•BULLETIN•

Volume 18, Number 1 | Winter 2011

•BULLETIN•

INSIDE THIS ISSUE

Policy Updates p 7

BU L L E T IN W W W.A C R O.O R G • 1

ACRO is Your OrganizationHelp it

Thrive!To become a member or to sign up a friend, please contact the ACRO office at (301) 718-6515.

ACRO Accrediation p 9 ACRO Membership Benefits p 12

Breaking Bad News . . . . . . . . 2

ACRO WELCOMES NEWMEMBERS!. . . . . . . . . . . . . . . . 3

Re-analyzing the ‘Rationed-Care’ Debate . . . . . . . . . . . . . 4-5

Headlines 2010-2011 . . . . . . . . 6

Radiation Oncology PolicyUpdates . . . . . . . . . . . . . . . . . . 7

ACRO Accreditation. . . . . . . . . 9

Letter from aPatient’s Daughter . . . . . . . . 10

Book Review . . . . . . . . . . . . . 11

Enjoy the Benefits ofACRO Membership . . . . . . . . 12

Mark Your Calendar . . . . . . . . 13

SDRT Subject of Oration inRadiation Oncology . . . . . . . 14

2011 Advertising Rates . . . . . 15

THERAPEUTIC BURDEN ON PATIENT

COMPROMISES HEALTHCARE EFFECTIVENESS

Note:The views expressed in the article are not necessarily those of the American College of Radiation Oncology.

The days when a physician could tell a patient, “Take this pill and call me in themorning,” are long gone, if they ever existed at all. Now, chronic illnesses may require anumber of treatments. According to Carl May, MD, at Newcastle University; Victor M.Montori, MD, at the Mayo Clinic; and Frances S. Mair, MD, at the University of Glasgow, thisresults in “poor patient adherence, wasted resources, and poor outcomes.” Therefore, thethree physicians called for “minimally disruptive medicine” in an article they wrote for theBritish Medical Journal (29 August 2009 issue).

No longer is healthcare mainly focused on cure of acute disease but has transitioned tomanagement of chronic disease. This latter situation requires continual patient responsibilityfor care.

Studies show that many patients do not follow treatment instructions because they“lack the capacity, skills, or understanding.” In one study by Barber et al (2004), nearly halfthe patients failed to follow treatment guidelines.

Reports (Wolff et al., 2002; WHO, 2003) show that >60% of older people have multiplechronic conditions. But the authors believe most research has overlooked patients who areunable to adhere to therapeutic regimens due to cognitive impairment or chroniccomorbidities. Additionally, in the name of containing healthcare costs, complex chronic-disease management is shifting from the hospital to the home, transferring much of theburden of treatment from medical professionals to the patient and the patient’s family. Alongwith treatment, this includes scheduling multiple visits to undergo tests or see physicians,

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EDITORIAL

2 • WWW.ACRO.ORG BULLETIN

ACRO BULLETIN

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Comprehensive socioeconomic, political, and professional news affecting the daily practice of radiation oncology

Editor A. Robert Kagan, MD

Chairman Louis Munoz, MD

President Michael Kuettel, MD, PhD

Vice-President J. Michael Kerley, MD

Secretary/Treasurer William Rate, MD, PhD

Executive Director Norman Wallis, PhD

Managing Editor Stuart J. Birkby

Published: Winter • Spring • Summer • Fall

The ACRO Bulletin welcomes letters, comments, sug-gestions, and submissions of articles for consideration.The Bulletin reserves the right to edit letters for clarity

and length.

The opinions and views expressed in the Bulletin are not necessarily those of the

American College of Radiation Oncology.

Please send your correspondence to:

A. Robert Kagan, MDEditor, ACRO BulletinAmerican College ofRadiation Oncology

5272 River Road, Suite 630Bethesda, MD 20816

(301) 718-6515 • www.acro.org

•BULLETIN•

BREAKINGBADNEWSBy A. Robert Kagan, MD, FACRO

Note:The views expressed in this editorial are not necessarily those of the American College of Radiation Oncology.

Nothing creates more misunderstanding than the bilingual “oncobabble” ofoncologic communication, especially for the unnerved patient who is dying. It is alwayseasier to work around bad news than to deliver it. Talking to patients about dying ishard. Unlike learning other medical skills, it does not become easier with repetition.The use of metaphors to describe the inevitability of dying often confuses patients,takes excessive time, and commonly leads patient understanding astray. The singlegreatest perquisite of patient contentment is freedom from the fear of death (withuncontrolled pain). Oncologists who only answer the questions patients ask often missan opportunity to ease this fear.

The laconic-speaking patient is the most difficult to communicate with becausefear and denial work synergistically. Sometimes it is helpful to talk about sports, food,or the patient’s vocation to open the patient up to further conversation. Realize thattalking about death is still taboo in our culture. So getting this taciturn patient tocommunicate may take more than one visit. Unsatisfied patients who, after an initialvisit, still do not understand the downside of their treatment or fully comprehend theirgrave prognosis, may blame the physician’s use of medical jargon and potentially leadto a malpractice suit. This can be avoided by asking the patient to describe his or herunderstanding of the informed-consent issues you have just enumerated anddiscussed.

We do not teach patient communication in training, which may be more importantto a doctor’s survival than technical proficiencies. Communication, like most physicianskills, must be practiced before some effectiveness and confidence are obtained. This isespecially true for delivering bad news directly and honestly.

continues on page 5

ACRO WELCOMES NEW MEMBERS!

