ASTROnews - All Comments

re: Web Exclusive: ASTRO leaders meet with GAO, detail self-referral concerns

Brent Kane, MD — Wed, 08 Sep 2010 23:35:21 GMT

There is something inherently wrong with a specialty making up for loses in their particular specialty by raiding another's business. Urologists, medical oncologists and breast surgeons have decided to gain income from their radiation oncology referrals under the guise of "integrated care."

Other specialties are raising unprecedented amounts of money to fight for this loophole to keep their self-referral income. Give to ASTROPAC now to help preserve the autonomy of our specialty.

re: ASTROgram: Public comment period for ETC's proton beam therapy report extended to June 10

dalmorgan — Thu, 10 Jun 2010 17:33:52 GMT

To the ASTRO proton team.

We are delighted to read this extremely helpful summary of proton therapy and appreciate the hard work necessary to produce such a wide ranging and ‘easy-to-read’ text. Since comments are invited, we suggest that some attention might usefully be given to the following points given below:-

• Factual error in historical section. The first hospital based proton therapy was actually in Clatterbridge (near Liverpool, UK), where proton therapy was used to treat ocular melanomas in a hospital setting as from 1989. It is true that LLUMC was the first to treat deeper cancers in a hospital setting.

• Page 4; the equation is that of Bethe-Bloch. It is worth mentioning this as it can be looked at by interested readers.

• The wording of this section is a little odd. The authors write that the “local proton energy spectrum does not change dramatically from the initial quasi-monoenergetic distribution”. What is perhaps meant is that the “width or energy spread of the local proton energy spectrum does does not change dramatically from the initial quasi-monoenergetic distribution”

• PTV discussion is confusing without diagrams. It may be true to say that the PTV concept may need modification, indeed in some tissues, tumour safety margins might be extended due to the dose reduction over a wider volume. There is a temptation for physicians to use protons with a tighter margin…..this is not appropriate.

• Page 6; a large number of fields should not be used because of the enhanced risk of malignant induction; spot scanning allows the option of fewer fields. One of the potential advantages of particle therapy is that fewer fields and a reduced total tissue traversion can be used. This then compensates for the enhanced RBE for malignant induction.

• Page 7; imaging every field applied more to the era of treatment in chairs …… with isocentric rotating gantries this is not so necessary.

• page 7 – the text says definitively that proton exit imaging is not possible. In principle this is possible by using higher energy protons which travel through the body and are then detected by an energy selective imaging system. This has lead to the consideration of techniques such as Proton Computed Tomography and Proton Transmission Radiography. These are active areas of active research but are not available in current commercial proton therapy offerings.

• Page 7 (bottom) the quality factor is itself related to the increased RBE. Also that high efficiency scattering devices can reduce the neutron yield.

• Page 8 - any proper assessment of neutron dose in dose quantities and risks expressed in mSv should already include a "reasonable over-estimate" of the risk factors or quality factors - so it is probably wrong to emphasise this as an additional separate uncertainty.

• Page 8 and 9: RBE is not “theoretically” related to fraction size, since this is a well-established fact in other high LET radiations such as neutrons; indeed a vast amount of animal data shows this to be the case. Also, it can be seen that the extent of the change in RBE with dose per fraction depends on the α/β ratio of the tissue (see the reassessment of neutron dose per fraction effects in the graphs within: A Carabe-Fernandez, RG Dale and B Jones. The incorporation of the concept of minimum RBE (RBEmin) into the linear-quadratic model and the potential for improved radiobiological analysis of high-LET treatments. Int. Journal of Radiation Biology, 83, 27-39, 2007). Thus late reacting tissues show a greater change and highest RBEs at low dose per fraction. One great difficulty with the assumptions made in Boston and summarised by Paganetti et al (2002) is that all the studies used early reacting (high α/β) tissues. There have been no studies involving true ‘late reacting’ assays such as brain necrosis. It follows that if the neutron RBE changes with dose per fraction are scaled down to the proton range then values of 1.2 or more are predicted to occur in late reacting tissue such as the CNS. This is important, as proton therapy has resulted in serious toxicity within the CNS in a non-trivial number of patients. Consequently, a considerable amount of research remains to be done to improve the safety of proton therapy in this respect.

