Raising The Profile of Radiation Oncology: Q&A With Astro President Dr. Theodore Deweese

The future of radiotherapy: Efficiency and accessibility p.
80
Your Industry Source for Healthcare and Equipment Coverage

September 2019
Raising
the
profile of
radiation
oncology
Q&A with
ASTRO president
Dr. Theodore DeWeese
p. 36
Also in this issue

LOOKING TOWARD A FUTURE WITH
FLASH THERAPY
• Researchers discuss what the cutting edge
technique could mean for the future of
cancer care. p. 26
WHAT'S NEW IN PROTON THERAPY

AND RADIOTHERAPY?
• We look around the industry at the latest
technology entering the market. p. 44
DOSE OPTIMIZATION
• When it comes to administering CT
scans, how do you ensure a quality
diagnostic image without excess radiation
exposure? p. 52
RADIATION SHIELDING
• Shielding may not be on your mind every
day, but when it's time for a shielding
project you can't afford to make mistakes.
p. 70
CT Solutions in Sight
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CONTENTS
September 2019
FEATURES EXCLUSIVE Q&As

26 20
Looking toward a future with flash therapy Art Gianelli
Researchers discuss what the cutting edge technique could President
mean for the future of cancer care. Mount Sinai St. Luke’s
Delivering healthcare in a 'Lean' framework.
30
Addressing gender disparities in the field of radiation
oncology
When it comes to salary and career opportunities, there are 34
substantial unexplained gaps between male and female Dr. Parag Parikh
radiation oncologists. Director of MR-Guided
Radiation Therapy and
44 director of GI Radiation Oncology
What’s new in proton therapy and radiotherapy? Henry Ford Cancer Institute
We look around the industry at the latest technology Discussing the value of MR-guided
entering the market. radiotherapy.
52 36
Dose optimization Dr. Theodore DeWeese
An update on finding the balance between quality President
diagnostic imaging and radiation exposure. ASTRO
Raising the profile of radiation oncology.
56
Spectral CT
Value, use cases and implementation insights from
Dr. Nakul Gupta. 60
John Boone
62 Professor of radiology and biomedical
AI comes to the CT market engineering, and chief of
Surveying the latest hardware and software enhancing the medical physics
capabilities of CT providers. University of California Davis
Ultrahigh-res scanning comes to CT.
70
Radiation Shielding
Shielding may not be on your mind every day, but when it's time
for a shielding project, you can't afford to make mistakes.
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70 CONTRIBUTING WRITERS

Lisa Chamoff
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Lauren Dubinsky
Thomas Dworetzky
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Deepak “Dee” Khuntia
COLUMNS & SECTIONS John W. Mitchell
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6
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Some of the top current events stories from our Daily News online COPY EDITOR David Imber
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Our online news is getting a makeover

For all its wisdom and good intentions, The new HCB News is built on a more modern coding infrastruc-
the old adage "don’t judge a book by its ture, so the entire aesthetic of our site is enhanced and up to date.
cover" is pretty clichéd advice. Sure, the As part of this project, we had to consider a lot of the same things
actual words inside the book are what that a book designer has to consider. The new homepage is basically
matters most, but that doesn’t mean good our new "cover" — and we hope that you will judge it favorably.
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Business News readers will have a more enjoyable and more intuitive
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If you’ve been reading our news for a long time then you know
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gest. A few years ago we rolled out our individual silos so that our 16 Editor in Chief
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to and navigate the site accordingly.
Knitting raises thousands for Scottish MR scanner

fundraising campaign
Posted online July 08, 2019 by Lisa Chamoff
A fundraising campaign to help pur- had to travel to Aberdeen for follow-up MR Since the beginning of May, thousands
chase a new MR scanner for Scotland’s scans every three months after having a can- of online sales of the Harriet’s Hat pattern,
remote Shetland Islands has gotten a cerous polyp removed from her colon. along with sales of Shetland wool yarn
boost from one of the region’s oldest Middleton, who says she has immersed from Lerwick retailer Jamieson & Smith and
traditions — knitting. herself in her beloved hobby “through good knitwear from Middleton and her knitting
A year ago, the Shetland Health Board times and bad,” began selling her hand-knit group, called MRI Maakers, has raised nearly
Endowment Fund began a campaign which items at craft shows to raise money for the £25,000, close to 10 percent of the total
aims to raise nearly £1.65 million to purchase a campaign. She then started receiving dona- raised so far, toward the target.
scanner for the archipelago, which consists of tions of yarn from local companies, such as “I was overwhelmed and still am over
16 islands inhabited by roughly 23,000 people. Jamieson’s of Shetland, forming a knitting the response to the campaign,” Middleton
Currently, about 600 patients a year must group to create more items for the fundraiser. told HCB News. “It shows the power of the
travel via plane, or up to 14 hours over often Middleton designed a pattern for a hat internet. I never thought when I decided to
rough seas on an overnight ferry, to either using the blue and orange colors from the do something to help raise money for the
Aberdeen or Glasgow on the Scottish main- campaign’s logo. Her son, Billy Middleton, appeal that my small effort would generate
land to have an elective outpatient MR scan. set up a website and social media accounts so much interest.”
Enter Harriet Middleton, a knitter who to sell and promote the pattern. Share this story: dotmed.com/news/47816
6 HealthCare Business News I september 2019 www.dotmed.com/news

HealthCare Business Daily News Online
Top trending headlines
• Breaking news as we went to print:
Philips execs knew of alleged
• M&A activity bribes in Brazil in 2010, says
whistleblower
• FDA approvals dotmed.com/news/48296
First scan in US performed with

• New studies uEXPLORER Total-Body PET/CT
dotmed.com/news/48248
• Market analysis Three reasons growth in the mam-
mo systems market will likely slow
Did you know this magazine is just the • Exclusive dotmed.com/news/48171
tip of the iceberg? Healthcare industry interviews Carestream completes sale of IT

current events impact your facility and business to Philips in most countries
• 16 personalized dotmed.com/news/48129
they happen when you least expect it. silos Patient record breaches in 2019 al-
That's why we cover them every day in ready double the total from last year
our 100% FREE Daily News online. • 100% FREE dotmed.com/news/48205
X-ray reveals grill-brush wire behind
dotmed.com/news
woman’s dangerous breathing ills
PSMA PET/CT may beat Axumin for

locating recurring prostate cancer,
says study
Register today dotmed.com/news/48170
and never miss MD Anderson to expand proton thera-

py center with $159 million project
another story dotmed.com/news/48206
Siemens to acquire Corindus

Vascular Robotics in $1.1 billion deal
X-ray scan reveals more than 500

teeth lodged in boy’s jaw
RadNet acquires Nulogix, opens

new AI division
Law to reduce unneeded Medicare

CT, MR exams delayed by Trump
administration
New technique may concentrate

radiotherapy dose for minimal
tissue damage
Dense breast laws not boosting

ultrasound screening rates: study
Radiotherapy beats anti-hormonal

therapy for some breast cancer
patients, says study
@dotmedcom
Daily News Online > dotmed.com/news
Some medical devices exempted from China tariffs

Posted online July 15, 2019 by Thomas Dworetzky
Last week, the Trump administration exclusion for some of its equipment after “If tit-for-tat retaliation continues, the
announced it would exempt 110 Chi- claiming that that the tariffs would only hurt administration’s objectives for a strong do-
nese products, including some medical their firm, as there are no other “good alter- mestic medical technology industry will be
equipment, from its 25 percent tariffs natives,” noted Reuters, and that it would undermined. We ask the administration to
placed on $34 billion of Chinese imports hurt it against European competitors. consider this adverse impact and to remove
on July 6, 2018. Other device components that have been all medical technology products from its re-
The exclusions are retroactive to that exempted include “veterinary ultrasound taliation lists,” it stated.
date, according to Reuters, and will be in devices, certain parts and accessories of elec- In addition, it urged that, “including med-
place for a year from last Tuesday. tro-surgical instruments, and dental X-ray ical technology products on the USTR list is
The U.S. has levied tariffs on $250 billion alignment and positioning apparatuses,” ac- troubling from a public health perspective.
of imports from China and now threatens cording to a report in Medtech Dive. Healthcare products have been consistent-
to tax another $300 billion, as the two na- But according to a June statement to ly recognized as being exempt from trade
tions continue going back and forth with USTR by the Advanced Medical Technology sanctions — even with countries which the
one another. (AdvaMed) Association, which represents United States considers to be security risks.”
There were 12 exclusion requests grant- over 400 medical device makers, many An ongoing trade war could threaten the
ed to Medtronic, including one for a com- devices that the group hoped would be 30 percent market share U.S. makers enjoy
ponent in a device used to treat liver tumors. exempted, including pacemakers, remain in China, AdvaMed noted.
Varian Medical Systems also received an subject to the 25 percent tariff. Share this story: dotmed.com/news/47897
NNSA awards agreements to CT and MR waiting times

US firms for Mo-99 production costing Canadians over $3
Posted online July 30, 2019 by John R. Fischer billion
Three companies have finalized negotiations for awards with Posted online July 05, 2019 by John R. Fischer
the Department of Energy’s National Nuclear Security Admin-
A new report commissioned by the Conference Board of
istration (DOE/NNSA) for the production of molybdenum-99
Canada, “The Value of Radiology, Part II” specifies that wait
(Mo-99) — using no highly-enriched uranium (HEU).
times for CT and MR diagnostics has cost the Great White
The three companies are Michigan-based Niowave, and Wis-
North $3.54 billion in lost productivity annually, and that an
consin’s NorthStar Medical Radioisotopes and SHINE Medical Tech-
investment of $4.4 billion must be obtained between now
nologies. A possible fourth cooperative agreement with Northwest
and 2040 to modernize its medical imaging equipment.
Medical Isotopes in Oregon is also under negotiation.
“The major challenge in modernizing Canada’s stock of equip-
“Mo-99 is a critical medical isotope that empowers us to fight
ment is that Canada’s CT and MRI machines are old, much older
back against heart disease and cancer,” Lisa E. Gordon-Hagerty, DOE
than the guidelines we use to gauge what’s ideal,” Robyn Gib-
undersecretary for nuclear security and NNSA administrator said in a
bard, economist for the Conference Board of Canada, told HCB
statement. “These agreements will facilitate its domestic production
News. “That means that, in the short term, decision-makers have
without highly-enriched uranium, greatly reducing the potential for
to balance two competing goals: modernizing the stock of equip-
proliferation of nuclear materials.”
ment and reducing wait times.”
Used in more than 40,000 medical procedures daily in the nation,
Approximately 380,000 people each year are forced to tem-
the objective of these deals is to ensure a supply of 3,000 six-day
porarily take leave from work to wait for MR and CT exams longer
curies of Mo-99 per week.
than the recommended maximum wait time. The loss of workers
Congress had appropriated $40 million for the awards for FY
hinders the ability of firms to produce goods and services, which
2018 and $20 million more for FY 2019. The three agreements call
in turn, hurts GDP and reduces government revenues by $430
for NNSA to give $15 million to each of the awardees, which will be
million annually.
matched by the firms.
Share this story: dotmed.com/news/47755

Consumer experience is top priority for 69 percent
of US hospitals: survey
Posted online July 10, 2019 by John R. Fischer
Improving consumer experience is top periencing improved quality outcomes and lowed by greater patient adherence to care
or second among the priorities of 69 improved patient engagement, while 65 plans, reductions in unnecessary utilization/
percent of healthcare C-suite executives, percent report a higher number of patients readmissions, and improved patient reten-
according to a survey conducted by re- sticking to care plans, and 54 percent seeing tion. While 81 percent of C-suite executives
search firm Sage Growth Partners. improved patient retention. use navigators with clinical backgrounds,
Commissioned by healthcare experience Utilized the most in oncology, orthope- programs of high value rely on non-clinical
and patient navigation enterprise, Docent dics and cardiology, the adoption of patient navigators, which were found to be more
Health, the survey examines strategies imple- navigation programs is mainly stimulated by effective than clinical ones.
mented by hospitals across the country to a desire to improve patient engagement, fol- Share this story: dotmed.com/news/47831
improve such experiences, a task which is
becoming essential due to changes in how
healthcare services are managed and paid
for, says Stephanie Kovalick, chief strategy
officer for Sage Growth Partners.
“Consumers are starting to feel a higher
burden of paying for services themselves,” she The Accurate and Affordable Answer to Home Reading
told HCB News. “Healthcare consumers have LG 27" 8MP Clinical Review Monitor
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paying for so much care out-of-pocket. As you
start to spend your own money, you’re much
more careful about the choices you make
in how to spend that money. We’re seeing
healthcare consumers a lot more discerning in
where they’re going to receive care and how
they make decisions for follow-up care based
on the experience they had the first time.”
The surveyors spoke to 100 healthcare
C-suite executives from different hospitals
across the country in the first quarter of
2019, with 64 percent from highly com- 27HJ713C-B
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ones, and three percent in noncompetitive
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Micro-X develops own carbon nanotube X-ray tube

Micro-X has manufactured a new car- to introduce carbon nanotube X-ray tech- of this sum was supported by funds from a
bon nanotube X-ray tube for its plat- nology to the medical imaging field, and as $2.4 million matching grant secured under
form of X-ray products. our sales of this new device grow, Micro-X the Federal Government’s Advanced Manu-
Composed of a carbon nanotube elec- is well-positioned to quickly supply antici- facturing Growth Fund.
tron emitter, development of the tube will pated demand from customers.” The process involved key elements such
make Micro-X one of two companies in CNT-based X-ray tubes are the first to as design, process engineering, production
the world capable of developing CNT- not use heated-filament electron emission, engineering and validation and testing. It
based X-ray tubes, alongside third-party reducing size, weight, heat and power. also focused on improving existing reliabil-
supplier, XinRay, for products such as the Originally relying on XinRay for manufac- ity standards and garnering support from
Carestream DRX-Revolution Nano mobile turing, Micro-X set to work developing its stakeholders to create a smooth transition
X-ray system. proprietary CNT emitter in 2017 at its base from the current supplier to Micro-X inter-
“The advances Micro-X has made in Adelaide, Australia, employing a small nally manufactured X-ray tubes.
in this new X-ray tube design — both in team of world-leading experts in engineer- In developing its own tubes, the compa-
the quality and potential lifetime of this ing chemistry and nanomaterials science to ny expects to achieve increased commercial
innovative new tube — will be of great work alongside researchers at Flinders Uni- margins and enhanced flexibility in future
benefit to healthcare providers,” Charlie versity and the University of Adelaide. product designs, including for the Rover and
Hicks, general manager of X-ray solutions The total cost of the project was approxi- Mobile Backscatter Imager product that is
at Carestream Health, said in a statement. mately $3 million, including for the develop- being developed with Thales.
“We at Carestream are the first company ment work and new capital equipment. Part Share this story: dotmed.com/news/47962
New AI solution identifies New study links low dose

high-risk patients from chest radiation to increased
X-rays cancer risk
Posted online July 23, 2019 by John R. Fischer Posted online July 26, 2019 by John R. Fischer
Chest X-rays may hold more information that could identify Administering low-radiation doses equivalent to that of
patients at high risk for a range of conditions, including heart three CT scans may boost the number of cancer-capable cells
disease and lung cancer. over normal cells in healthy tissue, according to a new study.
That’s the consensus arrived at by researchers at Massachusetts Researchers at the Wellcome Sanger Institute and the University
General Hospital, who have developed a new AI tool called CXR-risk of Cambridge used mice to show that low doses of radiation in-
to determine which patients would benefit the most from screening crease the number of cells with mutations in p53, a genetic change
and preventive medication. associated with cancer. They argue that such a risk should be con-
“We developed and tested this convolutional neural network sidered in radiation safety assessments.
in healthy outpatients. The hope is that it will help primary care “The reduction in radiation exposure is desirable, and limiting
physicians and patients make decisions about prevention, screen- imaging and using optimized scanning protocols are important
ing, and lifestyle,” Dr. Michael T. Lu, director of research of MGH ways forward,” professor Phil Jones of the Wellcome Sanger Insti-
Cardiovascular Imaging, told HCB News. The underlying idea is that tute and MRC Cancer Unit at the University of Cambridge, and Dr.
we can use CNNs to extract information about health and longevity David Fernandez-Antoran of the Wellcome Sanger Institute, told
embedded in everyday medical images.” HCB News.
Trained on analyses of more than 85,000 chest X-rays from Although information on the impact from exposure to low levels
42,000 subjects, the solution is designed to identify combinations of radiation is limited, all humans carry cancer-capable mutant cells
of features on a chest X-ray that best predict health and mortality. in healthy tissue, including those with p53 mutations. Cells with
Each image used to train it included information on whether or not this mutation increase in number as a person ages, though very
the person died at any point over a 12-year period. few turn into cancer.
Share this story: dotmed.com/news/48007 Share this story: dotmed.com/news/48049

Radiologists voice workload frustration in research
report released at SIIM
Posted online July 03, 2019 by John W. Mitchell
A survey conducted of a small sample of “[With conversational AI,] I would be Increased patient and reporting work-
radiologists at academic medical centers, able to extract data and put it into more loads have created what the president of
healthcare systems, radiology practices, structured reports,” said Dr. Brian Kaineg, the World Medical Association has called a
and hospitals confirmed a litany of radiol- neuroradiology, Quantum Radiology. “That “pandemic of physician burnout,” according
ogist workflow and practice complaints, would be ideal because then you could set to the report, which is entitled In your words:
such as tedious methods of measure- up a template that everything populates How AI is advancing the impact of radiology
ment, job burnout, and inefficient work- into and the radiologists wouldn’t neces- in healthcare. Porter Research conducted the
flow in the face of increasing workloads. sarily need to change the way they’re rou- survey between January and March of 2019.
The report, which consisted of interviews tinely dictating.” Share this story: dotmed.com/news/47789
with nine radiologists and their response to
23 questions, was prepared by Porter Re-
search and sponsored by imaging AI solu-
tions company, Nuance Communications.
Nuance released the report at the 2019 SIIM
annual meeting currently convened in Au-
rora, Colorado.
“Radiologists are being pressured by larg-
er and larger workloads, due, in part, to ris-
ing patient volumes and inefficient systems
and processes,” Karen Holzberger, vice presi-
dent and general manager of diagnostics for
Nuance, told HCBN. “The unfortunate result
is that many radiologists are burned out. We
wanted to hear directly from the source on
what can be done to alleviate the stress and
tension, and specifically, what role can in-
novative technology play?”
Dr. Alexander Towbin, a radiologist in the
department of radiology and medical im-
aging at Cincinnati Children’s Hospital, said
radiologists deliver a service in an expensive
environment that needs to be efficient.
“Workflow efficiency is something that
I believe is important,” said Towbin. “We all
know ... medical costs are out of control, and
no one can afford them; so we need to be ...
cognizant of what we spend and what we
ask for our patients.”
Holzberger said that incorporating narrative
reporting into structured data and integrating
intelligence and AI-generated findings directly
into the workflow to automate and augment
reports is a proven solution. The access to AI,
pre-populating data within reports, automat-
ing repetitive or time-consuming routine tasks,
structured reporting formats, and other fea-
tures are recognized as high-value capabilities.
With stock value up 51 percent, is Mindray too pricey?

Shenzhen-based Mindray Bio-Medical But some think it may have gone a bit in 2016.
Electronics has soared since going pri- too far, a little too fast, with a P/E ratio of The maker of in-vitro diagnostics equip-
vate in 2016, and is taking market share 39, despite a Bloomberg forecast of a 20 ment, life monitoring systems and medical
from both GE and Siemens. percent revenue growth and 21 percent an- imaging equipment, including color ultra-
And in May it got put into the MSCI nual income growth from now to to 2021. sound devices, has been liked by institutional
China All Shares Health Care 10/40 Index, That’s because the consensus price tar- investors, thanks, in part, to its rising R&D
which “captures large and mid-cap repre- get for Mindray is 158.90 yuan, showing a investment, and government support as
sentation across China A-shares, B-shares, possible 3.8 percent downside from present China seeks to become a bigger player in
H-shares, Red-chips, P-chips and foreign list- stock values. the global market, according to Bloomberg.
ings,” according to MSCI, and which “aims The company is “looking expensive,” al- At present prices, there are those who
to reflect the opportunity set of China share though not too much so versus other China think the values are a bit high and are hold-
classes listed in Hong Kong, Shanghai, Shen- high-fliers, like soy sauce maker Foshan Hai- ing off. Dai Ming, portfolio manager of
zhen and outside of China.” tian Flavouring & Food, Xiong Qi of Windsor Hengsheng Asset Management Co., told
Its stock has risen 51 percent, making it Capital Management told Bloomberg. Bloomberg that, “Mindray’s valuation is too
“a top performing equity on the ChiNext The firm had been listed in the U.S. on high. We will wait for a pullback to get in at
board” — and that has given it a $29 billion the NYSE until being taken by a subsidiary a more reasonable price.”
valuation, according to Bloomberg. of Excelsior Union Limited for $1.9 billion Share this story: dotmed.com/news/47896
Noritsu acquires R&F New bill calls for changing

Imaging Systems reimbursement for
Posted online July 10, 2019 by John R. Fischer radiopharmaceuticals
Noritsu America Corporation has acquired R&F Imaging Posted online July 24, 2019 by John R. Fischer
Systems, a sales and service company for medical imag-
ing equipment. A new bill that would ensure adequate Medicare reimburse-
The agreement is poised to provide Noritsu with medical im- ment for procedures that use radiopharmaceuticals has been
aging expertise while expanding the operations of the Atlanta- introduced before the U.S. Congress.
based R&F to nationwide scale. Issued by Representatives Scott Peters (CA-D.), Bobby Rush (IL-D.)
“Because we are a manufacturer, we understand the need and George Holding (NC-R.), the Medicare Diagnostic Radiopharma-
for and use of data collection to help large customers under- ceutical Payment Equity Act of 2019 is expected, if passed, to extend
stand trends and anomalies in their capital equipment,” Patrick patient access to highly-targeted, precision diagnostic procedures for
Todd, vice president of business innovations at Noritsu, told HCB more accurate diagnoses and treatment of diseases, such as Alzheim-
News. “Noritsu and R&F can provide a single service agreement er’s and Parkinson’s, by changing the way in which reimbursements for
to multi-site caregivers and medical imaging providers so that such exams are carried out.
the level of service is efficient, consistent, and easy to manage.” “Current CMS policy only allows for separate payment of diagnostic
In business since 1984, R&F offers a full line of X-ray sales radiopharmaceuticals in the hospital setting during the two- to three-
and services throughout the greater Atlanta area of Georgia, year transitional pass-through period. After the transitional pass-through
and brings to Noritsu experienced medical imaging technicians, period, the payment for the radiopharmaceutical becomes bundled with
certifications and manufacturer relationships, and industry con- many others in the procedure payment,” Terri Wilson, senior director of
nections, as well as a desire to expand geographically. patient access and healthcare policy at Blue Earth Diagnostics and cur-
In return, the industrial photographic imaging equipment rent chair of the MITA PET Group, told HCB News. “When this happens,
provider of 47 years offers R&F a national footprint working with hospitals are significantly underpaid for newer precision diagnostic radio-
clientele of all sizes, from independent shops to national chains. pharmaceuticals, and some may stop offering the service, thereby limiting
Share this story: dotmed.com/news/47850 patient access. HR 3772 would correct this issue.”

