Infrastructure and Economics

By Catherine M. Tuite, MD

Establishing a successful, economically viable interventional oncology practice is important to both interventional radiologists and radiology departments. Cancer is obviously a ubiquitous disease, and all radiologists and interventional radiologists treat it to some extent. The level of service provided, however, varies widely from one physician or group to another.

Interventional radiologists establishing an interventional oncology service must first decide on the level of service that they wish to provide. At level I, little longitudinal care is offered; the practice concentrates on providing venous access and similar services. At level II, intermediate services that require some longitudinal care are available; one example is biliary drainage, where the patient is followed in the hospital, but office follow-up care and long-term planning usually are not offered. A level-III interventional oncology service offers advanced services and assumes extensive longitudinal care. This is the level of practice at which ablation and embolization typically are offered, along with long-term follow-up care in an outpatient office setting and hospital care provided as the admitting physician.

Infrastructure Needs

To institute a practice at level III, one must develop a multidisciplinary team that extends beyond the department to include the hospital’s referring physicians. Scientific knowledge that allows productive discussion with medical and surgical oncologists will be required, and the service also must be committed to doing a great job at providing a full range of treatments.

A clinic or office practice is not part of most radiology practices and departments. Certain additions will be needed for interventional radiology; these include physical space, support staff, and some means of documentation of visits. A reception area and a waiting area will be needed, along with private, individual rooms where patients will be seen and areas where patients and physicians can discuss the plan of care. A space for patients to review billing and payment information also will be required.

Levels of Interventional Oncology Service

Level I. Limited longitudinal care is provided. Practice concentrates on venous access and similar services.

Level II. Intermediate services requiring some longitudinal care are offered.

Level III. Advanced services are offered, such as ablation and embolization, and the practice assumes responsibility for extensive longitudinal care.

Patients expect these spaces to look like the physicians’ offices with which they are familiar, so a small room adjoining a procedural suite will not be adequate. Likewise, they expect the interventional radiologist to dress as a physician in an office would; it is best not to arrive directly from, and still dressed for, a procedure. Even if dedicated clinic time is not initially feasible, it is an attainable goal for which the practice should strive.

In hiring support staff for the practice, be certain that the first person encountered by most patients, the receptionist, is prepared to facilitate care (not to obstruct it). Secretaries will be needed to set up appointments, clinic schedules, and procedure schedules, as well as to transcribe office notes. Dedicated schedulers can handle precertification for procedures and can put demographic information into the appropriate information systems.

A good medical records system will help the interventional radiologist talk to referring physicians productively, and patients should be reminded to bring their previous records and images to their first visit. Billing and reimbursement criteria also will be met more easily if the patient’s record is complete and accessible.

In addition to using the usual Web sites, brochures, and direct advertising to promote the practice, it is important to attend weekly tumor review boards with physicians from all relevant disciplines. This not only enhances referrals, but it also can improve the patient’s overall care through improved coordination of services.

Economic Factors

Even if the reasons for being an interventional radiologist are not financial, finances are still important to any practice. It is a fact of life that the practice’s activities must be supported financially if they are to continue. Alignment of the incentives of all involved can be ensured through the adoption of a team approach to interventional procedures. This is especially important to oncologists, who are referring more and more patients for image-guided interventions.

It is an unfortunate fact that most radiology departments do not support a clinical practice for their interventional radiologists. Less than half of radiology groups now support an interventional clinical practice or provide office space for their interventional radiologists to see patients. Of the groups that do support interventional practices, about three fourths provide support personnel, but only about two thirds provide interventional radiologists with the time needed to see patients.

Clearly, some radiology groups need to be informed that a major portion of the practice’s revenues can come from referrals for interventional radiology. The average downstream Medicare professional reimbursement that an interventional oncology patient can generate is considerable; chemoembolization patients, for example, generate downstream reimbursement of roughly $13,500, including procedures, imaging, and office visits.

