October 2018

Research awardees honored at the 2018 Annual Meeting

By Tyler Beck, PhD, ASTRO Scientific Program Officer

Each year, ASTRO awards early-career development and several seed grants to a few talented investigators to support their research. For the past several years, grantees have been honored during an Awardees Breakfast at ASTRO’s Annual Meeting. This year, ASTRO recognized the 2018 grant winners, as well as some of our previous award winners, by asking them to give updates about their research as part of a session we called the Research Spotlight. The session was held on Tuesday, October 23, and was moderated by the 2017-2018 chair of ASTRO’s Research Grants Evaluation committee, Gary Kao, MD, PhD. Considering the success of this new session, we hope to continue to highlight our former awardees at special sessions during future annual meetings.

We’ve been working hard to offer more opportunities to fund research in radiation oncology. If you are a researcher, please go to www.astro.org/fundingopps for more information on how to apply for one of our 2019 grant opportunities.

The following investigators presented summaries of their research at the 2018 Research Spotlight session:

Stephanie Markovina, MD, PhD, is an assistant professor of radiation oncology at Washington University School of Medicine, and the recipient of the 2016 ASTRO Junior Faculty Award. She has been building on work that she presented at the ASTRO 2017 Annual Meeting and provided some mechanistic insight into why SERPINB3 affects the radiosensitivity of cervical cancer cells. These findings may provide a clue to tackling radioresistant cervical cancer in patients who may otherwise recur and die from their disease.

Erina Vlashi, PhD, the recipient of the 2017 ASTRO Junior Faculty Award, is currently an assistant professor in the department of radiation oncology at the University of California, Los Angeles. She earned her doctorate studying high-affinity ligand-targeted drugs for cancer therapy and then studied tumor heterogeneity and cancer stem cells in the laboratory of Frank Pajonk, MD, PhD. Her current research focus is to understand the metabolic-stemness loop that appears to be fueled by ionizing radiation, with the goal of identifying druggable targets to improve the efficacy of radiation therapy for breast cancer and other cancers.

Devarati Mitra, MD, PhD, is a clinical fellow in radiation oncology at Massachusetts General Hospital, and the recipient of one of three 2017 ASTRO Resident Seed Grants. Her research focuses on using several carcinogen-associated mouse models of head and neck cancer to investigate how radiation can be used to manipulate the tumor microenvironment and potentially improve response to anti-PD1-based immunotherapy.

Shushan Rana, MD, is an instructor in the radiation oncology department of Oregon Health and Science University and also a recipient of the 2017 Resident Seed Grant. Dr. Rana presented his research on the regulation of tumor angiogenesis and endothelial inflammation upon ionizing radiation by vascular specific microRNA-15a. This work may provide further insight into optimizing the tumor vasculature to enhance radiosensitivity and immune infiltrate function.

Kekoa Taparra, PhD, is a medical student at the Mayo Clinic School of Medicine and one of two recipients of the 2017 ASTRO Minority Summer Fellowship. He received his doctorate from the Johns Hopkins University School of Medicine, training under the mentorship of Phuoc Tran, MD, PhD, in the department of radiation oncology. Kekoa’s research project focused on the clinical problem of reducing cardiac toxicity for Hodgkin lymphoma patients receiving mediastinal radiation. Under the guidance of Nadia Laack, MD, MS, his team found that combining coronary angiography and proton therapy could spare cardiac substructures from excess radiation exposure.

Michael LeCompte, MS, is a third-year medical student at Wake Forest School of Medicine and also received the Minority Summer Fellowship in 2017. He earned a Bachelor of Science in Biology at the University of North Carolina at Chapel Hill and a Master of Science in Biomedical Science at Wake Forest University Graduate School. His current work focuses on metabolic disorders and CNS malignancies, including the role of metformin in outcomes of brain metastasis patients treated with stereotactic radiosurgery.

Joseph Contessa, MD, PhD, (pictured) is an associate professor of therapeutic radiology and pharmacology and the Director of the Central Nervous System Radiotherapy Program at the Yale Cancer Center. He received ASTRO’s Junior Faculty Award in 2009 and has led a successful research career since then. His current research focuses on the role of receptor tyrosine kinases (RTKs) and other cell surface receptors in mediating therapeutic resistance to ionizing radiation.  During his presentation, he reviewed recent insights into targeting the function of glycoproteins and enhancing tumor cell radiosensitivity.
Posted: October 31, 2018 | 0 comments

CMS’ new direction: A drop in pay rates for radiation oncology?