• Clinical sections are mainly a summary of published reports, many of which were done at physics labs, with restrictions on beam time, horizontal beams, less than 5 fractions per week etc.

• Page 12 (CNS). The PSI paper looking at tumours without / with metalwork in the spine should be quoted, even though this is a limited study. It is also necessary to emphasise that the best possible surgery needs to be done and metal avoided where necessary by use of bone grafts, carbon fibre rods etc. Further surgery to remove metalwork may be indicated prior to proton therapy for these reasons. See Rutz et al IJROBP - Volume 67, Issue 2, Pages 512-520 (1 February 2007)

• Page 59 secondary malignancy: the published reports use the standard radioprotection model which assumes no fractionation effects, so may be misleading.

• Head and neck cancers section: e.g. in summary or introduction, more could be made of the potential advantages of not irradiating the contralateral neck, in terms of acute reactions, xerostomia reduction, redcued risk of embolic storke, and the later treatment of contralateral metachronous cancers (whether by surgery or further radiation).

• A general review of the advantages of particle therapy is contained in: Jones B. Personal View: The potential advantages of charged particle radiotherapy using protons or light ions. Clinical Oncology [Royal College of Radiologists], 20, 555-563, 2008.

• One could also consider the treatment of hypernephromas, although the literature is small, and also the exciting possibilities for proton therapy in partial breast irradiation and in re-irradiation of tumours arising in previously-treated areas.

With compliments and best wishes,

Bleddyn Jones, Chair of Particle Therapy Committee

(Bleddyn.Jones@rob.ox.ac.uk)

Stuart Green, President

(Stuart.Green@uhb.nhs.uk)

David A L Morgan, Council Member (David.Morgan@Nottingham.ac.uk)

British Institute of Radiology, London

June 2010

re: Web Exclusive: ASTRO commits to six-point patient protection plan

Carabell13521 — Sat, 06 Feb 2010 00:48:03 GMT

The creation of a database to record and report errors is a good idea; this would have instructive and educational value to ASTRO members and trainees. Important medicolegal precedents can guide current practice; ASTRO members with law degrees should be consulted,(Dr. A. Katz, for example). The lack of any such system prevents spread of information, and as a result, we depend on such articles as the recent NY Times series. Important cases are not well-known, such as the Mt. Zion SF cord transection, the killer Cobalt of Tufts-NEMC, the Florida woman whose opposite (wrong) breast was irradiated for 5 weeks, and the 8-figure malpractice judgment from MGH proton beam-induced blindness. (Dr. Zietman probably doesn't know about that case, though it came from his own institution!) The current system encourages secrecy, as there are powerful incentives to seal the records. Anonymous reporting to a centralized database could help the profession avoid repeating past mistakes.

re: Web Exclusive: Letter to the New York Times January 25, 2010

sapareto17974 — Fri, 29 Jan 2010 19:02:06 GMT

While tragic that the cases reported by the New York Times article have occurred, it would be even more tragic if patients were to forgo radiation therapy because of fear and misunderstanding of the extremely low risk of these kinds of outcomes.

Stephen Sapareto, PhD

re: Web Exclusive: Letter to the New York Times January 25, 2010

jaronowitz — Thu, 28 Jan 2010 19:00:31 GMT

We are all aware that radiotherapy, even when properly applied, can cause significant toxicity. Unfortunately, patients and their families often believe that toxicity is secondary to misadministration ('I was overdosed').