BULLETIN WWW.ACRO.ORG • 3

ACRO is pleased to welcome the following individuals who became new members in 2010:Lynn Abess, Los Angeles, CAMichelle Abrams, Bloomington, INNoel Aherne, New South Wales, AustraliaTushar Ahluwalia, Ludhiana, Punjab, IndiaScott Akins, San Antonio, TXMatthew Allen, Redding, CAMarco Amendola, South Miami, FLHans Arora, Chicago, ILJean-Phillipe Austin, Miami, FLRichard Bakst, New York, NYCynthia Ballenger, Greenville, NCBrandon Barney, Rochester, MNAndrew Baschnagel, Royal Oak, MIAjay Bhatnagar, Casa Grande, AZAlec Block, Forest Park, ILLara Bonner Millar, Philadelphia, PALucia Boselli, Bronx, NYJeffrey Brabham, Mount Dora, FLJeffrey Brindle, Watertown, SDYong Cha, Nashville, TNAnurag Chandra, Hammonton, NJRamanamoorthy Chitti, Valhalla, NYCasey Chollet, Oak Park, ILRahul Chopra, Syracuse, NYMichael Chuong, Tampa, FLDouglas Clark, Oklahoma City, OKEileen Connolly, New York, NYEdwin Crandley, Charlottesville, VAMyra Cruz, Buffalo, NYDeanna Davidson, Chattanooga, TNAbulmajeed Dayyat, Aljubaiha, JordanAnand Desai, Tucson, AZMichael Dobelbower, Birmingham, ALRandall Duckert, Omaha, NEMichael Eaton, Los Angeles, CALloyd Farinash, Charleston, WVDaniel Fass, Rye, NYFelix Feng, Ann Arbor, MIAndrew Figura, Columbus, OHBrandon Fisher, Philadelphia, PAChristopher Gallagher, Jenkintown, PAHeather Gatcombe, Atlanta, GAAbhijit Ghose, Calgary, Alberta, CanadaValerie Gironda, Tampa, FLBen Goodman, Indianapolis, INGary Gustafson, Troy, MIMichael Hall, Pittsburgh, PAAnna Harris, San Antonio, TXJohn Healy, West Dublin, IrelandJohn Heinzerling, Dallas, TXAaron Hicks, Syracuse, NYGeorges Hobeika, Miami, FLNadine Housri, New Brunswick, NJJerry Howington, Augusta, GAJiayi Huang, Royal Oak, MIMichael Hunter, Kirkland, WAArthur Iglesias, Miami, FLMehdy Jabir, Towson, MDWilliam Jones III, San Antonio, TXPeyman Kabolizadeh, Pittsburgh, PAIsaac Kaufman, Royal Oak, MI

Mohammad Khan, Rocky River, OHSusan Kirstein, Englewood, NJKevin Kniery, Waterbury, CTSri Kottapally, State College, PAJohn Koval, Sun City Center, FLAryavarta Kumar, Cleveland, OHSanath Kumar, Detroit, MIKelly LaFave, Orlando, FLWook Lee, Cedar Rapids, IADavid Lee, Royal Oak, MIPaul Mandelin, Los Angeles, CAAparna Mani, New York, NYLuisa Vanessa Marcial, Guaynabo, PROvidiu Marina, Royal Oak, MINiraj Mehta, Los Angeles, CAHugh Merriman III, Orangeburg, SCStephen Milito, Mechanicsburg, PAAstrid Morrison, Oklahoma City, OKSabin Motwani, New Brunswick, NJMichelle Neben-Wittich, Rochester, NYJohn Ng, New York, NYLan Nguyen, St Petersburg, FLNicholas Nickols, Los Angeles, CASimul Parikh, Pittsburgh, PANitesh Paryani, Jacksonville, FLPriti Patel, New York, NYJose Pichardo, Hawthorne, FLMelva Pinn-Bingham, Orange, CABrendan Prendergast, Birmingham, ALEmma Ramahi, San Antonio, TXAfshin Rashtian, Los Angeles, CAJean Claude Rwigema, Pittsburgh, PAParag Sanghvi, San Diego, CAMatthew Schwartz, Henderson, NVAmish Shah, New York, NYChirag Shah, Royal Oak, MISimona Shaitelman, Royal Oak, MIRonald Shapiro, Indianapolis, INLauren Shapiro, New York, NYWaseem Sharieff, Hamilton, Ontario, CanadaNeha Sharma, Brooklyn, NYCharles Simone, Bethesda, MDR. Victor Simoneaux, Jr, Bloomington, INGurpinder Jit Singh, Johannesburg, South AfricaSinisa Stanic, Sacramento, CAJohn Stewart, Irondale, ALKevyn To, Hamilton, Ontario, CanadaAndrew Trister, Seattle, WARichard Tuli, Baltimore, MDSteven Wahlen, Paradise, CAScott Watkins, Cumberland, MDRodney Wegner, Pittsburgh, PAGary West, San Antonio, TXJohn Wilkinson, Royal Oak, MIJoella Wilson, Galveston, TXMichal Wolski, Galveston, TXWeisi Yan, New York, NYCatheryn Yashar, LaJolla, CARaphael Yechieli, Detroit, MIYoussef Zeidan, Menlo Park, CAZheng Xiang-peng, Shanghai, PRC

SPECIAL REPORT

4 • W W W.A C R O.O R G BU L L E T IN

RE-ANALYZING THE

‘RATIONED-CARE’ DEBATE

Note:The views expressed in this article are gleaned fromthose of Peter Singer, a professor of bioethics at PrincetonUniversity, and are not necessarily those of the American

College of Radiation Oncology.

Over the past two years, during debates about healthcarereform, “rationed” became a dirty word, and the phrase“rationed care” had such negative connotations that PresidentObama avoided using the terminology.

Rationing by PriceYet the truth is healthcare in America is already rationed.