Billing for patient evaluation and management should include outpatient visits as well as rounds conducted within the hospital. In our practice, we attend rounds with a physician assistant every day; every patient seen is an evaluation and management encounter. We began billing for these encounters between 2004 and 2005, and this source of revenue has been significant. We billed for 904 visits in 2004, most of which were outpatient encounters. In 2005, we billed for more than 2,000 evaluation and management encounters because we included inpatient rounds. The charges billed for evaluation and management ranged from $30,000 to $260,000 per physician.

Clearly, interventional radiologists continue to practice for more than the money that they gain. Some of the nonfinancial reasons to support an interventional service are to gain name recognition and branding, to be acknowledged as experts in oncology, and to have the personal satisfaction of taking care of one’s own patients (including having an admitting service and managing difficult cases).

In addition, interventional oncology services might be part of strategic positioning to gain a competitive advantage over other specialties, if that is important to one’s practice. Having a clinical practice and being a source of referrals to the radiology department brings the needs of the interventional radiologist into alignment with those of the department. Because the needs of the patients are better served through the same alignment, this constitutes a recipe for all-around success.

Catherine M. Tuite, MD, is an interventional radiologist. This article has been excerpted from “Infrastructure and Economics of an Interventional Oncology Practice,” which she presented at the 31st annual scientific meeting of the Society of Interventional Radiology, April 4, 2006, Toronto.

Understanding the Oncology Patient

By Riad Salem, MD,MBA,FSIR

From an interventional oncologist’s perspective, that is, from the perspective of an interventional radiologist who is focusing on image-guided oncology therapies, the assessment of the oncology patient is much different than any other. This patient and their family will be entering a long-term relationship with the treating interventional oncologist. The patient will have many questions, and the interventional oncologist will need not only to answer them, but also to initiate communication with the patient’s referring physicians. This differs from the relationship established with patients receiving technical interventional radiology, for example.

Oncology patients have issues that are chronic in nature. As a result, the treating physician needs to be well versed in these issues as well as those that may affect the quality of life. Patients that are end-stage patients will not be in favor of therapies that might adversely affect their quality of life.

Gathering Knowledge

A thorough history of the patient’s surgical and chemotherapeutic procedures is needed, since interventional therapy could increase the toxicity of the drugs and procedures that the patient has already received. The patient’s comorbidities also must be understood if therapy is being considered. Review of prior imaging studies is important, and assessment of therapeutic options is vital.

It is necessary to be familiar with the standard of care for each type of cancer, since this will be helpful in understanding the physical consequences of the patient’s prior treatments. For example, many chemotherapeutic agents are hepatotoxic, so liver function may be abnormal in some oncology patients. Interpretation of liver-function tests will be called for before and after therapy in all cases. Metabolic abnormalities that alter these test results, but do not reflect intrinsic liver failure, also may be present.

Oncology patients often will have completed a significant amount of research on their medical condition. Hence, these patients will ask questions covering all facets of their research and assess whether any of their findings might relate to them. For this reason, it is necessary to remain well versed concerning new, innovative options that might be available and to stay up to date as experimental studies are released. The interventional oncologist often sees end-stage patients, and a realistic approach to setting goals for their treatment is needed as well.

Riad Salem, MD, MBA, FSIR, is director of interventional oncology in the Department of Radiology at the Robert H. Lurie Comprehensive Cancer Center of Northwestern Memorial Hospital, Chicago. This article has been excerpted from “From Caring to Cure: Initiating a Practice/Uniqueness of the Oncology Patient,” which he presented at the 31st annual meeting of the Society of Interventional Radiology, April 4, 2006, Toronto.

Applying Therapeutic Algorithms

By Michael C. Soulen, MD, FSIR

Although liver cancer is being used as an example here, the application of therapeutic algorithms to other interventional oncology cases follows the same general approach. It is important to keep the big picture in mind. For patients who present with hepatic malignancy, it is usually not possible to provide a cure outside of transplantation or resection. The usual mode of death is liver failure, therefore, the interventional oncologist’s goal is to prevent intrahepatic tumor progression. Despite the lack of curative interventions, many forms of therapy can be used, singly or in combination, to preserve liver function by keeping the tumor burden from progressing (or, perhaps, by reducing it). Doing so may preserve the patient’s quality of life and may extend life over the course of this disease.

