Simul Parikh on LinkedIn: Financial Toxicity in Radiation Oncology: Impact for Our Patients and for… (2024)

Everyone loves a good prior auth story. Here is some interesting logic from the good folks at EviCore by Evernorth / eviCore healthcare formerly CareCore National.Everyone pushes for shorter palliative regimens. Patients with low life expectancy are able to spend less time in treatment. It can be cheaper. It is at times as effective as longer courses.I really like using 1 to 5 fractions for almost all palliative cases - it's my opinion that 1 week should be maximal time for palliation. I know others do 2-3 weeks - I just have discomfort with prolonged treatments for dying patients, if I don't have certainty the longer treatment is superior in someway.So, for lung palliation, we know that IMRT is superior to 3D in terms of acute toxicity, as per randomized controlled trial. Grade 2 esophagitis was reduced from 24% to 2%. Remember, Evicore friends, these are dying patients. Do we really need to give 10x more esophagitis to patients already suffering?In any case, they are reluctant to let us utilized IMRT with 30/10 for palliative RT. Since I prefer shorter courses, I requested 17 Gy in 2 fractions. This is effective based on randomized trials, perhaps slightly less durable than 30/10. The other thing is with immunotherapy, patients are living far longer than before and now they live several months / years, but develop new symptomatic metastases. With IMRT, I will have room to treat any bone mets that pop up and spare the cord very nicely. I can also re-treat lung if it progresses. Well, no surprise, IMRT was denied. The irony is that prior authorization is cost containment, but this will not save any money. They will approve 30 Gy in 10 Fx with 3D, which costs more than 2 fractions of IMRT. So, the "medicine dictated by insurance" prefers a longer, more toxic and more expensive course of treatment. You really have to hand it to them to recommend the worst option for patient, payor and society. We sure live in interesting times!https://lnkd.in/gunzki_Q

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A patient finished treatment today and we had our bell-ringing ceremony for him. We are a tiny department and 6-7 of us are usually there. The patient typically says a few words, we share some laughs and tears with them and wish them luck. "Simul, are you ignoring the evidence that says this is potentially harmful? There may be unintended consequences." There are actual studies on this - about the "harms" of ringing the bell.Life is not simple and cannot always be simulated with a randomized trial. A few times a week, in the midst of the routine of work, the sadness of loss, we celebrate our patients. We ask them if they would like to ring the bell at the end of treatment. A minority of patients say "nah, I'm good" and we respect that. But, most say yes. Why do I do this in spite of "the evidence"? Note, I am saying evidence with many many grains of the most sarcastic salt you will find. - We are rarely all together in the department with the patient, as we all have our own roles. But, here we get to spend this moment with the patient and their family.- The patient just did something really hard! If they choose to celebrate it, we are here for them. If not, we will see you in 2 weeks. - It is a safe space for tears - there are times when every single one of us and the patient and family emote. It's okay even for you doctor to share a cry with you. - Patients that are really into it bring their family - kids, friends, partners. We get to celebrate with them, as well, and to see the people that will help take care of our patient when we aren't in the picture. Overall, the patients that choose it very much appreciate it. This is seen over the course of years and being a perceptive reader of people. There is a "killjoy" nature in oncology that want to take away even the smallest of joys. We are a community clinic in the truest sense of the word - we provide care, but also sometimes money for groceries and rent and prayers and rides. My door is literally always open and patients walk in on random days to chat.When you read studies like this or that resident Steve that says things like "Actually, ringing the bell might be harmful" (Steve is so annoying!), think a little more deeply about this. If you're at some center where you flew in, saw a student, a resident, a fellow and occasionally an attending physician once in a while, then flew out, this ceremony may not be appealing. If you are being taken care of by your neighbors and friends, people you attend church with or play pickleball with, people that you'll see out in the world that feel connected to you, celebrating small victories may be one of the small joys that keep patients going.And stop wasting time and energy studying this stuff. Just learn how to be a person. https://lnkd.in/gcFTMXvc.

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Does it matter what gender treats what disease site? Groundbreaking research shows that male radiation oncologists are more likely to treat prostate cancer and female radiation oncologists are more likely to treat breast and gyn. Patients are certainly allowed to have preferences and physicians are also allowed to. I suspect that female patients that undergo treatment for breast and gyn cancer are more comfortable with female rad oncs. And that it is okay. And same for prostate cancer.They conclude “Future research into the drivers of disease site selection should be explored.”I ask a simple question: “why?”Are we going to engineer who treats what? Are we going to dismiss patient preferences? Are we going to dismiss autonomy of physicians? Maybe this is something that people want to pursue, but I’ve not come across too many physicians or patients that feel that this is a clinical/QOL/PRO problem. Seems like low cure rates of many malignancies remain the larger issue.https://lnkd.in/gfvwKFsh