Peter Singer, a professor of bioethics at Princeton University, inThe New York Times Magazine, writes that American healthcareis rationed by price. Health-insurance premiums have doubledsince the turn of the century, making it impossible for manyindividuals to afford insurance or for small employers to providethe insurance to their employees. As a result, an increasingnumber of Americans have no access to medical care. Inaddition, healthcare is rationed through high patientcopayments and limits on pay to physicians and hospitals.

Unless you think life is worth any price, you too believe inrationed care. For example, if you knew you were going to die insix months but could extend your life for one additional yearwith a direct payment for a miracle treatment, how much would

you spend? $1,000? Probably. $100,000? Maybe. $1,000,000?Maybe not. For most individuals, there is a point at which onewould say, “No, that’s too much just to extend my life for oneyear.”

Putting a Value on LifeHealthcare rationing is inevitable, so Dr Singer asks, “What

is the best way to carry it out?” He notes that Britain’s NationalInstitute for Health and Clinical Excellence provides thecountry’s National Health Service with guidelines and has set£30,000 as the highest justifiable cost for extending life oneyear. Generally speaking, if medical treatment exceeds thisamount, it is not reimbursed. This, of course, causes the mediato characterize healthcare-system administrators as individualscarrying out death sentences for the ill and injured. Suchreactions have already been heard in America when reformopponents claimed President Obama’s plan would result in“death panels” that would mete out medical care.

Dr Singer admits that with rationing a number of patientswill die sooner rather than later, but this is already happeningindirectly. To prove this point, Joseph Doyle, a professor ofeconomics at the Sloan School of Management at theMassachusetts Institute of Technology, studied the records ofpeople in Wisconsin involved in auto accidents and taken to ahospital. Those with no medical insurance received 20% lesscare and had a death rate 37% higher than those with medicalinsurance. Estimates are that 20,000 Americans die each year asan indirect result of not having health insurance. Even 43% ofAmericans with medical insurance have reported that theyskipped seeking medical management of their chronic diseasesdue to cost.

CheckOutOurWebSite

Advancing Communication ...Realizing Opportunities ...

Founded in 1989 with a current membership of approximately 800, theAmerican College of Radiation Oncology is the essential professionalsociety for success in the practice of radiation oncology.

www.acro.orgDwight Fitch, MD • Website Editor

SPECIAL REPORT

BU L L E T IN W W W.A C R O.O R G • 5

continued from page 2Des Spense, in the British Medical Journal (2010, vol 340, p

2793), writes, “Medicine is a job of attitude not bookish learning,of emotion not logic.” To a large extent, he is referring to generalpractice, not a specialty such as radiation oncology. But, readingfurther, he pinpoints a glaring deficit in oncology: “Talking aboutdeath is difficult. It requires strength to be honest and direct. Butdoctors are human and seek to avoid the uncomfortable and toprotect themselves. Indeed, modern medicine systematicallyfractionates responsibility with ‘multidisciplinarism,’ with theunforeseen effect that no one is accountable. When it comes toend-of-life decisions, which health professional is responsible?”

Early on, when radiation oncology had its own beds in thehospital, our rounds included interaction with patients and theirfamilies, and we worked along with consultants to provideterminal care. Obtaining an autopsy (thought to be necessary forlearning about our mistakes) was one of our jobs. Today, caringfor the terminal patient is better done by hospice personnel,including trained physicians. Frankly speaking, the staff of anacute-care hospital does not manage the dying patient withmuch enthusiasm, thus, the patient becomes isolated. Withinteraction, patients are more satisfied with hospice staff.

Many think referral to a hospice is the same as a doctoradmitting that he or she has “given up.” Hence the referral ismade reluctantly and at a loss of self worth on the part of thereferring physician. Hospice is a symptom-managing branch ofmedicine. Hospice personnel solve physical and psychosocialproblems that cause many vexing and thorny conditions. Theseproblems are managed by hospice staff successfully, at leastuntil shortly before death.

The reimbursement for hospice care is low, which is adisincentive for physicians, including oncologists. But a rotationthrough hospice care would be a worthwhile experience andhelp limit the scariness of telling the truth to patients with cancerin lieu of adding more ineffective treatment.

Dr Kagan is the Editor of the ACRO Bulletin and past-president of ACRO. Reactions or responses to this article can besent to Dr Kagan at the Department of Radiation Oncology;Kaiser Permanente Medical Group; 4950 Sunset Blvd; LosAngeles, CA 90027.

Pricing ComplicationsDr Singer asks his readers to imagine a world in which no

limits were placed on the value of human life. The Department ofTransportation, for example, would use its entire budget on roadsafety. Meanwhile, car manufacturers would overload theirvehicles with so many safety devices that the cost of anyautomobile would be prohibitively expensive.

To start, Dr Singer believes we should ask healthyindividuals, “How much are you willing to pay to reduce the riskthat you may die?” For example, if you would pay no more than$50 for an air bag in your car, and there is a 1 in 100,000 chancethat an air bag will save your life, you value your life at $5 million($50 X 100,000).

But measuring a life’s value is rarely so straightforward.Many people believe the life of a teenager should have a higherpriority than that of a senior citizen. So perhaps calculationsshould be based not on the number of lives saved but on thenumber of life-years saved. Yet what if the teenager is a drugged-up gang member who has already committed murder, and thesenior citizen is an expert oncologist on the verge of curing allcancers? Should social-value judgments be considered whenallocating healthcare?

