In addition to its clinical benefits, the CyberKnife system has proven to be a powerful marketing tool for Winthrop University Hospital.

Jonathan Haas, MD, of Winthrop University Hospital is a proponent of the CyberKnife system.

In 2005, the radiation oncology department at Winthrop University Hospital, Mineola, NY, was looking for a “Jack of all trades” system to treat its patients.

So when Garry Schwall, Winthrop’s COO, decided to purchase a brand-new technology—a CyberKnife Robotic Radiosurgery system—that was much more specialized than what the radiation oncology department wanted, he not surprisingly received quite a bit of pushback.

What followed was a two-pronged campaign of salesmanship that had to win over both the clinicians and Winthrop’s board. Though an uphill battle, Schwall was ultimately successful, and Winthrop and its patients—particularly those receiving treatment for prostate cancer—have benefited from the COO’s willingness to take a risk and embrace a new technology.

Risky Business

Winthrop radiology oncology chief Jonathan Haas, MD, was planning to update the department. His plan was to find a solution that could do it all. “I couldn’t have been more wrong about that,” he said, reminiscing about the department’s pre-CyberKnife days.

At the same time, Schwall discovered CyberKnife through one of Winthrop’s neurosurgeons who was very excited about the technology. Unfortunately, Schwall and the neurosurgeon were about the only ones who saw the promise of the technology. For instance, Winthrop’s physicist couldn’t believe that the CyberKnife could operate at submillimeter level. His complaint? The CyberKnife was too accurate.

Haas was also among the skeptical, albeit open-minded, clinicians. That is, until he saw the CyberKnife in action at a nearby practice. He admits that he was converted during this visit.

Schwall’s hard sell of CyberKnife involved not only the clinicians but also the hospital’s board. However, he was able to show that the new modality had a good margin and planned a 2- to 3-year return on investment. “We were very conservative in our projections,” he said.

Having won over the skeptical clinicians and a hesitant board, Winthrop began construction on a new bunker to house the machine. The addition and the new system cost Winthrop about $5 million. There were some other expenses that Winthrop had to absorb as well. It cost about $5,000 per clinician to send them to a training site in California. (Winthrop has since become a training site itself.) “It was a risk, but not a major risk. If it hadn’t worked, it wouldn’t have been disastrous for us,” said Schwall.

In fact, Schwall greatly overestimated the risk. Winthrop was able to recapture its costs in about a year. And while much of this is a testament to the CyberKnife technology itself—it requires far less time and has far fewer side effects than conventional treatment—it is also a textbook example of how the business of medicine does not have to be at odds with the practice of it.

Schwall’s contract with CyberKnife maker Accuray included a provision that the company would not sell another system on Long Island for 2 years. This gave Winthrop the marketing edge it needed to reach potential patients. And while there are two more systems now in place on Long Island, Winthrop is the undisputed market leader, according to Schwall.

And CyberKnife isn’t just popular among patients. Haas and his colleagues have embraced the technology just as thoroughly as the patient population.

Anatomy of a CyberKnife

Accuray?s CyberKnife System suite.

While Schwall had sold Haas on the CyberKnife, it wasn’t until he was actually doing his first procedure that he had the “aha” moment that allowed him to see the potential of the technology.

This first procedure was a pituitary tumor, which Haas explains is a bad spot to perform radiosurgery. While the tumor can often be successfully destroyed via radiosurgery, it comes at a high cost—the patient’s eyesight. But, while Haas was nervous about the potential consequences for the patient, the clinical representative from Accuray was nonchalant. “He acted like it was nothing,” said Haas, who performed the surgery, removing the tumor and leaving the patient’s eyesight unaffected, which shows how accurate the new system was capable of being.

Among the most common radiosurgeries that Haas and his colleagues perform at Winthrop is that for prostate cancer. Haas explained that CyberKnife has several advantages over conventional treatment. First, the course of treatment is performed over 5 days and not 9 weeks as it is in conventional methods. Because it is radiating less of the rectum and bladder, there are fewer side effects, such as incontinence and impotence. According to the company, most patients experience a return to normal sexual activity with more than 90% of patients being able to maintain their erectile function a month post-CyberKnife. Less than 1% of patients have urinary incontinence. And there is no recovery time associated with the procedure, so patients can go back to their normal routine immediately.

The noninvasive system relies heavily on imaging technology, according to Haas, which is provided in real time, using marker seeds at the base and apex of the prostate, for instance, correcting the beam as the tumor moves. Haas says that much of his work is “marksmanship,” and the CyberKnife allows him to hit the bull’s-eye all the time.

One of the elements that allows Haas to have additional accuracy is the fact that the robotic arm has a structure similar to a human arm with a “shoulder,” “wrist,” and “finger,” giving Haas more flexibility as he is doing surgery.

For Schwall, the CyberKnife has been extremely reliable, and those few times when it has gone offline, Accuray has been able to fix it in just a few hours.

The system was down for about 6 weeks in 2010 for a scheduled upgrade, but because it was scheduled and the time from diagnosis of prostate and other cancers to treatment is a few weeks, it caused few headaches.