By Michael Kuettel, MD, PhD, MBA, FASTRO, ASTRO’s Health Policy Council Chair

ASTRO has pushed back on recent major Medicare proposals that would cut payments for radiation oncology services.

The Centers for Medicare and Medicaid Services (CMS) issued its proposed 2019 Medicare Physician Fee Schedule (MPFS) in July, with a troubling 2 percent cut to radiation oncology reimbursement. All radiation oncologists, regardless of whether they practice in a hospital or freestanding setting, receive payments under the physician fee schedule, which is why ASTRO devotes extensive resources to analyzing and advocating on these policies.

The proposed cuts for next year stem from two policy changes. First, reductions in prices for key radiation therapy supplies and equipment, including some big cuts for stereotactic radiosurgery systems and brachytherapy equipment. Second, a huge shift in CMS’s approach to evaluation and management (E&M) codes, resulting in a single rate for certain new and ongoing visits paired with reduced documentation requirements.

ASTRO asked CMS in comments to reconsider several equipment price changes after reviewing invoices showing higher prices for that equipment. On the E&M revision, ASTRO suggested modifications that would ensure radiation oncology could bill a proposed new code for complex visits and an increase in the total value of these codes so radiation oncologists would not suffer payment cuts for these critical services. If CMS adopts ASTRO’s recommendations, radiation oncology would likely receive stable payments for 2019, as the specialty moves toward adoption of a Radiation Oncology Alternative Payment Model (RO-APM).

The proposed MPFS also includes modifications to the 2019 Quality Payment Program (QPP).  ASTRO is concerned that practices participating in the QPP’s Merit-based Incentive Payment System (MIPS) are not realizing sufficient incentive payments to offset the costs of compliance.  ASTRO continues urging CMS to make MIPS changes to ease participation for radiation oncologists while moving forward with a RO-APM.

CMS has also issued the 2019 Hospital Outpatient Prospective Payment System (HOPPS) proposed rule. HOPPS is important to ASTRO because payments go to hospitals to reimburse the technical component of radiation oncology services. The HOPPS rule continues an expansion of the Comprehensive-Ambulatory Payment Classification (C-APC) methodology and includes modest changes to the proposed rates for radiation oncology services for 2019. CMS proposes a new device pass-through payment for the hydrogel spacer.
ASTRO submitted HOPPS comments, expressing ongoing concern that the C-APC methodology fails to adequately account for radiation oncology services. ASTRO also supported the hydrogel spacer pass-through payment based on evidence showing the material reduces toxicity for patients treated with radiation therapy for prostate cancer.

To learn more about the proposed rules at the ASTRO Annual Meeting, attend the 2019 Coding and Reimbursement Update on Monday, October 22, from 7:45 a.m. – 9:00 a.m. in Room 206. Also, keep an eye out for the final payment rules, which will will be released in November and will be effective January 1, 2019. ASTRO will host a 2019 Final Rules webinar to summarize the key issues impacting radiation oncology in both the MPFS and HOPPS on December 5, at 1:00 p.m. Eastern time.

In addition, for the latest in-depth information on health policy issues facing radiation oncology, attend the ASTRO’s 2018 Winter Coding and Coverage Seminar at its headquarters in Arlington, Virginia, December 7–8. This in-person workshop allows participants to hear from experts on top coding and coverage issues, including how these rules will impact their practice. ASTRO's Clinical Affairs department will be hosting MIPS office hours on-site where you can ask questions specific to your practice on the changes to the QPP.

See ASTRO’s or more details on radiation oncology payment, go to www.astro.org/Daily-Practice.
Posted: October 17, 2018 | 0 comments

ASTRO debuts all-digital posters at Annual Meeting

By Johanna Vanarsdall, Sr. Manager, Scientific and Education Programs

As we are preparing for the Annual Meeting at the end of this month, we are excited about the many new activities taking place in San Antonio. One especially novel feature is the all-digital posters. We are accustomed to walking through what seems to be miles of poster boards with paper posters at the Annual Meeting, but not so in 2018! The more than 1,700 posters will be available in a digital format on kiosks in the futuristic looking Innovation Hub. Additionally, authors will present their posters in a variety of sessions. We interviewed Johanna VanArsdall, ASTRO Senior Manager of Scientific and Education Programs and chief architect of this new concept, to give us some inside tips on how to get the most out of these posters.

