Running an interventional oncology practice: questions and answers

Radiofrequency ablation is a growing part of the practice established by interventional radiologist Dr. Paul Christy and his partners at Methodist Hospitals' Interventional Radiology Center in Omaha. Most of their RFA practice focuses on lung tumors, but they also treat tumors of the liver and bone. The 13-person group includes one part-time and two full-time interventional radiologists, as well as medical oncologists, radiation oncologists, surgeons, and other specialists.

Dr. Christy tells Diagnostic Imaging's Tumor Ablation Clinic how the practice got started, how group members made the case for tumor ablation to the hospital and their colleagues, and how they deal with patient care and reimbursement issues.

DI: How does your practice work?

Christy: At the lung cancer clinic, we meet every Thursday with thoracic surgeons, oncologists, interventional radiologists, general radiation, radiation therapy, and medical oncologists. We review the patient's films with pathology and decide what the best course is for that patient. For lung cancers, if they're not a candidate for surgery and it's a low stage Ia or Ib tumor, then we'll try RFA. We'll also try to give radiation therapy to patients who can tolerate it.

What inspired you to start using RFA?

Christy: I'd been reading about it quite a bit, and we have a busy oncology clinic, with two oncology groups that practice at Methodist Hospital. There were quite a lot of patients. We decided to talk to the hospital administration, and they were willing to participate. We looked at the different devices, selected one and bought it, and just started doing it. We now have the Boston Scientific and Valleylab systems.

Did you face skepticism from your oncology colleagues at the beginning?

Christy: Most of my colleagues pushed for it. The radiation therapists kind of look at us as being competition since they use a gamma knife or intensity-modulated radiation therapy. There's a little bit of resistance there. In general, the group overall prefers to treat any patient it can with RFA. Probably about half of the patients group members ask us to perform RFA on have a contraindication, and we recommend against it. If the tumor is too big or close to the heart, or if we're pretty sure there are mediastinal nodes, we won't treat them.

A lot of what we do depends on the whole hospital's culture: If you have a lot of aggressive oncologists, they're going to be calling you to do RFA. Moving a culture of an institution is like moving tectonic plates - it doesn't happen much. All you can do is educate them and have the service available for them. Once you get the patient referred, you can make the decision on whether to be aggressive.

How do you overcome the impression that you could be billing more if you were a diagnostician rather than performing ablation procedures?

Christy: If I sat around reading a stack of CT scans instead of doing a procedure, I could make more money. That's true of all interventional radiology now. We consider it part of our general radiology practice to have a strong interventional radiology section, regardless of what that pays. That can cause friction within a group because the group would rather have everybody making the most money they can, so I'm sure a number of partners would prefer that I just read chest x-rays instead of doing interventional radiology.

There's also the time spent tying up the CT scanner.

Christy: I think the hospital is kind of resigned to that fact as well. We have an older Philips single-channel spiral scanner with CT fluoroscopy, which is basically just an interventional scanner now. Now that the hospital has 64- and 16-channel scanners, nobody wants their patients scanned on that machine. Eventually, it will quit working, but by that point we'll have established the precedent of having a dedicated interventional scanner. Hopefully, it will stay that way.

Do you have a typical patient?

Christy: Our lung patients all have serious medical disease. They have bad COPD, so they're not surgical candidates, but they have limited cancer. Of everybody we treat for these low-stage cancers, I expect to cure about half of them. We have more than 50% local control, but 50% of the patients have progression of their disease elsewhere. Our patients' life expectancy is limited due to their medical disease. Usually, they still have fairly good quality of life and are still active. For the liver, for metastatic disease, our expectations aren't quite as high, but we're still hoping to have long-term disease-free survival in about 25%.

We also use RFA to treat pain. RFA is a great treatment for pain from malignancy. If a tumor is in the lung and up against the chest, patients can be made pain-free the day of the procedure. At our place, most of those patients end up getting referred to radiation oncology. We're looking at educating people about the value of palliation, but it's been slow going. Most of our patients are older than 65. Probably about 10% are younger than Medicare age.

Do you have a problem making the case for RFA with patients?

Christy: We don't have to sell anything, because patients want whatever can be done for treatment of their disease. Probably 10% of them are self-referred.

How did you explain the procedure to your patients, especially when you were first starting out?

Christy: When we first started doing RFA and didn't have a lot of experience with it, we'd tell patients that it uses techniques that are well established, that we've been using for years. As my partner says, these are new applications of old techniques. We don't know for sure know the outcome, and we tell them that. We tell them we'd like to achieve approximately 80% local control in 80% of the patients. That may take more than one treatment session, and a few of them have taken two or three. We have to be careful to select patients we think we can help. The only ones I treat now are the ones where I think we have a good chance of either totally eradicating all of their disease or palliating them and relieving their pain.

Describe the way you handle patient care issues.

Christy: You have to see the patients yourself, take care of them when they're in the hospital, and arrange all of their follow-up. That's the bare minimum. You have to provide very good service. If you don't provide the service, you'll be losing from the start. That's just expected.

We generally see people on an outpatient basis. We talk to them, examine them, tell them what they're in for and what they can expect. We make sure we have very recent imaging. We do all our cases under general anesthesia. I think most places probably use conscious sedation, but general is easily available for us and we think it's superior to not have the patients moving, to not have them in any pain. We usually have patients stay overnight, even though some of them could probably go home the same day. There are some that have to stay more than one day, either for pain control or pneumothorax, but almost everyone goes home the next day.

Have you had any problems with reimbursement?

Christy: The ones that are Medicare age and older have been no problem. We've had some problems with patients younger than Medicare age. We've had a number of insurance companies that refused to pay even after precertification. Blue Cross Blue Shield, for example, considers RFA investigative. I pointed out that Medicare pays for it, and they replied that just because Medicare pays for it doesn't mean it's right.

Younger patients tend to be ones who have metastatic disease, and we're being very aggressive with them. I guess it could be considered investigational in some patients, but these are the patients you don't want to send home and say there's nothing I can do for you. If you have a chance of giving some kind of control for them, you want to take it even if it's a smaller chance.