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Brief Opinion| Volume 6, ISSUE 2, 100605, March 2021

The Case for Brachytherapy: Why It Deserves a Renaissance

Open AccessPublished:November 06, 2020DOI:https://doi.org/10.1016/j.adro.2020.10.018

      Abstract

      The recent global events related to the coronavirus disease of 2019 pandemic have significantly changed the medical landscape and led to a shift in oncologic treatment perspectives. There is a renewed focus on preserving treatment outcomes while maintaining medical accessibility and decreasing medical resource utilization. Brachytherapy, which is a vital part of the treatment course of many cancers (particularly prostate and gynecologic cancers), has the ability to deliver hypofractionated radiation and thus shorten treatment time. Studies in the early 2000s demonstrated a decline in brachytherapy usage despite data showing equivalent or even superior treatment outcomes for brachytherapy in disease sites, such as the prostate and cervix. However, newer data suggest that this trend may be reversing. The renewed call for shorter radiation courses based on data showing equivalent outcomes will likely establish hypofractionated radiation as the standard of care across multiple disease sites. With shifting reimbursement, brachytherapy represents the pinnacle in hypofractionated, conformal radiation therapy, and with extensive long-term data in support of the treatment modality brachytherapy is primed for a renaissance.

      Introduction

      Given recent global events related to the coronavirus disease of 2019 (COVID-19) pandemic, the medical landscape and oncologic treatment perspectives have significantly shifted. Oncologic physicians are increasingly focused on maintaining equipoise of treatment outcome and medical accessibility with decreasing medical resource utilization. In support of these measures, radiation oncologists have used a variety of temporizing measures, including hormone therapy measures (eg, breast, endometrial, and prostate cancer), treatment delays (where appropriate), and hypofractionation across all disease sites.
      • Mohindra P.
      • Beriwal S.
      • Kamrava M.
      Proposed brachytherapy recommendations (practical implementation, indications, and dose fractionation) during COVID-19 pandemic.
      • Williams V.M.
      • Kahn J.M.
      • Harkenrider M.M.
      • et al.
      COVID-19 impact on timing of brachytherapy treatment and strategies for risk mitigation.
      • Guckenberger M.
      • Belka C.
      • Bezjak A.
      • et al.
      Practice recommendations for lung cancer radiotherapy during the COVID-19 pandemic: An ESTRO-ASTRO consensus statement.
      • Zaorsky N.G.
      • Yu J.B.
      • McBride S.M.
      • et al.
      Prostate cancer radiotherapy recommendations in response to COVID-19.
      • de Azambuja E.
      • Trapani D.
      • Loibl S.
      • et al.
      ESMO management and treatment adapted recommendations in the COVID-19 era: Breast Cancer.
      For breast, prostate, and gynecologic malignancies, low-dose rate (LDR) and high-dose-rate (HDR) brachytherapy represent the pinnacle of hypofractionated, conformal radiation therapy. Previously, studies showed a decline in both gynecologic
      • Han K.
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      • Fyles A.
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      • Viswanathan A.N.
      Trends in the utilization of brachytherapy in cervical cancer in the United States.
      ,
      • Gill B.S.
      • Lin J.F.
      • Krivak T.C.
      • et al.
      National Cancer Data Base analysis of radiation therapy consolidation modality for cervical cancer: The impact of new technological advancements.
      and prostate
      • Mahmood U.
      • Pugh T.
      • Frank S.
      • et al.
      Declining use of brachytherapy for the treatment of prostate cancer.
      brachytherapy despite data showing superior treatment outcomes. However, newer data suggest that the declining utilization rates may be reversing.
      • Schad M.D.
      • Patel A.K.
      • Glaser S.M.
      • et al.
      Declining brachytherapy utilization for cervical cancer patients - Have we reversed the trend?.
      ,
      • Corkum M.T.
      • Morton G.
      • Louie A.V.
      • et al.
      Is prostate brachytherapy a dying art? Trends and variation in the definitive management of prostate cancer in Ontario, Canada.
      Brachytherapy treatment approaches are well tolerated, safe, effective, and cost-effective. As radiation oncologists and patients move forward, brachytherapy represents an often underused and effective treatment modality.