Philips Q2 sales helped by Chinese healthcare
spending
Rising healthcare spending by the Chi- and we expect it to continue in the coming crease the amount by which our earnings
nese government boosted Philips to years,” he explained to the news agency. are hit by 20 million euros this year, but no-
above-expectations sales growth in Q2 Sales rose in the U.S. and Europe as well, body knows whether it will happen.”
— with comparable sales up 6 percent according to the company. The company now anticipated that it will
versus a 4.5 percent analyst forecast. “We saw growth in all our segments in lose about $51 million of earnings in 2019
The company saw a “double digit” sales the second quarter and we expect that to due to tariff impact.
rise in China, according to Reuters, due in continue,” Van Houten said, adding that, Despite that, the presently forecast 4
part to government expansion of hospitals “we had strong traction in emerging mar- percent to 6 percent total comparable sales
and purchase of more high-tech healthcare kets and that is set to continue. Also, we growth through 2020 remains in place, with
equipment. expect mature markets to come in stronger a projected profit margin up from 13.1 per-
“Healthcare in China is still not sufficient to in the second half of the year.” cent to 14 percent for the year.
meet the demands of an aging society,” Phil- Despite the positive sales news, the com- Adjusted earnings before interest, taxes
ips CEO Frans van Houten told Reuters. pany advised that ongoing tariff woes will and amortization (EBITA) rose 14 percent to
“The government has said it would impact both its components and products. 549 million euros in the second quarter, and
expand capacity, and that is exactly what “The main cloud hanging over us is the margin grew 11.8 percent, near expecta-
is happening. This trend for us is more im- possible fourth batch of tariffs,” Van Houten tions, said Reuters.
portant than fluctuations in GDP growth, stated. “If that would happen, it would in- Share this story: dotmed.com/news/48024
CMS proposes alternative US leading digital health

payment model for radiation record adoption, but falls be-
oncology hind elsewhere: Philips report
Posted online July 17, 2019 by John R. Fischer Posted online July 24, 2019 by John R. Fischer
The Centers for Medicare and Medicaid Services has pro- The U.S. is among the countries spearheading the adoption
posed an advanced alternative payment model for providers of digital health records globally... In fact, it’s the only digital
administering radiation oncology procedures. technology that the U.S. leads in healthcare, according to
Aimed at supporting the transition toward value-based care, Philips’ U.S. Future Health Index 2019 Report.
the Radiation Oncology (RO) Model encourages the adoption of The Dutch-based healthcare giant ranks the “Land of Opportu-
prospective site-neutral, episode-based payments by physician nity” below the 15-country average leveraging the full use of digital
group practices, hospital outpatient departments, and freestanding healthcare technologies, including telemedicine and AI. And while
radiation therapy centers for radiotherapy. This model is expected used by 84 percent of U.S. healthcare professionals, DHRs still come
to reduce Medicare expenditures, while maintaining or enhancing with their share of challenges.
the quality of care for Medicare beneficiaries. “Federal legislation, such as the HITECH Act, helped drive adop-
“The new model provides incentives for high-quality, more tion of DHRs over the last ten years and helped U.S. healthcare
convenient radiation treatments and rewards concordance with move away from disparate, paper-based processes to digital re-
evidence-based clinical guidelines,” Dr. Brian Kavanagh, immedi- cords,” Dr. Joseph Frassica, head of Philips Research, the Americas,
ate past chair of ASTRO, told HCB News. “The model also has the and chief medical officer at Philips North America, told HCB News.
potential to stabilize reimbursement in the long term and move the “Unfortunately, this rush to digitize came without common indus-
specialty from an antiquated fee-for-service payment structure to try standards for data exchange and normalization, contributing to
one based on quality and value.” data silos and interoperability challenges.”
The prospective episode-based payments would apply to the Lack of standardization hinders interoperability, with 52 percent
treatment of 17 types of different cancers, with providers receiving of American healthcare professionals less inclined to share health
payments during a 90-day period of care. CMS expects it to save records among their peers inside their own facilities.
$260 million for Medicare in that time. Share this story: dotmed.com/news/48008
Siemens forms $113 million alliance with UM

System and MU Health Care
Siemens Healthineers has teamed up research, innovation, engagement and inclu- Among the equipment supplied will
with the University of Missouri System sion,” said UM System President Mun Y. Choi be laboratory and imaging technology, in-
(UM System) and University of Missouri in a statement. “Forming an alliance with Sie- cluding the MAGNETOM Terra 7 Tesla MR
Health Care (MU Health Care) to estab- mens Healthineers enables us to work toward scanner, for clinical and research purposes
lish the Alliance for Precision Health. this mission by providing our university and focused on furthering ultra-high field MR
The German-based healthcare giant has health system with leading-edge technology capabilities. The UM System will also have
entered into a $133 million 10-year Value and resources, unique research and collab- access to Siemens’ AI and health digitaliza-
Partnerships agreement with UM System, oration opportunities, training for the next tion tools, such as syngo Virtual Cockpit, a
which includes all four universities, and generation of the healthcare workforce, and software solution for connecting radiology
MU Healthcare, in which it will supply both expansion of our contributions to medicine technicians remotely to scanner workplaces
southern entities with diagnostic and thera- and healthcare to rural Missouri and beyond.” to help personnel in different locations with
peutic devices to enhance care delivery, pro- The alliance is expected to help the UM Sys- sophisticated exams. Enterprise services and
mote education around technology and en- tem complete research, educational and clinical digital solutions will be provided as well, with
gineering, and help create research ventures. care objectives for its highest priority, NextGen Siemens utilizing insights about their prod-
“Our vision for the entire UM System Precision Health Initiative, a statewide effort ucts from the UM System and MU Health
is to advance the opportunities for success to provide treatments for cancer, Alzheimer’s, Care to improve upon the development of
and well-being in Missouri, the nation and cardiovascular disease and other illnesses that their medical technologies and services.
the world through transformative teaching, affect Missourians and people worldwide. Share this story: dotmed.com/news/47913
Konica Minolta and Shimadzu Agiliti acquires Zetta

bring Dynamic Digital Medical Technologies
Radiography to RADspeed Posted online July 10, 2019 by John R. Fischer
Pro at AHRA Healthcare technology management company Agiliti has
Posted online July 22, 2019 by John R. Fischer acquired Zetta Medical Technologies, a provider of services
and parts for medical imaging equipment.
Konica Minolta Healthcare Americas is accelerating the sale “Zetta brings to Agiliti a full complement of medical imaging
and distribution of its Dynamic Digital Radiography (DDR) device management and maintenance capabilities, and decades of
solution for X-ray in the U.S. healthcare market with the help experience across a broad range of equipment makes and models,”
of long-time partner Shimadzu Medical Systems. Tom Leonard, CEO of Agiliti, told HCB News. “Their full-service
Utilizing Konica Minolta’s new advanced image processing capa- approach is a perfect fit within our broader clinical engineering
bilities with Shimadzu’s RADspeed Pro radiographic imaging systems, offering to customers — building on our platform of supplemental
the technology provides users with a “movie” that shows the motion and outsourced biomedical repair and maintenance services to
of structures such as bones and lungs. It will make its official debut on include comprehensive support for high-end medical imaging
RADspeed Pro this week at the 45th annual AHRA meeting. technologies (CT, MR and PET/CT), and the scale to deliver those
“The only way to get the equivalent of a ‘movie’ is with extremely services nationally.”
high dose and varied workflow, which is inconvenient for the radi- The sale opens access for Zetta to Agiliti’s 7,000 healthcare
ologist and means a much larger procedure for the patient. Using facility partners across the U.S. through the company’s network of
the unique Konica Minolta technology and smart X-ray capabilities 86 local market service centers and five repair and maintenance
for image processing, we can produce at almost the same dose as a Centers of Excellence. Agiliti also provides a platform for acceler-
standard X-ray a moving image,” David Widmann, president and CEO ated growth and investment in the form of its 24/7 service model,
of Konica Minolta Healthcare Americas, told HCB News. “The radiolo- nationwide infrastructure and a team of more than 3,000 equip-
gist, pulmonologist and orthopedist can actually see the dynamics of ment management experts, which includes over 400 biomedical
the structure they’re looking at.” engineers and technicians.
Share this story: dotmed.com/news/47994 Share this story: dotmed.com/news/47851

Canon hit with $32 million fine by EU for Toshiba deal
Canon’s extraordinary deal structure so we are fining Canon €28 million. Our “As a second step, following approval
when it picked up Toshiba Medi- merger assessment and decision-making of the merger by the Commission, Canon
cal Systems Corp. (TMSC) has now depends on the Commission being sure that exercised its share options, acquiring 100
earned it a 28 million euro ($32 mil- companies are not jumping the gun and im- percent of the shares of TMSC.”
lion) fine from the European Commis- plementing mergers without our approval.” This is far from the first objection incurred
sion, Bloomberg reports. The EU further broke down the manner over the deal structure.
At issue was a tactic dubbed “warehous- in which Canon’s warehousing broke the Earlier in June, the Canon-Toshiba deal
ing” that got around filing requirements, EU rules. earned the companies fines of $2.5 million
antitrust enforcers said in a statement. “For the acquisition, Canon used a so- each to settle U.S. federal charges that they
“Companies have to respect our com- called “warehousing” two-step transaction violated premerger notification and wait-
petition rules and procedures, said Com- structure involving an interim buyer. ing period requirements of the Hart-Scott-
missioner Margrethe Vestager, in charge of “As a first step, the interim buyer ac- Rodino (HSR) Act with the unusual nature of
competition policy, adding that companies quired 95 percent in the share capital of the 2016 transaction.
“are obliged to notify and wait for our ap- TMSC for 800 euros, whereas Canon paid The settlement also requires that the
proval before a merger can go ahead.” 5.28 billion euros for the remaining 5 per- companies put in place HSR compliance pro-
Of the warehousing he noted, “Canon cent of the shares and share options over the grams and agree to inspection and reporting
structured a transaction to circumvent these interim buyer’s stake. This first step was car- requirements.
obligations when they acquired TMSC. This ried out prior to notification to or approval Share this story: dotmed.com/news/47787
is a procedural breach of our merger review by the Commission.
Elekta to distribute C-RAD

SIGRT technology in North
America and Mexico
C-RAD has granted Elekta the right to distribute its surface

image-guided radiation therapy (SIGRT) technology to pro-
viders for use in stereotactic radiosurgery, stereotactic body
radiotherapy, and motion management.
Beginning in the North American and Mexican markets, the
agreement brings together the benefits of C-RAD’s Catalyst HD sys-
tem, which integrates with Elekta linacs, and those of Elekta’s Versa
HD high-definition dynamic radiosurgery solution.
“Accuracy is key when escalating dose,” Dee Mathieson, senior
vice president of treatment solutions at Elekta, told HCB News. “The
X-ray products complement the patient set up and motion manage-
ment capabilities of the Versa HD to give confidence to the clinicians.”
A non-surgical treatment, stereotactic radiotherapy is used to
treat functional abnormalities and small tumors within the brain.
Stereotactic body radiotherapy is used to treat the same issues within
the body.
Capable of treating all parts and organs in the body, Versa HD
customizes high-energy X-rays to conform to a tumor’s shape and
destroy cancer cells while sparing surrounding healthy tissue.
The agreement is now in use in the North American and Mexican
markets, with plans to expand.
Global breast ultrasound market expected to reach

$1.7 billion by 2023
The global breast ultrasound market is peat scans,” Poornima Srinivasan, industry ing programs such as ABUS, which takes less
projected to reach $1.71 billion by 2023, analyst, transformational health at Frost & than 20 minutes for scanning.
according to Global Breast Ultrasound Sullivan, told HCB News. “In this context, Additional tasks that help include realign-
Market, Forecast to 2023, a report by automated breast ultrasound offers value in ing care models, focusing on automation
research firm Frost & Sullivan. terms of lesser time of less than five minutes and wireless, and expanding new clinical
Valued currently at $1.11 billion, use of and helps eliminate operator/sonographer areas such as optical ultrasound; improv-
novel techniques by vendors, combined with error as the ultrasound probe placement and ing the value proposition across clinical and
machine learning and deep learning algo- movement on the breast are standardized.” financial stakeholders and providing value
rithms for high-quality imaging and capa- Innovations like miniaturization, nonin- for better managed equipment services,
bilities, such as cloud and data analytics, are vasiveness, higher affordability and painless training, and technical upgrades; and offer-
expected to be the main drivers of growth, diagnosis are expected to further boost the ing usage-based, service-oriented delivery
along with proactive introduction of applica- use of ultrasound scanners. models in developing economies.
tions and value-based equipment by vendors Vendors seeking to benefit from this rise Srinivasan says that Asia-Pacific countries
based on regional needs. in the market are advised in the report to such as China and Japan offer opportunities
“Traditional breast ultrasound generally demonstrate evidence-based benefits such for ultrasound as a primary diagnostic tool,
faces issues in terms of longer examination as cost efficiency, improved clinical out- and that new business models focused on
times (more than 30 minutes) and sonog- comes and time efficiency of their solutions, operational efficiency and training will help
rapher error, depending on the character- as well as adopt targeted approaches that to increase its use in developed nations.
istic of breast tissues, which necessitates re- increase procedural volume in breast screen- Share this story: dotmed.com/news/47834
Mayo Clinic Florida campus to Hospital M&A revenue rose

get $233 million proton facility to $11.3 billion in Q2 this year
Posted online July 01, 2019 by Thomas Dworetzky Posted online July 26, 2019 by Lauren Dubinsky
Mayo Clinic is set to build a new $233 million integrated oncolo- Transacted revenue skyrocketed to $11.3 billion for the
gy facility including proton beam therapy on its Florida campus. second quarter of this year, almost four times higher than
The 140,000-square-foot facility, which will house a two-gantry that generated in the same time last year.
proton system, is now scheduled for a late 2023 opening, according These were the findings of a new Kaufman Hall report on
to a Mayo statement. merger and acquisition activity, and come despite a decline in the
“This facility will give us the ability to offer our patients the full spec- number of hospital and health system mergers and acquisitions
trum of cancer treatment options, including chemotherapy, immunother- in the same period.
apy, CAR-T cell therapy (chimeric antigen receptor therapy T cell therapy), “This trend is simply a response to the changing market,” Anu
surgery, proton beam therapy, gamma knife radiosurgery and traditional Singh, managing director at Kaufman Hall, told HCB News.
radiotherapy,” CEO of Mayo Clinic in Florida, Dr. Kent Thielen stated, The healthcare industry is under a high degree of uncertainty
adding that, “it will also give patients access to proton beam therapy due to the pressure to take on more risk while continuing to cut
clinical trials offered through our National Cancer Institute-designated costs. On top of that, organizations may have trouble competing
comprehensive cancer center.” against new disrupters in the industry, such as Amazon, CVS and
The new facility will be near the Mangurian Building, which offers United Healthcare.
hematology and oncology care, and the Oncology Infusion Center, in “Even larger organizations that have made strides in build-
order to better integrate cancer care on the campus. ing up sites of care and pursuing ambulatory strategies could
Proton therapy had already been added to the rosters of other also not have the financial or intellectual capital to thrive in a
Mayo Clinic campuses in Rochester, Minnesota, in 2015 and Phoenix value-based world where clinical and business intelligence are
in 2016. critical,” said Singh.
dotmed.com/news/47753 Share this story: dotmed.com/news/48065

Upcoming Events
Society for Imaging Informatics in Medicine Leading International Trade Fair
Event: 2019 Conference on Machine Intelligence in Medical
Imaging (C-MIMI) DÜSSELDORF, GERMANY
Location: Hilton Austin Hotel, Austin, TX 18–21 NOVEMBER 2019
Dates: September 22-23
Years in existence: 4 www.medica.de Member of
Average attendance: 250-300
Who should attend: Researchers, Clinicians and students,
Computer scientists, Engineers and Developers represent-
WORLD FORUM FOR MEDICINE
ing technology companies, Startup community working on
innovative solutions.
Annual Radiology Meeting in UAE
MEDICA 2019 –
Event: ARM 2019 Annual Meeting
Location: Dubai International Convention & Exhibition
Centre, UAE
Always
Dates: October 15-17
Years in existence: 4
Average attendance: 1700+
a heartbeat
Who should attend: Radiologists, Radiographers, Hospital
Administrators , Educators & Researchers , Residents & Tech-
2019-05-24 Medica 2019_USA_MEDICA_86 x 224mm_DOTMED_4c_7198

ahead!
nicians, Suppliers, Agents, Distributors, Dealers, Exporters,
Importers, Government Agencies & Radiation Oncologists.
Society of Interventional Radiology

Event: Lower Extremity Arterial Revascularization (LEARN)
Location: Renaissance Nashville Hotel, Nashville, TN
Average attendance: 100
Who should attend: Interventional radiologists, vascular
medicine physicians, and others with an interest in the clinical
management of lower-extremity peripheral arterial disease.
Society of Interventional Radiology

Event: ACTiVE
Location: The Hilton Scottsdale Resort & Villas, Scottsdale, AZ
Average attendance: 100
Who should attend: Interventional radiologists and
those who treat VTE. Features a multidisciplinary faculty of
interventional radiologists, vascular surgeons, hematologists,
pulmonologists and cardiologists.
MEDICA 2019
Location: Düsseldorf Fairgrounds, Dusseldorf, Germany
Dates: November 18-21
Years in Existence: 50 For show information: Messe Düsseldorf North America
Tel. (312) 781-5180 _ info@mdna.com
Average attendance: 130,000+ www.mdna.com
Who should attend: GPOs, integrated delivery networks, For hotel and travel arrangements: TTI Travel, Inc.
Tel. (866) 674-3476 _ info@ttitravel.net
HME/DME providers, physician private practice, medical labo-
ratories, HER/EMS/PHR/PACS/RIS, medical services providers.
Hospital Spotlight: Mount Sinai St. Luke’s
Mount Sinai St. Luke’s

Location: New York, NY
Year founded: October 18, 1846
(cornerstone laid in 1854,
opened to patients in 1858)
Number of beds: 495
Number of employees: 3200 (approx.)
President: Arthur A. Gianelli
Noteworthy distinctions:
First hospital in New York State to offer TECAB
1
(totally endoscopic coronary artery bypass sur-
gery), performed using micro-incisions. It offers a
quicker recovery time, decreases pain, and lessens 2
the risk of infection.
Verified as a Level II Trauma Center by the Veri-
fication Review Committee, part of the Commit-
tee on Trauma of the American College of Sur-
geons. This achievement recognizes the trauma
center’s dedication to providing optimal care for
injured patients.
Recognized by the American College of Surgeons
as an Accredited Comprehensive Bariatric Center.

Specialties:
Cardiology/Cardiovascular Surgery; Bariatrics/
Weight Loss; Cancer and Infusion Services; Trau-
3
ma Program (we are a Level II Trauma Center);
Geriatric Primary Care
Recent developments:
Opened in 2017, the Center for Clinical Cardio-
vascular Care offers a suite of specialty services
for comprehensive and integrated cardiovascular
patient care. An additional improvement to the
heart program includes a new catheterization lab.
The Imaging Suite is a 24/7 subspecialty ser-
vice with state-of-the-art scanning equipment,
including the use of MR and CT for neuroimag-
ing, cancer imaging, and cardiac imaging.
A new Surgery Practice Space opened in July
2019, featuring a modern design, with 14 extra
rooms equipped with state-of-the-art technol-
ogy to evaluate patients for potential surgery
4
in several subspecialties, including General Sur-
gery, Bariatric Surgery, Surgical Oncology, and
Colorectal Surgery.
A future-state Cancer Center will feature
a comprehensive cancer program, providing
screenings, medical oncology, and surgical on-
cology. The Infusion Suite, which opened in
2018, is the first step in making this program.
The Ambulatory Care Center Lobby was ren-
ovated and reopened in May 2018.
The Main Hospital Lobby will be revamped next
year. In 2020, we will also be adding a single-bed-
ded inpatient unit and a medicine practice space.
1. Members of the Mount Sinai St. Luke’s

Emergency Department.
2. John D. Puskas, M.D., chair of Cardiovascular
5
Surgery at Mount Sinai St. Luke’s and Mount
Sinai West, and Gianluca Torregrossa, M.D.,
perform the Mount Sinai Health System’s first
TECAB surgery.
3. The new Ambulatory Care Center lobby and
façade opened in May 2018.
4. The new Infusion Suite at Mount Sinai St.
Luke’s serves as an extension of the highly
regarded Tisch Cancer Institute at The Mount
Sinai Hospital.
5. Screens in the new Daily Management and
Incident Command Center display real-time
data for areas throughout the hospital, en-
abling staff to track patients during their stay
and monitor flow, admissions, discharges, and
other clinical operations.

