October 29, 2007

New in the Community
By Raia King
For The Record
Vol. 19 No. 22 P. 32

Radiosurgery is beginning to move out of academic health centers and into community hospitals. Though certainly not for every facility, some are finding that a flexible system such as the CyberKnife can help both patients and hospitals in the community setting.

When doctors and administrators at Naples Community Hospital (NCH) Healthcare System in Florida decided to pursue radiosurgery for their cancer treatment arsenal, they considered all the commercially available systems. Debra Freeman, MD, a radiation oncologist at the two-hospital, 539-bed system, was part of the team that made NCH the 16th facility in the United States to open a radiosurgery unit with the Accuray CyberKnife stereotactic radiosurgery (SRS) system.

“It did what we intended to have it for, which was doing intracranial radiosurgery, and allowed us to apply it to so many other things,” Freeman says. “We think we made the best choice possible.”

NCH and other community hospital systems are embracing advances in SRS for cancer treatment. In doing so, their doctors can treat patients they otherwise could only refer elsewhere. In the marketplace, hospitals can sometimes differentiate themselves from their regional competitors and create new revenue streams by reaching a previously unserved patient market. SRS with the CyberKnife Robotic Radiosurgery System enables physicians to treat intracranial and extracranial tumors with submillimeter accuracy.

Accuray, Inc. began developing the CyberKnife in 1987, but it wasn’t until the early ‘90s that a prototype version was produced for use at five academic research facilities. After receiving FDA approval in 2001, the CyberKnife began to attract the attention of U.S. community hospitals. As of December 31, 2006, Accuray had 91 systems installed around the world.

The ability to treat tumors with submillimeter accuracy inside and outside the head offers new treatment options to patients and facilities. In NCH’s first year with the CyberKnife, 70% of treatments were intracranial and 30% extracranial. Now, roughly three years after installation, Freeman says the split is approximately 35% intracranial and 65% extracranial.

Freeman says the ability to treat tumors outside the head makes it a more versatile unit. CyberKnife offers a flexible way to treat patients for whom surgery was complex, impossible, or simply unwanted. The system is being used to treat tumors in the brain, spine, lungs, kidneys, liver, pancreas, and prostate. That versatility represents a potential advantage over the original SRS system, the Leksell Gamma Knife, which has a longer, 30-year track record in treating brain tumors, but its design limits its use in cranial procedures.

“It [CyberKnife] allows us to treat tumors that would not otherwise be suitable for surgery,” Freeman says. “That was the main deciding factor for purchasing the CyberKnife. Most lesions that we treat with CyberKnife would be otherwise amenable for surgical recession but might be in a location that would make it difficult in a patient who is too ill or too elderly to undergo a surgical procedure or where there are medical risks for having surgery.”

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In Bristol, Tenn., John Fincher, MD, chief radiation oncologist at the 348-bed Bristol Regional Medical Center, has been using the CyberKnife since June 2004. Bristol Regional can now treat patients that it would have referred to an academic medical center.

Fincher recalls two patients who had received multiple courses of chemotherapy to treat inoperable tumors that would temporarily shrink after treatment but invariably return. Each patient received SRS, and, two years later, both patients have no evidence of disease.

“By the old books, that sort of stuff shouldn’t be happening because they each had metastatic disease,” Fincher says, “but it does. In terms of community hospitals, we didn’t experience that before. When these people would come in, we’d have to tell them that we were sorry, but there was nothing else we could do. We could send them to a big medical center and they could try an experimental protocol or something, but that would be risky with no guarantee of results. Now, we have an alternative that nobody else has.”

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Eric Rhoton, MD, FACS, a staff neurosurgeon with the 800-bed Mission Hospitals system in Asheville, N.C., has used the CyberKnife system for approximately two years. In addition to treating cancer, Rhoton utilizes the system to treat trigeminal neuralgia, a nervous system affliction that causes intense facial pain. In trigeminal neuralgia, the nerve that supplies feeling to the face is hyperactive and hyperirritable, consequently sending painful impulses from the nerve to the brain even though there’s no painful stimulus on the face. It is widely considered among the most painful conditions known, driving some patients to commit suicide.

Rhoton says a significant portion of his patients with this condition have received SRS treatment, and it has proven effective. “The usual treatments,” Rhoton explains, “would be either to go in and do open brain surgery called microvascular decompression or to make a radiofrequency lesion in the nerve by sticking an electrode or needle up through an opening at the base of the skull into the nerve and try to selectively deaden the portion of the nerve that’s hyperactive and causing the pain. The way the CyberKnife works is, instead of having to do anything open, it makes a lesion in the trigeminal nerve with the use of fine beams of radiation that can reduce or eliminate the hyperactive impulses.

“These patients are having this horrible pain, and then the idea of having to have brain surgery or some sort of needle stuck in through the base of their skull is really frightening to them,” Rhoton adds. “Once most patients hear about the different treatment options and potential side effects, they seem to be excited about getting the noninvasive CyberKnife treatment vs. some of the other neurosurgical treatments for the condition.”

Changing Patient Experience
In addition to providing treatment options where few or none existed, SRS with CyberKnife also changes the treatment experience for patients going through an already difficult time.

