Hospitals Not Using Cervical Brachytherapy Because of Cost

Pam Harrison

December 26, 2017

Brachytherapy is the gold-standard treatment for locally advanced cervical cancer, but it costs so much more than external-beam radiation therapy (EBRT) that many hospitals are dissuaded from offering it, a new analysis finds.

The finding was published online September 13 in the International Journal of Radiation Oncology Biology Physics.

"It's disturbing because we have this great treatment option that's an absolute requirement of curative therapy, and it's been available for decades, but the rates of actually using brachytherapy are dropping," senior author Timothy Showalter, MD, MPH, University of Virginia School of Medicine, Charlottesville, said in a statement.

"My hypothesis is that the poor reimbursement rates for brachytherapy have limited the availability of brachytherapy programs and associated declines in brachytherapy delivery," Dr Showalter told Medscape Medical News in an email.

"And if Medicare does not adjust reimbursement fees [for the treatment], I think that access to brachytherapy will remain limited, since new centers will choose to not start new brachytherapy programs, and the limited availability of brachytherapy will continue to be a significant barrier to quality care and optimal outcomes," he added.

"What we see when brachytherapy is not used is that it affects overall survival," Geraldine Jacobson, MD, MPH, secretary/treasurer of the American Society for Radiation Oncology (ASTRO) and professor and chair of radiation oncology at the West Virginia University School of Medicine, Morgantown, told Medscape Medical News.

"So of course this is of concern for us, because brachytherapy has been shown to be an integral treatment for invasive cervical cancer, and it adds to the cure rate," she added.

Commenting on the implications of the new study, Dr Jacobson emphasized to Medscape Medical News the impact that brachytherapy has on survival for patients with locally advanced cervical cancer. She said that it had been hoped that more modern radiation techniques, such as stereotactic body radiation (SBRT), would yield results comparable to those achieved by brachytherapy.

"When investigators looked at this, however, they saw that results using techniques including SBRT and IMRT [intensity-modulated radiation therapy] were poorer than those using brachytherapy and that the decrease in overall survival was more than if you had just eliminated chemotherapy," she elaborated.

So even in this more modern era of radiation, using these kinds of high-tech EBRT treatments does not make up for not using brachytherapy. Dr Geraldine Jacobson

"So even in this more modern era of radiation, using these kinds of high-tech EBRT treatments does not make up for not using brachytherapy," Dr Jacobson stressed.

She also noted that ASTRO, as the radiation oncologists' professional organization, is working toward having insurance companies change reimbursement rates for the more effective procedure.

She agreed with Dr Showalter that the costs of brachytherapy in nonacademic centers or small hospitals, where brachytherapy is not routinely performed, are likely to be much higher than the costs calculated in the current analysis.

"We are a state institution, and it is our mission to provide healthcare for people of the state, so it's never crossed my mind not to offer our patients what is standard-of-care curative treatment. I would be appalled to think that we would not do that for any reason. It's our job to provide this care," Dr Jacobson insisted.

"But for some centers, offering a treatment which is curative but where the costs are not reimbursed just seems like not good public policy," she observed.

"So I think this article will be very helpful for us in terms of trying to change reimbursement for the treatment," she added.

Study Details

For their study, Dr Showalter and colleagues evaluated all delivery costs associated with each step of the radiation treatment process, including costs of personnel, equipment, and supplies.

The investigators conducted interviews with staff in order to calculate the amount of time each staff person spent delivering care to each patient.

The team used time-driven activity-based costing, which allowed them to determine the overall cost of a treatment by estimating the cost of each resource used as well as the time during which each resource was used for each activity required to deliver the full course of treatment.

They then compared the overall cost of brachytherapy and EBRT for the treatment of cervical cancer, using 2016 Medicare reimbursement rates.

Complete Course of Radiation Therapy

"The complete course of definitive radiation therapy involved $12,861.68 of delivery costs to the health system," investigators report.