Hospital Spotlight
Q&A with
Art Gianelli
president of Mount Sinai St. Luke’s
Delivering healthcare in a 'Lean'
framework
By Sean Ruck
HealthCare Business News spoke with challenges facing that institution, I think we did occurred. We’ve targeted certain services to
Art Gianelli, MBA, MPH, president of really remarkable work in terms of improving expand and grow — cardiology, cardiac sur-
Mount Sinai St. Luke’s, to get the de- quality and safety and starting to recover the gery, bariatric surgery, orthopedic trauma,
tails his unique background brings to his finances of the hospital. We also reinvested cancer and our geriatric program.
role, and to hear his insight about the in the hospital in ways that hadn’t been done Staff are attracted to the opportunity to
hospital and healthcare overall. previously. We also encouraged the staff to work for the Mount Sinai Health System. They
believe that transformation was possible. And are also attracted to working for a hospital
HCB News: What inspired you to pur- finally, I joined a number of boards across the whose services are growing and increasing in
sue a career in healthcare? country. I was on the executive committee of complexity. Mount Sinai St. Luke’s is a Lean
Art Gianelli: My path was not a tradi- America’s Essential Hospitals, the regional pol- hospital. When I first came to Mount Sinai,
tional one. I worked for a significant time in icy board for the American Hospital Associa- I advised Dr. Ken Davis, the president of the
local government: first, as a director of option, the executive committee for Healthfirst. Mount Sinai Health System, that my experi-
erations for a town, then as a deputy county My goal was to gain knowledge and insight ence of running a hospital was through a Lean
executive for budget and finance. My ex- into running a hospital. Now, I actually teach framework and that’s what I wanted to do here
pertise was in finance, turnaround manage- hospital operations at Columbia University and at St. Luke’s. He was absolutely encouraging.
ment and strategic planning. at Mount Sinai. I’m proud of that, because it From day one, that’s what we’ve done here.
While I was deputy county executive, I wasn’t too long ago that I was just embarking We’ve used Lean to develop our daily manage-
was approached by the consultants the on a career as a healthcare administrator. ment system, for process improvement and to
county had hired to help develop a strategic
galvanize and energize the culture.
plan for its affiliated public hospital. The hos- HCB News: How long have you been It’s evident to anyone who comes here,
pital was chronically challenged, financially with Mount Sinai St. Luke’s? that the experience of working at St. Luke’s
and otherwise. The consultants wanted me AG: I’ve been with the Mount Sinai is different than at other hospitals. Here, the
to run the hospital. I laughed. I told them I Health System since February 2014. wisdom of the frontline staff is valued and
had not run a hospital before, I’d been suc-
cultivated. We want our frontline workers
cessful in my career, but that’s a challenge HCB News: What attracts staff to
to be emissaries of problem solving. I think
not like any other. And no one had been Mount Sinai St. Luke’s?
people who are attracted to that and that
successful historically in running that hos- AG: Similar to my prior hospital, Mount
level of agency with respect to their work,
pital. However, the more I thought about it, Sinai St. Luke’s needed a turnaround strat-
really want to come here. We also try to em-
I believed in the hospital’s mission and the egy. That was very clear to the leadership at
phasize the tenets of a just culture. Errors,
population it served and I decided to look Mount Sinai and that was my charge here at
when they do occur, are typically associated
at it as a real opportunity. I decided to take St. Luke’s. There’s been well over $100 million
with system and process failures.
a chance and go for it. I advised the consul- of capital investment to build an ambulatory
tants that they needed to persuade my wife, platform, to upgrade equipment, to replace HCB News: Can you tell us roughly
who was adamantly opposed to this, being the EMR, to transform the appearance and what the makeup of your patients is
very familiar with the hospital and its history. operation of the organization. There have also from a payor perspective?
But they were able to persuade her as well. been investments in the hiring of staff to cover AG: About 85 percent of the patients that
I took the leap and started my tenure. gaps in our hospital service, and we’ve hired receive care at Mount Sinai St. Luke’s are in-
Given the constraints we were under and the staff to keep up with the volume growth that’s sured by the government, either through Medi-

cade or Medicare. Any hospital that has that HCB News: What else do you think is having — should we have single payor, fix
ratio of government to commercial payors is unique about Mount Sinai? the ACA, do something else? — misses the
going to have challenges. Part of our strategy AG: I would say that the staff is not only point. The challenge right now is how do we
is to develop and grow programs that can second to none, but they are really culturally deliver really good healthcare to our patients
diversify our payor mix. Certain services have unique. It’s a very family-oriented organiza- that is both affordable and can be sustained
diversified quite nicely. Our bariatric surgery, as tion. That’s evident in terms of how staff in- by our healthcare delivery system? I would
an example, has seen our payor mix change sig- teract with each other and how they interact argue that the “Medicare for All” debate is
nificantly from an overwhelmingly government with patients. a false debate because it suggests that the
payor mix to one that is balanced. It’s a small In terms of services, the main growth way we’re going to address the cost of care
part of our business, but important. We have area for St. Luke’s since the merger with is through the government dictating what
to identify other services that can help us diver- Mount Sinai has been in cardiology and car- will be paid for health care services. I’m con-
sify the types of patients and payors that come diac surgery. Every element of our cardiology cerned about that price point being set at a
here. It’s challenging, but important work. and cardiac surgery programs has grown level that’s not sufficient to sustain the qual-
significantly over the last five years. We have ity of services we need to provide to patients.
HCB News: Our interview is taking world-class physicians leading the way. It’s a The real debate should be about how
place in June, which was designated as remarkable transformation since I first got we can organize the delivery system in a
Pride month a decade ago. I saw on the here, and we’ve seen remarkable growth way that reduces waste significantly such
Mount Sinai website in the “about us” while maintaining the highest possible level that we can change the trajectory of health
a section dedicated to LGBT Health. The of quality and safety. Mount Sinai St. Luke’s care costs. Some estimates have pegged the
section is extensive and also shows LGBT is also a long-standing trauma center with waste generated by our health care delivery
champions dating back to 2015. Were stellar orthopedic trauma surgeons who system at $750 billion annually. One of the
there any challenges to being able to po- have grown their practice significantly over reasons we’re committed to Lean at Mount
sition Mount Sinai as an LGBT advocate? the last several years. Sinai St. Luke’s is because its focus is the
AG: That’s an interesting question. I will We have a solid general surgery program elimination of waste and the introduction
tell you that the Mount Sinai Health System is which includes our trauma program, but also of value to the patient through innovation.
fully committed to LGBTQ care and to advo- includes vascular and bariatric surgery as well The second wish I would make — and
cacy on behalf of LGBTQ patients. That ranges as surgical oncology. The System Chief of it’s one of the things I talk about at Mount
from specific programs we offer — one of our Surgical Oncology is also the Chairman of Sinai — is about our ability to innovate. The
hospitals is a center for excellence for trans- Surgery for Mount Sinai St. Luke’s and Mount types of discoveries and the science that’s
gender surgery — to the approach we take Sinai West. We are thoughtfully and carefully happening here at Mount Sinai, it makes
with respect to patients who arrive at our hos- expanding our cancer program. Last year, we me immensely proud to be part of it in my
pitals. There’s training we do systemwide with opened an infusion suite and we’re hiring ad- small way. But we, as an industry, need to
our frontline staff regarding pronoun usage, ditional clinicians to provide targeted medical innovate for the day-to-day with the same
respecting the desires of our patients regard- and surgical oncologic services. enthusiasm and urgency that we apply to
ing how they identify themselves and how We’re installing a PET CT through the gen- finding a cure for cancer. Patients need to
they want to be identified by their caregivers. I erosity of a grant secured by our New York experience a health care delivery system that
think that’s part and parcel to the value Mount City councilman, Mark Levine. And finally, is seamless, integrated, connected, clear and
Sinai places on patients and employees. we’re privileged to be hosting the geriatric understandable. We need to do that. We
It’s also part and parcel to the history of program from Mount Sinai, since this program need to innovate at that level. There are
our hospitals. Mount Sinai was founded is ranked by US News and World Report as the places in the country that do it well. I think
in 1852 for people who were Jewish at a third best geriatric program in the country. Mount Sinai is on the way to doing it well.
time when the Jewish residents of New York We need to foster that type of commitment
couldn’t get care at certain hospitals. So HCB News: Healthcare is an ongoing to day-to-day innovation and improvement
there’s a long history of Mount Sinai identify- problem both in the political arena and throughout the health system in the United
ing with and seeking to support people who in the actual practice of delivering care, States. If we could do that, we would begin
have been historically oppressed or discrimi- due to continually rising costs, coordina- to impact cost, wring out waste and change
nated against. That’s also another reason I’m tion of care, etc. If you had one wish for how healthcare is delivered. My fear is that
really proud to be part of this system. something you could introduce to help our political debate obscures this reality —
We see all sorts of patients that are at solve the problem, is there something where the real action should be occurring.
the margins of society and we believe very that comes to mind? My hope would be that we change what we
strongly it’s our responsibility and obligation AG: I would like to have two wishes. First, talk about to talk about this.
to stand up for them and ensure that they I think the macro political debate that we’re Share this story: dotmed.com/news/48316
receive the best level of care.
IT Matters
EHRs, digital imaging and the

slow evolution of interoperability
By Sean Ruck
Fortunately, many in the imaging commu- more systems the radiologist has to work with.
Dr. Chris Roth
nity are working to bridge the data divide Part of the blame lies with physicians and hos-
between imaging and the EHRs. When you pitals permitting imaging metadata variation.
consider the spectrum of clinical multimedia Different scanner manufacturers call
in radiology, cardiology, ophthalmology, ob- nearly identical sequences by different
stetrics, the emergency department, opera- names. Different scanners within a hospi-
tive suites, dermatology and other medical tal may or may not have similar imaging
specialties, the opportunity is significant. metadata, depending on who configured
Most providers have the ability to take a the scanner, the scanner age, and how long
patient photo or video, integrate it into the ago those metadata were last reviewed.
electronic medical record, and assign some Until recently, there was no ability to cen-
straightforward metadata to it using the In- trally modify and standardize the image data
tegrating the Healthcare Enterprise Radiol- capture configurations on many devices at
ogy’s Encounter Based Imaging Workflow once. Integrating the Healthcare Enterprise
(IHE EBIW) profile. But this profile requires Radiology recently created a profile called
Hospitals and doctors are required to build work within and between institutions Management of Acquisition Protocols (IHE
use electronic health records or get hit to create appropriate clinical workflows and MAP) so that a leader technologist and
with financial penalties under Medicare interoperable data. “When capturing imag- physician can jointly and centrally review
reimbursement rules. While the rules have es, medical professionals often still disagree and modify the configurations of the entire
been around for years and most providers with the terms to use to describe the body scanner fleet, permitting consistent meta-
are following them, it doesn’t mean it’s been part,” says Roth. The HIMSS-SIIM Enterprise data capture, even across scanner vendors.
easy or that data improvement is where it Imaging Community is tackling this challenge “Most hospitals around the country keep
needs to be today. to determine the optimal ontology to consis- scanners for more than five years, often up
Part of the problem is the fact that in- tently describe body parts. Roth continues, to 10 years,” Roth says. “Some scans will
teroperability, even among the same type “Pretend there is an open fracture of the always only have older sequences, and thus
of technology, hasn’t met the expected or upper arm. The big bone in an X-ray of the older metadata describing them unless the
promised standards. Different vendors have upper arm is called the humerus. Taking a institution puts in the effort to standardize
had different levels of success, but that’s easy photograph of the broken bone sticking out how they capture scans. IHE MAP can assist
to understand. After all, putting a lot of re- of the same upper arm, the body part might with this data standardization and should be
sources into ensuring your tech plays well be described as arm or skin. True interopera- requested of scanner manufacturers during
with a competitor’s technology while having bility means the X-ray and the photo need to the RFP process as a play toward imaging
no assurances that they’re doing the same, relate to each other in computer terms, and data interoperability.”
is a tough pill to swallow. we must agree on those terms, so providers The inconsistencies create at least one
Dr. Chris Roth, associate professor of can consume them in the EHR together. additional source of friction. AI, which re-
Radiology, vice chair Information Technol- So it’s clear that the technology at many lies on accurate and consistent data as its
ogy and Clinical Informatics, director of Im- sites isn’t exactly delivering what’s needed for lifeblood, suffers. A radiologist who verbally
aging Informatics Strategy at Duke Health interoperability with imaging. But how well dictates in a less-structured way what they’re
explained the even greater interoperability are imaging departments complying? In a seeing, either due to limited technology or to
challenge that’s found between imaging in- broad sense, not too well. Part of the blame preference, isn’t adding clean and clear data.
formatics and EHRs. “Compared to many lies with the vendors, with different vendors On the other hand, a radiologist with current
other areas of medicine, Interoperability in having different ways of labeling very similar technology and a mind for innovation may
imaging is unique because you’re dealing techniques and different ways of capturing use more structured terms computers can
with a unique imaging format and com- and incorporating images into the systems, understand.
munications standard in DICOM,” he says. meaning the task is exponentially harder the Share this story: dotmed.com/news/48317

Cost Containment Corner
Cost-effective solutions for

healthcare IT deficiencies
By James D’Arezzo
Managing health- and physicians’ offices, end up with dupli- and widespread databases, pulling information
care these days cate EHR data that requires extensive (not to together through millions of I/O operations.
is as much about mention non-productive) search and retriev- The system’s analytic capability is dependent
managing data as al, which degrades IT system performance. on the efficiency of those operations, which,
it is about manag- in turn, is dependent on the efficiency of the
ing patients them- More data, more problems computer’s operating environment.
selves. The tsunami IT departments are struggling to keep up with In the Windows environment especially
of data washing over demand. Like the proverbial Dutch boy with (which runs about 80% percent of the world’s
the healthcare industry is a result of techno- his finger in the dyke, it is difficult for IT staff to computers), I/O performance degradation
logical advancements and regulatory require- manage the sheer amount of data, much less progresses over time. This degradation, which
ments coming together in a perfect storm. But the performance demands of users. can lower the system’s overall throughput
when it comes to saving lives, the healthcare The applications are getting more robust, capacity by 50 percent or more, happens in
industry cannot allow IT deficiencies to be- systems are generally more reliable, but any storage environment. Windows penal-
come the problem rather than the solution. speed (performance) is a constant challenge izes optimum performance due to server inef-
According to a recent report from Inter- that can get worse by the day. ficiencies in the handoff of data to storage.
national Data Corporation, the volume of From an IT investment perspective, im- This occurs in any data center, whether it is in
data processed in the overall healthcare sec- provements in technology have given us the cloud or on premises. And it gets worse
tor is projected to increase at a compound much faster networks, much faster process- in a virtualized computing environment. In a
annual growth rate of 36 percent through ing and huge amounts of storage. Virtualiza- virtual environment the multitude of systems
2025, significantly faster than in other data- tion of the traditional client-server IT model all sending I/O up and down the stack to and
intensive industries. has provided massive cost savings. And new from storage create tiny, fractured, random
Healthcare faces many challenges, but hyperconverged systems can improve per- I/O that results in a “noisy” environment that
one that cannot be ignored is information formance as well in certain instances. Cloud slows down application performance. Left un-
technology. Without adequate technology computing has given us economies of scale. treated, it only worsens with time.
to handle this growing mountain of often But costs will not easily be contained, While additional hardware can temporar-
complex data, medical professionals and sci- as the mounting waves of data continue to ily mask this degradation, targeted software
entists can’t do their jobs. pound against the IT breakwaters. can improve system throughput by up to 30
to 50 percent or more. Software like this has
Electronic health records Containing IT costs the advantage of being non-disruptive (no
Over the last 30 years, healthcare organiza- Costs continue to rise, proportionate to the ripping and replacing hardware), and it can
tions have moved toward digitizing patient demand for the three fundamentals (appli- be transparent to end users as it is added in
records, with 96 percent of U.S. hospitals cations, uptime and speed). the background. Thus, a software solution can
and 78 percent of physician’s offices now us- However, there are solutions that can help handle more data by eliminating overhead, in-
ing EHRs, according to the National Acade- contain IT costs. Data Center Infrastructure creasing performance at a much, much lower
my of Medicine. A recent report from market Management software has become an effec- cost and extending the life of existing systems.
research firm Kalorama Information states tive tool for analyzing and then reducing the With the tsunami of data threatening IT,
that the EHR market topped $31.5 billion in overall cost of IT. In fact, the U.S. government solutions like these should be considered in
2018, up 6 percent from 2017. Data Center Optimization Initiative claims to order to contain healthcare IT costs.
The adoption of EHRs is supposed to be have saved nearly $2 billion since 2016. James D’Arezzo is CEO of Condusiv Tech-
a solution, but instead it is straining an over- What is often overlooked is that processing nologies, a global provider of software-only
burdened healthcare IT infrastructure. This is and analyzing data is dependent on the over- storage performance solutions for virtual
largely because of the lack of interoperability all system’s input/output performance. Many and physical server environments.
among the more than 700 EHR providers. large organizations performing data analytics Share this story: dotmed.com/news/48318
Healthcare organizations, primarily hospitals require a computer system to access multiple

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W W W. AC E S U M M I TA N D E X P O. C O M
Flash Therapy
Looking toward a future

with flash therapy
By John R. Fischer
Researchers at the Institut Curie in Or- at once to a single participant in a short during flash therapy helps reduce damage
say, France made history in 2014 when sequence,” Dr. Vincent Favaudon, the incurred by healthy tissue surrounding the
they performed the first demonstration developer of the technique at the Institut tumor. Treating cancer this way, whether it
of flash radiotherapy, a technique that Curie, told HCB News. be a single session or multiple sessions, is ex-
delivers large doses of radiation in a Since then, flash demonstrations have pected to have a dramatic impact on patient
fraction of a second. Applying short pulses been conducted throughout Europe and outcomes and also hospital throughput.
of radiation to the thorax of mice at a dose the U.S., with researchers aiming to adapt “The dilemma in many cases is that the
rate of more than 40 Gy/s, the team exam- the practice for clinical use and improve the tumors are not physically separate from
ined the extent of lung fibrogenesis in the speed and safety of radiotherapy. To do this, certain, critical normal organs. They are
specimen for up to six months after radia- however, requires a thorough understanding sort of ‘weaved’ in,” said Dr. Billy Loo, a
tion, and found that normal, healthy tissue of flash, as well as answers to unanswered professor of radiation oncology at Stan-
sustained less damage, compared to that of questions around its use and impact. ford University. “Even if you’re sculpting
mice irradiated at a conventional dose rate. the dose very carefully, you’re ultimately
“We use a single dose treatment, Sculpting dose and sparing tissue going to be limited in how much radiation
meaning that the entire treatment is given The speed at which doses are delivered you can apply because the normal tissues

are right there. With flash, we are develop- in normal tissue, at least based on some pre- the most precise, highly sculpted radiation
ing strategies both to create highly sculpted clinical work, is less than with standard proton doses to tumors, while also capitalizing on
doses and deliver them super fast to maxi- or photon therapies. The mechanism underly- the biological benefits of flash to spare nor-
mize the sparing of normal tissues." ing this phenomenon is unclear.” mal tissues.”
Most of the research using flash so far In April, Vujaskovic and his colleagues
has been done in preclinical studies and we Potential applications for from the University of Maryland department
are still a long way from introducing flash flash therapy of radiation oncology unveiled lung cancer
therapy to the clinical setting. The type of The speed and specificity of flash therapy research as part of their first quantitative,
radiation most commonly used for these ex- make it particularly promising for cancers preclinical findings using flash therapy with
periments to date is electrons, though some where treatment currently requires mo- protons. The researchers recorded 25-30
demonstrations have used protons and syn- tion management. For example, with lung percent less damage to lung tissue, leading
chrotron X-rays. cancer, conventional radiotherapy calls for to less fibrosis of the lung, and an average
“Flash is not necessarily minimizing neces- synchronizing the beam with the breathing 35 percent decrease in skin dermatitis when
sary physical dose to the normal tissue, but cycle to target moving tumors at specified using flash.
when radiation is delivered at very high dose locations. It is the first of any flash demonstrations us-
rates, the healthy tissue apparently does not “That was one of the original motiva- ing protons rather than electrons to show sig-
‘see’ it,” said Dr. Zeljko Vujaskovic, a profes- tions behind the idea and advantage of su- nificant reductions in lung injury, according to
sor of radiation oncology at the University of per fast radiotherapy,” said Loo. “If we can Vujaskovic, who described flash therapy with
Maryland School of Medicine. “Therefore, the flip the problem around so that the treat- electrons as being primarily suited for superfi-
normal tissue is not responding to this high ment is almost instantaneous, it becomes cial tumors (such as those of the skin). “With
dose in the same way it would with protons or so fast that all of the motion in the body is protons,” he said, “this type of treatment can
photons. The damage from this ‘flash effect’ essentially frozen. That will allow us to give be delivered to deep-seated tumors.”
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Flash Therapy
Billy Loo
A long road ahead “Cost of technology has to be reduced
Despite the potential benefits of flash thera- and designed for better economy, compact-
py, important questions remain unanswered ness and compatibility with available infra-
and technological advancements will be structures so you don’t have to build new
necessary. buildings just to put in a machine,” said Loo.
While preclinical research is a good start- “There needs to be better automation and
ing point, Dr. Hans Langendijk, professor clinical efficiency so that more patients can
and chair of the department of radiation be treated on any given system in any given
oncology at the University Medical Center amount of time.”
in Groningen in the Netherlands, cautions From there a host of new questions open
that it lacks essential information in a num- up, such as how to train medical personnel
ber of its findings. The most important of on using the technology and how to ensure
these critiques, he said, includes the need patient access to the treatment, which will
for radio-biological experiments to confirm depend on health policies, healthcare sys-
that first results can be replicated under dif- tems and local politics of individual countries
ferent circumstances, and assessments of and insurance companies.
potential late-term outcomes.
Vincent Favaudon “What we see in radiation therapy is One step at a time
acute toxicities that may occur during the While flash may be years away from be-
course of radiation and immediately after ing used on patients in everyday settings,
radiation,” he said. “Most of these studies a great amount of progress has been made
have been focusing on those complications, around it, including the introduction of clini-
but the mechanisms that may result in late cal trials for humans.
complications — which, in some cases, may “If successful, we could treat patients in
occur even 10-15 years after — are com- a fraction of a second, instead of in seven
pletely unknown.” weeks, with less radiation-induced com-
Fractionation is another area where Lan- plications, and with a very high probability
gendijk said work needs to be done. to obtain tumor control,” said Langendijk.
“The first question is IF we have to frac- “This may be one of the most exciting de-
tionate or not. The second issue is when velopments I’ve seen in my career.”
you give the entire treatment in just a frac- The aim behind flash therapy is not
tion of a second, you have to be very sure just to enhance treatment efficiency but
that the dose delivery is correct, which re- access at lower costs, according to Loo.
quires intense physics quality assurance.” “Our goal is to develop technology to al-
Zeljko Bringing flash to the clinic will also re- low flash ultimately to be used in place of
Vujaskovic quire better equipment because existing existing radiotherapy, enabling it to bring
linear accelerators are incapable of deliver- down price and open up greater access to
ing radiation doses at the required speed. lifesaving treatments for patients.”
Loo and his colleagues at Stanford are Those are big goals, and achieving
working to change this by partnering with them will require the accumulation of
the SLAC National Accelerator Laboratory evidence to illustrate its benefits. On this
in an ongoing program called PHASER, front, there is still a tremendous amount
which incorporates multiple technological of work to be done.
advantages aimed at delivering ultrafast “I am optimistic, and do believe flash
radiation treatment. will find a role in radiation oncology,” said
Developing the technology to deliver Vujaskovic. “It will be a major step forward
flash is itself a two-fold challenge. Making in how radiation is delivered, but again, we
those capabilities viable for actual health- need to have more solid, firm data to move
care providers means that financial consid- this to become a standard of care.”
erations must also be made. Share this story: dotmed.com/news/48319