      Gynecologic Brachytherapy

      Gynecologic brachytherapy is a vital and irreplaceable component of definitive and adjuvant treatment for gynecologic malignancies. Multiple studies have demonstrated the efficacy of brachytherapy to treatment outcomes in cervical and uterine oncologic malignancies.
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      • Oswald M.J.
      The relationship between brachytherapy dose and outcome in patients with bulky endocervical tumors treated with radiation alone.
      • Viswanathan A.N.
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      Increasing brachytherapy dose predicts survival for interstitial and tandem-based radiation for stage IIIB cervical cancer.
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      Curative radiation therapy for locally advanced cervical cancer: Brachytherapy is NOT optional.
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      FIGO IIIB squamous cell carcinoma of the cervix: An analysis of prognostic factors emphasizing the balance between external beam and intracavitary radiation therapy.
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      Differences in outcome for cervical cancer patients treated with or without brachytherapy.
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      A phase III trial of surgery with or without adjunctive external pelvic radiation therapy in intermediate risk endometrial adenocarcinoma: A Gynecologic Oncology Group study (vol 92, pg 744, 2004).
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      Postoperative external irradiation and prognostic parameters in stage-I endometrial carcinoma - Clinical and histopathologic study of 540 patients.
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      Surgery and postoperative radiotherapy versus surgery alone for patients with stage-1 endometrial carcinoma: Multicentre randomised trial.
      • Nout R.A.
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      • Putter H.
      • et al.
      Vaginal brachytherapy versus pelvic external beam radiotherapy for patients with endometrial cancer of high-intermediate risk (PORTEC-2): An open-label, non-inferiority, randomised trial.
      Unfortunately, gynecologic brachytherapy utilization has declined in parallel with the clinical implementation of intensity modulated radiation therapy (IMRT) and volumetric modulated arc therapy.
      • Han K.
      • Milosevic M.
      • Fyles A.
      • Pintilie M.
      • Viswanathan A.N.
      Trends in the utilization of brachytherapy in cervical cancer in the United States.
      ,
      • Gill B.S.
      • Lin J.F.
      • Krivak T.C.
      • et al.
      National Cancer Data Base analysis of radiation therapy consolidation modality for cervical cancer: The impact of new technological advancements.
      Furthermore, attempts to replace brachytherapy with external beam treatment approaches have been unsuccessful. Notably, a recent phase 2 study of patients with predominantly locally advanced cervical cancer examined the feasibility of using a SABR boost as an alternative option to brachytherapy for medically unfit patients or those who refuse brachytherapy.
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      • Keyes M.
      Current state of brachytherapy teaching in Canada: A national survey of radiation oncologists, residents, and fellows.