Almost half of that cost went to personnel involved in delivering that care. They note that it took a total of 3786 personnel-minutes to deliver a full treatment course ― 1088 were used by radiation therapists alone.

The next largest cost was for the space needed to house the equipment for delivering radiation therapy and for the cost of equipment.

A comparison of the cost of delivering brachytherapy with that of EBRT showed that EBRT was less expensive in virtually all aspects of that delivery, largely because it takes at least 80% more personnel time to administer brachytherapy than it does to deliver EBRT.

Table. Cost Comparison of Brachytherapy vs EBRT for Locally Advanced Cervical Cancer

  Delivery Time to Deliver (Radiation Oncologist) Time to Deliver (Medical Physicist Time) Total Personnel Time Cost of Supplies
Brachytherapy $8610.68 423 min 415 min 2349 min $2219.50
EBRT $4055.01 80 min 46 min 1301 min NA


The researchers then compared the costs of delivering two different forms of radiation therapy to the amount of reimbursement from Medicare in 2016 and determined relative value units (RVUs).

RVUs were calculated for IMRT and 3-D conformal radiation therapy (3D-CRT).

After accounting for the costs and time involved in each type of treatment, the researchers found that Medicare reimburses four times more per minute for EBRT than for the more effective brachytherapy.

"A full course of definitive therapy provides radiation oncology attending physicians a total of 149.77 RVUs if IMRT is used or 135.90 RVUs if 3D-CRT is used," the researchers state.

In comparison, brachytherapy delivers roughly half the RVUs ― 77.08 RVUs for attending radiation oncologists.

Importantly, the amount of total reimbursement ― $6753.14 for brachytherapy ― falls considerably short of that for both comparator treatments ― $16,568.56 for IMRT and $9318.75 for 3D-CRT.

Delivery costs exceed reimbursement for brachytherapy, whereas delivery costs are lower than reimbursement for EBRT. Dr Dr Timothy Showalter and colleagues

"This indicates that, at the institutional level, delivery costs exceed reimbursement for brachytherapy, whereas delivery costs are lower than reimbursement for EBRT," the authors conclude.

Analyses also indicate that there is about a fourfold difference in the amount of time an attending physician must spend delivering brachytherapy for the same compensation that they would receive delivering EBRT.

High-Volume Facility

Dr Showalter noted that he practices in a high-volume facility with an integrated brachytherapy suite, which makes treatment delivery more time efficient.

"However, I have recognized over the years that brachytherapy may not be feasible in small practices, due to the demands on physician time coupled with low reimbursement," he said.

Previous studies appear to bear this concern out. It has been reported that the use of brachytherapy for locally advanced cervical cancer declined from 83% in 1988 to 58% in 2009.

This decline appears to have had a deleterious effect on outcomes. The same study showed that at 4 years, cause-specific survival was 64.3% for women who were treated with brachytherapy compared with 51.5% for those treated with EBRT (P < .001).

Approximately 58% of the patients who received brachytherapy were still alive at 4 years, compared with about 46% for those whor eceived EBRT (P < .001).

Reducing Costs

In an accompanying editorial, authors led by Sushil Beriwal, MD, University of Pittsburgh School of Medicine, Pennsylvania, suggest that knowing the costs of delivering a specific type of treatment may help providers find ways to reduce these costs without affecting outcomes.

For example, costs could be reduced by ensuring that personnel who receive high compensation only spend time on those aspects of care that demand their particular skills.

The solution that has been adopted by many centers in the United States is to favor EBRT-based modalities over brachytherapy, because costs and reimbursement for EBRT can be optimized, Dr Beriwal and colleagues observe.

"This tragically ignores the hidden cost of worse outcomes in women with cervical cancer which does not show up on the balance sheet," they state.

"Fixing this situation depends on both rebalancing the rate of reimbursement for complex brachytherapy and thoughtful process design on the part of providers to minimize costs," the editorialists observe.

The authors and editorialists have disclosed no relevant financial relationships.

Int J Radiation Oncol Biol Phys. Published online September 14, 2017. Abstract, Editorial

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