Equal Opportunities
Addressing gender
disparities in the
field of radiation
oncology
By Dr. Luca Valle and Dr. Ann Raldow
Conversations surrounding pervasive inequities in all aspects Yet, other high-impact studies led by Dr. Reshma Jagsi and col-
of the workforce are now having their long overdue moment leagues have suggested this may not be the case, since substantial
in the spotlight of American society, and healthcare is no unexplained salary gaps have been proved to persist even after ad-
exception. justing for specialty, academic productivity, and work hours.
Paradoxically, perhaps because the field of medicine attracts Within the field of radiation oncology, gender has been shown
a select group of forward-thinking, emotionally intelligent, and to influence many aspects of a physician’s career, including oppor-
logical people motivated to help others, many have been lulled into tunities for academic advancement, scholarly activity, invitations to
believing that gender disparity in medicine does not exist, or when participate in scientific panels, funding for physician researchers, and
it does, it exists for purely rational reasons. For example, while nu- even disease sites treated.
merous studies have described the trend of men earning more than As a new trainee in radiation oncology who has always had an
women at many stages of their careers, these differences are often interest in understanding and mitigating inequities as they manifest
attributed to different career choices made by men and women in in healthcare, I was curious as to how gender might be influenc-
medicine, including the decision to enter less remunerative special- ing salary and clinical activities in our field. Shortly after starting
ties and work fewer hours. residency at the University of California Los Angeles, I sought out

the mentorship of Dr. Ann Raldow, who is a member of the UCLA female radiation oncologists in the facility-based setting collected
Jonsson Comprehensive Cancer Center, and we set out to tackle on average $33,026 less than their male counterparts. In the non-
the question of whether a disparity existed in clinical activities and facility-based setting, this gap was predictably wider, with similarly
reimbursement in the field of radiation oncology. highly productive females collecting an average of $345,944 less
We were both rather surprised to find that female radiation than males.
oncologists submit fewer charges to Medicare, are reimbursed less It is important to note that observational studies such as ours
per charge submitted and receive lower Medicare payments overall cannot establish an exact cause for the differential practice and re-
in comparison to male radiation oncologists. imbursement patterns we report, but speculating on some of their
driving factors is an important next step in determining how we
might level the playing field.
Within the field of radiation oncology, The first question to ask is: are these differential findings even
related to gender at all? It seems like an unavoidable conclusion,
gender has been shown to influence a but it is possible that there are other extraneous factors that we
did not control for in our study that are driving these results more
physician’s career, including academ- significantly than provider gender.
If, however, gender is indeed influencing our findings, either di-
ic advancement, scholarly activity, rectly or indirectly, this may be rooted in several factors. In terms of
clinical activity, less clinical activity may be a natural consequence
invitations to participate in scientific of the value-based labor choices that female practitioners make,
particularly within a gender-structured society where women
panels, funding for researchers, and continue to be expected to shoulder the greater share of domestic
responsibilities. However, less activity might also be tied to overt
even disease sites treated.
Our study was designed by querying a large database called the
Physician and Other Supplier Public Use File (POSPUF). This data-
base was created to increase financial transparency in the United
States healthcare system by tracking data on individual physician
reimbursements from Medicare. This allowed us to formally and
objectively characterize productivity and reimbursement patterns
among male and female radiation oncologists on a national level
for the first time.
We looked at payments in both non-facility-based (or freestand-
ing, often private practice) radiation oncology clinics, as well as
facility-based (or hospital-based, often academic) radiation oncol-
ogy clinics, since distinctions in billing practices would cause any
reimbursement in the non-facility-based setting to be higher due to
the collection of technical fees by physicians who own the machines
used to deliver radiation.
Delving into the details of the study, what we found was that
of the 4,393 radiation oncologists submitting claims to Medicare,
female physicians who worked in a non-facility-based setting sub-
mitted an average of 1,051 fewer charges and collected $143,610
less in revenue than male physicians. Female radiation oncologists
working in a facility-based setting submitted on average 423 fewer
charges and collected $26,735 less in professional revenue than
their male counterparts.
These discrepancies were even wider when making comparisons
in the group of radiation oncologists submitting the most Medicare
claims. Even among similarly highly productive radiation oncologists,

Equal Opportunities
sexual discrimination leading to fewer referrals from surgical and oncologists in our field are male, decreased seniority in practice
medical oncologists. It is also possible that in designing their clinic hierarchies could be resulting in fewer lucrative referral patterns
schedules, women prioritize time spent with a given patient over for the less senior female radiation oncologists.
number of patients seen, and that prioritizing quality over quantity In order to help distinguish amongst these potential etiologies,
results in fewer claim submissions to Medicare. And finally, there we plan to look at the claims submitted by men and women over
may be less billing support in practices attracting female providers, this same time period to determine if there is a difference in the
thereby resulting in a failure to capture services that are actually types of services that men and women bill for. We also plan to dig
being provided. a little bit deeper into the population of physicians who collect the
In terms of reimbursement, decreased collections for women most Medicare dollars to see if we can learn anything about how
might be the natural consequence of gender-related decreases billing patterns differ between men and women among those col-
in clinical activity described above. However, decreased volume lecting the highest reimbursements from Medicare. The answers to
of claim submission alone is insufficient to explain the gap in some of these questions will be presented at our society’s annual
reimbursement, particularly when you consider our finding that meeting (ASTRO) later this year in Chicago.
women also collect less per charge despite the fact that Medicare There are a number of action items for healthcare executives
and administrators looking for ways to mitigate this disparity.
Ensuring that adequate billing support is available to all providers
A more complex yet critical challenge is key, as is assuring that there are no significant imbalances in
referral networks. These are relatively quick and easy interven-
is cultivating a workforce culture tions that can make an impact while efforts continue to pinpoint
the source of the variation. A more complex yet critical challenge
where women are perceived as key is cultivating a workforce culture where women are perceived as
key members of the treatment team and valued as equals, as this
members of the treatment team and will help mitigate disparities both within economic reimburse-
ment and beyond.
valued as equals, as this will help It is our hope that these next steps will move us closer to un-
derstanding and deconstructing sex-based barriers for economic
mitigate disparities both within advancement within the specialty of radiation oncology and we look
forward to making important strides in this direction.
economic reimbursement and beyond. We would like to acknowledge the expertise and input of the
other co-authors on this study, including Julius Weng, M.D.; Reshma
Jagsi, M.D. DPhil; Fang-I Chu, Ph.D.; Sumayya Ahmad, M.D.; and
Michael Steinberg, M.D.
reimburses male and female providers at the same rates. This is About the authors:
likely due to women submitting different kinds of codes than Luca Valle, M.D., is
men, and the codes women submit are likely less well-remuner- in his second year of
ated. Many female radiation oncologists, perhaps for reasons training as a radiation
of mentorship and patient demographics, elect to treat breast oncology resident at
and gynecologic malignancies, and both of these subfields of UCLA. His research fo-
radiation oncology rely primarily on 3D conformal technologies cuses on health policy,
and brachytherapy techniques that are on the lower end of the healthcare dispari-
reimbursement spectrum in terms of planning and delivery codes. ties, and health services. He is a graduate of Dartmouth Medical
Additionally, value-driven management decisions based on the School and is a member of the American Society for Radiation
communal attributes socialized into women (versus the agentic Oncology. Ann Raldow, M.D., MPH, is an assistant professor in the
attributes socialized into men) could partially explain a payment Department of Radiation Oncology at the David Geffen School
differential. For example, when two equivalent treatment options of Medicine at UCLA. She also is a member of the UCLA Jonsson
are available, it is possible that female radiation oncologists are Comprehensive Cancer Center’s Cancer Control and Survivorship
more likely to select the more cost-effective option. We have Program. Dr. Raldow’s research focuses on therapeutic decision
seen this in other specialties, where women have been shown to making, cost-effective care, quality of life and health outcomes
adhere more closely to clinical guidelines, forego costly interven- assessments.
tions, and engage in shared-decision making with patients more Share this story: dotmed.com/news/48320
frequently. And finally, since many of the most senior radiation

View From The Hill
Bill aiming to reduce prior

authorization delays for
cancer treatment introduced
in Congress
By John R. Fischer
In early June, a group of U.S. representatives introduced a new

bill that proposes a plan for reducing obstacles to cancer care,
including restrictive prior authorization practices.
Named The Improving Seniors’ Timely Access to Care Act of 2019,
the bipartisan federal legislation aims to reform prior authorization to
prevent unnecessary delays in patient access to critical cancer treat-
ments, and enable radiation oncologists and other clinicians to use their
clinical judgment to prescribe the best course of treatment for patients.
“There is legitimate concern that the administrative burdens asso-
ciated with prior authorizations might sometimes result in physicians
feeling forced to provide lower value care to avoid extra delays for
approval of care that they believe to be more clearly in the patient’s
best interest,” Brian D. Kavanagh, the immediate past chair for the
ASTRO Board of Directors, told HCB News when the bill was intro- tage plan by requiring the plans to relay relevant information, includ-
duced. “The physician is balancing what they believe to be the best ing annual disclosure of medical treatments subject to prior autho-
possible, most personalized course of treatment against the patient’s rization; the percentage of requests that are approved and denied;
mounting anxiety about delayed access to treatment. It is frustrating and the average time for approval. In addition, it supports the use of
that the initial denials imposed by benefits managers often occur be- an electronic prior authorization process to streamline decisions and
cause they use guidelines that are outdated and lag behind currently avoid unnecessary delays for certain procedures.
accepted practice standards.” “The best effects of the bill for patients would be to mandate
More than nine out of 10 physicians experience delays in provid- speed and transparency on the part of the companies engaged in
ing lifesaving treatments to their patients due to prior authoriza- managing health insurance benefits for those suffering from cancer
tion, with one-third equating the average delay to longer than one and other serious medical conditions,” said Kavanagh. “We hope
week, according to a nationwide survey conducted by ASTRO. Each some of the current built-in inefficiencies and delays with the current
week of delay in starting cancer therapy causes a 1.2 to 3.2 percent system can be eliminated so that patients can receive care in a timely
increase in the likelihood of death, and adds stress and anxiety to manner without unnecessary added angst.”
patients who are already concerned about their health. The bill has been endorsed by several leading health providers, pa-
Doctors or staff members who object to these delays or denials tient advocacy groups, and other organizations, and was introduced
can file appeals for review at a higher level within the Radiation On- by Rep. Suzan DelBene (D-Wash.), Rep. Mike Kelly (R-Pa.), Rep. Roger
cology Benefits Managers (ROBMs). Many, however, are often forced Marshall, MD (R-Kan.) and Rep. Ami Bera, M.D. (D-Calif.).
to consult with one or more individuals who may or may not have “As a doctor, I’m proud to be co-sponsoring this long-needed
any training in oncology, while patients are left waiting, with no guar- legislation to help relieve administrative burdens on practicing physi-
antees that they will receive treatment. This adds emotional distress cians,” said Rep. Ami Bera in a statement. “Physicians spend far too
and prolongs symptoms that can adversely impact their quality of life. much time on burdensome paperwork and seeking authorization
The new legislation seeks to increase transparency in the prior on certain items, when they can be spending that time taking care
authorization process by making clear what the regulations of the of their patients. This bill modernizes the process, and is a win for
ROBMs are to help clinicians in their decision-making. It also aims to physicians and patients.”
reduce unnecessary delays for patients covered by Medicare Advan- Share this story: dotmed.com/news/47519

MR-Guidance
Q&A with
Dr. Parag Parikh
director of MR-Guided Radiation Therapy and
director of GI Radiation Oncology
Henry Ford Cancer Institute
Discussing the value of MR-guided
radiotherapy
By Gus Iversen
Last November, Dr. Parag Parikh, joined waitlist for the ViewRay and we have dou- survival in patients who received high-dose
the radiation oncology department at bled our therapy staff to support this. MR-guided radiation therapy to the pan-
Henry Ford Cancer to lead its MR-guided creas, as compared with standard dose ra-
radiation program. HealthCare Business HCB News: We’ve been hearing a lot diation. This is the only study using ablative
News sat down with him to find out how recently about the cutting-edge capabili- doses of radiation given over 5 fractions, and
the new role is working out and why he feels ties of MR-guided radiation therapy. This has a goal of recruiting 133 patients.
that MR-guided radiation is such a promising is a field where Henry Ford is at the cut- We also have a study using 5 fractions of
field for the future of cancer treatment. ting edge. What kind of research are you radiation to treat prostate cancer, using the
currently conducting with these tools? MRI to help boost the dose of the dominant
HCB News: Can you tell us a bit about
your background in radiation oncology
and what it’s been like to join the team
at Henry Ford?
With the advent of the alternative payment model,
Dr. Parag Parikh: I attended medical
school and residency at Washington Univer-
essentially capitating both professional and
sity in St. Louis. I had an early interest in tech-
nology development for tracking moving
technical charges per diagnosis in 90 day events,
tumors and worked under Dr. Daniel Low
to investigate CT scanning of lung tumor
there is an incentive for improvement in outcomes
respiratory motion and implantable electro-
magnetic transponders that could be put
without increasing number of treatments.
into the lung to help guide radiation therapy.
I continued as a faculty member at Wash-
MR-guided radiation therapy machines are uniquely
ington University for 12 years, and our team
treated the first MR-guided radiation ther-
positioned to do this, allowing safe, effective
apy patient in the world in 2014. With the
novel adaptive MR-guided radiation therapy
treatments in one week or less for many diseases
trial by Drs. Lauren Henke and Jeff Olsen, we
realized that abdominal radiation therapy
traditionally treated over 5.5 weeks.
would never be the same.
I returned home to Detroit to join Henry PP: We have several ongoing clinical tri- nodule of prostate cancer in each patient.
Ford in 2018. As the group with the longest- als. First, we are leading the national SMART Finally, we have a corollary study for brain
running clinical MR-linear accelerator pro- study [NCT NCT03621644]. This study builds tumor patients looking at new imaging in-
gram, it was like jumping into a well-running upon retrospective data (Rudra, Cancer Med- formation that may inform how or when to
automobile. We now have a one-month icine, 2019) showing an almost doubling of change radiation therapy for glioblastoma.

Henry Ford Hospital where Dr. Parikh
directs the oncology department's MR-
guided radiation therapy program.
HCB News: The MR environment has almost all of the sites, it has certainly become clinical efficacy with heightened efficiency.
unique shielding and safety demands. Is the standard of care for hepatobiliary cancers, With the advent of the alternative payment
the same true for MR-guided radiation as well as small amounts of lymph node dis- model, essentially capitating both profes-
therapy? If so, what kind of strategies ease in the abdomen or pelvis. The ability to sional and technical charges per diagnosis in
are being used to make sure staff follow visualize these tumors, control for respiratory 90 day events, there is an incentive for im-
protocols? motion and change the radiation plan based provement in outcomes without increasing
PP: The MR environment is new to most on stomach and intestine position allow safer number of treatments. MR-guided radiation
radiation oncology departments and we and faster ablative radiation doses. therapy machines are uniquely positioned to
worked hand-in-hand with our radiology The current reimbursement for MR-guid- do this, allowing safe, effective treatments
colleagues to implement best practices for ed adaptive radiation therapy is favorable. in one week or less for many diseases tra-
MR safety. We are included in the hospital- We will obtain reimbursement for additional ditionally treated over 5 ½ weeks. More-
wide MR safety conferences and we also had radiation therapy plans delivered during the over, some users are using their systems to
our staff take the same training as offered radiation course if the anatomy changes in a do away with traditional simulation, which
to radiology staff. A robust safety culture meaningful fashion and these charges have will shorten treatment times further and im-
has prevented any MR safety-related events almost universally been accepted. prove value for the patient. I see MR-guided
in the two years our center has been open. radiation therapy becoming a standard ma-
HCB News: Looking ahead, what role chine in any dual linear accelerator clinic.
HCB News: Is MR-guided radiation do you imagine MR-guided radiation Challenges being addressed currently are
therapy still primarily in the research therapy playing in cancer treatment a treatment times, distribution of adaptive ra-
phase or is it being used more clinically decade from now? What challenges (in diation responsibilities to therapists from the
for certain indications? What is the reim- terms of cost, access, illustrating ben- physician/physicists, and physician training.
bursement situation like? efits, etc.) need to be addressed? For a technology that is less than five years
PP: There are now over 20 programs offer- PP: The long-term radiation therapy old, these steps are occurring rapidly.
ing clinical MR-guided radiation therapy. For practice will need to show simultaneous Share this story: dotmed.com/news/48321