Putting a Value on the Absence of SufferingAnother complication for medical rationing is the

recognition that healthcare is not always carried out to save livesbut to reduce suffering. Dr Singer asks, if a quadriplegic choosesfive years of life without disabilities over ten more years of life asa quadriplegic, does that mean the patient believes living as a

quadriplegic is half the value of living without disabilities? Suchthinking has resulted in the development of a unit of measurecalled the “quality adjusted life-year” (QALY), which is used tocompare the benefits of different healthcare options. This, ofcourse, contrasts with those who believe all lives—disabled ornot, old and young, sick and healthy—are of equal value. But DrSinger argues that, if, for instance, the life of a person withcancer is equal to the life of a healthy person without disease,there is no benefit in treatment or in curing the cancer. Thissuggests there is no use for cancer specialists, such as radiationtherapists, or, for that matter, medical professionals at all.

So how should healthcare rationing be addressed withouttaking healthcare decisions out of the hands of the patients?

Dr Singer believes Americans might accept rationing if theyare given the option of non-rationed care at their expense. Heproposes a universal public plan that would only pay fordiagnostic or therapeutic procedures within a set QALY.However, Americans would have the freedom to purchasesupplementary medical insurance for any costs of care over theQALY.

But it would take brave political leaders to propose such achange given the tenor of the healthcare-reform debate today.

See it different? Send a Letter to the Editor, c/o A. Robert

Kagan, MD, ACRO Bulletin, Kaiser Permanente Medical Group,

4950 Sunset Blvd., Los Angeles, CA 90027.

EDITORIAL

HEADLINES 2010–2011

6 • W W W.A C R O.O R G BU L L E T IN

BRIEF SUMMARIES OF

IMPORTANT NEWS FOR THE

RADIATION ONCOLOGIST

SBRT May Slow Pancreatic-Cancer ProgressionUnfortunately, a diagnosis of pancreatic cancer is usually a

death sentence for those patients who cannot undergo surgery.However, researchers at Henry Ford Hospital in Detroit believethe use of stereotactic body radiation therapy (SBRT) may delayprogression of the disease by approximately six months.

Without treatment, patients with pancreatic cancer liveabout four to six months after diagnosis. The Detroit studyinvolved 12 patients (median age, 83) with inoperable stage I orII pancreatic cancer. Patients underwent between three andseven courses of SBRT. As a result, the patients lived about 10months; one-third of the patients lived for more than a year.

Lead researcher Michael Haley, DO, admits that SBRT is notcurative, but “it does seem to allow some progression-freesurvival benefit with minimal side effects for patients.”

Parotid-sparing IMRT Reduces Dry MouthThe January 13, 2011, issue of The Lancet Oncology

reported that intensity-modulated radiation therapy (IMRT) forhead-and-neck cancers not only spares the parotid gland fromradiation exposure but is more likely than conventional radiationtherapy to result in dry mouth.

Lead researcher Christopher M. Nutting, MD, and colleaguesfrom the Royal Marsden Hospital in London randomized 94patients with pharyngeal squamous-cell carcinoma to eitherIMRT or traditional radiation therapy. After 12 months, 38% ofthe patients who underwent IMRT reported grade 2 or worse

xerostomia; 74% of the patients who underwent conventionalradiation therapy reported grade 2 or worse xerostomia. Aftertwo years, 29% from the IMRT group and 83% of theconventional radiation-therapy group reported grade 2 or worsexerostomia. No significant difference in non-xerostomiacomplications between the groups was noted.

Defective Gene May Be Reason for Good Response toColorectal-Cancer Radiation Treatment

Researchers in Sydney, Australia, recently identified adefective gene that they believe results in a good response toradiation therapy for colorectal cancer. They examined the MCCgene, which was defective in approximately half the cases ofcolon and rectal cancer that they analyzed. Though the MCCgene was responsible for tumor development, it also made thetumor less resistant to radiation and thus easier to kill.

DEVELOPING NEW GUIDELINES

BU L L E T IN W W W.A C R O.O R G • 7

RADIATION

ONCOLOGY POLICY

UPDATESBy Andrew L. Woods, Esq

CMS Launches First Phase ofPhysician Compare Website

On December 30, the Centers forMedicare and Medicaid Services (CMS)announced the first round of updates forits Physician Compare website. Theupdate expands CMS’ Healthcare ProviderDirectory with the inclusion of doctor-specific information into the informationaltools for Medicare beneficiaries and otherconsumers. The new site was required bythe Patent Protection and Affordable Care Actand contains information about physiciansenrolled in the Medicare program.

The information on the site includescontact and address information foroffices, a physician’s medical specialty,where the physician completed his or herdegree as well as residency, whether thephysician speaks a foreign language, andthe physician’s gender. Later in 2011, CMSplans a second phase for the website,including information indicating whetherprofessionals participate in a voluntaryeffort with the agency encouragingdoctors to prescribe medicineselectronically. In the future, the site will beexpanded with information about thequality of care Medicare beneficiariesreceive from physicians. The ACA requiresCMS to develop a plan to implement thisexpansion by 2013.

Emergency Update to the CY2011 Medicare Physician FeeSchedule (MPFS) Database

On December 29, CMS issued anemergency update to the CY 2011Medicare Physician Fee Schedule (MPFS)database in the form of a transmittal,which was released after several radiationoncology groups sent letters to CMSalerting the agency of a potential technicalerror in the valuation of 77427.

Through this transmittal, CMSaccepted the arguments of radiation

oncology groups that the work RVUs for77427 should be 3.37. Also of importance,the transmittal establishes the newconversion factor for 2011—$33.9764—based on the zero percent updatecontained in the Medicare and MedicaidExtenders Act of 2010 (see below) andother changes contained in the update. Inaddition, due to the budget-neutral natureof changes to the PFS RVUs contained inthe update, CY 2011 RVUs will changeslightly in most cases relative to the CY2011 PFS Final Rule.

