19 Building an Interventional Oncology Practice
Like much in medicine, new practices and procedures must have adequate clinical studies for background, an unmet need to be filled, or a new and better way to treat patients to become accepted. Interventional radiology has, for years, demonstrated to referring physicians that the endovascular, image-guided approach is preferable or adjunctive to many medical therapies and certainly less invasive than surgery. But given the lack of large clinical trials, level-1 evidence, and already established referral patterns, how does an interventional oncology (IO) practice grow and thrive? Actually it sounds very straightforward, but the execution is difficult.
First, get yourself a copy of a general medical oncology text and start studying. This information has not been taught to radiologists in residency or in medical school. Look at the treatment regimens, their response rates, and the survival rate. Know the common diseases very well and understand where minimally invasive image-guided techniques may benefit the patient. Two other books would also be helpful: one on molecular biology and the other on immunology. Much of the future of cancer therapy is based on understanding the molecular biology and genetics of the tumor and designing a drug or treatment to exploit it. Immunology has recently come to the field of oncology through the use of immune checkpoint inhibitors and the understanding of the immunology of the tumor.
Second, learn “onc-speak,” or talk like an oncologist. There are several terms that they use that are not found outside of the field:
Doublet: A combination of two chemotherapy agents; singlets are rarely used, but triplets are often used.
Dose dense chemotherapy: Chemotherapy regimen that has less time between agents than standard chemotherapy.
OS: Overall survival or the time from diagnosis of the cancer until death
PFS: Progression-free survival—the time from the initiation of a therapy until the disease progresses. There can be a PFS for the liver, with liver-directed therapy and an overall PFS for spread beyond the liver, for example, lymph nodes.
SOC: Standard of care.
SD: Stable disease—no change in the index lesion(s) on crosssectional imaging in a particular time period.
PD: Progressive disease—increase in the size of the index lesion as determined by the measuring system employed, for example, mRECIST (modified response evaluation criteria in solid tumors). It is usually greater than a 25% increase in size of the lesion’s greatest diameter.
PR: Partial response—less than a 25% increase in size of the lesion’s greatest diameter.
CR: Complete response or eradication of the imaged disease, not necessarily cure since the patient must be followed for 3 to 5 years for that determination.
RR: Response rate—the sum of the SD and CR and PR.
QoL: Quality of life as measured by commonly accepted tools such as the SF-86, but there are quite specific measures for various tumors.
ALBI: This score is a combination of the albumin and bilirubin levels by a specific formula that removes the qualitative judgment from the Childs–Pugh cirrhosis levels and is very prognostic.
Cytoreductive therapy: Any therapy that locally removes tumors, for example, RFA (radiofrequency ablation) so that the grams of chemotherapy applied per gram of tumor is increased.
Immuno-oncologic therapy: The use of the patient’s own immune system to fight the tumor. For example, the use of PD-1 immune check point inhibitors that prevent this protein on the outside of T-cells from binding with its ligand, PD-L1. When PD-1 binds with PD-L1, the T-cell is prevented from attacking any cells, in this case tumor cells. There are also immune checkpoint inhibitors that bind to the ligand and perform the same function.
Third, attend every multidisciplinary tumor board available at your hospital, but do NOT under any circumstance show the imaging studies. If you show the imaging, you will be identified with “them,” the nontreating physicians, making the task of building a practice much more difficult. Depending on the size of the group, sending two radiologists to every tumor board sounds excessive, but given the downstream increase in referred studies due to the IO practice, it is well worth it. The list of patients and their tumors is usually published a few days in advance, which will allow review of the disease, the pathology, and then think about the potential for IO intervention. If you think that the patient to be discussed would benefit from IO, look up the pertinent references on PubMed or in JVIR (Journal of Vascular and Interventional Radiology) and know the results so that when another clinician questions your outcomes, you will be informed. Take copies of the articles to the tumor board if it is a controversial case. Sit with the surgeons and medical oncologists and get to know them on a personal basis. Do not be afraid to speak during the discussion as it will show your knowledge (or lack thereof, so be careful!) and weigh in on whether a patient should have IO intervention.