      The study was closed early owing to high toxicity rates, including death due to complications of therapy. The cervical cancer clinical practice guidelines by the American Society for Radiation Oncology state that either SABR or IMRT are only suitable replacements for brachytherapy when considered for patients refusing or ineligible for brachytherapy.
      • Chino J.
      • Annunziata C.M.
      • Beriwal S.
      • et al.
      Radiation therapy for cervical cancer: Executive summary of an ASTRO clinical practice guideline.
      Modern HDR brachytherapy is a form of hypofractionated, conformal therapy commonly delivered in 4 to 5 treatments for cervical cancer.
      • Albuquerque K.
      • Hrycushko B.A.
      • Harkenrider M.M.
      • et al.
      Compendium of fractionation choices for gynecologic HDR brachytherapy-An American Brachytherapy Society Task Group Report.
      However, there are 2- and 3-fraction regimens
      • Patel F.D.
      • Kumar P.
      • Karunanidhi G.
      • Sharma S.C.
      • Kapoor R.
      Optimization of high-dose-rate intracavitary brachytherapy schedule in the treatment of carcinoma of the cervix.
      ,
      • Souhami L.
      • Corns R.
      • Duclos M.
      • Portelance L.
      • Bahoric B.
      • Stanimir G.
      Long-term results of high-dose rate brachytherapy in cervix cancer using a small number of fractions.
      that have been used more in resource-poor settings that can be used to preserve resources in these times, decreasing the treatment time so that curative treatment can be delivered faster. Complex interstitial cases are often done in the operating room in the modern era, but gynecologic brachytherapy procedures can be safely delivered without use of operating room time in an HDR suite without the need for anesthesia or through the use of moderate sedation for interstitial cases.
      Advances in imaging technology, such as magnetic resonance imaging, allow for adaptive image guided brachytherapy (IGBT) with simultaneous dose escalation to tumor targets and sparing of organs at risk. Compared with point-based brachytherapy planning, volumetric-based planning using IGBT has demonstrated improved tumor control and significantly reduced toxicity.
      • Sturdza A.
      • Potter R.
      • Fokdal L.U.
      • et al.
      Image guided brachytherapy in locally advanced cervical cancer: Improved pelvic control and survival in RetroEMBRACE, a multicenter cohort study.
      • Charra-Brunaud C.
      • Harter V.
      • Delannes M.
      • et al.
      Impact of 3D image-based PDR brachytherapy on outcome of patients treated for cervix carcinoma in France: Results of the French STIC prospective study.
      • Potter R.
      • Georg P.
      • Dimopoulos J.C.
      • et al.
      Clinical outcome of protocol based image (MRI) guided adaptive brachytherapy combined with 3D conformal radiotherapy with or without chemotherapy in patients with locally advanced cervical cancer.
      Additionally, a cost-utility analysis of IGBT showed that magnetic resonance imaging has the potential to decrease health care costs compared with 2-dimensional or computed tomography–guided brachytherapy through reduced costs from cancer recurrence and treatment toxicity.
      • Perdrizet J.
      • D'Souza D.
      • Skliarenko J.
      • et al.
      A cost-utility analysis of magnetic resonance (MR) guided brachytherapy versus two-dimensional and computed tomography (CT) guided brachytherapy for locally advanced cervical cancer.