Gynecologic Bill SignedOn December 22, President Obama

signed HR 2941, the Gynecologic CancerEducation and Awareness Act (Johanna’sLaw) into law. The new law, whichrequires the Department of Health andHuman Services (HHS) to increaseawareness and knowledge of healthcareproviders and women with respect togynecologic cancers, cleared Congress onDecember 10. This legislation reauthorizesJohanna's Law through 2014.

President Signs 2010 Medicareand Medicaid Extenders Act

On December 15, the Presidentsigned the Medicare and MedicaidExtenders Act of 2010 (MMEA) into law.The Senate passed the physician-payment update on December 8, 2010,and the House of Representatives clearedthe legislation on the following day.

Section 101 of the MMEA prevents ascheduled payment cut for physiciansthat would have taken effect on January1, 2011. The new law provides a zero-percent update in physician-reimbursementlevels for calendar year 2011 and includesseveral one-year extensions of otherexpiring Medicare provisions, includingan extension of the existing 1.0 floor onthe "physician work" geographic practicecost index, through December 31, 2011.

The legislation is offset primarilythrough the following provisions:

• Cuts to exchange subsidiescontained in the Health ReformBill. The new law increases theexisting limits (currently $250 foran individual and $400 for afamily) that can be recovered from

the health-insurance tax-creditoverpayments.

• The use of Medicare improvement-fund monies. Originallyestablished as a $22 billion fundfor "improvement to Medicare,"the fund has been used forprevious physician-paymentupdates and makes a limitedamount of money available tooffset the costs of the MMEA.

CMS Hosts PQRI, eRx NationalProvider Conference Call

On December 13, CMS hosted anational provider conference call on the2010 Physician Quality Reporting System(PQRS) and Electronic PrescribingIncentive Program (eRx). The presentationfocused on 2011 and 2012 PQRS and eRxpayment adjustments, requirements forparticipation, and the self-nominationdeadline for EHR, Registry, MOC, GPRO Iand GPRO II.

MedPAC Indicates Support for1% Increase in 2012 DoctorMedicare Payments

On December 2, MedPAC convened apanel to assess payment adequacy forphysicians and discussed recommendinga 1% increase in Medicare payments forphysicians in 2012. The 2012 updaterecommendations, which will appear inMedPAC’s March 2011 recommendationsto Congress, were voted on in January2011. The commissioners appearedgenerally in favor of the 1% increase,which they also had recommended for2011. Congress is not obligated to followthe recommendations of this independentadvisory body but often uses theserecommendations to frame the debate.

AHRQ Releases Guide for Head-and-Neck Cancer Treatment

On December 1, the Agency forHealthcare Research and Quality (AHRQ)Effective Health Care (EHC) Programannounced a clinical guide for thecomparative effectiveness and safety ofradiation therapy for head and neckcancer. This guide can be accessed onlineat http://www.effectivehealthcare.ahrq.gov.

continues on page 8

8 • W W W.AC RO.O R G BU L L E T IN

THERAPEUTIC BURDEN

communicating information about treatment to multiplecaregivers, and attempting to comprehend the multipleinsurance statements that inevitably arrive in the patient’s mail.

More complex medicine was meant to help patients withchronic disease, but, conversely, it may lead to non-adherenceand a poorer quality of life. Solutions to this paradox will not besimple. The authors suggest the following to start:

1. Clinicians need to develop tools to identify over-whelmed patients.

2. Coordination of care between a patient’s primaryphysician and treatment specialists should be encour-aged.

3. Comorbidites must be recognized and addressed inpractice guidelines.

4. Multiple treatments should be prioritized according tothe patient’s wishes.

The authors emphasize that the burden of treatment isdistinct from the burden of illness. As therapists, radiationoncologists must be able to recognize the difference and, thus,develop minimally disruptive treatments for their cancerpatients, which will lead to more effective care.

References1. Barber N, Parsons J, Clifford S, et al (2004). Patients’ problems with new

medications for chronic conditions. Qual Safe Health Care 13: 172–175.2. Wolff JL, Starfield B, Anderson G. (2002). Prevalence, expenditures, and

complications of multiple chronic conditions in the elderly. Arch Intern Med 162: 2269–2276.

3. World Health Organization (2003). Information sheet: Facts related to chronic diseases and the WHO global strategy on diet, physical activity andhealth. Geneva: WHO.

continued from page 1

CMS Quality Measures Workgroup Request forComments On Clinical Quality Measures

The Quality Measures Workgroup, formed by the HIT PolicyCommittee (a federal advisory committee advising HHS), isdeveloping recommendations on clinical quality measuresenabled for use within electronic health-record systems. InDecember 2010, the Workgroup issued a request for comment onclinical quality measures.

Andrew Woods, Esq, of the Liberty Partners Group, is thelegal advisor for ACRO.

continued from page 7

BU L L E T IN W W W.AC RO.O R G • 9

ACRO ACCREDITATION

AccreditationPowered byPatients First

AccreditationPowered byPatients First

Protect Your Patients & PracticeGet AccreditedCall ACRO 301.718.6515 Today!