The result of the upgrade has been an even bigger boon for patients, clinicians, and administrators. Haas says that he can now perform prostate and other procedures significantly faster. For instance, what was a 2-hour prostate procedure in 2005 can now be finished in as little as 40 to 45 minutes.

But for all of the benefits of CyberKnife, Schwall is quick to note that it isn’t a panacea. “It’s a tool in the toolbox,” he said.

Haas noted that the treatment is most appropriate for a very specific tumor. If the cancer has spread, then the patient will have to undergo more conventional treatment. And at Winthrop, that means the patient has options. “The patient has access to every treatment under the sun,” he said. “Treatment is tailored for every patient. We look at what’s best for them—CyberKnife, brachytherapy, or surgery.”

While CyberKnife is undoubtedly of clinical benefit, Schwall did have trouble outside of Winthrop with a very specific group—payors.

Reimbursement Woes

In the earliest days that prostate cancer patients and others were being treated with CyberKnife, Schwall says that there were “a lot of denials.” The reason was that many payors saw CyberKnife as an “experimental” treatment.

But that has changed as the CyberKnife program has matured and the payors have become familiar with the technology. At Winthrop, those denials are much less frequent now.

One factor that may fuel the denials for prostate patients is that some urology groups—at least on Long Island—do not recommend the use of CyberKnife for cancer treatment.

Of course, there have been several developments in the intervening years. More clinicians are using the system, it is being used for more applications—Haas says that Winthrop will be treating breast cancer with it in the near future—and patients have discovered it on the Internet and are demanding it.

Probably the most important development is that the 5-year clinical data—the benchmark for the scientific efficacy or failure of a technology—has come out about prostate cancer. And Haas says that it is “predictably great.”

The Numbers Don’t Lie

According to a recently published study in the journal Radiation Oncology, 93% of patients had no recurrence of their cancer at a median follow-up of 5 years. This compares favorably to results obtained with other treatment modalities, including surgery and conventional radiation therapy.

Screening Saves Sisters

Since launching the ABUS breast screening program 3 months ago, Jefferson Radiology has found two mammographically occult cancers that would not have been found without ABUS. One month after a negative mammogram, Lisa, 44, had an ABUS exam that identified a 9 mm hypoechoic lesion. She was recalled for targeted handheld ultrasound for further characterization of the finding. This confirmed the presence of a suspicious mass, which biopsy revealed to be an invasive carcinoma.

Her sister was present for the exams and, though over the age of 40, had not yet had a mammogram. She later returned and had a mammogram and ABUS as a result of her experience. Both sisters felt very grateful for the technology and expressed that the process had helped them—we had a way to screen for cancer and found it. Both now recommend mammography and ABUS to friends and family.

Additionally, here are a few quotes from patient satisfaction surveys since we initiated the ABUS breast screening program:

  • I had a breast ultrasound and it was a totally pleasant experience. The technician was very friendly and courteous and I really felt like she wanted me to be comfortable. The room setup was also very pleasant and comfortable, almost spa-like.
  • I was fortunate to have the exam with the new automated breast ultrasound machine!

— J. Phillips, MD

The study, which followed 41 patients treated at California’s Stanford University and Naples (Florida) Community Hospital, found generally low levels of urinary and rectal toxicity following the 5-day course of CyberKnife treatment, showing that it can control the disease while sparing critical structures.

While Winthrop was not part of the study, according to Schwall, its system is among the busiest in the country, and is on track to treat 1,600 patients for all applications this year, up from 1,300 in 2010. According to Schwall, these Centers for Medicare and Medicaid Services (CMS) figures are the highest number of CyberKnife treatments in the country.

And the reason for this is simple: Winthrop has done a good job getting the word out.

Marketing Coup

Schwall used the first 2 years of market dominance to good advantage. The hospital launched a marketing campaign extolling the lack of sexual and urinary side effects with the CyberKnife.

As patients got to know about Winthrop, this marketing campaign changed, noting that the hospital has every prostate cancer treatment. There is also a campaign aimed at referrers as well.

But it was those 2 years that really gave Winthrop the edge. While there are two other CyberKnife systems on Long Island—as the numbers indicate—patients are more apt to seek out the services at Winthrop. “Patients want to be treated by who has done the most of these procedures,” said Schwall.

Popularity among patients, acceptance by clinicians, and a steady stream of reimbursements have made the CyberKnife system a big win for Winthrop. But there was one benefit that even Schwall didn’t anticipate.

Unanticipated Benefit

The CyberKnife system has been a big help in Winthrop’s ability to recruit and retain the best and the brightest, says Schwall. “We’re able to attract high achievers who want to be stimulated and challenged by the new technology,” he said. “That’s something we didn’t think about early on.”

One thing that he has anticipated is that this “tool in the toolbox” is becoming more entrenched as more and more health enterprises add it to their treatment options. He does anticipate that “every hospital is going to have one.”

C.A. Wolski is a contributing writer for Axis Imaging News.