The nuts and bolts of how RFA can enhance an interventional practice

Dr. Francis Facchini, an attending radiologist at Decatur Memorial Hospital and an assistant professor at Northwestern University's Feinberg School of Medicine, is one of three dedicated interventional radiologists performing radiofrequency ablation and other tumor ablation procedures in the hospital's cancer practice. He spoke to Diagnostic Imaging's Tumor Ablation Clinic about the practical aspects of incorporating RFA into a cancer practice and what role he expects the technology to play in the future.

Tumor Ablation Clinic: Describe how interventional radiology is incorporated into the cancer practice.

Facchini: We have three attending full-time interventional radiologists. Given the evolution of interventional radiology and the hypercompetitive atmosphere we're in, particularly in vascular disease, we have looked at reinventing ourselves, becoming more involved not only in the diagnosis of cancer but also the treatment. I think interventionalists throughout the country - in every aspect, not only cancer - are going from technician to clinician. It's a paradigm shift.

Francis Facchini, M.D.

The medical and surgical oncologists look at me as a member of a therapeutic team rather than solely a diagnostician. We have multimodality conferences, which I think are absolutely paramount to the practice. We actually sit in conference with these folks and discuss patient care case by case. Many times the referring physician is requesting RF, but perhaps the RF isn't the best thing. Perhaps it would be better to use a chemoembolization, a bland embolization, radiation.

Many options unrelated to RF can go with RF. As we open the door to becoming a clinician caring for these cancer patients, we may get a percentage of cases that are RF but significantly more become other things: malignant fluid management or palliative care options, for example. The fact that we go beyond RF is another aspect of the practice development. It builds your business tremendously to offer that soup to nuts approach to cancer care.

TAC: What are the economic benefits of incorporating RFA into your practice?

Facchini: It enhances the cancer practice incredibly. It allows you to keep patients within your practice or hospital who would otherwise go elsewhere. I think, ultimately, if you develop a good, strong practice, you can take care of more patients. It becomes a moneymaker, but I don't look at it that way. It's absolutely a necessity for a comprehensive cancer practice.

TAC: What sort of economic effect does RFA have on your practice?

Facchini: Interventionalists have been putting needles in places forever, and getting places with ultrasound or CT is not an issue. We also have access to these CT scanners and these ultrasound machines. They're already part of our practices, so to add them doesn't take any capital outlay. What really takes capital outlay is a generator. The generators are made by three companies - ValleyLab, Rita, or Boston Scientific - and can range in price significantly. The needles can also range widely in price. Often these companies can do leasing programs and such that can help decrease the exposure.

But in addition to the RF procedure, you have the halo effect: As you do interventional cases, it increases the amount of CT, the amount of MR, and the amount of ultrasound you do. If you make a dollar from RF, you make multiple dollars from the halo effect.

TAC: How easy is it to break even incorporating RFA into your practice?

Facchini: That's a difficult question, and there are many factors to go into. For example, the generator can cost as much as $30,000 to purchase, and the probes can cost from $1000 to $2000 apiece. I think, if you look at the procedure just in and of itself and say I'm only going to look at RF and the economics that are from RF, it's going to be 30 or more procedures annually. If you look at the halo effect, it's going to be a lot less.

But I choose not to look at that. I choose to look at the fact that it's an incredible thing for patients, and patients benefit. They tend to stay at our hospital as a result. When they stay at our hospital, our other doctors continue to take care of them. They don't go elsewhere.

TAC: How easy is it to get reimbursed for RF procedures?

Facchini: Until there are a lot of data it's hard, but we have a terrific billing company. I've had multiple one-on-one conversations because we do a lot of RF and a lot of palliative RF for debulking of disease. Because there's not much written on this, inevitably we get a significant amount rejected, about 50%. Once you have a conversation - and usually if the conversation is one-on-one between the physician reviewer and the doctor performing - it almost always gets approval.

When these physician reviewers talk to the patients and the patient says, "I couldn't breath, I couldn't walk, and now I'm feeling good," it's very hard to deny those payments. We've actually had very good reimbursement on case-by-case basis.