I am concerned that the TIMES article will engender a defensive posture among radiation oncologists, a tendency to UNDERDOSE, in an effort to avoid toxicity that could be misconstrued as misadministration.

re: Web Exclusive: Letter to the New York Times January 25, 2010

bechtel13145 — Thu, 28 Jan 2010 17:40:23 GMT

I think it would have added a little punch if you could have made some reasonable estimate of the number of people potentially cured in that time frame also. But the quick response was great.

re: Web Exclusive: Letter to the New York Times January 25, 2010

tendicott — Tue, 26 Jan 2010 02:37:46 GMT

May I add my thanks, Dr. Williams, for your rapid response. The NY Times report is riveting, and does a good job of communicating the anguish endured by that patient and family. But it adds to the climate of fear around sharing information about medical errors, and it does a terrible job of communicating the potential benefits of radiation therapy. The reader is left with the sense that radiation is given without regard to the health and comfort of our patients. I wonder how many people will decide not to seek curative radiation therapy because this article was written, and thus how much real damage this article has done.

Thyra Endicott MD

re: Web Exclusive: Letter to the New York Times January 25, 2010

videtic19000 — Tue, 26 Jan 2010 01:50:12 GMT

Dr. Williams, thank you for your prompt, clear and context-appropriate response. I read the article yesterday in my local newspaper, as supplied by the NY Times service and was utterly astonished by its tone, inappropriateness and imbalanced presentation. No doubt, this has been prompted by the brachytherapy debacle at the VA.

Sincerely, Gregory Videtic,MD

re: ASTROgram: 2009 ASTRO Annual Meeting registration, housing open June 10

Buchsbaum13432 — Wed, 12 Aug 2009 21:03:47 GMT

Will assisted listening device for the hard of hearing be available? What type ? Thank you for yor help. Roy Buchsbaum M.D. rbuchsbaum@usouthal.edu or 251- 445-9848

re: ASTROgram: ASTRO joins efforts to develop domestic isotope supply

Katherine Bennett — Mon, 10 Aug 2009 23:01:31 GMT

Our apologies. Here is the direct link - cs.astro.org/.../web-exclusive-astro-joins-effort-to-develop-domestic-isotope-supply-mo-99-shortage-spurs-action.aspx.

re: Web exclusive: CMS Updates Physician Supervision Requirements for Diagnostic Tests in an Office or Free Standing Radiation Therapy Center

e_sculapius — Mon, 10 Aug 2009 00:40:18 GMT

77421 -

In our department IGRT is done with software that the therapists use to govern set-up shifts before treatment (Acculoc). The physician is in the department and able to provide supervision if indicated. In order to bill the professional component of 77421 does the physician need to review the images before treatment?

Matt Manning

re: ASTROgram: ASTRO joins efforts to develop domestic isotope supply

sapareto17974 — Mon, 03 Aug 2009 21:35:49 GMT

The hyperlink is recursive and doesn't take you to any detailed article.

re: Web exclusive: CMS Updates Physician Supervision Requirements for Diagnostic Tests in an Office or Free Standing Radiation Therapy Center

Katherine Bennett — Wed, 17 Jun 2009 20:58:34 GMT

For specific coding questions, please submit them directly to ASTRO's Health Policy Department via this Web site - www.astro.org/.../index.aspx.

re: Web exclusive: CMS Updates Physician Supervision Requirements for Diagnostic Tests in an Office or Free Standing Radiation Therapy Center

drisro1 — Wed, 17 Jun 2009 03:02:54 GMT

The transmittal appears to address submission of the technical or global code. What about submitting the professional component in a hospital based practice? Is the supervision requirement the same?

re: Web exclusive: CMS Updates Physician Supervision Requirements for Diagnostic Tests in an Office or Free Standing Radiation Therapy Center

ptripuraneni — Tue, 16 Jun 2009 18:05:20 GMT

This is great news! Kudos to ASTRO and others that worked to bring on the change in the policy that reflects a reasonable practice.

We set the parameters of what the therapists can do. Beyond those parameters, MD is called. At the end of the day, MD signs off all of them.

What do others do?