RO Model) that stated that the final rule had been given a designation of long-term action and that the final rule would need to be published with the standard 3-year time limit. The latest that we would hear the final rule would be July 2022. CMS is required to publish the final rule within this 3-year timeline based on the previous publication of proposed regulations. Many radiation oncologists and even some media outlets perceived this to mean that the RO Model would be delayed until 2022. However, it is not likely that the final RO Model rule will be delayed that far , and there is still indication that a final rule will be released sometime in 2020, and potentially even during the first quarter/half of 2020. There could be a short turnaround for practices that are selected for the RO Model to operationalize the Model, but we will not know for sure until the final rule is released, so stay tuned for more information.

If you would like more information on the RO Model’s Proposed Payment Methodology, and what it could mean for your practice, here’s an article I recently wrote for JCO Oncology Practice. However, we anticipate several major changes to the final RO Model and will provide updates as soon as they become available.

CMS’ Appropriate Use Criteria (AUC) for Advanced Imaging Services:

Starting on January 1, 2021, CMS will be fully implementing the Appropriate Use Criteria Program for advanced diagnostic imaging services provided to Medicare beneficiaries. Examples of advanced imaging include: computed tomography (CT), positron emission tomography (PET), nuclear medicine, and magnetic resonance imaging (MRI). This year (2020) will be an educational and operations testing period for this program with no payment consequences, but it’s important for you to start working with your operations and administrative teams.

If you order an advanced diagnostic imaging service for a Medicare beneficiary (who uses his/her Medicare benefits for insurance coverage for the imaging scan), you will be required to consult a qualified Clinical Decision Support Mechanism (CDSM), which are electronic portals through which appropriate use criteria (AUC) is accessed. There will be a code that you will need to append to the order to acknowledge consultation with the CDSM and documentation that will need to be generated. For questions regarding the program, you can directly contact CMS Imaging at [email protected] . Several professional societies and healthcare organizations are evaluating the impact of this new program on provider burden – feel free to let us know about your early experience with this program.

If you have a brachytherapy related reimbursement issues that arises, please don’t hesitate to let us know. With increasing use of prior authorizations, we are seeing more commercial insurances adding brachytherapy procedures to their list of prior authorization codes, and through ABS’ combined efforts with ASTRO, we are continuing to address these issues.

Stay tuned over the next few months for more Socioeconomic Updates!

Nikhil G. Thaker, MD

Chair of the Socioeconomics Committee

American Brachytherapy Society

Twitter: @NGThaker_XRT

@AmericanBrachy

Patient Safety Corner

Insights From a Recently Reported Event: Dose-per-fraction

Timothy N. Showalter, MD, MPH, Bruce Libby, PhD

University of Virginia School of Medicine, Charlottesville, VA

On a regular basis, our institutional Radiation Safety Officer circulates event reports from the NRC that may be of interest to authorized users. Earlier this week, our team received a message for event number 54483, which involved a patient receiving great dose than prescribed during high dose-rate (HDR) brachytherapy.

The event report on the NRC website states that a patient received a radiation dose in 1 fraction of HDR brachytherapy that was intended to be administered over 2-3 fractions. Additional details are limited, but this even serves as a useful example to consider what best practices and safeguards can be put in place to present similar events from occurring in the future.

Our brachytherapy team discussed this event to review practices at our own institution that may minimize such an event from occurring in the future. The following is a list of best practices and policies that we follow that may help to catch such an even in the future before it affects a patient:

1. Verification of dose per fraction: The written directive should include the dose-per-fraction and planned number of fractions. At our institution, the medical physicist and physician sign the form just below where this information is listed. During plan checks, the physicist ensures that the same radiation dose is listed in the computer treatment plan, the isodose line shown on the plan, the written directive, and the signed prescription in the record and verify system. This check for consistent dose may help identify a broad range of errors.

2. Prescription written prior to treatment delivery: Our institutional policy requires a written and signed brachytherapy prescription in the radiation oncology record and verify software system (in our case, MOSAIQ®). This provides an added check for dose and fractionation.

3. Checklist: Our pre-treatment checklist, which must be initialed by the authorized user, includes verification of radiation dose for that fraction of HDR brachytherapy, in addition to other items such as patient identification, treatment site, and confirmation of applicator position.

4. Time or Curie-seconds rules of thumb: Attention to expectations for treatment time and Curie-seconds, based on a general range typical of a standard applicator or dose, can provide a reference point that may help identify potential errors. For example, at our institution, a typical vaginal cylinder brachytherapy procedure would involve 6-10 minutes of treatment delivery time. When the planned treatment time differs significantly, the authorized user and physicist can investigate to either explain the difference (e.g., unusual applicator diameter or treatment dose) or to identify an irregularity or error.

Earlier this week, a potential error was prevented at our institution for a vaginal cylinder brachytherapy procedure when Dr. Libby noticed an unusually low number of Curie-seconds listed for the plan. The plan was rechecked and revised prior to treatment. We suggest you consider having a similar discussion with the brachytherapy team at your own institution to evaluate the safeguards in place to prevent delivery of the wrong dose during brachytherapy.

RATES GO UP AFTER TODAY!

Join us in Big Sky, MT, February 14 - 16 as we come together for BrachySummit 2020. Our Scientific Chair, Dr. Kristin Bradley and Scientific Co-Chairs, Drs. Peter Rossi & Mitchell Kamrava have organized an outstanding meeting with superb speakers. Maintaining a vibrant brachytherapy practice and helping teams to start and/or re-invigorate their brachytherapy practice are key meeting objectives.

Highlights include:

· A prostate “journal club” session on practice-changing clinical trial publications that will identify and discuss the important trial in GU cancers that have come out in the last year. In addition, this session will review upcoming GU studies in development.

· A debate between Dr. Brian Davis and Dr. Mitchell Kamrava on whether LDR or HDR brachytherapy is better for prostate cancer.

· A gynecologic session focusing on how to minimize and manage brachytherapy complications with a discussion of the current data and dose recommendations for image-guided cervical brachytherapy.

For brachytherapy practitioners, this is the conference to attend. Register today and join experts from around the country to review the latest medical evidence, emerging techniques, and future directions of brachytherapy.

Looking for the 2020 Class of ABS Fellows

Spread the word: American Brachytherapy is looking for their 2020 Class of ABS Fellows. Join an elite group of physicians and medical physicists known for their far-reaching contributions to brachytherapy!

Deadline is today, January 31, 2020!

Click here for more information

COMMITTEE CORNER

Want to get more involved with the ABS? Here's your chance! Our goal to reshape the vision and future of the ABS to best serve the industry continues to guide how we approach every aspect of the organization. We've revamped our volunteer opportunities to better meet your needs. If you're interested in being part of one our committees, please feel free to fill out an interest form and return to Melissa Pomerene .

We look forward to working with you!

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