ASTRO
Q&A with
Dr. Theodore
DeWeese
ASTRO president
Raising the profile of radiation oncology
By Sean Ruck
The 2019 American Society for Radia- my heart was — around the notion of help- I also would link that emphasis directly
tion Oncology (ASTRO) Annual Meet- ing those who need it, and I have this great with support for the research mission ASTRO
ing takes place this year from Septem- interest and love of science and biomedi- provides in order to move the field forward,
ber 15th through the 18th at McCormick cine — what better place to do that than and to make sure our newest members in-
Place West in Chicago. HealthCare Busi- in medicine? No one in my family had ever herit a thriving and dynamic field that con-
ness News spoke with ASTRO president, Dr. been to college, much less medical school, tinues to be centered on our patients.
Theodore DeWeese, vice dean for the Johns so I rolled the dice and actually was admit-
Hopkins School of Medicine and the Sidney ted into medical school. All these years later, HCB News: What are the biggest chal-
Kimmel Professor in the Department of Ra- I have loved every moment. lenges facing ASTRO members today?
diation Oncology and Molecular Radiation TD: I think the restrictive coverage poli-
Sciences at Johns Hopkins University, to learn HCB News: What is on your agenda cies that payors have is a real issue for us
about his background and to get an update as president of ASTRO? and our patients. It is frequently a challenge
on the organization. TD: Broadly, there are two categories. obtaining prior authorization for treatment,
First, we want to engage all of our mem- which is associated with a large administra-
HCB News: What inspired you to get bers and support them in their role in caring tive burden and cost. ASTRO has done some
involved in healthcare? for patients with cancer. It means having to work recently evaluating this topic across our
Dr. Theodore DeWeese: When I was in fully educate the public and other physicians membership. It’s been very clear that nearly
college, I came to realize just how much I loved about the unique role that radiation oncol- uniformly — over 90 percent of our mem-
science in the broadest sense, meaning chem- ogy plays within the oncology care team bers have said — patients have been delayed
istry and biology and physics. I was very lucky – particularly, that we are one of the most in receiving radiation therapy because of re-
to have an opportunity to work in a laboratory effective modalities to cure patients. strictive prior authorization practices that are
in the School of Medicine in Colorado. I didn’t There are very high demands for quality employed by many insurers. When a patient
know at the time, but I was doing what we and safety that come with the work we do. has a life-threatening illness, the associated
would now term “translational research”. We That’s very important for the broader audi- threat with delaying their care is just not a
were developing an assay for a particular rare ence to understand our role as oncologists, healthy situation to be in whatsoever.
disease and came up with a way to do that, and is really key in all of this, so we want to As it turns out, about two-thirds of those
and then had an FDA-approved product. As propagate a very clear and positive message denials that originally come from these prior
my first research project, and since I had no about those aspects of who we are. authorizations are overturned anyway. So
framework, I just thought it was the coolest The second is the continuous learning re- it’s a process that’s stressful, potentially risky
thing ever and I had no idea what a rare op- quired of those of us in cancer, generally, and for the patient, and extremely expensive
portunity that was for me. radiation oncology, specifically, because it’s and problematic for the healthcare team.
I also have always loved people and vol- a fast-moving field. We need to make sure Most management of patients today is
unteering and did that in various ways in our members feel they are as contemporary multi-modality, for example, chemotherapy
college and with a variety of organizations in in their knowledge as possible in areas like plus radiation. These treatments have to
Denver. The linkage of those two things, and biomarker development, cancer genetics be sequenced very accurately, and when
really the second in particular, that’s where and immunotherapy linkages with radiation. there’s a delay in either side of that, it can

throw everything off track. A week of de- Another development is molecularly tar- morning yoga and more healthy eating op-
lay for bureaucratic reasons could turn into geted radiation. This involves tiny molecules tions. The schedule is less compressed, too,
a significant delay far beyond a week be- that target cancer cells and have a radioiso- and there’ll be much more time for people
cause everything needs to be resequenced. tope linked to them. These small radiola- to network.
beled molecules are injected into a patient’s
HCB News: Other than what you pre- bloodstream and circulate in the blood, HCB News: Can you give your predic-
viously mentioned, are there benefits to binding to the cancer cells and delivering tion as to how you think radiation oncol-
being a member of ASTRO? radiation right to the cancer. Prostate cancer ogy will change over the next 10 years?
TD: The other portion of education, to be is one of the places this is being developed. TD: I think, number one, radiation on-
a little more explicit, is the continuous learn- There’s also the notion that radiation cologists are natural conveners — bringing
ing through the various journals that ASTRO oncology is performed in what is termed, other medical disciplines together to work
provides. There’s also the education provided “closed loop medicine”. That is to say, you on behalf of patients. I think this is both a
through a myriad meetings we support. And see patients, do all the tests, design a plan, result of just the nature of those who enter
the third major aspect is the linkages ASTRO test the plan before you deliver to the pa- our field as well as how we are trained. So
creates with other professional organiza- tient, the patient comes, and you reevaluate I believe you’ll see multidisciplinary teams
tions, which helps to create guidelines and right before you give it to them, and then across the country more often being led by
other materials that educate our members you treat them. That’s repeated every day. So the radiation oncologist.
and other oncologists on how to manage our field generates a tremendous amount of I think you’ll see growing importance of
their patients. data that can be mined with deep-learning the management of patients with more ad-
For continuing education, a number of algorithms and other artificial intelligence vanced disease. Radiation therapy will be
the articles in our publications qualify for models. These models will to help us learn used in combination with immunotherapy,
self-assessment CME. One can read the ar- who might need more or less radiation, as one example. I don’t just mean for pallia-
ticle, then take an online questionnaire that based on certain features seen in thousands tive care, but curative care.
asks some questions that show you grasped of patients before them that we mine from I anticipate a growing involvement with
the key highlights of the article. Being able to these huge data repositories. radiation pharmaceuticals. This is just another
support the busy clinicians by having this sort way to deliver radiation therapy to our patients
of opportunity directly in the publications HCB News: What are you most ex- but one where we have great expertise in who
they receive as a member of ASTRO, I think, cited about seeing or experiencing at to treat, given our oncologic training, as well
is a very important way to support their this year’s conference? as in the dosimetry necessary to provide effica-
needs and ensure a continuous level of edu- TD: There is a whole new learning style cious and safe treatment. Genetic medicine, as
cation used to the benefit of our patients. we’re putting forward for the meeting — the I noted before, is going to be a really significant
presidential course in particular. It’s meant to portion of our field — in the research we con-
HCB News: Are there any recent de- be much more interactive. We are starting duct, the education we provide and the use of
velopments in the field you’re particu- with a topic that is somewhat controversial: it in daily management to guide us to the most
larly excited about? radiation therapy in the curative treatment of optimal and precise care for our patients.
TD: There are actually quite a number. metastatic disease. Our goal is to really engage Another growth area for us is research in
One of the most important advances over the audience in the topic with several “level AI. We need to push forward in this arena to
the last six or seven years is the role of immu- setting” talks with the goal of getting all of the learn how and where AI can be used in our
no-oncology. It’s been clear by several pub- audience on the same page as to the state- field to guide care we provide, and to do so
lications that the combination of radiation of-the-state of metastatic cancer. This will be in an ethical way and in a manner that pre-
therapy with some of the so-called check- followed by an Oxford-style debate between serves and enhances the physician-patient
point inhibitors — the immuno-oncology experts, which we will use as a platform for relationship.
drugs — is more beneficial than the drug much smaller breakout sessions where the Something that is very important to me
alone. Melanoma, for example, is a disease various aspects of that topic can continue to is that we will push hard to create a more di-
where this has been seen. Moreover, I think be discussed and debated. It’s more interactive verse radiation oncology workforce-one that
it’s extremely exciting, we are beginning to between audience participants and the lectur- will allow ASTRO to have all voices around
understand the molecular underpinnings ers and educators. We are excited to bring the table, so that the best decisions can be
of how the radiation-checkpoint inhibitor this new format to ASTRO this year and really made. It is also key so we look far more like
interaction is occurring. We are now coming hope it is a more enjoyable and engaging way the patients we see and treat every day. Ul-
to a place where we can start to think about to educate our members. timately, creating change that improves the
screening patients to determine who would This year’s conference has more focus on lives of our patients is most important.
most benefit from a particular approach. health and healthy living, with activities like Share this story: dotmed.com/news/48322

ASTRO
DOTmed advertiser special section
ASTRO 2019 Exhibitors
Hitachi — Booth 1039 accelerators, CT Scanners, PET/CT, MRI systems and more. As dedi-
Hitachi provides flexible particle therapy solutions from single com- cated partners, we offer start-to-finish solutions and a full range of
pact room to multi-room solution. Hitachi also offers proton, heavy- equipment related services including installation, parts support and
ion particles and hybrid (proton + carbon) solutions. Hitachi is a pio- warranty. Far too many people around the world don’t have access
neer in the spot scanning technology for particle therapy. Our state of to the medical treatment and services they need. At ROS, we believe
the art system have been selected and demonstrated by prestigious we can change that. We can extend the life of valuable medical
users worldwide. For more information, please visit Hitachi booth at equipment without compromising safety, quality or environmental
ASTRO 2019. sustainability. We can help hospitals and clinics use their resources
more efficiently, make their budgets go further, and provide more
IBA — Booth 3028 services to their patients.
IBA will showcase the latest innovative technologies coming to
proton therapy with a focus on Motion Management, Proton Arc Sun Nuclear — Booths 2624 & 3415
Therapy and Proton Flash Therapy. These topics will be presented at Sun Nuclear provides innovative QA solutions for Radiation Ther-
our booth 3028 by our team of experts as well as at the IBA Proton apy, Patient Alignment, and Diagnostic Imaging. Our mission is to
Therapy Conference. enable healthier lives by improving the avoidance, detection and
Following its open integration approach, IBA will also showcase treatment of cancer. More than 5,000 cancer centers rely on us
multiple workflows to integrate proton therapy in the clinic with its for independent, integrated Quality Management. With a focus
partners Elekta, Philips and RaySearch. on support, we aim to ease technology adoption, improve out-
Do not hesitate to book a demo at https://radiation-oncology. comes and enhance workflows — so that healthcare providers can
iba-events.com or visit us at booth 3028. achieve real results for Patient Safety. Visit us in Booths 2624 and
3415 for product demonstrations and in-booth talks. Learn more:
Mobius Imaging — Booth 4638 sunnuclear.com/astro.
Mobius Imaging is the premier developer and supplier of Airo®
TruCT, the largest inner bore mobile diagnostic and intraoperative CT Varian — Booth 1405
imaging system. The company will be providing live product demon- At Varian, we envision a world without fear of cancer. For more than
strations of the Airo, booth #4638, at ASTRO 2019. Attendees will 70 years, we have developed, built and delivered innovative cancer
be able to observe Airo mobility, receive a hands-on demonstration of care technologies and solutions to help clinical partners around the
Airo operation, see Airo image quality, and learn more about its appli- globe treat millions of patients each year. We are harnessing ad-
cations in Radiation Therapy through in-booth media presentations. vanced technologies like artificial intelligence, machine learning and
data analytics to advance cancer treatment and expand access to care
Radiology Oncology Systems — Booth 4045 for patients globally. We call our approach Intelligent Cancer Care.
ROS is a global provider of pre-owned radiation therapy and diag- Please visit us in booth #1405 to experience firsthand our evolving
nostic imaging equipment, accessories, and parts including linear ecosystem of technologies for fighting cancer.

ASTRO to host Annual Meeting
in Chicago, September 15-18
ASTRO will host its 61 st Annual plans to address key challenges facing both professor of radiation oncology at the
Meeting at McCormick Place in Chicago, radiation oncology and the larger house of University of Toronto. She also directs the
September 15-18, 2019. The meeting will medicine, including physician burnout, re- palliative radiation oncology program and
feature updates on clinical trials, cancer strictive prior authorization practices and has led numerous phase I, II and III trials,
research and new approaches that involve workforce diversity. including trials that focused on the use of
radiation therapy in cancer treatment. Dr. Dawson leads a multidisciplinary personalized stereotactic body radiation
Complimentary registration is offered for team of cancer specialists in upper gastro- therapy (SBRT) for patients with liver can-
credentialed news professionals who wish to intestinal (GI) cancers at the Princess Mar- cer, who historically were not candidates
cover the meeting. garet Cancer Centre in Toronto and is a for radiation therapy.
The 2019 ASTRO Annual Meeting is expect-
ed to attract more than 10,000 oncologists, cli-
nicians, researchers and other health care pro-
fessionals from across the globe. Throughout MEET THE NEW
the four-day meeting, researchers will present
peer-reviewed abstracts on advances in clini-
cal care for cancer patients, while panels and
interactive case discussions featuring leading
experts will underscore the meeting’s theme,
“Innovate, Collaborate: Transform.”
Dr. Laura Dawson chosen as

ASTRO president-elect
The members of ASTRO
have elected four new of- A Better Fit for
ficers to ASTRO’s Board Your Workflow
of Directors. Laura Daw-
son, M.D., FASTRO, will The next CT SIM+™ and MICRO+™
begin her term as Presi-
lasers from Sun Nuclear have been
dent-elect in September
redesigned to support optimal
during the society's 61st
positioning precision, reinforced
Annual Meeting in Chicago, alongside Neha
housing with tool-free entry, and
Vapiwala, M.D., the new secretary/treasurer-
elect; Constantine Mantz, M.D., the new
workflow-optimized software.
Health Policy Council vice-chair; and Brian Mar-
ples, Ph.D., the new Science Council vice-chair.
“I am honored to be elected as ASTRO’s
president-elect. Radiation oncology is a Get a firsthand look in
highly effective intervention that most can- ASTRO Booth 3415
cer patients benefit from at some point dur-
ing the course of their disease. Unfortunate-
ly, not all patients have access to radiation
therapy, and there is a need for improved
public awareness about its benefits,” said
Dr. Dawson.
In her tenure as president-elect and sunnuclear.com
eventual chair of ASTRO, Dr. Dawson also

ASTRO
ASTRO News
CDR Systems — Booth 1445 “One of the four treatment rooms in our current center is IMPT
CDR Systems, a global patient positioning and immobilization solu- capable and is in very high demand by our patients and physicians.
tions provider introduces the PowerWEDGE™ for Radiation Therapy. Proton therapy expansion at M.D. Anderson will greatly increase
Calgary, AB CDR Systems launches the PowerWEDGE™ specifi- patient access to IMPT, as all four treatment rooms in the new center
cally designed to improve the experience for patients that struggle will be equipped with this advanced technology, more than doubling
with lying flat on their back, the most common treatment position for our current IMPT capacity,” said Gunn. “The new center will feature
the treatment of cancer using external beam radiation therapy. The numerous technical advancements that will further improve proton
PowerWEDGE™ provides an angulation option for patient immo- therapy delivery and precision, such as in-room CT volumetric imag-
bilization that previously could only be offered in a lay flat position. ing and tumor motion tracking.”
This new all-in-one medical device is designed to enhance patient The center experienced a nearly 11 percent increase from 2017 to
comfort and setup accuracy through improved comfort and is offered 2018 in the number of patients who underwent proton therapy. The
with 8 additional module attachments ensuring patient setup can expansion of the 73,500-square-foot facility is expected to provide
be tailored for a wide range of treatment needs, including: cranial more accessibility to patients who would benefit greatly from PT. This
stereotactic (SRS), Body Stereotactic (SBRT), head and neck, breast, includes those with cancer of the head and neck, which currently
lung, liver, spine or pelvic treatments. make up 38 percent of the cases at M.D. Anderson; prostate, lung,
“It is clear a significant subset of the patient population struggle liver, and brain, and a range of pediatric cancers.
to lay in a flat position and a solution that upholds inter and intra The expansion is estimated to be completed by November 2023.
patient positioning accuracy without compromising comfort was Construction will be carried out by Gilbane Building Company.
needed. We have created the PowerWEDGE to answer just that. Carl
Denis, CEO at CDR Systems. Varian — Booth 1405
For an introduction to CDR Systems: At Varian, we envision a world without fear of cancer. For more
• Booth# 1445 at the ASTRO 2019 Annual Meeting, September 15 than 70 years, we have developed, built and delivered innovative
- 17, 2019 McCormick Place West Chicago, IL. cancer care technologies and solutions to help clinical partners
• Schedule a collaborative in person demonstration with a CDR prod- around the globe treat millions of patients each year. We are har-
uct specialist right in your radiotherapy department. nessing advanced technologies like artificial intelligence, machine
• Web based eDemo hosted by a CDR Product Specialist streamed learning and data analytics to advance cancer treatment and ex-
right to your conference room, tablet or personal computer. pand access to care for patients globally. We call our approach
• Toll Free: +1-855-856-7035 or www.cdrsys.ca Intelligent Cancer Care.
During ASTRO 2019, Varian will share a new comprehensive
Hitachi — Booth 1039 adaptive solution that harnesses the power of artificial intelligence.
The University of Texas M.D. Anderson Cancer Center has revealed It’s an AI-driven adaptive solution that includes treatment planning,
plans to more than double the size of its proton therapy center. delivery, and monitoring to fuel the next generation of adaptive
The $159 million project will expand the building to more than therapy. Varian’s Adaptive Intelligence solution is designed to
160,000 square feet, enabling it to take in more patients who require deliver high-quality treatments and incorporate diagnostic quality
treatment with the advanced form of radiotherapy. MR, PET, and CT images during planning and treatment—enabling
“We are excited to more than double our IMPT capacity in the the physician to choose the imaging appropriate for the cancer and
new center to approximate 100 patient treatments per day, better tumor type. Varian’s Adaptive Intelligence solution will empower
ensuring timely patient access so that more patients can benefit from clinical teams to treat more precisely, so they can provide personal-
this technology,” G. Brandon Gunn, associate medical director of ized, optimized care for patients. Please visit us in booth #1405 to
the Proton Therapy Center at the University of Texas M.D. Anderson experience firsthand our evolving ecosystem of technologies for
Cancer Center, told HCB News. fighting cancer.
The expansion will include eight radiation therapy systems devel-
oped by Hitachi that rotate at 360 degrees around patients to deliver Leaders in radiation oncology awarded ASTRO
therapy to the exact area that requires treatment, a technique known Fellow designation
as intensity-modulated proton therapy. The American Society for Radiation Oncology (ASTRO) has selected
The center will also install an additional synchrotron, the accelera- 26 distinguished members to receive the ASTRO Fellow (FASTRO)
tor used to create proton beams, and rooms with improved, modern designation. The 2019 class of Fellows will be recognized in Septem-
designs for better patient experiences. ber during ASTRO’s 61st Annual Meeting in Chicago.

The ASTRO Fellows program recognizes • Ramesh Rengan, M.D., Ph.D., University of • Catheryn Yashar, M.D., University of Cali-
individuals who have made significant con- Washington School of Medicine fornia, San Diego
tributions to the field of radiation oncol- • Ugur Selek, M.D., The University of Texas • Torunn Yock, M.D., MCH, Massachusetts
ogy and to the Society through research, M.D. Anderson Cancer Center-Istanbul General Hospital
education, patient care and service to the • Helen A. Shi, M.D., MS, MPH, Massachu- Fellows candidates must be nominated by
field. Since its inception in 2006, the FAS- setts General Hospital a current ASTRO Fellow, accompanied by
TRO designation has been awarded to just • Benjamin D. Smith, M.D., The University of three letters of support from ASTRO mem-
353 of ASTRO’s more than 10,000 members Texas M.D. Anderson Cancer Center bers. A committee reviews all nominations
worldwide. • Srinivasan Vijayakumar, M.D., University of and presents the candidates to ASTRO’s
“On behalf of ASTRO, I commend these Mississippi Medical Center board of directors for approval.
26 outstanding physicians and scientists for • Akila N. Viswanathan, M.D., Johns Hopkins
their collective and far-reaching contribu- Medicine
tions to our specialty, as well as for each in-
dividual's work to advance cancer research,
education and clinical care to improve pa-
tient outcomes,” said Paul Harari, M.D., FAS-
TRO, Chair of the ASTRO Board of Directors.
The 2019 Fellows are:
• Ron R. Allison, M.D., Federal Medical Center
• Felipe A. Calvo, M.D., Clinica Universidad
de Navarra
• Allen M. Chen, M.D., University of Cali-
fornia, Irvine
• Gregg Franklin, M.D., Ph.D., New Mexico
Cancer Center
• Joel Greenberger, M.D., UPMC Hillman
Cancer Center
• Michele Yvette Halyard, M.D., Mayo Clinic,
Scottsdale
• Daphne Haas-Kogan, M.D., Dana-Farber
Cancer Institute/Brigham and Women’s
Hospital
• Kathleen M. Hintenlang, Ph.D., The Ohio
State University
• Vivek Kavadi, M.D., Texas Oncology
• Paul Keall, Ph.D., The University of Sydney
• Larry L. Kestin, M.D., MHP Radiation On-
cology Institute
• Deepak Khuntia, M.D., Varian Medical
Systems
• David Kirsch, M.D., Ph.D., Duke University
Medical Center
• Sunil Krishnan, M.D., The University of
Texas M.D. Anderson Cancer Center
• Fei-Fei Liu, M.D., Princess Margaret Cancer
Centre
• Daniel Low, Ph.D., University of California,
Los Angeles
• Matthew Manning, M.D., Cone Health
• Rinaa Punglia, M.D., MPH, Dana-Farber
Cancer Institute

NEW
ASTRO
PRODUCT SHOWCASE
The following are just some of the products and services on display at ASTRO 2019. To view these
products online, or to share with colleagues, visit dotmed.com and enter the code DM 48330 in the
search window, or enter the address www.dotmed.com/news/48330 in your browser.
PRODUCT RectalPro75 ENDORECTAL BALLOON SBRT IMRT PROTON

QLRAD — Booth 4835
SHOWCASE QLRAD s RectalPro75 lowers toxicity, is patient friendly due to the anatomical shape
and is caregiver friendly. Immobilizes the prostate, reduces movement to have a
better day to day reproducibility due to a symmetrical balloon as well and spread
the rectum to be in low dose area.
MRgRT Motion Management Phantom

CIRS — Booth 4215
The integration of MR imaging in radiation therapy facilitates real time motion management. The CIRS MRgRT Mo-
tion Management QA phantom is designed to address such needs. The phantom is MR Safe due to piezoelectric
motors and non-ferro-magnetic materials. The moving insert contains an organic shaped target (tumor) filled with
gel, which is surrounded by the same background gel used to fill the body. The body represents a heterogenous
background due to simulated lungs, liver, kidney and spine. All organs as well as the moving target, except for the
lungs, offer ion chamber dosimetry capabilities. The simulated organs are anatomical in shape and have a life-like
spatial relationship. The phantom allows users to calculate the Beam Latency specific to hybrid MRI-Linac systems.
Precision Laser Systems

Sun Nuclear — Booths 2624
& 3415
Sun Nuclear Precision Laser Systems -
CT SIM+™ with RapidSIM™ Software ProBeam® 360 Proton
and MICRO+™ - have been rede- HyperArc High-Definition Therapy System
signed to optimize your clinical work- Radiosurgery Varian — Booth 1405
flow. The CT SIM+™ moveable laser
Varian — Booth 1405 The ProBeam® 360 Proton Therapy System from
HyperArc™ high-definition radiotherapy Varian is defining next-generation proton therapy.
system supports your PET/CT Simula-
represents a significant step forward for It offers uncompromised clinical capabilities, with
tion workflow. Industry-leading preci-
linac-based radiosurgery. An intracranial ultra-high dose rates, a 360-degree gantry, and
sion and accuracy provide enhanced
radiosurgery solution that harnesses the exceptional precision, all within a 30% smaller
confidence for patient safety. A mod-
power of Varian’s TrueBeam® and Eclipse™ footprint. High dose rates are used today to re-
ern, unassuming design combined
platforms, HyperArc is a streamlined, end- duce treatment time, manage motion, and can
with accessible software allows your
to-end solution that can be adopted by improve treatment plan quality and conformity.
team to work unimpeded by physical
clinics worldwide to extend the benefits of We expect next-generation proton therapy to
or technological barriers. The MICRO+
radiosurgery to many more patients. Hyper- employ even higher and ultra-high dose rates.
fixed laser system supports fixed pa-
Arc SRS-specific optimization tools to opti- The ProBeam 360° System features the most
tient alignment for diagnostic imag-
ing and radiation therapy, including
SHOWCASE
mize dose and treatment delivery. Dedicat-
ed algorithms enable an efficient workflow
powerful particle accelerator available to treat
cancer. It incorporates RapidScan™ technology,
MR Simulation and MR linacs. Preview
that can be completed in a conventional which revolutionizes motion mitigation by deliv-
the newly redesigned laser systems in PRODUCT
radiotherapy time slot—even when treating ering each field within a single breath-hold for
ASTRO Booth 3415.
multiple targets simultaneously. most patients.
42 HealthCare Business News I september 2019

NEW www.dotmed.com/news
Hitachi — Booth 1039
The world’s only synchrotron-based single room solution, the synchrotron accelera-
WEN
tor technology allows for less shielding thus minimizing the overall size of the layout
TCUDORP
and the concrete cost to the building. Compared with our past layout, Hitachi has
minimized and optimized the configuration yet utilized the identical gantry and ac-
celerator technology which has been proven with our multi-room solution.
ESACWOHS
The combination of Hitachi’s 360 degrees compact rotating gantry and 30 x 40
cm irradiation field size enables users to widely treat many tumor sites. In addition,
Hitachi’s spot scanning technology allows Intensity Modulated Proton Therapy
(IMPT) under fully-integrated Image guidance with gantry mounted isocentric
CBCT. Our system is capable of interfacing with any motion management solu-
tions, treatment planning system and oncology information system.
Airo® TruCT
Mobius Imaging — Booth 4638
Airo® TruCT is a 32 slice, mobile, larg-
est inner bore CT system which provides
intra-procedural diagnostic imaging for
applications in radiation therapy including
Proton Therapy and brachytherapy. Devel-
oped by Mobius Imaging, which special-
izes in standing diagnostic, interventional,
and intraoperative CT imaging systems,
Airo’s Point-of-Care CT imaging may re-
duce procedural time and help increase
treatment accuracy.
PROTEUS®ONE
IBA — Booth 3028
IBA PROTEUS® family is the proton therapy platform of the future
with a comprehensive set of tools for motion management, with
a demonstrated spot-scanning proton arc therapy irradiation, and
finally, with an ultra high-dose rate capability for flash research.
PROTEUS®ONE is the only compact single-room image-guided
IMPT solution, allowing easy integration into a variety of healthcare
settings. Smaller and more affordable than conventional multi-
room proton systems, but with the same clinical applications.
PROTEUS®PLUS
IBA — Booth 3028
IBA PROTEUS® family is the proton therapy platform of the
future with a comprehensive set of tools for motion manage-
ment, with a demonstrated spot-scanning proton arc therapy
irradiation, and finally, with an ultra high-dose rate capability
for flash research.
PROTEUS®PLUS is a multi-room proton therapy solution with
the latest advances in precise, image-guided and intensity mod-
ulated proton beam delivery.