“One of my best friends had to have a radiosurgical procedure in which I had to put the frame on him, and that was a real traumatic experience for him.” Rhoton says. “It really meant a lot to me that we were able to find a device that required no frame and was completely painless and well-tolerated by patients of all ages.

“I’ve had patients in their 90s who have had the CyberKnife and tolerated the procedure well, and that group of patients simply would not have been treatable with even the frame radiosurgery systems like the [linear accelerators] or the Gamma Knife,” Rhoton adds. “People who are just frightened of surgical procedures in general and would forego them because of that fright are willing and tolerating the CyberKnife, so it really adds a nice dimension for them.”

Accuray’s system does not require a frame to immobilize the patient, and it usually doesn’t require surgically implanted fiducials to precisely track the position of tumors. Radiosurgery is less invasive because it uses low-energy x-ray, making images to find bony anatomy for landmarks; it can even use soft tissue as targets. Treatment usually does not require general anesthesia and can be performed on an outpatient basis.

The unit accurately tracks the tumor position with real-time, high-resolution images throughout the entire treatment course while continuously correcting beam delivery to account for patient movement such as respiration or digestive function. The system’s accuracy enables clinicians to treat tumors with high doses of radiation while minimizing harm to the surrounding healthy tissue. Traditional radiation therapy treatments deliver lower levels of radiation over a longer course of time. SRS enables patients to receive as few as one to five treatments of higher radiation so they can complete treatment sooner.

Rhoton also notes that treatment can be quick and convenient for the patient. “You come in, you get your treatment, and you’re back on the street ready to go about your business,” Rhoton says. “There was one patient who was excited that he was able to get his treatment in the afternoon and still make his meeting that evening. That’s kind of the typical advantage for someone who has a very busy schedule. … There’s really not any downtime other than the time that you have to invest to get the procedure done. You’re ready to resume your usual activities rapidly after the treatment is done.”

Financial Considerations
While doctors and patients see the benefit of the CyberKnife system, it doesn’t come cheap. The Naples (Fla.) Daily News reported that NCH spent $4.7 million to build and equip its center. Freeman says the financial justification usually depends on a hospital’s existing competitive market and the other tools available.

“One of the questions I get asked quite a bit is, ‘Well, if this is such a great tool, how come every university hospital across the United States doesn’t have one?’ The answer is, ‘Because it’s not free,’” Freeman says. “Universities and cancer centers may already have radiosurgery available in the form of the [linear accelerator-based] or the Gamma Knife, and then they have linear accelerators as well, so it may not make sense for those centers that already have a form of radiosurgery to invest more to have a CyberKnife. If you have a hospital that doesn’t have any form of radiosurgery, then I think you can justify the dollar investment because you have a device or a tool that can treat a broader scope of diagnoses than the other systems can.”

Adding an SRS system to a community hospital can increase patients and revenue by boosting referrals from regional physicians. “Patients who find out about what the machine can do and, if it’s appropriate for their situation, are willing to travel to get that treatment,” Freeman says. “We’ve certainly broadened our referrals. We wouldn’t have necessarily had a reason to have referrals from the southeast region of the United States to Naples, Fla., if we didn’t have something special to offer.”

Approximately 70% of NCH’s patients treated with the CyberKnife are from the hospital’s geographic area, while 20% are from other regions in Florida and 10% from other states, according to Freeman.

Freeman has also seen how NCH has opened a new market of patients receiving extracranial radiosurgery procedures. “You can use CyberKnife as an alternative where your alternatives would be few and far between,” she says. “In terms of being able to market your facility, you can offer a bigger variety of services for patients, and I think that always gives a center a competitive edge. The fact that we have changed our whole flux from primarily intracranial to extracranial just demonstrates the versatility of the CyberKnife. I think for community-based centers it’s hard for some of the other systems to compete because they don’t have that same versatility.”

Fincher also sees the value of market differentiation. “I think any time you add that level of technology, you create a certain level of respect as a referral center that you didn’t have before,” he says. “We now get some referrals from out of state. Some are long distances out of state. The fact that we have a CyberKnife created some referrals because the system can do things that other pieces of equipment cannot. We’ve had patients specifically come from Gamma Knife centers because they were a little intimidated by the prospect of putting a frame on and being locked into the machine. They come in and we explain the process, and those particular folks are very grateful to have this as an alternative.

“From a financial standpoint,” Fincher continues, “if you are in a competitive setting, as most hospitals are, a competitive advantage will give you an increase in your referral base. So then this is the horse that leads you into battle and pulls the rest of the troops along. … You get referrals to your other doctors and you get a lot more referrals for the diagnostic radiology department, and so they’re doing a lot more procedures. You still have to build your base though, and that’s the key. If you have a good neurosurgical program, then you’re going to be successful with a CyberKnife, period.”

— Raia King is a freelance writer based in King of Prussia, Pa.

Resources

Francis B. “One woman, one robot.” Naples Daily News. August 16, 2006. Available here.

CyberKnife Patient Support Group. Available here.

CyberKnife Society. “Radiosurgery Systems Comparison.” Available here.