Building the Practice

Interventional oncology is the fastest-growing area of interventional radiology and becoming an increasing revenue generator for health care institutions.

Interventional oncology constitutes a minimally invasive approach by which image-guided therapy is delivered to patients with solid tumors. The field dates back to the 1960s and 1970s. Chemoembolization?an image-guided approach used to block the tumor?s blood supply and deliver chemotherapy?dates back to the 1980s in Asia, where liver cancer is highly prevalent.

The field of interventional oncology is displaying explosive growth. Many educational and communication efforts serve to advance awareness of its value for cancer patients. Moreover, recent strides made in interventional oncology are greatly facilitating patient care, improving outcomes, and making a positive impact on the business of hospitals and medical institutions.

A Managing Role

Michael C. Soulen, MD, professor of radiology at the Hospital of the University of Pennsylvania, Philadelphia, recalls the early days of interventional radiology when he was undergoing his residency training. ?At that time, the primary mode of practice was for the medical or surgical oncologist to manage the patient,? said Soulen. These doctors were the leading physicians who would request specific procedures from the interventional radiologists, who served as proceduralists with a supportive role only.

Soulen was one of the first interventional radiologists to actively manage patient care. ?My own training was in the model of the interventional radiologist as a clinician.?

Soulen commenced his position at the University of Pennsylvania in 1991, when interventional radiologists did not admit patients routinely. Soulen started the practice of admitting, consulting with and following patients. He engaged in collaborative relations with other oncology specialists utilizing a multidisciplinary approach. It was this relational framework that served as a major foundation for the growth of the interventional radiology practice at the University of Pennsylvania. By 2002, 45% of billing was coming from the interventional radiology practice. ?Eventually, we had four or five interventional radiologists admitting 300 patients a year. Now well over one half of our business comes from our practice.? Currently, Soulen focuses primarily on oncology, and refers other types of cases such as patients with fibroids to other interventional radiologists.

Research and Clinical Trials

Experts emphasize that building a strong interventional oncology practice often hinges on focused research efforts and involvement with clinical trials.

Interventional radiology procedures that are useful for targeting malignant tumors include chemoembolization, as well as ablative techniques such as radio-frequency ablation (RFA) or ablation using heated probes or cryogenic probes. One of the systems for RFA is the Leveen probe from Boston Scientific. This device was invented by Robert Leveen, who had conducted his research at the University of Pennsylvania. RFA is useful for eliminating small tumors (<3 cm in diameter) of the liver, kidney, lung, and bone. This probe is delivered in a manner that is similar to that of a biopsy needle. In the early 2000s, yttrium-90 labeled embolization particles began to be employed. The University of Pennsylvania had been involved with clinical trials in primary liver cancer.

William Rilling, MD, FSIR, director of vascular/interventional radiology and professor of radiology and surgery at the Medical College of Wisconsin, Milwaukee, discussed what is being done to actively build the practice in his institution. Rilling emphasized the importance of interventional radiologists playing a managing role, acting as a key input source for referral to other specialists. ?Having that presence has been critical for us to be able to grow the practice and develop treatment algorithms that have become standard within the institution,? said Rilling.

These developments are complicated, requiring cooperation of multiple disciplines within the institution. Medical devices need to be purchased by the institution, and personnel require training for their correct use. Furthermore, reimbursement needs to be monitored. ?That infrastructure has to be built in order to do a good job with building the program,? said Rilling. At the Medical College of Wisconsin, physicians participate weekly in five different multidisciplinary tumor boards that are all subspecialty focused: thoracic, pancreatic/biliary, hepatic, GI/colorectal, and musculoskeletal groups. Each of these groups includes surgical, medical, and radiation oncologists. The teams of experts determine the course of care for the patients. Rilling noted that liver cancer (primary and metastatic) represents the most common tumor type seen within the institution, followed by kidney cancers. As a result of CT scans, a lot of kidney cancers are being detected and treated early on an outpatient basis with percutaneous cryoablation.

Educating Physicians and Patients

A number of professional organizations are devoted to educational efforts that build awareness of interventional oncology. The Society of Interventional Radiology (SIR) is a national organization of physicians, scientists, and allied health professionals who are devoted to improving public health through disease management and minimally invasive, image-guided therapeutic interventions. SIR President James F. Benenati, MD, FSIR, medical director of the Peripheral Vascular Lab at the Baptist Cardiac & Vascular Institute in Miami, emphasized that SIR has made a major commitment to education. ?The annual meeting is devoted to covering interventional oncology in depth,? said Benenati. Part of the educational mission is to help interventional radiologists promote their field within their own institutions. Dedicated sessions are held on market building, and active campaigns help physicians market their practice. ?By writing standard policies and procedures jointly with other specialties, we foster collaborations with oncologists and other specialists so we can work well together,? commented Benenati.

Benenati believes that interventional oncology is a natural extension of the interventional radiologist?s role and that development of the field is critical. Interventional radiologists ?need to be able to understand the disease process and therapeutic options, and know how to manage the patient as it relates to the procedure they are performing. They need to give the patient an ability to make an informed decision.?