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In radiation oncology, there have been a dramatic rise in the number of publications regarding the harms caused by radiation therapy delivery on the environment - a few articles are linked below. This is no small matter - there are the obvious factors - the linear accelerator itself, medical waste, but then there is the matter of travel time / distance to treatments and other carbon producing activities that are required for the optimal treatment of cancer.Much of this is a medical and modern society issue, rather than a radiotherapy-specific issue. We simply do not have both the technology and the will to make the change that is so sorely needed to protect the planet. As this is mostly out of our control, we can focus on the one thing we do - limit emissions from travel by reducing the number of miles we drive for our treatments and also the number of visits. The way for our treatments to become more green is to simply explain to patients that for routine therapies (95% of radiation treatments) they should get care close to home. Radiation oncologists are amongst the most highly specialized and well trained physicians in American medicine. What can be done well at the academic can most certainly be done well at the community center. The system as it stands encourages larger centers to incentivize patients to come to "the mother ship". I have witnessed this during consultation where patients are told that their local physician may not be able to handle treating their DCIS or early stage breast cancer at home and encourage them to drive 50-100 miles one way daily. Environmental change is a collective action problem. Our leaders at academic centers are well-suited to "be the change". Send a patient back home for their treatment! They and the planet will thank you. https://lnkd.in/gwwc_axyhttps://lnkd.in/gXadmAiYhttps://lnkd.in/gyRJ2Vhg

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We have an exciting new partner on our podcast, "The Accelerators" and his name is Cameron Tharp, MPH, RT(T). We just released our first episode with him, discussing topics of interest for radiation therapists. We will be doing a deep dive into this world - RTTs are core members of the treatment team, well-educated and highly skilled. My contention is that we are underutilizing them and should consider increasing their scope of practice. This could look like contouring/treatment planning, patient care - early weekly management visits or follow-ups, or other functions. It is suboptimal to waste human capital and I think we have an amazing opportunity to improve the function of the clinic and patient care. Let's see where the conversation goes.Please give the episode a listen and a hearty "welcome" to Cam!(also on Spotify and any other site for podcasts)https://lnkd.in/gMhBKkRp

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Would stereotactic radiotherapy work for macular degeneration?There has been preliminary work on this and now there is an RCT. They blinded by using sham RT (!). 2:1 Randomization to intervention arm. The treatment arm received 16 Gy / 1 Fx. This was a superiority trial with endpoint of number of ranibizumab injections (RT should reduce) and they also looked at visual acuity as a secondary endpoint. The treatment arm received 3 less injections and maintained acuity. They were more likely to develop microvascular abnormalities, but interestingly, those patients had superior visual acuity (not s.s.) They also looked at cost - SRT reduced per patient cost by about $725 for NHS patients, as compared to treatment without it.Now, in the US, this is unlikely to lead to any change in practice or referrals. 1) Optho would have to refer and they would lose out on injections, which are reimbursed reasonably well. 2) Radiation is considered "brutal" by mainstream media and lay people 3) This is a huge moneymaker for pharma.However, it is an interesting use of RT for a benign indication. There appears to be much more excitement about this amongst the community vs academia, and I've found that to be interesting. LD-RT for osteoarthritis has taken off and American Society for Radiation Oncology has barely touched on it, though at the 2024 meeting this Fall, I suspect it will be a hot topic. Finally, a thought experiment ... SRT was invented far before Lucentis. Let's say that 25 years ago, SRT was used to treat macular degeneration and was the standard of care. Then this medication comes out showing that with just 3 additional treatments, one could avoid SRT and maintain acuity. I wonder how that would have played out.https://lnkd.in/gFGpzXzz

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I wanted to share an article about cancer survival and ... marriage. This is a relatively older (2014) but remains quite poignant. They looked at a huge dataset (>500,000 patients with lung, colorectal, breast, pancreatic, prostate, liver/intrahepatic bile duct, non-Hodgkin lymphoma, head/neck, ovarian, or esophageal cancer) and looked at survival in cancer patients ( married vs unmarried and then also married vs single/separated/divorced/widowed. There were small differences in demographics between the married vs not married, but married people had more advanced disease an higher nodal disease. They found that married patients were more likely to undergo definitive treatment (surgery or RT), have significantly higher cancer specific survival. All subgroups of unmarried patients were more likely to present with metastatic disease, be undertreated, and die of their cancer than their married counterparts. This effect size was much more pronounced in men.The effect size was found to be greater than chemotherapy!I can say I didn't need the study to tell me this, having been in the business for greater than a decade and seeing how married people do vs unmarried. Clearly, this is "hypothesis generating" as it is not prospective, but it also falls in the common sense bucket (maybe Common Sense Oncology can chime in?). This finding has been replicated in meta-analyses and yet I have not seen major cancer centers consider approaching this group of patients for supportive care, while we tend to to this for other groups with far less data. Targeting these vulnerable groups (particularly unmarried and widowed men) with social interventions may be a cost effective approach to improve outcomes and I hope centers work on this low-hanging fruit.Next time you're irritated with your spouse, remember, they are potentially literally saving your life so give them a hug!https://lnkd.in/gpm7zmdA

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