Insurance coverage for CyberKnife Therapy

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Sy - 20 Sep 2007 10:38 GMT

My general situation was diagnosed last month with Prostate Cancer

Stage T1c
Gleason Score-6 (3+3)

I won't bore you with other numbers or data inasmuch as they are
secondary to an Insurance issue.

The usual treatment options were given.

-Radical Prostatectomy
-Conformal Radiation Therapy
-Seed Implant
-CyberKnife treatment

According to my Urologist, and 2 Radiation Oncologists I am a perfect
candidate for the CyberKnife.

I am lucky to live within 15 minutes of Overlook Hospital in Summit,
N.J.. which has the CyberKnife. It is a type of stereotactic
radiosurgery which is ultra-precise and the treatments would be 5
consecutive days each treatment being about an hour as opposed to the
less precisely targeted Conformal Radiation Therapy requiring 5 days
per week for 8 weeks and 15 minutes per treatment session. The
difference in treatment times speaks to the ability of the CyberKnife
to very accurately dispense high-dose radiation with ultra-precision so
as to spare healthy tissues.

Let me say from the outset that I have been in the Medical Products
business for 20+ years and am not naive about the strategies used by
device manufacturers to market their procedures and products.

Having said that, everything I've read about the CyberKnife speaks to
it's effectiveness as well as to it's ability to minimize healthy cell
daamage. Originally developed at Stanford in the 1980's it was used to
treat inoperable brain lesions and has since been "cleared" by the FDA
for use in other body systems including the Prostate.

The longitudinal studies as to it's efficacy are not as long in
duration (years out) due to the fact that the CyberKniife is still
relatively new but are equal or better than matched types of older
therapies.

Anyway, I had a long discussion with the Business Manager of the
Radiology Dept. who advised me that my particular Insurance plan
(Oxford Health Plan) has recently been reluctant or unwilling to pay
for CyberKnife treatment but would of course pay for seed implants or
EBRT.

Oxford apparently contends that the CyberKnife is "experimental" which
is not an accurate statement inasmuch as it has been cleared by FDA for
use throughout the body. CyberKnife treatment is generally covered by
most insurance plans as well as Medicare the latter being of extreme
import insamuch as private insurance plans tend to emulate Medicare
coding and coverage for their procedures and patients.

Bottom line: I am anticipating resistance from the Insurance company
and would appreciate anyone's feedback on such matters. I don't see
how, if ample Medical corroboration is supplied that they could
rightfully deny my request for this treatment

I was wondering what oversight the New Jersey Dept. of Insurance might
have in such a matter. I would doubt that a company could legally sell
Health Insurance policies in this state then make "arbitrary" decisions
regarding appropriate treatment.

Any feedback will be appreciated,

Sy G.

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cmdrdata - 20 Sep 2007 12:50 GMT

> My general situation was diagnosed last month with Prostate Cancer
>
[quoted text clipped - 65 lines]
>
> Sy G.

Sy, I'm probably the only one in this group that had the treatment you
described
(high dose SBRT in 5 fractions). AFAIK, this method of therapy for PCa
is still
considered experimental (mine is a Phase I/II study). Luckily, my
insurance
covers that payment as 5 IMRT sessions. In reality, since I was
enrolled as a
study patient, the Onc would have absorbed these RT fractions if I had
fought it,
but I didn't. I'd interested to know and exchange histories later if
you decide to
go ahead with it. Email me and I'll answer any private questions you
have
pertaining to this treatment. I had mine in Feb 2007.

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Sy - 20 Sep 2007 17:28 GMT

[[ This message was both posted and mailed: see
the "To," "Cc," and "Newsgroups" headers for details. ]]

Hi,

Please tell me what the acronyms SBRT and IMRT mean. I assume it's a
very targeted and powerful "ray" either proton or somesuch.

I don't understand why people refer to the CyberKnife as
"experimental". Yes, "longitudinal" experiments (rather "studies" )are
being conducted to determine longitudinal outcomes. However to the
best of my knowledge the FDA does not grant a 510-K registration to any
device which is "experimental" in the literal sense of the word.

Thanks for your feedback.

Sy

> > My general situation was diagnosed last month with Prostate Cancer
> >
[quoted text clipped - 81 lines]
> have
> pertaining to this treatment. I had mine in Feb 2007.

