Sbrt and adjuvant chemo

[Ray D. Ayshun]

This was never a part of my training, but I wonder if anyone has size/path criteria for sending a lung Cancer patient to get adjuvant chemo after sbrt.

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[evilbooyaa]

There's a KEYNOTE trial enrolling now evaluating Pembro after SBRT for larger early stage NSCLC

But, no, have not seen adjuvant chemo after SBRT.

 

[FrostyHammer]

There's some retrospective data on this topic but if it's 4 or more cm I start to think about it if the patient wants to be aggressive, but the downside is that it's based on an unplanned subset analysis of that one surgical CALGB trial, so it's hardly a sure shot unless I decide to pull a Dan Spratt and make firm recommendations based on that level of evidence.

I'm the rare case it's 5 or more cm I'll start leaning more and more towards it but only if the patient is motivated enough and has good enough age/PS that I think they can tolerate 4-6 cycles of carbo and taxol/Alimta.

I've also had very rare cases of <4 cm tumors I referred to hemeonc where there was massively long diagnostic delays (like 4-6 months) and the primary was higher risk (e.g. larger, central - not the standard T1 peripheral). But even that was for a discussion of pros and cons, not necessarily giving chemo.

 

[medgator]

This was never a part of my training, but I wonder if anyone has size/path criteria for sending a lung Cancer patient to get adjuvant chemo after sbrt.

People extrapolate from surgery. So size > 4cm is one criteria I'm aware of

 

[FrostyHammer]

There's a KEYNOTE trial enrolling now evaluating Pembro after SBRT for larger early stage NSCLC

But, no, have not seen adjuvant chemo after SBRT.

There are many trials like this. MDACC trial is in follow up (opdivo), pacific-4 (imfinzi), another NRG trial (atezo), and I think a couple more

 

[xrt123]

The performance status of my patients referred for SBRT is inferior to those taken to surgery. Therefore I think toxicity often may outweigh benefit and not sure you can use the 4 cm criteria. On the other hand these patients are not pathologically staged like with lobectomy and chemo may have better opportunity for benefit. A great question that will hopefully be answered by immunotherapy trials above. We generally do not refer for chemo in These instances and tumor board typically agrees

 

[Lamount]

Agree with others that I do this for tumors > 4 cm...
With masses this large, I am more likely to do 7.5 Gy x 8 or 7 Gy x 10, so not truly “SBRT”

 

[drewdog1973]

Not sbrt from an American billing perspective. Most people worldwide would consider it Sbrt

 

[Palex80]

Not sbrt from an American billing perspective. Most people worldwide would consider it Sbrt

SBRT is defined by the technique, not the fractions. 8 x 7.5 Gy offers a similar BED to most 3-5 fraction SBRT regimes.

 

[medgator]

SBRT is defined by the technique, not the fractions. 8 x 7.5 Gy offers a similar BED to most 3-5 fraction SBRT regimes.

Insurance in US defines by fraction number, 5 or less, among other things

 

[Palex80]

Insurance in US defines by fraction number, 5 or less, among other things

I am sorry, but I beg to differ.
No insurance is going to tell me what's stereotactic and what's not based on the number of fractions.
What they pay for may be based on the number of fractions, but that does not alter the definition of "stereotactic".

How would you describe the technique you use to irradiate an AKN with 25 x 1.8 Gy. Is that stereotactic or not?

 

[drewdog1973]

I think the 🐊 was agreeing with you, but just stating that is how it works state side.

 

[Lamount]

I am sorry, but I beg to differ.
No insurance is going to tell me what's stereotactic and what's not based on the number of fractions.
What they pay for may be based on the number of fractions, but that does not alter the definition of "stereotactic".

How would you describe the technique you use to irradiate an AKN with 25 x 1.8 Gy. Is that stereotactic or not?

It’s arbitrary but it’s a thing. American insurance companies will not reimburse you for “SBRT” if you deliver more than 5 fractions, even if you are using the same technology. This is why many US rad oncs shy away from many hypofractionated stereotactic regimens that are 6-15 fractions.
I am no billing expert as I work at a big hospital and don’t do much of it, but my understanding is that “SBRT” in 5 or fewer fractions is a flat rate lump sum, whereas more than 5 fractions IMRT can be billed as “IMRT” where everything (I.e weekly visits, IGRT) is billed separately.
You would make a lot of money in the US for your fractionated AKN treatment because the weekly visits are well compensated... and probably make more than you would for “SRS” or “SBRT”

 

[seper]

SBRT is a large lump sum, I hear we need 4 weeks of IMRT-IGRT in hospital setting to trump SBRT reimbursement
Furthermore, for SBRT prescribing doc gets all wRVU’s. For IMRT, I have to share with those covering my cone-beams and OTV’s.