Treatment Categories

A patient with a hepatoma will fall into one of three categories. The least common patient has a resectable tumor that is not only able to be removed, but is situated in such a way that the underlying liver can tolerate its removal. Patients with underlying cirrhosis, for example, may be unable to tolerate removal of even the smallest tumor. If resection is possible, it is ideal, and the patient should be referred for surgical consultation.

Patients with a single tumor less than 5 cm in diameter, or two to three tumors with diameters of less than 3 cm each, may be transplantation candidates, depending on other factors. If the facility is not a transplant center, this type of patient should be sent to one. Transplantation waiting times can be highly variable according to region. If a long wait is likely, neoadjuvant therapy (embolization, ablation, or both) can be performed. This is intended to prevent tumors from progressing beyond the size at which transplantation is permitted while the patient waits for a donor organ.

In our practice, patients whose tumors are less than 2 cm in diameter are usually watched, without treatment; hepatomas may remain stable in size for up to 1 year. Close observation is required, but the need for intervention is not urgent. Imaging and clinic visits are scheduled every 3 months so that no progression can go unnoticed.

Most of the patients seen for hepatoma will be candidates neither for resection nor for transplantation. For these patients, interventional oncologists will be providing the primary modes of therapy. Cancer stage, performance status, and liver function should be reviewed to determine whether any therapy is likely to be useful.

Candidates for therapy may be offered percutaneous ablation if their tumors are smaller than 3 cm in diameter and are not numerous. Embolization followed by ablation may be chosen for tumors of 3 to 8 cm. If the patient’s tumors are large, diffuse, or multifocal, catheter-directed therapy may be best. In patients with advanced cirrhosis (Childs C) or late-stage cancer (Okuda III), therapy is unlikely to improve survival and may make quality of life significantly worse. In such cases, it is best to recommend no treatment and to give end-of-life counseling instead. This is especially important because hepatoma patients often have no other oncologists involved in their care, so this counseling might be available from no one else.

Michael C. Soulen, MD, FSIR, is professor of radiology and surgery in the Division of Interventional Radiology at the University of Pennsylvania, Philadelphia. This article has been excerpted from “Treatment Algorithms for Hepatic Malignancies,” which he presented at the 31st annual scientific meeting of the Society of Interventional Radiology, April 4, 2006, Toronto.

Imaging Before and After Treatment

By Reed A. Omary, MD, MS

Interventional radiologists must be concerned with the multiple imaging measures of a tumor’s response to treatment. Reduced size, of course, is accepted as improvement by everyone, but there is also a need to assess necrosis. Imaging is a surrogate way of defining the pathology that is present. Anatomic response is the most common means of assessment; it involves measuring the longest (largest) diameter of the tumor before therapy and following it over time. Response Evaluation Criteria in Solid Tumors (RECIST), familiar to oncologists, is the method of measurement used in most clinical trials. Another method, used by the World Health Organization (WHO), tracks the product of the two largest diameters; necrosis or volumetric data also can be used. CT and MRI studies lend themselves to volumetric calculation, which seems more accurate than the one-dimensional RECIST or two-dimensional WHO methods. Functional indicators (such as necrosis) are considered secondary to anatomic indicators in evaluating the results of treatment, but this can lead to some inaccuracies.

Multimodality monitoring of tumor response is becoming very useful. Modalities need not be combined simultaneously in order to yield helpful information, and scans may take place some time apart using different modalities.

Modality Strengths

Catheter-directed CT angiography is an easy, elegant technique that determines the blood supply of the tumor. A microcatheter is placed in the targeted vessel, iodinated contrast is injected, and the results indicate not only the tumor’s blood supply, but which areas would be affected by catheter-directed therapy delivered using the same vessel.