Latest And Greatest
It’s possible that an ISO could order replace-
ment parts from the OEM at full price, only
IBA ProteusPLUS
to charge you an additional markup.
What's new in rad This technology received FDA 510(K) clear-

ance in December 2017.
In June 2018, Hitachi acquired Mitsubishi
and proton therapy Electric Corporation’s particle therapy division.

“With the addition of Mitsubishi, we
have added 7 proton centers and 4 carbon
By Lisa Chamoff centers to our user group. We are extremely
happy with the progress of our synergies and
Cancer treatment is getting faster and October 2018, and the Nagamori Memorial hope to see more growth in the near future”
more precise, with the future promis- Center of Innovative Cancer Therapy and said Sash Matsumoto, general manager at
ing to usher in ultra-high, cancer-killing Research in Kyoto, which opened for treat- Hitachi America Ltd.
radiation dose in less than a second. In ment in April 2019.
the here and now, manufacturers of proton The site in Osaka, which has three treat- IBA
therapy and conventional radiation oncology ment rooms, is the first heavy ion therapy IBA, which has roughly 30 proton therapy
treatment systems are continuing to increase center designed to be dedicated for dose- systems in clinical operation around the
speed and precision in an effort to create the driven continuous scanning technology. It is world, is working on developing a new mo-
best outcomes. one of only a few locations in the world to tion management technology that is a mix of
Here’s what’s new in both proton therapy offer the advanced form of particle therapy, beam management and image guidance to
and radiation oncology. which uses more energy in the tumor tis- freeze moving targets.
sue, which can be more destructive to the “The tumor in the lung that moves as a
tumors, can treat radioresistant cells, and patient is breathing — that’s what motion
Proton therapy requires fewer treatment sessions. management will address,” said Frédéric
Hitachi Proton The site in Kyoto includes real-time image Genin, chief product officer for proton ther-
Treatment has begun at two proton ther- gating motion management technology, apy at IBA.
apy centers in Japan: the Osaka Heavy Ion which allows treatment of tumors during It is also working with a partner in Royal
Therapy Center, which began operating in patient motion, according to the company. Oak, Michigan, to develop arc proton thera-

SECURE THE FUTURE OF PROTON THERAPY
MOTION ARC FLASH

MANAGEMENT THERAPY1 THERAPY1
The right partner to increase delivery of innovative

healthcare experiences to more patients
For over 30 years, IBA has collaborated with leading institutions to deliver
peak proton therapy performance that enhances and saves patient’s lives.
Our continuing mission is to make proton therapy accessible to all patients

who could benefit from it. That is why we continue to develop innovative
approaches that advance the precision and efficiency of proton therapy.
PROTEUS® class is the proton therapy platform of the future offering a

comprehensive set of tools for motion management, a demonstrated spot-
scanning proton arc therapy irradiation, and finally, an ultra high-dose rate
capability for flash research.
1. Arc therapy is work in progress and Flash therapy is currently under research. Both are not available for sale.
IBA | 2000 Edmund Halley Drive, Suite 210 | Reston, VA 90191 | 571.449.4992 | www.iba-worldwide.com
Latest And Greatest
py, delivering the beam continuously as the
gantry is rotating.
“In classic proton therapy you deliver
the beam from two to up to four angles,”
Genin said. “Arc proton therapy has three
advantages. It improves the throughput of
the facility, simplifies the treatment work-
flow and has the potential to improve clinical
outcomes for specific cases.”
The company has also successfully dem-
onstrated that its ProteusONE and ProteusP-
LUS are able to deliver Flash irradiation,
which delivers high doses of protons at ultra-
high speeds in less than one second, poten-
ProTom Radiance 330 Treatment Room
tially reducing toxicity in healthy tissue. The
company has launched an advisory board to
chael Tajima, senior director of marketing tion we have developed accessible to any
help with adoption.
at Mevion. oncological center that offers radiotherapy,”
“There’s a lot of research to be done and
The company is also launching a new said P-Cure Chief Executive Officer Michael
IBA is committed to fill that gap,” Genin said.
ceiling-mounted cone beam CT, which is Marash. “This will eventually enable every
now clinically available in Europe and soon cancer patient to obtain the best treatment
Mevion
to be FDA approved, developed by the com- in the field.”
Since last year, two proton therapy centers
pany medPhoton, and it is going to be in- P-Cure’s system is in use at the North-
with Mevion HYPERSCAN technology have
stalling a new Siemens CT on rails at Barnes- western Medical Chicago Proton Center. The
come online clinically — the University of
Jewish Hospital in St. Louis. company is supplying its system to medical
Oklahoma Stephenson Cancer Center and
For patient positioning, the company is centers in the U.K. and China, and is nego-
Maastro, formerly the ZON Proton Therapy
integrating the C-RAD Catalyst system for tiating with other cancer treatment centers
Centre at Maastro Clinic, in the Netherlands.
both surface tracking and gating. It is also and research institutes in Israel and around
The company worked with RaySearch
working to validate three new couch tops the world.
on new RayStation capabilities to enhance
and launch them this year.
Adaptive Aperture.
“Now it can shape apertures at any en-
“We’re excited to be providing a suite of ProTom International
new (image-guided radiation therapy) solu- ProTom International has been working with
ergy level with more conformality,” said Mi-
tions,” Tajima said. “We’re really trying to its proton therapy partners to make updates
leverage the best in the field.” to its products.
“You’re always looking at ways you
Mevion HYPERSCAN
P-Cure can improve your product,” said Stephen
In July 2019, proton therapy company P- Spotts, chief executive officer of ProTom
Cure, which markets a gantry-less solution International. “A lot of what we work on is
that reduces the installation costs of a proton behind the walls, so to speak.”
therapy center, announced that it had com- At an installation at Massachusetts Gen-
pleted a $15 million series B funding round eral Hospital, where patient treatment is
led by Hong Kong-based Popular Line Medi starting soon, the company is working on a
cal Group Limited. new workflow-driven user interface that is
The financing will help expand P-Cure’s fully integrated into the facility’s own oncol-
development center and production capac- ogy information system called WhiteBoard.
ity in Israel, according to the company. The The center will also have a fully integrated
company plans to establish a training and couch-mounted cone beam CT with an au-
services center for doctors, physicists, and tomatic patient positioner.
technicians in its new research and develop- “With the cone beam CT mounted on
ment center in Shilat. couch and robotic patient positioner you’re
“Completion of the financing round will not moving the patient from the imaging to
enable us to make the smart medical solu- treatment position,” Spotts said.

The company is also moving forward with The CyberKnife VOLO optimizer simplifies “CMS is now reimbursing based on value
a new center, the Australian Bragg Centre for the process of creating treatment plans for of care,” Lawson said. “If you can treat a pa-
Proton Therapy in Adelaide, where there will the radiation therapy system using a new op- tient with fewer fractions while improving the
be a new gantry design. timization algorithm, reducing both planning quality of treatment … that is a winning com-
“We decided some while ago, because of and delivery time, and increasing plan quality. bination in this new healthcare environment.”
our beam line and what we wanted to accom- “The algorithm calculates treatment Accuray also launched the Synchrony
plish with our system, we needed to design plans very quickly while also considering how motion tracking and correction technology
our own proprietary gantry,” Spotts said. “The the robot more efficiently navigates to deliver for the Radixact system.
new gantry design dramatically reduces the reli- the required dose,” said Corey Lawson, vice “It allows you to efficiently keep beam
ance on the building accuracy. Things are never president of product strategy at Accuray. on at all times, targeting the tumor through-
perfect. The floor is never completely flat. This Lawson said clinicians are experiencing up out its full range of motion. This allows cli-
design is built so that the reliance on the ac- to a 90 percent reduction in planning time nicians to also tighten margins around the
curacy of the building is as close to zero as pos- and up to 50 percent faster delivery time. tumor, which results in the sparing of normal,
Hitachi_4_78-7_190807.pdf 1 8/9/19 9:58 AM
sible. The gantry that we have used in the past
is wall-mounted. There are in-bed plates built
into the building. This will be sitting on the floor
with pedestals that are completely adjustable.”
The company is also working on updat-
ing its scanning nozzle to give it a larger field
of view and treatment volume, with a less
intrusive nozzle design.
Varian
In October, Varian introduced its ProBeam
360° proton therapy system. With a 30 per-
cent smaller footprint than the previous sys-
tem, the system increases the affordability of
proton therapy by reducing vault construc-
tion costs by approximately 25 percent and
cutting the construction time to 10 months C
from about two years, said Chris Toth, presi- M
dent of Varian’s Oncology Systems business. Y
The ProBeam 360° system also provides CM
customers with a pathway to potential MY
future treatment advancements, such as CY
Flash therapy.
CMY
“We look at this as a 2020 way of how

K
we personalize every radiation therapy treat-

ment,” Toth said. “What we may have un-
locked is therapy that can kill the cancerous
tissue and miss the healthy tissue. It could
mean a completely noninvasive treatment.
There is a lot of work to do to go from pre-
clinical to clinical, but we have not seen an
innovation like this in a lifetime.”
Radiation therapy
Accuray
Accuray has continued to refine the treat-
ment planning optimizer for the CyberKnife
robotic radiation therapy system.

Latest And Greatest
know that by using ExacTrac they can confi-
dently monitor their patients using sub mil-
limetric precision under 1 millimeter, at any
couch position, even while the beam is on.”
Earlier this year, the company released an
update to its Elements Multiple Brain Mets
SRS treatment planning software, which has
already been used to treat more than 3,000
patients worldwide using the single isocen-
ter technique. Algorithms that are part of
the software are designed to guarantee tar-
get coverage and minimize dose to healthy
tissue, regardless of user experience. The
company also integrated its Monte Carlo
dose calculation algorithm into the software.
Varian ProBeam 360 Another indication-specific software
module for treatment planning, Elements
Cranial SRS, was also updated to allow for
healthy tissue from radiation,” Lawson said, that includes surface tracking technology consistent and rapid volumetric modulated
noting that it is a technology unique to Ac- for a wide range of radiotherapy indications. arc therapy (VMAT) plan generation.
curay. ExacTrac Dynamic uses surface tracking to- “In particular, our Cranial SRS software
“It requires high-speed collimation,” gether with thermal imaging, making sur- has the option to limit modulation and com-
Lawson said. The collimation system is able face tracking much more robust, and complexity of treatment, rapidly generating plans
to quickly adjust the beam to keep pace with bines it with integrated X-Ray imaging at any that are more efficient, and that are faster
rapidly moving tumors like those in the lung, couch position during treatment.” and easier to deliver,” Murphy said. “It auto-
liver, or pancreas. Others in the industry are Clinicians can enable more precision by matically selects the table and gantry angles
not capable of keeping up with a rapid res- integrating ExacTrac with the Brainlab Ele- using a 4-Pi arc angle optimization”
piration rate. This is very unique to Accuray.” ments treatment planning software, Murphy Brainlab Elements Spine SRS was also
Phantom studies have been conducted said. updated. It utilizes unique algorithms de-
at the University of Wisconsin-Madison. The “By using our Elements software togeth- veloped for spine curvature correction that
technology has been installed at a second er with ExacTrac, we can potentially treat distinguish soft tissue from bony anatomy,
customer site, Froedtert & the Medical Col- with much smaller margins, because we’re and for automated Clinical Target Volume
lege of Wisconsin, which plans to treat the monitoring the patient so closely during (CTV) definition, automatically applying In-
first patient using Synchrony with Radixact in treatment,” Murphy said. “Our customers ternational Spine Radiosurgery Consortium
the very near future.
The company plans on broadly rolling out
the technology at the end of the year.
Brainlab
At ASTRO, Brainlab will be showcasing a
new version of its ExacTrac Patient Position
Monitoring system. Called ExacTrac Dynam-
ic, it is a solution for precision radiotherapy
positioning and monitoring that can accom-
modate a wide range of linacs and clinical
workflows. It is not yet FDA cleared.
“Customers are currently buying two or
three different systems for patient monitor-
ing,” said Patrick Murphy, director of the
Accuray CyberKnife VOLO
oncology portfolio at Brainlab. “Now you
Optimizer Conformal Lung
can have one system for cranial radiosurgery
48 HealthCare Business News I april 2019 www.dotmed.com/news

Welcome to a new era in oncology
It’s been said that the next wave of progress in oncology

will come from an increased ability to harness the power
of technology—collecting and analyzing data to enable better,
faster decision-making in clinical care and business processes.
That next wave is here. We call it Intelligent Cancer Care™.
Learn more at varian.com/intelligent

and at ASTRO 2019 Booth #1405.
© 2019 Varian Medical Systems, Inc. Varian is a registered trademark, and

Intelligent Cancer Care is a trademark of Varian Medical Systems, Inc.
Latest And Greatest
RaySearch
RaySearch
The company is building RayCommand
on its RayStation treat-
ment planning system
and RayCare oncology
information system with a
treatment control system
called RayCommand.
The new system is de-
Brainlab Elements signed to link RayStation
Spine SRS and RayCare and coordi-
nate activities in and be-
tween treatment rooms
consensus guidelines for spine radiosurgery that make it easier to to maximize resource
contour consistently and avoid potential errors during plan creation. utilization and treatment
accuracy. The product is about two years from being released, said
Elekta Bjorn Hårdemark, deputy chief executive officer of RaySearch.
In December 2018, Elekta received FDA 510(k) clearance for its Elekta RayCommand will also lead the way for online adaptive radiation
Unity MR-linac, a high-field magnetic resonance radiation therapy treatments, Hårdemark said.
system, which allows clinicians to see and track soft tissue during “Clinical practice today is to make a plan for the way a patient
radiotherapy treatment. looks several days before the first day of treatment, and deliver that
On the software side, Elekta will also showcase its MOSAIQ Plaza, same plan over several weeks. To deal with patient and tumor chang-
a “formal ecosystem of applications” built around its MOSAIQ ones, oncologists use margins,” Hårdemark said. “The most modern
cology information system, and that works seamlessly with Elekta’s way to deal with anatomical changes it is online adaptive therapy. We
radiotherapy solutions, said Sukhveer Singh, president of oncology have the software technology to achieve this, but we haven’t connect-
informatics solutions at Elekta. ed that to any treatment room yet. With RayCommand, we could.”
RayCommand would also be vendor neutral.
Elekta MOSAIQ “Varian and Elekta and ViewRay are also working in that direc-
Plaza tion for their respective systems, but we can do it for any system,”
Hårdemark said.
In December of 2018, the company added two machine learning
systems to RayStation. One is used for patient segmentation. In the
U.S., the company was FDA-cleared for using machine learning to
define where the healthy organs are. In other markets, the technol-
ogy was cleared to find where the tumor is.
Machine learning is also Varian Bravos
used for planning. afterloader
“It learns from previous system
MOSAIQ Plaza includes Elekta’s own SmartClinic, which enables examples what a dose distri-
process visualization and automated, streamlined care coordination, bution looks like for particular
and Care Collaboration, which supports tumor boards and multidis- patients,” Hårdemark said.
ciplinary meetings with cross-specialty data visualization; Monaco
HD treatment planning software; IBM Watson for Oncology, which Varian
provides data-driven decision support; and voice automation using In October 2018, Varian un-
Palabra’s voice recognition technology and customizable templates veiled its Bravos afterloader
for patient notes. system for brachytherapy
“The traditional EMRs are designed to be transactional while the treatments, which delivers
value-based oncology needs more evidence-driven and workflow- radiation via tiny radioactive
oriented solutions,” Singh said. “MOSAIQ Plaza enables value-based source placed directly into
oncology with a portfolio of apps that seamlessly integrate with the tumor. The new device
MOSAIQ as the single source of truth.” improves workflow with a

Zap-X
ViewRay
MRIdian Linac
for the first time to treat patients at Barrow Brain and Spine in Phoe-
nix. A second installation in Beijing is almost complete. The company
is close to applying for a CE mark.
The Zap-X platform has a self-shielding technology, which makes
touchscreen that includes patient and treatment information and a a costly cement radiation vault unnecessary, as well as real-time
customizable pre-treatment checklist, and LED lights to guide clinicians dosimetry.
through the correct connection process of the transfer guide tubes. “One of the ZAP-X’s major attributes is that it allows us to site
“They ensure the right dose is given at the right place, at the right radiosurgery where the patients are, such as ambulatory surgery
time,” said Chris Toth, president of Varian’s Oncology Systems business. centers,” said John Adler, chief executive officer of Zap Surgical.
In April, the company announced it was forming the Adaptive “The idea is to take radiosurgery out of the basement and make it
Intelligence Consortium to research and move forward AI-driven much more available in the world today. Radiosurgery requires what
multimodality adaptive radiotherapy treatments. is arguably the most complex tech in all of healthcare. We are trying
Also this year, Varian acquired Cancer Treatment Services Inter- to remedy that by making a simpler-to-use machine, which at the
national. same time, is also safer.”
The acquisition includes the American Oncology Institute in Hy- Share this story: dotmed.com/news/48323
derabad and 10 multidisciplinary cancer centers across India as well
as a U.S.-based Oncology Solutions division that provides cancer care
professional services to healthcare providers worldwide.
“It gives the company unique access to global cancer data,” Toth
said.
ViewRay
In February 2019, ViewRay received FDA 510(k) clearance to market
the new soft tissue visualization capabilities for its MRIdian Linac sys-
tem, which combines a linear accelerator with an MR scanner, was
cleared by the FDA in February 2017, and has treated approximately
5,000 patients.
Called SmartVISION, the technology doubles the frame rate of the
MR from four frames per second to 8 frames per second.
“Essentially what this does is it gives you better tracking capa-
bilities and more disease-specific imaging capabilities,” said Michael
Saracen, vice president of clinical marketing at ViewRay.
There is also expanded high-definition visualization and enhanced
contrast between different tissues, to assist clinicians with tissue visualiza-
tion and beam contouring, a diffusion-weighted imaging feature that
tracks treatment progress by distinguishing between tumor and normal
tissues, and enhanced MLC speed to potentially reduce treatment time.
“The SmartVISION helps [clinicians] to do what they are doing,
better,” Saracen said.
Zap Surgical
The company received FDA clearance in October 2017 for its Zap-X
stereotactic radiosurgery system. In January of this year it was used

Optimized Imaging
CT dose
How much is just enough?
By John R. Fischer
Ten years ago, radiologists and medi- more discretion when choosing diagnostic imaging,” Dr. Mahadevappa Mahesh,
cal imaging stakeholders received an imaging exams and ensuring providers were ACR Medical Physics Commission chair and
alarming wake up call. A report issued by adequately equipped to determine, deliver chief physicist for Johns Hopkins Hospital,
the National Council of Radiation Protection and monitor the exposure of their patients. told HCB News. “Also, the ACR-DIR data are
and Measurements (NCRP) revealed that the A prime example is the ACR Dose Index facilitating to set national or regional diag-
radiation exposure to the U.S. population Registry (DIR), which many providers rely on nostic reference levels for a variety of CT ex-
from medical procedures had risen dramati- to compare their CT dose data to their peers ams. Recently efforts are underway to roll out
cally over the span of a few decades. locally and nationally. Since 2011, the pro- a dose index registry for fluoroscopy exams.”
This concern around radiation dose gram has amassed nearly 2,200 facilities as But dose registries and improvements to
marked a turning point for the medical im- active participants and contains data from technology don’t resolve radiation exposure
aging industry, paving the way for accredita- more than 81 million CT scans. issues unless providers act on them. That
tion programs and official dose committees, “The information provided helps facilities means taking up the mission of ensuring
as well as the maturation of dose technolo- to examine and review their CT protocols, patients receive the right types of exams
gies and, more broadly, a greater awareness and where necessary, cut down and opti- with just enough dose to obtain a reliable
of dose exposure. New initiatives pushed for mize their techniques for improving their CT diagnostic image.