 

[medgator]

SBRT is a large lump sum, I hear we need 4 weeks of IMRT-IGRT in hospital setting to trump SBRT reimbursement
Furthermore, for SBRT prescribing doc gets all wRVU’s. For IMRT, I have to share with those covering my cone-beams and OTV’s.

I think it's closer to 3, but your point is taken regarding coverage

 

[drewdog1973]

@seper - can you clarify this? If I sign the RX and plan for sbrt lung on Friday and go on holiday, I would get the wRVU, not the doctor that was on site the week I was gone?

 

[medgator]

@seper - can you clarify this? If I sign the RX and plan for sbrt lung on Friday and go on holiday, I would get the wRVU, not the doctor that was on site the week I was gone?

Plan is billed the day it signed iirc, you should get credit for the planning charge, whatever that rvu amounts to

 

[Reaganite]

Not sure what you all mean by lump sum unless you are just referring to professional charges. Globally, 5 fraction SBRT pays more than 3 fraction SBRT (on the technical side) since each SBRT fraction is reimbursed individually. On the prof end 3 vs. 5 probably doesn't make a difference since you only get 1 stereotactic treatment management day to bill either way.

And I agree with Gator: 3 weeks of IMRT = SBRT at Medicare prevailing, although some groups are able to uniquely jack up the rate for SBRT delivery with same payors so that ratio doesn't always hold true on the private side.

 

[seper]

Yes, that’s how RVU’s were attributed at my last 2 places I’ve worked at. Covering doc delivering individual SBRT fraction gets nothing (with the exception of OTV x 1, I guess, if you are gone for the whole course)

@seper - can you clarify this? If I sign the RX and plan for sbrt lung on Friday and go on holiday, I would get the wRVU, not the doctor that was on site the week I was gone?

 

[Neuronix]

Yes, that’s how RVU’s were attributed at my last 2 places I’ve worked at. Covering doc delivering individual SBRT fraction gets nothing (with the exception of OTV x 1, I guess, if you are gone for the whole course)

The sbrt daily delivery RVUs are all technical unless you're replanning with adaptive RT then you get professional IMRT charges.

 

[drewdog1973]

Yes, that’s how RVU’s were attributed at my last 2 places I’ve worked at. Covering doc delivering individual SBRT fraction gets nothing (with the exception of OTV x 1, I guess, if you are gone for the whole course)

So the wRVU for the OTVx1 is split out from the rest of the charges?

Im asking because a lot of this creates a lot of scheduling headaches if there are a lot of docs at the site

 

[Neuronix]

So the wRVU for the OTVx1 is split out from the rest of the charges?

Im asking because a lot of this creates a lot of scheduling headaches if there are a lot of docs at the site

That's how we do it, yes. Whoever covers the OTV gets that charge (77435 typically).

 

[GI_RadOnc]

That's how we do it, yes. Whoever covers the OTV gets that charge (77435 typically).

At one place I worked, they kept track of who covered the machine; and then split all the 77435 for all the SBRT among the percentages of who covered the machine for the setups. As mentioned by others; rarely does the OTV require much physician input with patients with little toxicity. More administrative work; but it encouraged cross-coverage; which is otherwise disincentivized.

 

[evilbooyaa]

So the wRVU for the OTVx1 is split out from the rest of the charges?

Im asking because a lot of this creates a lot of scheduling headaches if there are a lot of docs at the site

Lots of differences in how institution's bill, which directly lead to differences in how likely folks are to cross-cover in timely manner.

Was used to a setting where the person who verified the SBRT CBCT got nothing, thus leading to a lot of people not being willing to cover other attendings' SBRT. Lead to a discussion that certain 'docs of the day' needed a stick to improve compliance - and a situation where if a non-doc of the day was called to verify b/c DoD was AWOL, certain billing changes were made to incentivize people to help when called upon (even if not DoD)

 

[radoncopotamus]

That's how we do it, yes. Whoever covers the OTV gets that charge (77435 typically).

I have seen this lead to certain docs who cover one fraction of a 5 fraction SBRT to put in an otv note to claim that 77435 charge over the treating doc who covered the other 4 fractions. Academic backstabbing at its finest.