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cmdrdata - 20 Sep 2007 21:21 GMT

> Please tell me what the acronyms SBRT and IMRT mean. I assume it's a
> very targeted and powerful "ray" either proton or somesuch.
[quoted text clipped - 4 lines]
> best of my knowledge the FDA does not grant a 510-K registration to any
> device which is "experimental" in the literal sense of the word.

IMRT (intensity modulated RT) is the existing approved therapy (by the
medical group that governs RT, aka RTOG and also by the insurance
companies) for PCa. Typically it delivers low dose 200cGy x 40+
fractions (aka treatments).
SBRT - stereotactic body radiation therapy is approved for brain, lung
and liver, but not yet fully approved for prostate. By its nature and
technology, cyberknife is a trade name for an RT machine capable of
delivering precise, multiple, and "conformal" beamlets in 3-D. These
features allow the RT Onc to be able to deliver higher dose than the
traditional IMRT machines, while maintaing similar or less side
effects.
Furthermore SBRT for prostate aims for high-dose and low number
of fractions (in my case 900 cGy x 5). Be aware though that total rad
is not a linear calculation, i.e., total dose 80 Gy for IMRT is not
the
same as my 45 Gy (something to do with alpha-beta ratios) although
it is believed that the impact to the prostate obliteration is the
same.
And so far (6+ months) my SEs are minimal.

The reason it is still a study for PCa is that high-dose application
to a
a prostate from cyberknife like machine to a target that moves (due to
breathing and bladder volume) is still being reviewed. Dr. Berit
Madsen
from Virginia-Mason did a medium dose SBRT and I was led to believe
that it was not as successful ( I corresponded with her). Existing
data
for high dose brachytherapy has been good, thus my decision to go
with the study. So bottom line is, cyberknife itself is not
experimental,
but the application of that techinque for PCa monotherapy is not yet
mainstream.

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Alan Meyer - 23 Sep 2007 16:50 GMT

> ...
> The reason it is still a study for PCa is that high-dose application
> to a
> a prostate from cyberknife like machine to a target that moves (due to
> breathing and bladder volume) is still being reviewed.
> ...

I have read something similar to this. What I read was that
Cyberknife was originally developed for brain surgery. The
brain, being encased in skull bone, could be clamped into
a perfectly rigid position so that the extremely precise radiation
beams could be very accurately positioned.

Of course that's critical in brain operations. Any damage
inflicted outside the tumors could damage a person very
seriously.

With the prostate and many other organs, I don't know if
the specialists yet know 1) if they can take advantage if
this high precision with an organ (the prostate) that is not
as easily clamped in one spot or 2) whether there is great
value in such precise targetting, or whether it's better to
just radiate the entire area anyway on the grounds that
there may be microfoci of cancer all around the prostate.

So, while it sounds like a promising technique, I think it
may still be experimental and I'm not sure anyone really
knows whether the results will be better, worse, or about
the same as the other radiation techniques.

And now for the standard disclaimer: I am no kind of expert
in any of this and the real scoop on the issues that I raised
above should come from someone vastly more qualified
than I am.

Alan

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cmdrdata - 24 Sep 2007 16:12 GMT

> With the prostate and many other organs, I don't know if
> the specialists yet know 1) if they can take advantage if
[quoted text clipped - 8 lines]
> knows whether the results will be better, worse, or about
> the same as the other radiation techniques.

Exactly the point. I participated in this RT study because
I believe that high dose (HD) will kill the cancer, and
that newer machine can deliver precise targetting. But, as
you indicated, I do experience minor (so far) side effect (SE)
in that I continue to have occasional rectal bleeding (grade 1).
Hopefully, the Rad Onc will learn how to apply this HD RT
better in th future so others may benefit to shortened, more
effective, and less SE treatment. I was put in a custom made
lower body mold, had 3 gold fiduciary markers, and although
the machine can do millimeter precision, my rectal wall
evidently got zapped anyway. Anecdotally, my cowper's
gland is still intact, as are my erectile nerves. I still have
a small clear viscous ejaculation. So the machine accuracy
is a testament to that. The live imaging done just prior to
zapping evidently was not sufficient if the darn thing moved
a few minutes later. I suspect that someday they will be
able to CONTINOUSLY adjust the beam treatment plan as
beams are being emitted.
mold

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