AG: This seems like a big step, transitioning to an all-digital poster format. Why did ASTRO decide to make this move and did you get any resistance from authors?
Johanna: Over the years, we heard many complaints from attendees and authors that the poster hall was too far away and in a remote location. The all-digital posters will be available in the Innovation Hub, located right on the Exhibit Hall floor. ASTRO has been working up to all-digital posters over the last few years. We began implementing digital posters in 2014 with our Poster Discussion Sessions. At that time, these posters were simply a digital rendering of the paper poster. Today’s digital posters are on touch-screen monitors with interactive features, including video and other media.
We surveyed Annual Meeting attendees at previous years’ Annual Meetings, asking if they had a preference for digital versus paper posters. More than 75 percent of respondents said they preferred digital posters, so we felt it was a natural progression. As for the authors, most have been very excited about the digital format. Although, I have to admit, I’m betting that at least one person will arrive with a large tube in his or her hand.

AG: How will the digital posters work and will authors be available to talk with us about their posters, as they have in the past?
Johanna: All posters will be available for open browsing between 10:00 a.m. and 5:00 p.m. on Sunday, Monday and Tuesday in the Innovation Hub. Posters will be available on touch screen kiosks and viewers can search by track, author or poster number. You can also reach out to the author, using a QR code (if permission was given by author), further enhancing networking and information sharing.
Four Poster Viewing Q&A Sessions have been scheduled in the Innovation Hub. Posters will be grouped by disease site, and all poster authors will have the opportunity to provide a 7-minute overview of their poster using our unique touch-to-zoom feature during a scheduled time. These sessions will be overseen by a Moderator. Understanding the poster ID will help you make it to the poster presentations you want to hear. The first two letters indicate which day it will be presented, the next number identifies the station assignment and the last four numbers are the unique poster number assigned to each poster.

And finally, as in years past, Poster Discussion Sessions, similar to Oral Scientific Sessions, will be offered during the course of the meeting. These sessions will be held in a meeting room and offer CME. Each session will have nine authors who will have six minutes to present their posters. After the presentations, discussants will highlight key points, compare abstracts and moderate questions and answers. Poster viewing and face-to-face dialogue with authors occur at the end of the session, as authors stand by their digital poster and offer further discussion. Nineteen Poster Discussion Sessions are scheduled during the meeting.

AG: Wow, it sounds like you have everything well-organized and that there will be many opportunities to learn from the science being presented at this meeting. One last question, do you have any advice or instructions for poster presenters for when they check in?
Johanna: Yes, I do. All posters should be uploaded no later than this Friday, October 12. Poster presenters must check-in at the Poster Check-in desk located just outside of Hall 1 near the main registration area at least two hours prior to their presentations. A second poster check-in desk is located at the Concierge desk in the Innovation Hub during Exhibit Hall hours. Staff will be available to assist with uploading last-minute changes.
For more information about when a specific poster is being presented, refer to the MyASTROApp or conference planner.
Posted: October 9, 2018 | 0 comments

Treating Spinal Metastases: An Interview with Dr. Chia-Lin (Eric) Tseng

By Lisa Braverman, Red Journal Managing Editor

Chia-Lin (Eric) Tseng, MD, with the department of radiation oncology at Sunnybrook Health Sciences Centre at the University of Toronto in Canada, answered a few questions from the Red Journal editorial team about his recent co-authored article, “Imaging-Based Outcomes for 24 Gy in 2 Daily Fractions for Patients with De Novo Spinal Metastases Treated with Spine Stereotactic Body Radiation Therapy (SBRT).” SA-CME is available for this article through ASTRO Academy.