Optimized Imaging
safety and image quality,” said Vino Durai-

Vino Gregg
raj Ph.D., DABR, regional vice president of
Durairaj Daversa
technical operations at West Physics. “That,
I think, is where most imaging facilities are
facing a challenge.”
The right dose for the right

patient
Ten or twenty years ago, protocols for
a head CT or a chest CT would be the
same for all types of patients. Now, it is
possible to tailor dose based on patient
size. “Technologies such as dose modu-
lation, along with awareness, are help-
ing to customize dose on an individual
level,” said Mahesh.
Specific factors to consider depend on
Dr. Mahadevappa Dr. Ge Wang
the scan, with common ones including
Mahesh age, body size and weight. Cases involving
pediatric patients especially should take
these factors into consideration, according
to Durairaj.
“If a pediatric patient has an adult-sized
body part and you’re using pediatric imag-
ing protocols you would normally use, then
the image quality is going to be compro-
mised,” he said. “In that case, we are not
providing the patient care required for that
particular patient.”
The ACR’s CT Accreditation program
not only raises awareness about dose
protocols, but ensures that sites imple-
ment them for lower and appropriate
dose levels. Using the knowledge they
Dose vs. image quality published on the subject with excellent re- gain from these programs, facilities are
One way radiologists are getting quality im- sults. Low-dose CT reconstruction can be examining and adjusting their imaging
ages with lower dose exposure is through done now with a deep neural network. This protocols to meet industry standards,
iterative reconstruction, a type of software is really a cutting-edge development with which has led to a downward trend in ra-
algorithm that collects noisy data produced real-world utilities.” diation dose. Also helping are campaigns
by low-dose scans and reconstructs it into an As a result, more CT manufacturers are such as Image Wisely and Image Gently,
image with improved quality. The arrival integrating these tools into their scanners. which provide information about dose
of artificial intelligence, machine learning Other dose management technologies long and certification.
and especially deep learning, have all raised in use, such as dose modulation, which en- “A lot of participants take an Image
the bar on what’s possible with iterative re- ables the scanner to adjust radiation dose Wisely pledge,” said Durairaj. “The par-
construction. based on factors such as the patient’s size ticipants display pledge certificates in the
“Deep learning brings the right tool for and heartbeat, are also maturing due to imaging department so when patients
using bigger data," said Dr. Ge Wang, a new capabilities. walk in, they feel welcomed and say, ‘Okay,
chair professor of biomedical engineering “The biggest challenge for imaging pro- the imaging professionals that are scan-
at Rensselaer Polytechnic Institute. “It can fessionals is to be well-trained on the equip- ning me today are conscious in dose reduc-
reconstruct high-quality CT images from ment and keeping up-to-date with techno- tion strategies and dedicated to following
very noisy data. Multiple papers have been logical advancements, to maximize patient patient safety initiatives.’”

Administering CT dose responsibly is a is certainly a gap between facilities that try other, some experts are hopeful that a new
team effort that requires different stake- to achieve compliance versus those that go era of patient safety and dose optimization
holders within the imaging process to have above and beyond all optimization fronts could be on the horizon.
a voice. According to Gregg Daversa, put forth by the regulatory and accredita- “There are so many new, exciting, out-
vice president of business development for tion bodies.” of-the-box technologies coming out in
West Physics, one of the keys to establish- At the same time, vendors are also help- areas such as natural language program-
ing a culture of dose optimization is for- ing to ensure patients receive optimized ming, neural networks and quantum com-
malizing an official dose committee that doses by taking into account protocols, puting,” said Wang. “They all may turn out
meets on a regular basis. regulations and needs around CT dose in to be very important, so it’s very hard at this
“An ideal CT dose committee would the technologies they develop. As itera- point to predict the future.”
involve a radiologist, a medical physi- tive reconstruction and machine learning Share this story: dotmed.com/news/48324
cist, a lead CT technologist, and a busi- techniques continue to complement each
ness administrator,” he said. “When you
get these four stakeholders at the table is
when the core team comes together to
take the data they’ve been working with
and implement changes to optimize dose
and image quality.”
New challenges and new hopes

Patients are becoming increasingly aware
of the risks involved in radiation exposure,
Injector Support
and misinformation is a fact of life for
many people researching imaging exams
& Service
online. This creates a unique challenge for
providers, who are tasked with articulating
relative pros and cons, as well as sharing
facility details concerning accredited and
quality control programs.
“At the radiation dose levels used for
routine medical imaging such as CT, there
is no good evidence to demonstrate ad-
verse effects,” said Mahesh. “However,
there is confusion about this and depend- Providing professional,
ing on who spins the story, people are timely and superior
often really concerned even with routine
medical imaging.”
support and service
Mahesh is currently involved in a follow- for medical
up to the 2009 NCRP report which is called contrast injectors.
Medical Radiation Exposure of Patients in
the United States, and is expected to be
released in November. The report should
give an indication as to whether or not ef-
forts to reduce dose have had a substantial injectorsupport.com
impact in the last 10 years. 888.667.1062
“From my experience, most imaging
facilities attempt to meet the compliance
of regulatory and accreditation bodies
implementing the standards, whereas oth-
ers strive to reach a balance between dose
and image quality,” said Durairaj. “There

Dual Energy
Spectral CT — Value, use

cases and implementation
By Dr. Nakul Gupta
Houston Methodist
Computed Tomography (CT) has trans- While traditional CT is performed using a based imaging modalities, including CT. One
formed medical care worldwide since single peak energy level, spectral (or “dual of the primary advantages of spectral CT is
its development in the 1970s, and the energy”) CT refers to methods that obtain that it allows separation of the total attenu-
technology has advanced considerably information regarding tissue attenuation at ation of the tissue into that which is attribut-
since then, allowing for an ever increas- 2 or more energy levels. Broadly speaking, able to iodine, and that which is attributable
ing number of applications. CT utilizes this may be achieved by either varying the to water (the primary constituent of biologi-
a rotating X-ray tube detector array in or- energy level of the beam generated by the cal tissues) through a process called material
der to generate cross-sectional images of X-ray tube, or by discriminating between the decomposition. This allows quantification
the body, typically utilizing an X-ray beam energies of the incident X- photons at the of iodine content, and generation of iodine
covering a broad energy range, but with a detector. This allows for multiple new types overlays or iodine basis images.
peak energy of 120 kilo-electron volts (120 of images to be generated and multiple new Iodine quantification is an active area
kVp), although this may be higher or lower applications. of research as a quantitative imaging bio-
in certain clinical situations. The image cre- marker, and is being studied as an indicator
ated assigns grayscale values based on the Material density images of treatment response in various cancers,
attenuation of the beam (i.e., how much Iodine has been employed for many decades for example. Additionally, there is a growing
was absorbed or scattered in the patient). as a means to generate contrast in X-ray- body of evidence that iodine images can

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help discriminate between benign and po- non-contrast scan followed by a contrast- the liver, both for hypervascular and hypo-
tentially malignant incidental renal masses enhanced scan. This allows the radiologist vascular masses. Additionally, they can be
on routine abdominal contrast enhanced to differentiate between tissues that were used in angiography to enhance vascular
CT’s — a common occurrence. Typically, intrinsically bright on the image prior to con- contrast. This can be leveraged to reduce
these incidental findings would require trast administration from those which be- contrast dose, which can both reduce cost
bringing the patient back for a follow up came bright only after contrast administra- as well as improve patient safety (lower
multiphase scan with and without contrast. tion. However, this comes at extra expense, risk of contrast induced nephropathy), and
With iodine images it is now possible to time, and radiation dose to the patient. can also reduce the need for repeat scans
characterize the majority of these lesions at With spectral CT, once the iodine and wa- due to a suboptimal contrast bolus. CT pul-
the initial scan, saving time, cost, and radia- ter contributions have been decomposed, monary angiography occasionally suffers
tion dose to the patient. virtual unenhanced images can be gener- from transient contrast interruption which
Another area where material decomposi- ated which mimic a non-contrast scan. In can result in a non-diagnostic scan, for ex-
tion is poised to bring value to CT is in bone some applications this virtual unenhanced ample. In these cases patients are often
marrow edema imaging. In this case, calcium image may be able to replace an actual non- re-dosed with contrast and rescanned, re-
sulting in both double the contrast load as
well as double the radiation dose. With vir-
Spectral CT allows separation of the total attenua- tual monoenergetic imaging, lower energy
images can be reconstructed that enhance
tion of the tissue into that which is attributable what contrast there is and can salvage an
otherwise non-diagnostic scan, reducing
to iodine, and that which is attributable to water cost as well as contrast and radiation dose
to the patient.
(the primary constituent of biological tissues) On the other hand, higher energy images
can be generated which reduce metal arti-
through a process called material decomposition. fact, such as in the presence of orthopedic
hardware. This is of significant benefit in the
This allows quantification of iodine content, and evaluation of joint prostheses, where tradi-
tional CT scans suffer from severe artifacts.
generation of iodine overlays or iodine basis images. The difference is so dramatic, in fact, that
in our own institution, many orthopedists
now specifically request scans to be done
with dual energy. We also use higher energy
is used as one of the basis materials, and by contrast scan in multiphase pre- and post- virtual monoenergetic images in addition
removing its contribution to the image, it contrast protocols, saving time, radiation to metal artifact reduction to improve CT
becomes possible to visualize bone marrow dose and cost. myelography in the presence of spinal hard-
edema, which could previously only be done ware, and have not looked back.
with MRI. Although research is ongoing and Virtual monoenergetic imaging
this is still in its infancy, many centers are be- X-ray beams consist of individual photons of Niche applications
ginning to employ it in the clinical routine. varying energy, although with a user selected In addition to the broader applications de-
These are typically performed in the trauma peak energy level (i.e. 120 kVp). This is re- scribed above, there are several niche ap-
setting, such as when evaluating spinal com- ferred to as a polyenergetic or polychromatic plications to be aware of. For one, spectral
pression fractures. Currently, determining the beam. The image generated is therefore a CT allows characterization of kidney stone
acuity of spinal compression fractures at CT composite of all of the different energy X-ray composition, which can affect how they may
can be unreliable, and many patients go on photons contained in the beam. Spectral CT respond to various treatments. This can be
to have an MR, resulting in additional cost allows the generation of virtual monoener- valuable information to the urologist, and
and possibly length of stay. With spectral CT, getic images, as if the beam consisted entire- allow for more expeditious triage to the cor-
it may be possible to answer this question up ly of a single X-ray energy. This can benefit rect treatment. Additionally, through simi-
front, reducing both cost and length of stay. in several ways. lar techniques, spectral CT can be used to
Lower energy images can be generated detect gout tophi. In fact, spectral CT is al-
Virtual unenhanced (aka “virtual that enhance the appearance of iodinated ready included as a criterion for establishing
non-contrast”) imaging contrast. These have been shown in multi- a diagnosis of gout, and can also be used to
Many scan protocols call for an initial ple studies to improve lesion conspicuity in monitor patients who are on therapy.

Training and workflow protocol design, as well as radiologist edu- ing contrast dose, or reducing radiation
considerations cation regarding the new types of images dose by eliminating certain non-contrast
As with any new technology, its value will and their use. To this end, there are many exams or repeat scans. While the plethora
not be realized without adequate staff workshops and conferences available for of available images may seem overwhelm-
training. Luckily, there is little difference this purpose. While it may not be possible ing at first, taking a stepwise approach to
from the technologist’s perspective be- for every radiologist to attend, at least a implementation and designating a handful
tween scanning a single energy or dual handful of radiologist “champions” should of radiologist champions can help make for
energy scan on the latest systems. In fact, be designated who can take the lead. One a smooth transition.
most systems also allow generation of at of the major concerns from radiologists is About the author: Dr.
least some basic spectral reconstructions the increasing number of images to review. Gupta is an Assistant
at the scanner console itself, in automated What we have found helpful to encour- Professor of Radiol-
or semi-automated fashion, which can age adoption in this regard is to begin by ogy and Director of
then be pushed to PACS for review. This introducing virtual monoenergetic images, Body MRI at Houston
avoids the need for the technologist and/ since these have the “look and feel” of Methodist Hospital
or the radiologist to have to use a sepa- traditional CT images, but with the advan- with fellowship
rate workstation or thin client, saving valu- tages discussed above. In many cases these training in body cross
able time and minimizing interruption of can replace the routine image set, resulting sectional imaging. His academic interests
the standard routine. The more important in a net-neutral image count. include dual energy/spectral CT, as well as
task is deciding when and where to lever- In summary, there are many ways advanced body MRI applications.
age the capabilities of spectral CT without in which spectral CT can benefit clinical Share this story: dotmed.com/news/48325
overwhelming the radiologist with a sea of practice and enhance value, whether by
images. This requires careful attention to unlocking novel CT applications, reduc-

Ultrahigh-Res CT
Q&A with
John Boone
professor of radiology and biomedical
engineering, and chief of medical physics
University of California Davis
Ultrahigh-res scanning comes to CT
By Gus Iversen
If you’re a regular reader of HealthCare ment, I saw the opportunity for my young with imaging matrices of 512 x 512, 1024 x
Business News magazine, the name academic radiologist colleagues to have an 1024, and 2048 x 2048. The MTF, which is
John Boone might be familiar to you. A opportunity to evaluate and report on this the traditional measure of spatial resolution
couple of years ago we sat down with him technology in a series of clinical protocols in imaging systems, has a limiting resolution
to talk about a novel breast scanning CT sys- spanning applications from neuroradiology for clinical operation on the order of 3.2 pairs
tem he developed alongside colleagues at to musculoskeletal radiology — and that per millimeter, which is consistent with the
UC Davis. We recently reached out to him was the primary motivating factor for me 150 µm voxel dimensions.
again to discuss another CT innovation — in this project.
ultrahigh-resolution. This CT scanner (which is now the Can- HCB News: What does ultrahigh-res
Boone is a researcher, educator, and on Aquilion Precision) has high-resolution mean in terms of CT scan image quality?
clinical medical physicist with long-stand- features, which, in my opinion as a medi- Does it open up new capabilities?
ing interests in CT technology. He is former cal physicist specialized in CT technology JB: We are all aware of the various mo-
president of the American Association of are a game changer for CT imaging — per- dalities available in the radiology department
Physicists in Medicine (AAPM), and cur- haps not for every CT examination, but for for imaging patients and, of course, each of
rently chairs the CT subcommittee for this a number of imaging applications I believe these modalities has its strengths and weak-
organization. He is also the primary author the high-resolution capabilities will lead to nesses. Traditional resolution CT imaging
of the ICRU (International Commission on more accurate diagnoses and better patient excels at contrast resolution (the ability to
Radiation Units) Report 87, “Patient dose care. The system has a 40 mm-wide detector see large lesions with subtle contrast differ-
and image quality assessment in computed (measured at the isocenter, per industry stan- ences) but is not particularly exciting when it
tomography”. dards), with 160 – 0.25 mm wide detector comes to spatial resolution (the ability to see
arrays along the long axis of the scanner (the small objects) — which for most clinical CT
HCB News: In April, UC Davis Health Z dimension). There are 4 different acquisi- scanners the smallest resolvable element is
announced that it was performing clini- tion modes, which the manufacturer refers on the order of 0.50 mm. But with this new
cal imaging exams using an ultrahigh- to as normal resolution, high resolution, su- CT scanner, we have the ability to resolve
res CT scanner. Can you tell us a bit per high-resolution, and ultrahigh-resolution 0.15 mm voxels; and the obvious question is,
about the technology and how it came modes. Of course, the size of the detector “What human anatomy has spatial features
to be acquired by the facility? elements is not the only resolution-limiting on the scale from 0.15 to 0.5 mm?” The
John Boone: About 2 years ago, I was factor, and this scanner has 7 different focal answer to this is the answer to your question
approached by an executive from (then) spot sizes that can be used, unlike any whole- about “new capabilities”. We believe that
Toshiba, about the potential of siting this body clinical CT scanner I have seen in the the increase in spatial resolution achievable
new high-resolution CT scanner at UC Da- past. Obviously, the smaller focal spots need by this new CT scanner technology will al-
vis. I was immediately excited about the to be used with the higher resolution detec- low meaningful improvement in diagnoses
prospect of evaluating this new technology tor modes to actually achieve high-resolution involving lung parenchyma, the anatomy
— and as a leader in the research adminis- images. The system is capable of reconstruct- of trabecular bone (in trauma and disease),
tration of my academic radiology depart- ing images with 0.15 mm pixel dimensions, liver texture, and microvasculature — the

Avante's new Center of Excellence
in Charlotte, NC provides 160,000
latter of which includes diagnoses related to compared with other conventional CT olution CT; we are also focusing on mus-
square feet for the company’s
cancer, vascular disease, and a whole host scanners at UC Davis Health? Is there a culoskeletal imaging, and have imaged a
imaging, oncology and
of other pathologies. Thus, the prospective learning curve? number of cadaver limbs in various
ultrasound studies
divisions.
capabilities of this scanner are exciting to JB: This scanner has a large repertoire which show huge potential; we also feel
me, and through clinical trials we are trying of options, as you would imagine, and we that neuroradiology applications such as
to methodically evaluate which specific areas are still very much on the learning curve in temporal bone imaging is clearly some-
of CT imaging this new device will advance. terms of protocol development. We have thing that this scanner will provide new
all become used to the complexity of mod- diagnostic accuracy for. We have a fleet of
HCB News: Can you provide any ex- ern CT scanners, with automatic exposure CT scanners at our medical center, and we
amples of how those exceptional im- techniques (tube current modulation), and are prioritizing the use of this new scanner
ages have impacted diagnostics for your all the other factors involved in CT proto- for a subset of our ambulatory patients to
patients? cols. With this scanner, we add to the mix 7 focus on these specific areas.
JB: Your readers will recognize that as different focal spot sizes, 4 different recon-
the voxel dimensions of the CT image get struction modes, 4 different reconstruction HCB News: Has anything about the
smaller, the spatial resolution increases, but algorithms (each with many flavors), and new system been a surprise?
so does the quantum noise. At the same you can begin to realize how complex this JB: For me personally, there have been
radiation dose levels, fewer X-ray photons system is. This scanner is a research scanner huge surprises relating simply to the in-
traverse a smaller voxel relative to a larger to some of us, but it is FDA approved and stallation of the scanner. Since this inter-
voxel, so consequently, there will be larg- therefore, it is used at our institution for view is for Healthcare Business News, I
er quantum noise levels when the smaller clinical imaging from 7 am to 5 pm. The feel compelled to mention the following:
voxels are reconstructed. When the Canon standard of care imaging comprises the I wear many hats, but as a clinical medical
scientists presented this technology to me bulk of our clinical investigations compar- physicist for 35 years, I have always viewed
and a group of other medical imaging sci- ing high-resolution to low-resolution CT. the delays of equipment installation in the
entists, of course this was the first question We really are still at the front end of the hospital setting as result of bureaucratic
that came to mind. Initially the solution to learning curve given the complexity of this inefficiency and indecision. However, as
decrease quantum noise with the high-res- CT scanner, and I hope over the next few principal investigator of this project, I was
olution images was dealt with using itera- months we will be able to focus on a num- intimately involved with most of the steps
tive reconstruction techniques, which have ber of specific clinical protocols and opti- that were required to install the CT scan-
become the industry standard method for mize them to achieve the best compromise ner into our clinical CT area. I was so fully
noise suppression in CT over the past de- between spatial resolution and noise. This impressed at how a thousand people came
cade. I was frankly impressed to find that new high-resolution scanner is certainly a together in a thousand meetings to expe-
this manufacturer has also developed CT game changer, but realistically it will take dite the installation of this CT system. I had
reconstruction methods designed to reduce a couple of years for my radiologist col- no idea of the complexity of the process,
noise based upon artificial intelligence tech- leagues to learn how to use this new tech- and am dumbfounded, and grateful to all
niques — their deep learning reconstruction nology in order to confidently and routinely those who participated in making the sit-
algorithm. I’m very excited to see how the use this tool to advance patient care. ing of this CT scanner at UC Davis possible.
DLR algorithm reduces noise in the high- From the vice chancellor and CEO of the
resolution images, however this software HCB News: Can you discuss any re- hospital, to the many administrators, ar-
was only recently FDA approved and is about search you are currently conducting chitects, engineers, IT staff, lawyers, X-ray
to be installed on our scanner in the next with the use of the system? technologists, and so many more that were
week or two. For many applications, we JB: As a medical physicist, there are involved in the necessary discussions and
were waiting for the DLR algorithm in order many basic science studies we are plan- decisions required to install this CT scan-
to fully assess the system clinically, and we ning to do, and these studies are ongoing. ner. I have a newfound respect for all those
now have our sleeves rolled up to do so. So We have focused our early clinical investi- who have a hand in the siting of complex
please ask me this question in a year or so, gations on areas of CT imaging where we imaging equipment. As a longtime la-di-da
and I will have a better answer after we have feel that the spatial resolution capabilities full professor in the school of medicine, my
done the research. of this new scanner will most impact pa- advice to similarly gilded colleagues around
tient care. Our current priorities are in lung the country is simple: hug your administra-
HCB News: Operationally, how has imaging, and I can report that our chest tors today!
training and utilization of the system radiologists give 2 thumbs up on high-res- Share this story: dotmed.com/news/48326