LETTER FROM A PATIENT’S DAUGHTER

10 • WWW.ACRO.ORG BULLETIN

RADIATION ERRORSCOMPOUNDED BY POORRESPONSE FROM MEDICAL

COMMUNITYEditor’s Note: In the Summer 2010 issue, the ACRO Bulletin

published anecdotal evidence of radiation-dose errors, whichruined patients’ lives and traumatized patients’ families. Much ofthe information was gleaned from the writings of WaltBogdanich at The New York Times, with additional input fromphysicians such as Howard I. Amols, MD, chief of clinical physicsat Memorial Sloan-Kettering Cancer Center. The following letterwas written to Dr Amols by a daughter who lost her mother to aradiation overdose. The ACRO Bulletin was given permission byDr Amols and the daughter to publish this letter with minimalediting to show how such a mistake can affect a patient’s lovedone and how, as physicians, we need to re-evaluate ourprofession’s reaction to such a mistake. The daughter’s name isnot being printed to preserve her privacy. For those who wantmore information about this case, please contact Dr Amols atMemorial Sloan-Kettering Cancer Center, Department of MedicalPhysics, New York, NY 10021.

Dear Dr Amols

I’ve read your comments in Walt Bogdanich’s articles overthis past year. My mother was one of the patients that hehighlighted. She was given twice the dose in half the time for atotal of 3,400 rad in two-and-a-half days at [Name withheld]Medical Center, but her doctors never told us, and the hospitalfailed to report it to the Bureau of Radiation for nearly fivemonths after the event.

My mother’s condition continued to worsen despite herphysicians telling her and us that she would be fine. Six months afterher radiation, several of her ribs broke, and that was the beginningof the end. My father died a month later from a fatal heart attack,which I will always attribute to the stress they were enduring.

My mother’s condition continued to worsen. She washospitalized for pain management in March 2007. She washospitalized again in November 2007, 14 months out from herradiation for reasons they never defined. She was havingbreathing troubles. They took her to [Name withheld] GeneralHospital, where she was intubated, having seizures, transferredto ICU, and, a few days later, sent home. Now she could barelywalk. She was losing weight, very weak, and in constant pain.After she died, her radiation oncologist tried to say it wasbecause of my father’s death. I strongly believe it was quite theopposite. The doctor was just looking for excuses.

My parents were only 76—very strong, independent, andhappily retired. My mother was an artist and loved life. Theynever had a history of any medical or mental-health problemsuntil this all started. She took an overdose of Tylenol and tied aplastic bag over her head a month after she was discharged from

the same hospital that overdosed her and died 15 months afterher radiation treatment.

I later saw in the notes I requested from the hospital that shewas randomized for NSABP B39. I contacted the principalinvestigators. They didn’t care when they found out she was notradiated at one of their hospitals. I contacted HHS HumanSubjects Protection, and they didn’t care either because theNSABP denied that she was part of a study.

The only way I pieced this all together was after she died. Isearched for countless hours and around Thanksgiving 2008 anNRC event popped up that was my mom’s. My jaw dropped. Thephysicist had entered the wrong film magnification into the HDRafterloader, and my mother received all her radiation in half thetime, and nobody told her. The staff simply sent my mother andfather home on Day Three of her scheduled treatment and saidher treatment was over.

I contacted the NRC. It took months to get to the rightperson, who sent me to the Ohio Bureau. But the Ohio Bureautold me they could not help because the incident was past thestatute of limitations. After five months of persistence, the OhioBureau sent me documentation about the event and theadministrative penalty that was assessed due to the hospital notreporting the event. I also requested my mother’s medicalrecords from the hospital. It was very difficult to get through. Allmy mother’s doctors worked at the same hospital. It was as if itwas one big cover-up. Her radiation oncologist refused to sendher records by saying she didn’t have them. The only records Ireceived were limited notes that were in the hospital record. Iwrote to the Ohio House of Representatives and Senate, as wellas the governor. I was told that since I lived in California, Ineeded to write to my own politicians. During that time, Icontacted countless agencies and individuals to find answers. Ialways reached dead ends. I contacted the FDA, ABR, the SalkInstitute, different news media, etc, but not a single call from anydoctors. Almost everyone turned a blind eye.

Then there was Walt Bogdanich, who called me the very dayI wrote him in the previous year. He had included my mother inhis article. It was validating beyond words. He already knew ofmy mother’s event when I contacted him. The Akron Beacon-Journal and public radio did not run his series, of course. I wastold by an editor that [Name withheld] Medical Center is a hugesponsor, and there is a “firewall” between news and sales. Sothe hospital functions as though nothing untoward happens. Yet,it had two events—in July 2006, then my mother’s in September2006, and nobody cared.

I got a letter from the NRC last week basically saying theytake public safety seriously, but they did all they cared to do inmy mother’s case, so I got the feeling they were telling me to “goaway.” I am writing you because it remains so unsettling. I wasnever able to get clear information about what happened to mymother or what her dose could have done to her.

Can you offer any other suggestions?

Very sincerely,[Name withheld]

BOOK REVIEW

BU L L E T IN W W W.A C R O.O R G • 11

WHEN CANCER HITS HOME: CANCER TREATMENT ANDPREVENTION OPTIONS FORBREAST, COLON, LUNG,PROSTATE, AND OTHERCOMMON TYPESBy Patrick Maguire, MD Paperback, 2010, $16.95

Many of our patients come to their initial radiation-oncologyconsultation having read reams of information about theirparticular cancer type immediately following their diagnosis. Aselect few—the most medically sophisticated—may actually bebetter prepared for their consultation as a result. They mayactually be able to ask appropriate questions about theirtreatment plan, side effects, etc. Unfortunately, though, thissmall subset of patients and their families are the exception.

More commonly, when patients meet their radiationoncologist, their heads are swimming. They are lost in a sea ofinformation and even the brightest folks are understandablynervous. Retaining any information at this stressful time can benearly impossible. When they return home, in their search forfirm ground, patients and their loved ones often turn to theInternet. However, they have no navigator to guide themthrough these treacherous waters. Which sites are trustworthyand reliable? Which information is outdated? Is this new“breakthrough” cancer treatment appropriate for me?

