No reason ever* to endure 40 IMRT treatments as primary therapy anymore

I think the issue is NOT equivalent oncological effectiveness, the issue is toxicity. When radiation is given at higher dose rates, even small "misses" can matter a lot more. This means that a lot of care has to be taken in limiting margin size (especially on the rectal side), using cone beam CT for every fraction, setting very tight dose constraints, assuring that the bowels are not distended, and that the bladder is full. Faster machines, like VMAT, can help, as can Tomotherapy with its continuous monitoring. Older, 3D-CRT machines are probably not such a good idea. This also means that the RO and physicist may have to work harder on the planning. If this is something the RO is inexperienced with, and he is the only RO available, then it might be wiser to let him do it the way he knows.

TA
There's no argument with your point and maybe why some ROs aren't comfortable doing high dose imrt. In terms of cost , I had 10 gray in 3 fractions billed by a hospital at $29800 per fraction and paid at 97% by Medicare with the balance paid by Medigap. So 100% of amount billed by hospital was paid! That compared to one fraction at 1.5 gray billed by a private RO clinic at $2200 and paid at $450 or 20%. Seems strange.
Bob

TA
I haven't received the invoice for the 2nd and 3rd fraction of SBRT. The date of service was June 2 and that was my first fraction . Maybe they billed for all three fractions at one time? If so the cost for 3 fractions was $29800 and was fully reimbursed. I believe I had 10 gray per fraction. But may have been 9. I'll get back to you when this is clarified.
As far as low dose IMRT by Dattoli they wanted to do six weeks or 30 fractions. Assuming they would use 1.5 gray per fraction (the dose administered to my pelvic lymph nodes) that would have been 45 grays. At $2200 per fraction that would have totaled $66000 for low dose IMRT to a single 9 mm bone met but reimbursed at only 20%. So the net cost to the insurer is MUCH LESS for IMRT. Dattoli has two linacs which he keeps well utilized. But his reimbursement rate from Medicare is very low as I said. So he needs volume. His nurse commented that he would get a higher reimbursement for SBRT but preferred the safety of IMRT for his patients. He is however getting a machine which administers SBRT later this year. He will make more money administering SBRT. He's a great doctor with a great team but he'll be forced to administer SBRT due to convenience to patients. I still don't understand why the reimbursement rates are so different.
Clearly, for mets located away from other vital organs SBRT is the way to go.
Bob

That's correct TA. We have discussed SBRT and Hypofractionation and the RO is well aware of the oncological effectiveness but also the toxicity..he is not comfortable with that possibility . He may be somewhat restricted by the equipment he uses..it's not the oldest, but not the cutting edge technology either. As I say we'll discuss it more.

Tall Allen,
I looked at your blog abstract of the paper.
Very interesting.
I tried to look at the paper but could not see the entire paper without a subscription log-in to asco.org.

The study says it was of 168 high risk patients.
10-year freedom from biochemical failure was 72% for the Hypo group vs. 65% for the Conv group.(no statistically significant difference).

Do you know how they defined "high risk"?
Was it high Gleason? Was it high PSA?
Was it a mix of both or maybe some other factor?

Those are different types of high risk. Did they break out the treatment outcomes by the type of high risk?

TA

Just got the final billing for my SBRT which was done at a local hospital. Code 77373 was billed $16,214 for EACH of three fractions. SBRT at hospitals is reimbursed 100% as part A. Other codes were also billed. But code 77373 was the whopper.

Bob