Ultrasound is an excellent modality for imaging guidance, but a poor one for follow-up, since lesions can be missed. Any visceral x-ray digital subtraction angiography should be preceded by an initial aortogram for vessel and variant awareness. Rotational 3D angiography is recommended, if available, because it provides good images of vascularity and tumor location. CT is an easy-to-use modality, and quality is less variable than that of MRI. As positron emission tomography (PET)/CT units become more available, the role of CT for follow-up will continue to grow. Intra-procedural CT also is helpful when a catheter is in place.

MRI is subject to tremendous variability in quality. It is a good tool for viewing metastatic disease in the abdomen and the best way to evaluate liver anatomy. PET is excellent for evaluating metastases or primary lung cancer. Just as there are multiple tumor therapies, there are multiple imaging modalities that are useful in tumor-response assessment.

Reed A. Omary, MD, MS, is associate professor at Northwestern University Feinberg School of Medicine, Chicago. This article has been excerpted from “Importance of Pre- and Post-Imaging,” which he presented at the 31st annual scientific meeting of the Society of Interventional Radiology, April 4, 2006, Toronto.

Continuity in Follow-Up Care

By J.F. Geschwind, MD

A comprehensive continuum of care is important because interventional oncology is trying to find a place similar to that occupied by medical and surgical oncology. Over the past decade, interventional radiologists have found better ways to provide patient care and, in so doing, have clearly established the survival benefit conferred by interventional oncology.

Continuity of Care Steps

  1. Initial diagnosis and therapy plan.
  2. Treatment.
  3. Follow-up care.
  4. Inpatient admission and care.
  5. Consultation.

Interventional oncologists must provide follow-up care, with the intent of ensuring that disease does not recur undetected. The need for continuing care has increased over time, creating some burden on practice paradigms because radiology services are not typically set up to handle problems related to patient care.

In interventional oncology, it is critical to establish a continuum of patient evaluation and management. This represents a commitment to patient care, and it requires a team approach. It is critically important to have the necessary space and support from the department to provide ongoing care.

Steps Within the Continuum

Much like a surgeon, the interventional radiologist provides continuity of care by handling the initial diagnosis and therapy plan, the treatments themselves, follow-up care, inpatient admissions and care, and consultations.

It is vitally important to be involved in multidisciplinary meetings, such as weekly tumor boards. This involvement improves the visibility of the service, and it also helps the interventional radiologist know when to say no to proposed therapies that are unlikely to be beneficial. Interventional radiologists generate referrals to other services for management (including transplantation and systemic chemotherapy), so these specialists will realize that referral is a two-way street.

Most of the patients seen at our facility are treated with chemoembolization. For this example of a patient with liver cancer, continuity of care begins with the receipt of the patient’s images and laboratory assessments. Based on these, some preliminary approaches—such as radiofrequency ablation, chemoembolization, or radioembolization—are considered. If the patient is a candidate for treatment, an appointment is then made for the initial clinic visit and consultation. If a procedure is scheduled, then it typically is performed as soon as possible, since time is of the essence for these patients. The patient is admitted overnight, and postprocedural imaging and laboratory work are performed.

Building Relationships

At this point, the relationship that the interventional radiologist establishes with the patient really begins. It usually ends only with the patient’s demise. Follow-up visits and frequent reassessments are scheduled to make sure that the disease is constantly monitored for stability. At the first sign of disease progression, repeat treatment or referral for other therapies takes place.

At all stages along this continuum, interaction and communication with other specialties are vital. The role of physician assistants and nurse practitioners should be emphasized, as well; in our practice, they provide 90% of the continuity of care, from the initial history and physical examination through the entire process.

For a comprehensive continuum of care, the patient must have no unresolved problems or unanswered questions. Make as much time available as possible to answer the patient’s questions, and be sure to explain every step in the treatment plan.

J.F. Geschwind, MD, is associate professor of radiology, surgery, and oncology, and director of vascular and interventional radiology at Johns Hopkins University School of Medicine, Baltimore. This article has been excerpted from “Providing Continuity in Follow-up,” which he presented at the 31st annual scientific meeting of the Society of Interventional Radiology, April 4, 2006, Toronto.