Over the past several years, I have found myself in thechallenging position of having to navigate the “cancer journeys”of several close family members. My father and my wife’sparents went through treatment for advanced or metastaticmalignancies. All three died within five years. I miss them

terribly. However, I am grateful that, as a cancer specialist, I wasable to minimize the anxiety and other psychologic hurdles thatthey faced during their treatment.

Who provides reliable advice to patients and familieswithout access to someone with an oncology background? Incancer clinics today, that is a nearly impossible feat for theattending oncologist and increasingly difficult for even the mostcaring and nurturing oncology nurse. Pamphlets offered bymedical societies are a start, but they are often too cursory.Disease-focused textbooks give too much detail.

My answer to this problem resulted in the December 2010publication of When Cancer Hits Home. It is a layperson’s guideto cancer, written with minimal medical jargon so it is easy tounderstand. Part I reviews risk-reduction strategies. Part IIdiscusses the 20 most common cancers in the United States,including current treatment options and personal stories for eachtype.

Patients’ journeys through cancer diagnosis and treatmentare harrowing enough, without added anxiety fed by theunknown. If you believe your patients might benefit from asingle, reliable source for cancer information that is easy tounderstand, then I urge you to evaluate When Cancer Hits Home.

Hospitals and cancer centers are eligible for bulk-rate pricing.Please contact the author at http://patrickmguiremd.com.

Reviewed by the author

Book reviews should be addressed to the Editor, ACROBulletin, Department of Radiation Oncology, Kaiser PermanenteMedical Group, 4950 Sunset Blvd, Los Angeles, CA 90027.Reviews may be edited for clarity or to fit available space.

Book Reviews Wanted!After a long day of radiation oncology practice, have you sat down in the evening with an especially good book of fiction?If so, share your reading with other ACRO members!

Send your book review to:

A. Robert Kagan, MD

Editor, ACRO Bullet in

Department of Radiation Oncology

Kaiser Permanente Medical Group

4950 Sunset Blvd

Los Angeles , CA 9 0 0 2 7

(323) 783-3865

INVITATION TO JOIN

12 • WWW.ACRO.ORG BULLETIN

ENJOY THEBENEFITS OF ACROMEMBERSHIP

The American College of RadiationOncology is the essential, professionalsociety for success in the day-to-daypractice of radiation oncology. Since1990, ACRO has focused its attention onboth the clinical and economic aspects ofpracticing radiation oncology. As aprofessional medical society representinga relatively small subspecialty, ACRO hasled the effort to ensure appropriatereimbursement for clinical care and hasprovided services to help its membersbecome better clinicians.

Its mission is to strive to ensure thehighest quality care for radiation therapypatients and promote success in thepractice of radiation oncology througheducation, responsible socioeconomicadvocacy, and integration of science andtechnology into clinical practice.

So what does ACRO membershipprovide?

• Experienced, effective, and intelligentlegislative counsel. ACRO keeps aneye on Washington and the Centersfor Medicare and Medicaid Serviceswhile you take care of your patients.

• Proactive Practice Accreditation.ACRO Accreditation helps youdemonstrate the quality of yourpractice.

• Online access to the AmericanJournal of Clinical Oncology (AJCO).Through ACRO membership, youhave instant access to articles and alibrary of past issues.

• Discounted medical-practiceinsurance. Exclusively for radiationoncology practices, so you get theattention you deserve and thecoverage you need.

• Comprehensive billing and codingsupport. ACRO provides you with theresources to make sure your practiceis fully compensated by third-partypayers.

• Practical and dynamic PracticeManagement Guide. Designed byexperts and published by ACRO, theguide is provided at a discount tohelp you practice more successfully.

• Opportunities to become involved.You can participate on committeesand become active in the College.

• Intimate and educational annualmeeting. The ACRO annual meeting,usually held in late winter at analternating, warm-climate locationnear the West or East coast, is meantto provide those in the radiation-oncology field with easy access tospeakers, commercial exhibitors, andthe opportunity to obtain CME andSAM credits.

For more information about joiningACRO, call (301) 718-6515 or visithttp://www.acro.org.

www.acro.org

Check Out Our Web Site

netAdvancing Communication ...

Realizing Opportunities ...

MARK YOUR CALENDAR

BULLETIN WWW.ACRO.ORG • 13

A CALL FOR ‘CLINICAL PEARLS’Good research can be descriptive, but a bias has developed in the healthcarecommunity leading to the exclusion of such work by many peer-reviewed journals infavor of experimental studies with randomization, which many assume to be the onlyvalid design for obtaining new medical knowledge.

Consequently, the ACRO Bulletin is calling for submissions of “Clinical Pearls,” a250–500-word description of a special clinical case you believe is unique buthas not become part of the medical literature due to its exclusion from

experimental research.

Unusual case reports not only provide interesting reading but complementquantitative work through a process research methodologists refer to as “triangulation.”

Here is your chance to enhance medical knowledge by sharing a clinical case report withothers in radiation oncology.