Tell us about your study.
Spine stereotactic body radiation therapy (SBRT) has been made possible in recent years due to advances in patient immobilization, target visualization and delivery techniques. Consequently, it has emerged as a potential treatment option for selected patients with spinal metastases. However, as there is currently no level I evidence, ongoing randomized studies (NCT00922974, NCT02512965) are expected to provide higher quality outcome data with respect to spine SBRT versus conventional radiation. In this study, we report mature outcomes for a large cohort of patients with no prior radiation (de novo) to the spine treated with 24 Gray (Gy) in two daily fractions for metastases, which represents the same SBRT regimen under evaluation in the Symptom Control-24, phase-3 randomized trial (NCT02512965). Our study provides evidence supporting the safety and high efficacy of this fractionation scheme in achieving tumor control for de novo spinal metastases. The outcomes presented in this study will serve as benchmark data for ongoing trials of this regimen.

Why is there such a wide variety of fractionation schemas for the spine, even when treating the same cancer type?
The optimal dose fractionation for spine SBRT in the setting of metastases is uncertain at present. Several dose-fractionation schemes for spine SBRT are currently in use, most commonly 16 to 24 Gy in one fraction, 24 Gy in two fractions, 24 to 27 Gy in three fractions and 30 to 35 Gy in five fractions. However, no level I evidence exists to support the use of one fractionation over another. Although some published reports have suggested improved local control with single fraction SBRT compared with a multi-fraction approach, single fraction treatment has also been associated with a much higher risk of vertebral compression fracture (VCF), according to recent studies. A recent systematic review of post-SBRT VCF based on 11 studies using a variety of fractionation schemes reported an overall crude VCF rate of 13.9 percent and a salvage intervention rate of 37 percent (range 11 percent-60 percent). The challenge with purported higher local control rates of one fractionation scheme over another is the retrospective nature of the reported data, which are subject to various biases and heterogeneity of the treated population, including histology. A randomized clinical trial (NCT01223248), although not specific to spine, is currently open to address this question, comparing 24 Gy in one fraction to 27 Gy in three fractions delivered to sites of cancer metastasis.

What do you think are the advantages of SBRT compared with regular external beam radiation therapy for spine metastases?
Spine SBRT may be employed as an alternative to conventional palliative radiation in the treatment of de novo metastases, in re-irradiation and in the postoperative setting, although currently without the support of level I evidence. We are awaiting the results of randomized studies comparing SBRT with conventional radiation (NCT00922974, NCT02512965). The use of higher doses per fraction in SBRT, particularly 8 Gy or more, may increase tumor cell kill compared with conventional external beam radiation via a number of mechanisms, including radiation-induced tumor-antigen specific immune response, endothelial/vascular injury or simply increased cell death due to a higher delivered biologically effective dose. To date, most published institutional series have reported high local control rates, ranging from 80 percent to 96 percent at one year, for spine SBRT of de novo metastases. Furthermore, spine SBRT is particularly suitable in the context of re-irradiation as it allows dose escalation to the tumor while achieving rapid dose falloff to minimize spinal cord dose exposure.

Should all metastatic cancer patients with spine disease have SBRT? Which ones should not?
The optimal management of spinal metastases is complex and requires a multidisciplinary approach with input from radiation oncology, spine surgery, medical oncology and radiology. Considerations should be given to patient factors, oncologic factors and treatment-specific factors. Patient factors may include neurological function, pain, age, comorbidities, performance status, estimated life expectancy and patient preferences. Oncologic factors may include tumor histology and molecular characteristics, overall disease burden, patient response to prior treatments and available systemic therapeutic options. Treatment-specific factors may include location of the metastatic disease within the spine, grade of epidural disease, radiographic appearance, prior surgical or radiation treatment and degree of spinal instability. In general, patients who have very poor performance status, high grade epidural spinal cord compression (Bilsky 3) or cauda equina compression, or who have frank spinal instability (SINS ≥ 13) are considered unsuitable for upfront spine SBRT. Ultimately, level I randomized evidence is needed to more definitively understand the indications, clinical outcomes and appropriate patient selection for spine SBRT.

Are there any special considerations with regard to the use of spine SBRT?
Yes, spine SBRT is complex not only in its planning and delivery, but in the multidisciplinary clinical decision-making process necessary for implementation. Therefore, it is critical not only for physicians to understand the technical know-how, but the rapidly evolving clinical concepts and appropriate application of spine SBRT in selected patients. Caution must be exercised when this treatment is used in the absence of sufficient experience and/or multidisciplinary support.
Posted: October 3, 2018 | 0 comments