      Breast Brachytherapy

      Partial breast irradiation (PBI) has demonstrated comparable treatment outcomes to whole breast irradiation with regard to local tumor control, toxicity, and cosmetic outcomes.
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      • Cecchini R.S.
      • White J.R.
      • et al.
      Long-term primary results of accelerated partial breast irradiation after breast-conserving surgery for early-stage breast cancer: A randomised, phase 3, equivalence trial.
      • Coles C.E.
      • Griffin C.L.
      • Kirby A.M.
      • et al.
      Partial-breast radiotherapy after breast conservation surgery for patients with early breast cancer (UK IMPORT LOW trial): 5-year results from a multicentre, randomised, controlled, phase 3, non-inferiority trial.
      • Ott O.J.
      • Strnad V.
      • Hildebrandt G.
      • et al.
      GEC-ESTRO multicenter phase 3-trial: Accelerated partial breast irradiation with interstitial multicatheter brachytherapy versus external beam whole breast irradiation: Early toxicity and patient compliance.
      • Whelan T.J.
      • Julian J.A.
      • Berrang T.S.
      • et al.
      External beam accelerated partial breast irradiation versus whole breast irradiation after breast conserving surgery in women with ductal carcinoma in situ and node-negative breast cancer (RAPID): A randomised controlled trial.
      • Meattini I.
      • Marrazzo L.
      • Saieva C.
      • et al.
      Accelerated partial-breast irradiation compared with whole-breast irradiation for early breast cancer: Long-term results of the randomized phase III APBI-IMRT-Florence trial.
      Initially, accelerated PBI provided a method to shorten typical 5- to 6-week standard fractionation radiation courses to 5 days. The recent publication of the UK Fast Forward study offers an even faster external beam option for the delivery of radiation to the breast.
      • Murray Brunt A.
      • Haviland J.S.
      • Wheatley D.A.
      • et al.
      Hypofractionated breast radiotherapy for 1 week versus 3 weeks (FAST-Forward): 5-year efficacy and late normal tissue effects results from a multicentre, non-inferiority, randomised, phase 3 trial.
      However, hypofractionation is still underused in the United States.
      • Parikh R.B.
      • Fishman E.
      • Chi W.
      • et al.
      Association of utilization management policy with uptake of hypofractionated radiotherapy among patients with early-stage breast cancer.
      Therefore, brachytherapy remains a viable, short treatment option with new data exploring noninvasive techniques and even shorter treatment regimens.
      • Hepel J.T.
      • Leonard K.L.
      • Sha S.
      • et al.
      Phase 2 trial of accelerated partial breast irradiation (APBI) using noninvasive image guided breast brachytherapy (NIBB).
      ,
      • Khan A.J.
      • Chen P.Y.
      • Yashar C.
      • et al.
      Three-fraction accelerated partial breast irradiation (APBI) delivered with brachytherapy applicators is feasible and safe: First results from the TRIUMPH-T trial.
      Early data for breast brachytherapy delivered in 1 to 4 fractions have demonstrated excellent local tumor control and cosmetic outcomes.
      • Khan A.J.
      • Chen P.Y.
      • Yashar C.
      • et al.
      Three-fraction accelerated partial breast irradiation (APBI) delivered with brachytherapy applicators is feasible and safe: First results from the TRIUMPH-T trial.
      ,
      • Jethwa K.R.
      • Park S.S.
      • Gonuguntla K.
      • et al.
      Three-fraction intracavitary accelerated partial breast brachytherapy: Early provider and patient-reported outcomes of a novel regimen.
      The phase 2 Triumph-T trial showed excellent local tumor control (albeit with a short median follow up) and breast cosmesis using a 3-fraction breast brachytherapy technique, and a similar 4-fraction regimen had excellent cosmesis with no locoregional recurrences at 6 years.
      • Khan A.J.
      • Chen P.Y.
      • Yashar C.
      • et al.
      Three-fraction accelerated partial breast irradiation (APBI) delivered with brachytherapy applicators is feasible and safe: First results from the TRIUMPH-T trial.
      ,
      • Wilkinson J.B.
      • Chen P.Y.
      • Wallace M.F.
      • et al.
      Six-year results from a Phase I/II trial for hypofractionated accelerated partial breast irradiation using a 2-day dose schedule.
      Furthermore, in elderly patients, single-fraction regimens have also demonstrated excellent oncologic outcomes,
      • Hannoun-Levi J.M.
      • Lam Cham Kee D.
      • Gal J.
      • et al.
      Accelerated partial breast irradiation in the elderly: 5-year results of the single fraction elderly breast irradiation (SiFEBI) phase I/II trial.
      and a recent study comparing PBI with PBI + hormone therapy or hormone therapy alone in women age >70 years with low-risk, hormone-positive, early stage breast cancer demonstrated that PBI was superior when compliance with hormone therapy was poor,
      • Ward M.C.
      • Vicini F.
      • Al-Hilli Z.
      • et al.
      Cost-effectiveness analysis of endocrine therapy alone versus partial-breast irradiation alone versus combined treatment for low-risk hormone-positive early-stage breast cancer in women aged 70 years or older.
      and tested compliance interventions have demonstrated no improvement.
      • Hershman D.L.
      • Unger J.M.
      • Hillyer G.C.
      • et al.
      Randomized trial of text messaging to reduce early discontinuation of adjuvant aromatase inhibitor therapy in women with early-stage breast cancer: SWOG S1105.
      ,
      • Hershman D.L.
      • Shao T.
      • Kushi L.H.
      • et al.
      Early discontinuation and non-adherence to adjuvant hormonal therapy are associated with increased mortality in women with breast cancer.
      Therefore, even with the likely adoption of shorter external beam radiation treatment regimens, breast brachytherapy remains an excellent option for women and provides good local control and cosmetic outcomes.