Please send your submissions to: A Robert Kagan, MD; Editor, ACRO BulletinDepartment of Radiation Oncology; Kaiser Permanente Medical Group4950 Sunset Blvd; Los Angeles, CA 90027(323) 783-3865

American Society for TherapeuticRadiology and Oncology8280 Willow Oaks Corporate Drive,Suite 500Fairfax VA 22031Telephone (703) 502-1550Website http://www.astro.org

State of the Art Techniques: IMRT,IGRT, SBRTMarch 11–13, 2011Encore at WynnLas Vegas NV

ASTRO Cancer Imaging and Radiation Therapy SymposiumApril 29–30, 2011Atlanta Marriot MarquisAtlanta GA

ASTRO 53rd Annual MeetingOctober 2-6, 2011Miami Beach Convention CenterMiami Beach, FL

Mark Your Calendar Some 2011 Meeting Dates

American Radium Society11300 W Olympic Blvd, Suite 600Los Angeles CA 90064Telephone (310) 437-0581Website http://www.americanradium-society.org

ARS 93rd Annual MeetingApril 30–May 4, 2011Ritz Carlton Palm BeachPalm Beach FL

Polish Radiation Research SocietyNational Institute of Public Health/National Institute of Hygiene24 Chocimska Street00-791 Warsaw POLANDWebsitehttp://www.icrr2011.org/main/article/ptbr

14th International Congress of Radiation ResearchAugust 28–September 1, 2011Palace of Culture and ScienceWarsaw, POLAND

Radiological Society of North America820 Jorie BoulevardOak Brook IL 60523Telephone (800) 381-6660Website http://www.rsna.org

RSNA 97th Scientific Assembly and Annual MeetingNovember 27–December 2, 2011McCormick PlaceChicago IL

RADIATION THERAPY AT THE RSNA SCIENTIFIC ASSEMBLY

14 • WWW.ACRO.ORG BULLETIN

SDRT SUBJECT OF ORATIONIN RADIATION ONCOLOGY

The radiation-oncology news at the recent RadiologicalSociety of North America (RSNA) Scientific Assembly was thatsingle-dose radiation therapy (SDRT) might be more effectivethan intensity-modulated radiation therapy (IMRT). So said ZviFuks, MD, the Alfred P. Sloan Chair of Radiation Oncology at theMemorial Sloan-Kettering Cancer Center and professor ofradiation oncology at Cornell University. Giving the RSNAAnnual Oration in Radiation Oncology at Chicago’s McCormickPlace on December 1, 2010, Dr Fuks explained that the tumor-targeting method of SDRT is more precise, leading to improvedcure rates.

Dr Fuks noted that when treatment is done many times,such as with IMRT, patient and tumor position changes. Also,despite redesigning safety margins, normal-tissue exposure toradiation continues to be a concern. However, with improvedtechnology, allowing dynamically adaptive image guidance andthe use of implantable tumor-localization devices, treatment canbe done in a single session.

Dr Fuks addressed the argument that radiobiology requiresdose fractionation to overcome the tumor cell’s resistance totreatment due to interfractional reoxygenation. But SDRTappears to work differently from traditional fractionatedradiation therapy. “Instead of the classical hypothesis that onlythe tumor’s stem cells are affected, now we find two targets thatare hit simultaneously—the stem cells and the endothelium ofthe microvascular system,” he said to RSNA meeting attendees.He then showed research results pertaining to mouse, dog, andhuman models, reflecting significant cure rates, which could befurther improved with gene therapy.

The doctor also told his audience that centers in the UnitedStates and Europe have used SDRT successfully to treat braincancer, breast cancer, and non–small-cell lung cancer. Combined

with surgery, it has appeared to improve treatment of head-and-neck, pancreatic, prostate, and soft-tissue cancers.

Dr Fuks emphasized that SDRT is becoming an effectiveweapon in the radiation oncologist’s armamentarium becauseof advances in technology and an improved understanding ofcancer treatment on a biological basis.

Editor’s Note: The 2010 RSNA Annual Oration in RadiationOncology was dedicated to Frank Hussey, Jr, MD, a leadingexpert in our field, who died this past April at age 84. Dr Husseyworked as a radiation oncologist and radiologist at LutheranGeneral Hospital in Park Ridge, IL, and Alexian Brothers Hospitalin Elk Grove Village, IL. He also conducted research at theFermilab Cancer Treatment Center in Batavia, IL.

© Chicago Convention & Tourism Bureau (“CCTB”)

The largest medical convention of its kind, the RSNA ScientificAssembly and Annual Meeting is held annually in Chicago.

2011 ADVERTISING RATES

BULLETIN WWW.ACRO.ORG • 15

Advertising Rates & SpecificationsComprehensive socioeconomic, political, and professional news affecting the daily practice of radiation oncology

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Payment must accompany order. Make checks payable to American College of Radiation Oncology (ACRO), or payment may be madeby credit card (MasterCard, Visa, or American Express); call for details. Payments should be submitted to “ACRO BulletinAdvertising” to the address shown above. Advertisers who cancel ads will not receive refunds.

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SPECS FOR DESIGNED ARTWORK:Please send designed artwork in QuarkXpress 6.0 or lower, Macintosh format or Vector EPS file with fonts converted tooutlines and supporting/link artwork embedded in the file. Files can be received via 100MB Zip Disk, CD-Rom or electronically to kim.davis@experient-inc.com. Please contact Kim Davis at kim.davis@experient-inc.com for ftp upload information.Please note: The final newsletter will be printed in two colors (PMS 200 C and Black). Your ad can be one or two color, butplease be certain to use the colors specified above.

1. 1. Printouts – Please include hard-copy printouts. (Always include hard-copy composite printouts of the job, as well as laser printoutsof each color separation, marked with the correct color.) When sending files electronically, please stuff these files to ensurequicker transmission and receipt of your Email. If a file is sent electronically, please include a PDF file for a proof.

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Classified Advertisements50 words or less $90; 51-100 words, $135 each word over 100, $1 per word. Box service is $30 additional per insertion.No multiple insertion or agency discounts

The ACRO Bulletin accepts classified advertising for: Positions Available Positions Desired Fellowships and Residencies Tutorials/Courses

Ads must be submitted, typed, and double-spaced. Initials or abbreviations equal one word. Telephone numbers with area code equal one word.For technical questions regarding advertisements, contact ACRO at (301) 718-6515.

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