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Fine-tuning cancer treatments A software program helps doctors tailor radiation therapy to national guidelines for better outcomes Tuesday, August 28, 2001 By Christopher Snowbeck, Post-Gazette Staff Writer
A man with prostate cancer whose tumor is small and whose disease hasn't spread beyond the prostate gland might reasonably expect to receive radiation treatments five days a week for six to eight weeks.
At least, that's what most radiation oncologists agree is the best defense against the cancer someday reappearing. But in a small subset of cases, patients get something less.
In some cases, the side effects of radiation cause patients to beg off. Sometimes, patients miss appointments. Yet in some cases, physicians just don't adhere to accepted guidelines.
A new project by radiation oncologists throughout Western Pennsylvania is using a computer program to document how well local doctors follow recommendations for treating prostate and other types of cancers and make them aware of what the guidelines are when they plan treatments.
Dr. Jim Fontanesi, a pediatric radiation oncologist at Wayne State University and a founder of the Chicago company that developed the computer program, says the program is already having an impact here.
"In the first 18 months, we had a 50 percent reduction in the number of patients not being treated for early stage prostate cancers within specific guidelines," Fontanesi said. "What we're saying to doctors is, this is how you're performing as a group and you know your individual performance. If you're providing too few radiation doses, where the outcomes are not as good, don't you think it's mandatory to take your practice to the next level?"
Highmark Blue Cross Blue Shield has hired Innovative Solutions in Healthcare to provide the software locally to hospitals and free-standing radiation oncology centers. So far, most radiation oncology facilities in the region have signed on, with the exception of those in the UPMC Health System. Officials from Highmark and UPMC say they are working to put aside their competitive concerns so they can collaborate on the project.
Creating standardized treatments
The program is just one example of how radiation oncologists are working to standardize the treatments they provide, a goal consistent with the federal Institute of Medicine's call earlier this year to improve the system for delivering health care.
"In the old days -- and that was only 10 years ago -- the feeling was that every doctor should do what he thought was best. Well, I think we're beyond that now," said Dr. Rodger Winn, who chairs the guidelines steering committee for the National Comprehensive Cancer Network in Philadelphia. The Philadelphia group has created national guidelines for treating nearly every cancer and has distributed them free on computer CDs.
Claims data from Highmark Blue Cross Blue Shield suggests the local problem. Prostate cancer patients, for example, treated at different facilities in Western Pennsylvania might receive dramatically different numbers of treatments. From April 1999 to March 2000, patients at one radiation oncology center averaged 30 treatments per year while patients at another center averaged only three. All other radiation oncology facilities were somewhere in between.
"I'd look for much more consistency and the range to be tighter than what we found," said Keith Morganlander, Highmark's project manager for the radiation oncology program.
Highmark's data showed the same sort of variation in radiation treatments for breast cancer. Even so, the company's numbers couldn't definitively show whether a particular facility was providing too much or too little radiation. Instead, the numbers raised questions.The company decided to offer the Innovative Solutions in Healthcare software so local radiation oncology facilities could tackle the issue.
Initially, doctors were skeptical, fearing that Highmark would use the information to cut costs. Morganlander's response: "I told them, 'We could cut your reimbursement without this software.'"
To put providers at ease, Highmark adopted the program as a quality improvement program in which the company could monitor the performance of the centers without knowing which was which.
All but three non-UPMC hospitals have signed contracts to participate in the program; two of the three are expected to join soon, while the third has agreed to submit quality information but not use the Innovative Solutions software.
While sharing the general suspicion about Highmark's motives, UPMC has also been reluctant to participate because of new government rules promoting patient confidentiality, said Chuck Bogosta, associate director and chief financial officer of the University of Pittsburgh Cancer Institute. Even so, Bogosta said that UPMC is "very hopeful that we'll be part of it."
"We believe it's a good software package and, if utilized correctly, can really help us," he said.
UPMC is also more likely to join now that Highmark is looking to transfer administration of the program to an independent community group.
Signing on
One of the first radiation oncology groups to embrace the program is at Westmoreland Regional Hospital. Daniel A. Berkley, manager of the radiation oncology service, said that once doctors are trained to use the software in the next few months, they will directly enter information into the system when planning a patient's radiation treatment.
Take the example of a prostate cancer patient. The physician starts by telling the computer the size of the primary site of the cancer, whether and how many lymph nodes are involved and whether the cancer has spread to another part of the body. Then, the doctor will enter the results of a blood test and biopsy that characterize the risk that the cancer will spread quickly. The computer program then offers the doctor a recommendation.
In demonstrating the system last week, Berkley entered into the computer the case of a fictitious patient with relatively small prostate cancer that hasn't spread beyond the gland and doesn't seem likely to spread quickly. Berkley also told the computer that the patient would receive a combination of direct-beam radiation treatments and implants of radioactive seeds.
After churning the information, the computer reported that national guidelines would call for the patient to receive between 18 and 30 daily treatments. The system also provided references to medical journals that support the recommendation.
The physician might still choose to ignore the recommendations. A doctor could determine, for example, that a patient is too frail to withstand the recommended dosage or might alter the treatment plan because of changes in the patient's health. If so, the system asks doctors to write a short note explaining their decisions.
Use of the program at Westmoreland thus far has resulted in few changes in practice. "To this point, it's kind of validating a lot of things that we are doing," Berkley said. "I think we're very much in line with national standards."
Beyond adhering to national standards, the computer program collects data on patients throughout the region and allows doctors to study which treatments produce the best outcomes. That's especially important for smaller facilities that don't treat as many patients, because meaningful outcomes studies must be based on large populations, said Dr. Julian Proctor, clinical director of radiation oncology at Jameson Hospital in New Castle.
Nearly 30 physicians in Western Pennsylvania are scheduled to be trained in using the software by Nov. 1. Four doctors are now using it, including Dr. Russell Fuhrer, clinical director of the radiation oncology department at Allegheny General Hospital.
"We're going to be able to police ourselves and make sure everyone is practicing good medicine," he said of the program. "The ultimate goal of the radiation oncology project is to make sure that the Western Pennsylvania community is receiving radiation treatments on a par with national standards."
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