      Prostate brachytherapy

      Prostate brachytherapy results in excellent treatment and toxicity outcomes has a short overall treatment time (OTT), and is more cost effective than other radiation treatment options. Prostate brachytherapy (HDR or LDR) is considered equivalent to radical prostatectomy and external beam radiation for the treatment of prostate cancer and can be completed in 1 (LDR) or several (HDR) implantations.
      • Rodrigues G.
      • Yao X.
      • Loblaw D.A.
      • Brundage M.
      • Chin J.L.
      Low-dose rate brachytherapy for patients with low- or intermediate-risk prostate cancer: A systematic review.
      ,
      • Grimm P.
      • Billiet I.
      • Bostwick D.
      • et al.
      Comparative analysis of prostate-specific antigen free survival outcomes for patients with low, intermediate and high risk prostate cancer treatment by radical therapy. Results from the Prostate Cancer Results Study Group.
      The use of either LDR or HDR prostate brachytherapy decreases OTT compared with external beam standard fractionation and some hypofractionation schemes when used as a boost.
      • Williams V.M.
      • Kahn J.M.
      • Harkenrider M.M.
      • et al.
      COVID-19 impact on timing of brachytherapy treatment and strategies for risk mitigation.
      As monotherapy, HDR and LDR approaches have a shorter OTT than SABR, which is typically delivered in 5 to 7 every-other-day fractions.
      • Vargas C.E.
      • Schmidt M.Q.
      • Niska J.R.
      • et al.
      Initial toxicity, quality-of-life outcomes, and dosimetric impact in a randomized phase 3 trial of hypofractionated versus standard fractionated proton therapy for low-risk prostate cancer.
      Brachytherapy as monotherapy is appropriate for patients with low-risk or favorable intermediate-risk disease or as a boost in patients with unfavorable intermediate- and high-risk disease. When used as a boost for patients with unfavorable to high-risk disease, recent data from 2 prospective randomized trials have shown that brachytherapy significantly prolongs biochemical progression-free survival by >50% compared with dose-escalated external beam radiation.
      • Morris W.J.
      • 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.
      ,
      • Hoskin P.J.
      • Rojas A.M.
      • Bownes P.J.
      • Lowe G.J.
      • Ostler P.J.
      • Bryant L.
      Randomised trial of external beam radiotherapy alone or combined with high-dose-rate brachytherapy boost for localised prostate cancer.
      Furthermore, retrospective data also suggest that brachytherapy used as monotherapy for low-risk disease can prolong biochemical progression-free survival compared with either surgery or external beam radiation.
      • Grimm P.
      • Billiet I.
      • Bostwick D.
      • et al.
      Comparative analysis of prostate-specific antigen free survival outcomes for patients with low, intermediate and high risk prostate cancer treatment by radical therapy. Results from the Prostate Cancer Results Study Group.
      In addition, the median cost of prostate cancer therapy has been shown to be less with brachytherapy compared with either SABR, IMRT, or proton therapy.
      • Mahase S.S.
      • D'Angelo D.
      • Kang J.
      • Hu J.C.
      • Barbieri C.E.
      • Nagar H.
      Trends in the use of stereotactic body radiotherapy for treatment of prostate cancer in the United States.
      A 2013 study by Hayes et al found that brachytherapy was the most effective and least costly initial treatment option for men with low-risk prostate cancer, including men who chose active surveillance.
      • Hayes J.H.
      • Ollendorf D.A.
      • Pearson S.D.
      • et al.
      Observation versus initial treatment for men with localized, low-risk prostate cancer: A cost-effectiveness analysis.
      Fortunately, although older data suggested that treatment with prostate brachytherapy was declining,
      • Mahmood U.
      • Pugh T.
      • Frank S.
      • et al.
      Declining use of brachytherapy for the treatment of prostate cancer.
      this trend appears to reversing.
      • Corkum M.T.
      • Morton G.
      • Louie A.V.
      • et al.
      Is prostate brachytherapy a dying art? Trends and variation in the definitive management of prostate cancer in Ontario, Canada.
      Prostate brachytherapy is also useful in the setting of isolated intraprostatic recurrence after definitive treatment with radiation. A recent phase 2 trial, as well as several retrospective studies, demonstrated excellent rates of cancer-free and biochemical recurrence-free survival with brachytherapy and had acceptable, predominantly grades 1 and 2 gastrointestinal and genitourinary toxicity.
      • Aaronson D.S.
      • Yamasaki I.
      • Gottschalk A.
      • et al.
      Salvage permanent perineal radioactive-seed implantation for treating recurrence of localized prostate adenocarcinoma after external beam radiotherapy.
      • Yamada Y.
      • Kollmeier M.A.
      • Pei X.
      • et al.
      A phase II study of salvage high-dose-rate brachytherapy for the treatment of locally recurrent prostate cancer after definitive external beam radiotherapy.
      • Crook J.M.
      • Zhang P.X.
      • Pisansky T.M.
      • et al.
      A prospective phase 2 trial of transperineal ultrasound-guided brachytherapy for locally recurrent prostate cancer after external beam radiation therapy (NRG Oncology/RTOG-0526).
      Compared with other local salvage techniques, such as prostatectomy, high-frequency ultrasound, or cryotherapy, prostate brachytherapy has similar rates of biochemical control at 5 years with lower toxicity rates, such as incontinence and bladder neck stricture.
      • Parekh A.
      • Graham P.L.
      • Nguyen P.L.
      Cancer control and complications of salvage local therapy after failure of radiotherapy for prostate cancer: A systematic review.
      Prostate brachytherapy remains a viable treatment option for patients, provides excellent outcomes with acceptable toxicity, and is cost effective.