Fourth, if you can arrange to get clinic space in the same physical space as the medical oncologists, you will manage to see them at least once a week in a setting where the IO is treating patients just like the medical oncologist. In such a setting, it is only natural for a bond to form between the medical oncologist and the IO so that the IO is seen as a partner not just as a doer of procedures. It makes it very convenient then for the medical oncologist to immediately refer the patient to the IO and start the referral process. An alternative is to have the oncologist call you to come to their clinic for a consultation, particularly if the patient lives far away, if it is inconvenient for the patient to return for a clinic appointment with the IO. Remember an effort to make it easy for the oncologist (e.g., one phone call) and easy for the patient to see you will result in an increase in the oncologic volume. Demonstrations that you are flexible enough to make the patient a priority go a long way to getting the oncologist to trust you.
Fifth, see ALL patients for therapy in the clinic first. After all, referring a patient to surgery will result in a clinic appointment and not an operating room date. This will allow the independent evaluation of the patient by the IO team and perhaps some refinement of the treatment plan.
Sixth, the cancer center is usually a semiseparate entity that has its own faculty or members. After regular attendance at the tumor boards, it will be only natural to become a faculty/member of the cancer center.
Seventh, if there is enough available manpower in IR, get and use your admitting privileges. This way the IO can take care of the patient without burdening the medical oncology service. And do not hesitate to consult specialists.
Eighth, join the American Society of Clinical Oncologists. Yes, there are nonmedical oncologist members. Display your membership certificate in your clinic or office. This also gives you a subscription to the Journal of Clinical Oncology, the place to find out what is going on in your major referrer’s community and what the direction of therapy is for a particular disease so you can discuss it intelligently. It also shows your commitment to oncology and your dedication to keeping current.
Ninth, read a book on sales and marketing. Yes, that’s right. The IO is selling his/her abilities and therapies to the medical oncologist. Recognize that they are the customer and go out and see them in their office, in clinic, on the oncology floor; get in their face and sell.
There is an old adage about consulting physicians: the 3As.
Available. You need to be able to be easily contacted by referring physicians so that you get the cases. Hire the best people available to answer the telephones since they are the “face” of your practice. They need to know your policies on scheduling, holding anticoagulants, referring physicians getting the report, admissions, etc. The best practice is to have a “one call” referral: if the medical oncologist can get the patient in to see the IO in one call, a clinic appointment made with the patient, and then therapy discussed. Before the therapy is instituted, make a call or, preferably, send a written plan to the oncologist to outline the therapy discussed. One of the two biggest complaints about referring patients to the IO is the lack of communication so that the referring physician is apprised of what is going on. They do not want to feel left out of the loop. Send them the treatment plan, all dictations, and a plan for follow-up. The other complaint is that no adequate follow-up plans are made. If follow-up is due in 2 weeks by telephone call or clinic visit, it needs to be recorded in the chart and the referring oncologist notified of both the plan and the results of the call.
Affable. Be nice. You do not need to be obsequious as you only get the respect you demand. Be firm and stick to your boundaries. There is a fine line between demanding respect and being arrogant. Be sure that you are on the right side of that line.
Able. You need to know what you are talking about and be able to deliver. The absolute worst thing to do is to overpromise and underdeliver. In the process of building any practice, but specifically an IO one, prove your abilities in the easy cases building up to the more difficult ones. You may want the difficult ones immediately, but if there is a complication you won’t have a reservoir of goodwill on which to draw. Nothing will kill an IO practice faster than having a serious complication on an early case. This is true for new physicians at any hospital. You may be experienced, but if you are a newcomer, you still have to prove your abilities to a new audience.
This undoubtedly sounds like a lot of work—it is! But if you want a quality IO practice, follow the above guidelines and words of wisdom because THEY WORK. It is not instantaneous, but with patience and persistence, it pays off.