Benenati is a co-course director for the Congress on Interventional Oncology (CIO), which is a dedicated meeting providing continuing medical education for practicing interventional radiologists that offers ?practical clinical information.? According to Benenati, ?CIO has a well-known, internationally respected faculty. It utilizes a didactic approach, and takes advantage of interactive polling and case presentations.? The meeting reinforces the minimally invasive approach of interventional oncology, allowing patients options that otherwise would not be available.

CIO is held over the weekend immediately preceding the International Symposium on Endovascular Therapy (ISET) so that CIO will get attention. Attendance has grown in the past 2 years, and has almost doubled in a year.

The World Conference on Interventional Oncology (WCIO) is a 4-day annual meeting that travels around the world to bring together all of the specialties?interventional radiology, medical and surgical oncology, radiation, and gastroenterology?with a complete devotion to the science and technology of image-guided cancer therapy. The 6th annual meeting of WCIO will be held this month in Philadelphia. Inspired by WCIO, the European Conference on Interventional Oncology (ECIO) meets in Europe every 2 years.

Educating patients about interventional oncology is equally important in building the practice. A wealth of information is available online for patients, promulgated not only by the societies but also by individual hospitals and practices. Furthermore, manufacturers of ablation devices develop educational Web sites and materials directed toward patients to increase awareness of interventional oncology procedures as well as their own brands. Several medical centers offer education days for various disease states as part of an institutional outreach effort aimed at the community. The team of physicians who treat a particular disease give lectures to patients and their families. An example includes gastrointestinal (GI) cancer day at the medical center of the University of Pennsylvania. All of the GI cancer experts gather to present to patients and their families and to answer their questions.

Promoting the Value of the Field

At the SIR annual meeting this year, a major effort was devoted toward helping hospital administrators understand the value of interventional oncology in terms of increased patient throughput, reducing the need for major surgeries, and shortening hospitalization times by providing high-quality care on an outpatient, minimally invasive basis. According to Benenati, ?We actually have program-directed content directed at the hospital administrators to help them understand the value of interventional oncology.? This year approximately 50 hospital administrators attended free of charge.

Rilling spoke at the SIR Annual Meeting this year about how interventional radiologists can work with the administration toward optimizing the practice. ?We have to be on the same page in order to succeed,? said Rilling. An important example of how an interventional radiologist markedly improves the quality and efficiency of patient care is the management of patients who are receiving chemotherapy. Drug delivery often requires a Hickman catheter, a chest port, or a venous access port. ?In the old days, you had to consult a surgeon, wait for an appointment with the surgeon, and wait for surgery.? This approach could create a delay of weeks, whereas now an interventional radiologist can be scheduled within 24 hours and chemotherapy can be administered the same day.

When assessing the value of the interventional oncology practice, Rilling emphasized that looking at the contribution margin of an individual procedure only is a shortsighted analysis. It is important, rather, to consider the entire picture of building the overall volume of cancer patients into the hospital who otherwise might not be treated there. Furthermore, downstream revenue is generated from imaging tests. For example, neuroendocrine tumor patients such as those with carcinoid survive quite a long time. ?It could be 5 to 7 years that we follow these patients, and 40 to 50 of these patients represent a lot of revenue to the hospital,? said Rilling. By having the interventional oncology infrastructure in place and offering treatments that are not available elsewhere, the Medical College of Wisconsin is seeing a rapid growth in outside referrals as well as increased business within the institution.

Hospital administrators need to be made aware of reimbursement issues, too. Soulen finds that there are ?tremendous vagaries with reimbursement for the different types of procedures.? Furthermore, much variability exists in approaches depending on the insurance company and the state. Soulen discussed a specific insurance company that would not reimburse in Pennsylvania for almost any procedure for a particular type of cancer. ?It is a huge challenge for us in terms of the major therapeutic procedures we do and the insurance coverage and reimbursement,? said Soulen. ?From the patient standpoint, it is definitely a barrier to access to care.?

The Future of the Practice

So what?s next for interventional oncology? Rilling emphasized that the business generated from interventional oncology grows by marketing and by conducting clinical trials. Reimbursement is tied to clinical results. Furthermore, when patients run out of known treatment options, they are given new hope in a clinical study utilizing a novel therapeutic agent or approach. According to Rilling, these trials are especially important for medical oncologists whose patients have run out of medical treatment options. ?It?s the right thing to do.? The interventional radiology department employs their own dedicated research coordinator. ?The trials also drive patients to the institution,? said Rilling. About half of the trials are investigator initiated and the other half originate with industry sponsors who manufacture devices as well as with cooperative groups such as the Eastern Cooperative Oncology Group (ECOC).

Stephen B. Solomon, MD, chief of the Interventional Radiology Service in the Department of Radiology at the Memorial Sloan-Kettering Cancer Center (MSKCC), New York, commented that ?Advances in imaging and advances in device development are allowing the use of sophisticated imaging to see inside the patient and avoid surgery. And advances in tool design allow us to destroy tumors without having to remove them. So the whole field of image-guided interventional oncology is a technology-based one that is blossoming.? On June 7, the Center for Image-Guided Intervention (CIGI) will open at MSKCC, and Solomon will serve as its director.

---

Chip Reuben is a contributing writer for Axis Imaging News.