      Economic Considerations

      The use of hypofractionation in the United States has been increasing, leading to a decline in radiation oncology departmental revenue through reduced episodic fee-for-service reimbursement.
      • Moore A.
      • Stav I.
      • Den R.B.
      • et al.
      The financial impact of hypofractionated radiation for localized prostate cancer in the United States.
      ,
      • Konski A.
      • Yu J.B.
      • Freedman G.
      • Harrison L.B.
      • Johnstone P.A.
      Radiation oncology practice: Adjusting to a new reimbursement model.
      This trend coincided with a period of transition from volume- to value-based care. During this period, the total proportion of U.S. health care payments tied to quality- and cost-focused alternative payment models (APMs) increased from 23% in 2015 to 34% in 2017.
      Health Care Payment Learning & Action Network
      Measuring progress: Adoption of alternative payment models in commercial, Medicaid, Medicare Advantage, and Medicare Fee-for-Service programs.
      The shift to value-based care was further accentuated by the recent Radiation Oncology APM (RO-APM) proposal from the Centers for Medicare and Medicaid Services in 2019.
      Centers for Medicare and Medicaid Services
      Radiation oncology model 2019.
      COVID-19 has since accelerated the transition to extreme hypofractionation, including stereotactic radiation therapy and brachytherapy. After COVID-19, we anticipate the continued use of shorter treatment schedules and modalities that minimize patient exposure to high-cost hospital resources, postoperative care, or hospitalization. Brachytherapy is well-positioned to capitalize on these changes given its high value proposition. Most brachytherapy treatments can be delivered with minimal resources,
      • Williams V.M.
      • Kahn J.M.
      • Harkenrider M.M.
      • et al.
      COVID-19 impact on timing of brachytherapy treatment and strategies for risk mitigation.
      lower fully loaded treatment delivery costs via time-driven activity-based costing analyses,
      • Ning M.S.
      • Klopp A.H.
      • Jhingran A.
      • et al.
      Quantifying institutional resource utilization of adjuvant brachytherapy and intensity-modulated radiation therapy for endometrial cancer via time-driven activity-based costing.
      ,
      • Thaker N.G.
      • Ali T.N.
      • Porter M.E.
      • Feeley T.W.
      • Kaplan R.S.
      • Frank S.J.
      Communicating value in health care using radar charts: A case study of prostate cancer.
      or in alternative locations, such as ambulatory surgery or freestanding centers.
      • Tumati V.
      • Folkert M.R.
      • Lawson S.
      • et al.
      Remote location interstitial brachytherapy with patient stabilization and subsequent transport to an outpatient center for treatment is safe and effective for the treatment of gynecologic malignancies.
      As a low-cost modality,
      • Laviana A.A.
      • Ilg A.M.
      • Veruttipong D.
      • et al.
      Utilizing time-driven activity-based costing to understand the short- and long-term costs of treating localized, low-risk prostate cancer.
      brachytherapy can be associated with less patient coinsurance and copayment for patients who may be facing unemployment or reduced income, as well as loss of health insurance coverage. Despite these benefits, reduced physician reimbursement for brachytherapy has exacerbated a decline in revenues for practices that are already affected during the pandemic.
      American Society for Radiation Oncology
      ASTRO sends COVID-19 impact letter to Congress.
      This places radiation oncology practices at a further financial risk in an already high fixed-cost business.
      The adoption of the RO-APM may improve financial stability by providing episodic payments for disease site-specific radiation oncology care. These payments would be tied to average episode reimbursements rather than the volume or modality of service. This APM redesign appropriately attempts to incentivize shorter courses of low-cost, high-quality treatment (ie, brachytherapy). This change would also protect physicians from uncontrollable downside risks, such as from COVID-19, and provide financially stable payments to practices.
      However, despite these theoretical benefits, several key changes are necessary to the RO-APM to ensure sustainability of and access to radiation oncology care in the United States. A practice’s bundled reimbursement in the RO-APM will be closely tied to its historical reimbursements per episode of care. Practices that were early adopters of hypofractionation and high users of cost-effective treatments, such as brachytherapy (ie, efficient practices), will receive lower reimbursements than practices that have been slow adopters of hypofractionation or who have not used cost-effective modalities (ie, inefficient practices). The RO-APM also does not account for the cost of episodes of care that require combination modality therapies, including brachytherapy as a boost, and inadvertently incorporates palliative care episodes in the calculation of bundled rates. Solutions exist that can align incentives in the RO-APM toward high-value cancer care, including brachytherapy without unfairly penalizing efficient practices, which is a win for patients, providers, and society as a whole.