We fight for reimbursement, and we go through what we did with uterine fibrioid embolization or varicose veins or similar procedures we've done in the past. As an interventionalist, I'm used to that. We fight the varicose battle or the UFE battle on a regular basis. We're used to doing.

TAC: What sort of patients are you treating?

Facchini: Patients fall into multiple categories. The major categories are patients with nonsystemic, local disease that is small enough that it can be potentially eradicated by RF, and patients with systemic disease who have bulk-related painful symptoms. Most of these are high-risk patients who can't undergo a surgery, and they need some way to eradicate the tumor. RF as a means of debulking is gaining considerable promise as we move on.

TAC: How does the use of RFA break down in your practice?

Facchini: Probably 40% liver, 30% bone lesions, 10% lung, 10% kidney, and 10% skeletal, musculoskeletal, and soft tissue.

TAC: What proportion of your practice uses RF, and what proportion uses other IR methods?

Facchini: We're incorporating RF a lot more. I think it's growing. I would say it's probably 30%. What we're finding is that combined therapies are a real benefit. RF treats from the inside out and embolization treats from the outside in. You get that complementary effect.

We're doing a lot of vertebroplasty and kyphoplasty for spine metastases. We find that if you do RF, it really doesn't add much time, it adds no significant risk, and it has been very effective in pain control. Research still needs to be done with kyphoplasty and vertebroplasty alone versus kyphoplasty and vertebroplasty with RF to determine whether there's any change in symptomatic relief of these bony metastatic lesions. But we are at this point doing quite a bit of it, and trying to compile data to see if there is a difference.

I think there are going to be some exciting things happening. Some early interesting data have to do with whether RF potentiates external-beam radiation. I think we're just entering into what is an exciting part of radiology, specifically interventional radiology, with RF.

TAC: What's the best way to establish a practice that incorporates RFA?

Facchini: Most people who are going to have successful RF practices are going to have an emerging cancer program. Often folks don't recognize what they already have in the way of a cancer program because they don't look at biopsies and vascular access as an entree to the cancer practice. We often see cancer patients very early in their care because we biopsy them.

If you recognize what can and cannot be done with RF in an interventional oncology practice, and if you know what the indications and inclusions are for patients entering into an interventional oncology practice, you have an added opportunity because you see them very early. It places the impetus on the radiologist to become well versed in the issues surrounding medical and surgical oncology.

It think the easiest way to do it is the multispecialty collaborative approach, to have a relationship with your surgical and medical oncologist. If that is not possible, it becomes more of a challenge.

TAC: How are you getting referrals for RFA?

Facchini: We get some from my diagnostic imaging partners who understand what I and the other interventionalists can do. Others come from our medical and surgical oncology colleagues, general surgeons, and our diagnostic imaging guys who see cases and call the oncologist who referred them. Some also come from urologists and pulmonologists.

TAC: Is it practical to develop a practice around RFA alone?

Facchini: There's no such thing. I don't think that you can just do RF. You have to be comfortable doing biopsies and image-guided procedures. You should always have the ability to offer things other than RF, specifically the embolization techniques. These are often complementary, and the patients have better outcomes when you look at it as an approach using multiple techniques. You're going to find very few people out there who do only RF, and they're going to be at a university-based practice where one of their partners is doing the other things.

TAC: What about an outpatient practice?

Facchini: An outpatient type of practice is a much bigger challenge, because with RF you have issues postprocedurally having to do with pain control and inflammatory management. I generally like to watch these patients overnight, so I'm currently not in the point of my practice where I would do these as an outpatient.

TAC: But that is one of the selling points of RFA - that it is an outpatient procedure.

Facchini: There's a big difference between a 23-hour observation, which is technically outpatient, versus truly coming in the morning, doing it, and going home in the afternoon. There are some patients you can do that for. The percentage is probably less than the percentage of people who should just be watched overnight. As I evolve and get better and after I've done it for many years, I might move toward that.

TAC: What role do you expect RFA to perform in the next couple of years?

Facchini: It's gone from liver-directed therapy to multiple solid organs, from potentially curative to palliative also being a big part of it, from a stand-alone therapy to a therapy to be combined with multiple things, many of which are still being defined, like external-beam radiation. There's still a lot to be done here.