      Conclusions

      Brachytherapy is vital and irreplaceable for gynecologic malignancies, and results in excellent treatment and toxicity outcomes for breast and prostate malignancies. Brachytherapy is value-based and cost effective. The utilization of brachytherapy declined in the early 2000s, and has been associated with a decrease in resident brachytherapy caseload. The decline in residency brachytherapy training has been identified as a barrier to achieving brachytherapy competence and clinical independence.
      • Williams V.M.
      • Mansoori B.
      • Young L.
      • Mayr N.
      • Halasz L.M.
      • Dyer B.A.
      Simulation-based learning for enhanced gynecologic brachytherapy training among radiation oncology residents.
      In an effort to combat the decline in brachytherapy, some resident training centers have instituted brachytherapy simulation workshops to improve resident brachytherapy training,
      • Williams V.M.
      • Mansoori B.
      • Young L.
      • Mayr N.
      • Halasz L.M.
      • Dyer B.A.
      Simulation-based learning for enhanced gynecologic brachytherapy training among radiation oncology residents.
      ,
      • Zhao S.
      • Francis L.
      • Todor D.
      • Fields E.C.
      Proficiency-based cervical cancer brachytherapy training.
      and the American Brachytherapy Society has called for expanded training opportunities. The American Brachytherapy Society initiated a 10-year strategic program to address the declining rates of brachytherapy utilization, referred to as 300 in 10. The goal is to train 30 competent brachytherapists per year over 10 years through a multifaceted approach that includes developing a national brachytherapy curriculum, simulation-based medical education, 2-month fellowships for senior-level residents, a certification process, and maintenance of certification.
      Given preexisting inclinations for shorter radiation courses, a new radiation oncology normalcy will likely establish hypofractionated radiation as the standard of care across multiple disease sites. With shifting reimbursement, brachytherapy represents the pinnacle in hypofractionated, conformal radiation therapy, and with extensive long-term data in support of the treatment modality brachytherapy is primed for a renaissance.

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