Latest In CT
AI comes to the CT market

By Lisa Chamoff
Artificial intelligence (AI) has been a buzzword in imaging for

the last few years. Recently, in the CT market, AI has gone from
dream to reality, with several companies offering image quality en-
hancements using machine learning.
This comes along with the release of compact systems for outpa-
tient orthopedic imaging and wide-bore systems for larger patients.
Here’s a look at what’s new in CT scanners and software.
Carestream's
OnSight 3D
Extremity System
“We are able to handle much smaller pieces of metal and bigger
pieces of metal such as knee implants,” said David Chan, regional
business director for the U.S. and Canada for Carestream. “They can
Canon AiCE 1
see micro fractures or signs of infection.”
The scanner allows imaging from the distal femur to the toes with
Canon Medical Systems and without weight bearing, and the distal humerus to the fingertips,
In June of this year, Canon Medical Systems received FDA clearance allowing surgeons to have a better image of the problem before a
for its Advanced Intelligent Clear-IQ Engine (AiCE), which uses a deep procedure. The systems are designed for sports medicine facilities.
learning algorithm to differentiate signal from noise in CT images, so Carestream is next tackling deep learning to improve image qual-
noise is suppressed while signal is enhanced. ity as well as the validation of 3D measurements.
“It makes it easier for the physician to read and have a natural tex- “Now, weight-bearing measurements are done on 2D projection
ture for the image,” said Tim Nicholson, senior marketing manager radiography,” Chan said. “We’re leveraging some of these devel-
for Canon Medical Systems. “With the (previous) dose reduction, you opments into 3D measurements and validating their accuracy and
gave up texture. With this type of reconstruction using deep learning, validity in a working group.”
it really brings that image quality up another step and it can go a step
further in lowering the dose because there’s less noise in the image.” CurveBeam
AiCE is available on new purchases of Canon’s Aquilion ONE / Since receiving FDA clearance for its LineUP bilateral weight-bearing
GENESIS Edition, released three years ago, and the Aquilion Precision CT imaging system for the knees and lower extremities, in May 2018,
platforms, released in April 2018. The company plans to eventually CurveBeam is developing an upgrade that will extend imaging capa-
make AiCE available on new mid-tier scanners. bilities up to the hips.
“We believe our deep learning reconstruction will be superb be- “The body would be slightly modified so that the gantry could
cause it’s fast enough to use on every single exam,” Nicholson said. raise higher,” said Vinti Singh, marketing manager for CurveBeam.
“We have quantifiable claims we used in our FDA submission on “The capability to scan up to the hip is essential for preoperative
noise reduction and low-contrast detectability.” planning for knee replacement surgery because the hip is a required
anatomical reference point.”
Carestream The key features of the device, including a compact footprint and
Carestream released its OnSight 3D Extremity System in February the ability to plug into a standard wall outlet, will remain.
2017. Since the release, it has added workflow improvements and “Research demonstrates weight-bearing CT may be instrumental
enhanced metal artifact reduction. in detecting early signs of knee osteoarthritic degeneration,” Singh

CurveBeam
LineUP FUJIFILM Medical Systems “We’re new in this space but we’re not
U.S.A., Inc. new to digital imaging, with continued
FUJIFILM Medical Systems U.S.A., Inc. an- advancements from X-ray film in 1936 to
nounced its entry into the CT market at last digital radiography and AI today,” said Rick
year’s ASTRO with its FDA-cleared FUJIFILM Banner, senior director of marketing for CT,
FCT Embrace, which the company says is the DR and women’s health at FUJIFILM Medical
world’s first 64- to 128-slice scanner with an Systems U.S.A., Inc.
85-centimeter bore.
FUJIFILM FCT
Embrace
said. “In addition, studies show you can view

the knee meniscus better via weight-bearing
CT arthrogram than on MRI.”
The company is aiming for a 2020 release
for the hip scanner.
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Latest In CT
The system provides a seamless transi-
tion from oncology to radiology with rapid
acquisitions of chest and gating studies and
GE Healthcare - Revolution Apex
a wide 49-centimeter table, Banner said.
The scanner comes with FUJIFILM’s Low-
dose Iterative Solution Approach (LISA) with
PixelShine, which uses advanced data-driven
algorithms to reduce image noise and mini-
mize artifacts, while maintaining or improv-
ing spatial resolution for more optimal dose
and image quality.
“I see this being a good fit for a large
academic, medium-sized hospitals and out-
patient facilities as their bread-and-butter
scanner,” Banner said.
The scanner was also built with a modu- GE Healthcare were previously reconstructed. FDA cleared
lar design, resulting in fewer parts, leading GE Healthcare has had many new releases in in April, the technology produces what GE
to easier maintenance, Banner said. For ex- the CT space over the last year, starting with calls “TrueFidelity” images that improve
ample, the brushes, which create carbon three new additions to its Revolution family noise texture while maintaining dose.
dust, have been removed, and so don’t of CT scanners. “We are very excited about the image
need to be cleaned or replaced. It also has The Revolution Apex comes with GE’s quality GE’s Deep Learning Image Recon-
a touchscreen monitor with a keyboard and new Deep Learning Image Reconstruction, struction engine has created,” said Scott
mouse as well. which uses algorithms based on images that Schubert, general manager for premium CT
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The Revolution Apex also comes with a thoracic diseases, according to the company. tomers can stay up to date on the latest
new Quantix 160 X-ray tube, designed to It also targets pulmonary perfusion by identi- technologies through an annual subscrip-
deliver both power and coverage together, fying areas that have relative deficits of per- tion model.
with two times more power than the previ- fusion in the lungs, for use in diagnosing is-
ous X-ray tube in a 16-centimeter-wide cov- sues such as pulmonary embolism or chronic Hitachi
erage system. obstructive pulmonary disease (COPD). After the debut of its Supria True64 in
“For the first time in the CT industry we “Before the application, the physician 2017, Hitachi is working on a new 64-128
can provide power and wide coverage,” would just have to do it quantitatively, bring slice CT in the premium market segment
Schubert said. together the CT image with perfusion image for general hospitals and their EDs, which
The company also launched new capabili- and figure out the boundaries of the lobes of fits between the economy 64-128 market
ties on its Revolution EVO Gen 2 and Revolu- the lung,” Schubert said. for imaging centers and small hospitals
tion Frontier Gen 2 systems. Revolution EVO “That was a manual and less quantitative and an ultra-premium, 64-128-slice high-
Gen 2 uses Snapshot Freeze 2 and Fast Stroke approach than in the past.” end segment.
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Thoracic VCAR with GSI Pulmonary Per- *All product and company names are trademarks™ or registered® trademarks of their respective holders.
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Latest In CT
movable table, and is capable of full-field
diagnostic X-ray imaging as well as CT. It
comes with ClarityPACS and ClarityPractice
Hitachi Supria for scheduling patients, reviewing, reporting,
storage and billing.
“The ClarisXT is the result of eight years of
development, and almost 30 years of involve-
ment in the medical imaging field,” Neushul
said. “We will introduce this device into por-
table applications, orthopedic practices and
small clinics, and eventually we hope to use
it for spine surgeons and for lung nodule
screening. We are bringing CT technology to
a level that will allow traditional X-ray users to
expand their imaging capability to include 3D
The scanner will do cardiac, neuro- “Regular CT sensors are small-tiled ar- imaging. ClarisXT is a low-dose, high resolu-
logical shuttle, interventional and DECT rays, with 600-pixel micron spacing,” tion system, with a guided workflow inter-
exams and is designed with innovative Neushul said. “Our system has a single large face, simplifying the acquisition process. This
features to accommodate larger bariat- area detector with pixel spacing of 140 mi- new device will provide an exciting oppor-
ric patients and with high workflow, said crons.” tunity to improve patient care at all levels.”
Mark Silverman, director of CT market- In 2012, the company obtained an FDA
ing for Hitachi. 510(k) clearance for an earlier device, the NeuroLogica
“This new scanner is targeted to gen- ClarisCBCT, and iCRco is now in the process NeuroLogica, a healthcare subsidiary of Sam-
eral hospitals for inpatient and outpatient of obtaining FDA 510(K) allowance for the sung Electronics Co. Ltd., has partnered with
needs, which we feel is the largest segment new device, which it says has a larger diag- Winnebago Specialty Vehicles to increase
of the U.S. market,” Silverman said. “For nostic reconstructive volume. access to mobile CT clinics across the U.S.
CT at Hitachi we don’t target the academic The ClarisXT is a lightweight, portable The vehicles come equipped with Neuro-
buyer. We target to provide the most ver- CT solution that includes a workstation with Logica’s BodyTom Elite, a 32-slice full-body
satile and best value proposition for the review capability, a movable gantry and CT scanner, which has an imaging algorithm
general hospital buyer. We’re really talking
about a machine that is better in terms of
capabilities, quality and value for general
hospitals.”
The product is FDA 510(k) pending and
Hitachi plans to showcase it at this year’s
RSNA.
iCRco inc.
iCRco inc.’s latest product, the ClarisXT, is
a multi-modality device that provides high-
resolution 3D imaging, as well as full-field di-
agnostic X-ray. ClarisXT replaces a traditional
X-ray system in an orthopedic, sports medi-
cine or medical clinic. The system is designed
for general X-ray applications, orthopedic
imaging, bones and joints, as well as head
and neck studies.
ClarisXT provides four times better reso-
lution than traditional CT, at a third of the
dose, said Stephen Neushul, president, iCRco inc. Claris XT
chief executive officer and head engineer
of iCRco.

“You can drive it around the hospital,”
Neurologica BodyTom
Webster said. “If someone is in the hospital
Mobile Lung Unit
for a traumatic brain injury, you can monitor
them instead of transporting them. With
this, now the patient stays in the ICU in the
bed and they don’t have to move them.
Philips
At ECR in March, Philips launched its Incisive
CT, a general purpose 64-slice and 128-slice
scanner.
The 72-centimeter bore “workhorse”
scanner comes with a “Tube for Life” guar-
antee — Philips will replace the new vMRC
for low-dose lung screening that was ap- the American Lung Association, Atrium tube X-ray tube, which the company says is
proved by the FDA in 2018. Health’s Levine Cancer Institute and others. already more reliable, throughout the entire
“Winnebago Specialty Vehicles has a The companies plan to work together to lifespan of the system at no additional cost.
long history of mobile medical care,” said build more mobile screening vehicles. This guarantee has the potential to re-
David Webster, chief executive officer of At RSNA 2018, NeuroLogica launched duce operational expenses by an estimated
NeuroLogica. and its 16-slice, small-bore CT scanner, $400,000.
NeuroLogica and Winnebago Specialty OmniTom. The mobile system can be used “One of the most expensive components
Vehicles division collaborated this summer at the point-of-care in the neuro-ICU and in CT is changing the tube,” said Karim
for the first Mobile Lung Symposium in Min- in the operating room for neurosurgery Boussebaa, business leader for computed
neapolis, Minnesota, hosting speakers from cases and full-body pediatrics. tomography and advanced molecular im-
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Latest In CT
to shift services to the outpatient environ-

Philips Incisive CT
ment. That’s really where the SOMATOM
go.Top Cardiovascular Edition is going to
be implemented.”
Aside from a tablet-based workflow
that allows the technologist to stay with
the patient for a majority of the exam, the
scanner also comes at a price point that’s
suitable for an outpatient environment,
Dedman said.
At last year’s RSNA, Siemens unveiled an
artificial intelligence platform called AI-RAD
Companion, and the first application avail-
able on the new platform is for chest CT. The
AI-RAD Companion Chest CT application
is designed to mark and measure potential
abnormalities in the lungs, heart, and aorta
to assist the radiologist in their interpretation
of chest CT scans.
“The idea is to provide the radiologist
with more data-enriched images and allow
them to be more efficient and accurate in
aging at Philips. “The model has been to “With all of the scientific and clinical their interpretation,” Dedman said. “The
drive revenue through services. Philips has research proving the value of CCTA, it’s radiology workforce is not growing at the
engaged in a different approach with our now the question of, ‘Where can these same pace as the exam volume. We feel a
customers, one where we want to be part- services be delivered?’” Dedman said. tool like the AI-Rad Companion allows us to
ners. Incisive CT reflects that approach.” “Historically, a CT scanner capable of high- offload work. We clearly see this as a com-
The company expects the scanner to be quality cardiac imaging is installed within plement to the radiologist.”
available in the U.S. later in the year. a hospital. We’re seeing a trend, though, Share this story: dotmed.com/news/48327
Siemens Healthineers
At the American College of Cardiology
annual meeting this past March, Siemens
Healthineers debuted the SOMATOM
go.Top Cardiovascular Edition, a new ver-
sion of the 128-slice CT scanner designed
with the necessary hardware and software,
as well as a workflow geared specifically to-
ward cardiac imaging.
The scanner is capable of providing the
high-quality coronary CTA (CCTA) images
required for the HeartFlow FFRCT Analysis,
a cardiac test developed by HeartFlow Inc.,
that enables clinicians to better evaluate the
impact a blockage has on blood flow and
determine the best treatment for patients,
according to the company.
Research has shown that CT for front line
coronary CT imaging has value, said Mat-
Siemens Somatom
thew Dedman, director of marketing for GoTop
CT at Siemens Healthineers North America.

Best Practices
Ten-year study finds

low-dose CT is the standard
for lung cancer screening
By John R. Fischer
Started in 2002, the primary results of the NLST were released in

2011, revealing that annual exams with LDCT reduced lung cancer
mortality among high-risk patients by 20 percent and overall mortal-
ity by 7 percent compared to controls.
The findings led the United States Preventive Services Task Force
in 2013 to recommend LDCT as the standard for U.S. screenings of
high-risk individuals, who are defined as those between 55 and 80
with a smoking history greater than or equal to 30 pack-years and
who have not quit within the last 15 years.
The NELSON trial found LDCT to reduce deaths from lung can-
cer by 26 percent in high-risk men and by up to 61 percent in
high-risk women. Those with such risks were defined as current
and former smokers between 50 and 74 who smoked greater than
10 cigarettes daily for more than 30 years or more than 15 a day
for over 25 years.
Taking into account the findings of both trials, the IASLC Early De-
tection and Screening Committee affirmed its support of the use of
LDCT for significantly reducing lung cancer mortality among high-risk
individuals, prompting it to urge the adoption of screening programs
The implementation of low-dose CT in lung cancer screenings that incorporate multidisciplinary groups of experts.
may significantly reduce mortality among high-risk individu- It also encouraged the use of best practices for identifying high-
als, according to the findings of a 10-year Dutch-Belgian trial. risk individuals; acquiring consistently high-quality images from LDCT
Presented last year at the International Association for the Study and incorporating radiological guidelines, including definitions for
of Lung Cancer (IASLC) 19th World Conference on Lung Cancer positive versus negative results; integrating smoking cessation into
(WCLC) in 2018, the NELSON lung cancer screening trial argues on lung cancer CT screening programs; incorporating a defined process
behalf of LDCT as a standard for assessing risk of lung cancer devel- of surgical or other diagnostic interventions for suspicious nodules;
opment, aligning with the findings of National Lung Screening Trial and using a defined clinical work-up for “indeterminate nodules”
(NLST) conducted in the U.S. and for pathology reporting of nodules.
“In screening, you’re not dealing with patients with lung cancer Mulshine says training around these methods is crucial in identi-
but people at risk for the disease,” Dr. James Mulshine, professor of fying and addressing high risks of developing lung cancer early on.
internal medicine at Rush University in Chicago and chair of the Early “Institutions are not always used to performing low-dose CT so
Detection and Screening Committee of the IASLC, told HCB News. they have to learn to do it and do it well, with screening,” he said.
“In this pre-disease setting, we want to reduce the harm of medical “It’s the leading cause of death in the U.S. and the rest of the world
radiation to as low as possible. In the last decade, the medical indus- and we’d like to help avoid that in these tobacco-exposed individuals
try has shown it can produce extraordinary, high-quality imaging at who are at elevated risk of developing this disease.”
very low dose so that the risk to this asymptomatic subject popula- The IASLC acknowledges that implementation of LDCT screening
tion is quite negligible. That’s why we specify low dose in this setting. worldwide is up to the authority of each individual national health
We want to incur as little difficulty for these individuals as possible.” service.
A total of 1.6 million deaths occur each year due to lung cancer, The 19th WCLC took place in Toronto, Canada.
with more than 60 percent diagnosed after the cancer has metasta- Share this story: dotmed.com/news/45021
sized, leading to worse outcomes.

Building Barriers
Radiation shielding — experts

share tips to get the most
value
By Lauren Dubinsky
Photo courtesy: Veritas

Laying down
ceiling blocks
for shielding.
On a day-to-day basis, radiation shield- What information should tor of marketing and IT at NELCO World-
ing is probably not something that is providers share with their wide. “If you’re above a 10 megavolts ma-
on the top of a healthcare provider’s list shielding partners? chine, you’re not just dealing with gamma
of concerns, but these massive projects Shielding a diagnostic imaging facility and but you’re also dealing with neutrons to
are crucial to any facility. Whether it’s an shielding a radiotherapy facility are two shield for.”
imaging department or a radiotherapy treat- completely different tasks. Both require the Because of that, it’s beneficial to engage
ment center, having a basic knowledge of facility to share certain information with the with the company early on in the planning
shielding will help you make sure the right shielding company, but radiotherapy takes phase regarding planning for the space re-
decisions are made when shielding projects things to a whole other level. quirements, the ancillary space around the
or issues arise. A few experts in the field “Radiotherapy is a lot more complicated room and fitting feasibility. All of that can
shared their insight with HCB News on these because you’re dealing with much higher have a large impact on the budget and
matters. levels of radiation,” said Cliff Miller, direc- schedule for completing the project.

“A radiation therapy vault may need four or eight feet of concrete lead as well as rolling barriers, which encase lead in a metal frame.
on four- or eight-foot-thick walls and that obviously takes up a lot NELCO has a comprehensive environmental health and safety
of room,” said Miller. “We can incorporate other materials to make program to address all of the safety concerns that their customers
the thickness of the rooms smaller so that maybe you can fit an extra have with lead.
treatment room in or fit it into a space that you didn’t think could fit “We limit the amount of cutting and what we bring on to a job
one before.” site,” said Miller. “We’re not going to be cutting on a job site, be-
Although shielding for the diagnostic setting is much simpler, cause that can spread the lead throughout a building and we control
there still is pertinent information that needs to be relayed. An- the area where the lead is being installed so no one can access it.”
drew Martin, director of physics at Veritas Medical Solutions, said Lead is less expensive than other materials, like tungsten, but it’s
that facilities should identify the brand, model and features of the still not considered to be inexpensive. To prevent waste, NELCO cuts
equipment they have selected, the maximum available dimensions, lead with a knife instead of a saw so there is no dust.
any obstructions within the area or logistics to the work space, the According to Veritas’ Martin, lead is not a structurally sound mate-
treatment types, dose per patient, the maximum treatment capacity rial on its own and is subject to a phenomenon called Lead Creep. In
they intend to offer and their local radiation protection regulations. those cases, a structural cage will typically be required to ensure the
Paul Rochus, business development executive at MarShield lead does not creep over time and collapse.
Radiation Shielding, stressed the importance of knowing what sort “You can use concrete instead of lead but need a much, much
of attenuation they need as well as the lead thickness. To determine greater thickness,” said Petrone. “In a new building construction and
that, they can consult with a health physicist or may have someone where land is not expensive, that could be okay and is often a choice,
on staff in their radiation safety department. but in a city that becomes problematic.”
But one thing every facility should always make sure to have is a But Petrone added that the ultimate solution is to involve all stake-
good set of architectural drawings, according to Thomas Petrone, holders upfront in the process. By doing that, you can minimize lead
chief executive officer and chief medical physicist at Petrone Associates. or other shielding by working with architects and physicists to come
“These would have been created through a good working pro- up with the ideal placement of the radiology equipment.
cess between the owner, the equipment manufacturer, the technical
staff who will utilize the equipment and the medical physicist,” he
said. “The physicist must provide a good shielding requirements
analysis before the shielding company can adequately bid the job.”
In the analysis, alternative shielding materials such as normal and
high-density concrete can be considered for higher energy machines.
On the lower-end side, such as mammography, gypsum board may
sometimes be used in place of some lead.
To lead or not to lead?

For the diagnostic setting, lead is the shielding material of choice, • Lead Lined Cabinets
but is it always the best choice? NELCO’s Miller definitely thinks so • Radiation Barriers
— citing that “it’s the most cost-effective, easy to install, quickest to • Modular Booths/Walls
install, it’s flexible and gives a finished product that the customers • Lead Curtains
are happy with.” • Lead Bricks & Sheet Lead
The downside of lead is that it’s toxic and requires special manu- • Borated Polyethylene
• Leaded Glass & Acrylic
facturing, handling, transportation and working restrictions. The
• Lead Lined Storage Containers
WHO stated that lead negatively affects the development of the brain
• X-Ray Rooms Design
and nervous system in children, and may also lead to high blood pres- & Construction
sure and kidney damage in adults. • Tungsten Vials
The Institute for Health Metrics and Evaluation found that lead & Syringe Shields
• Lead Pig Vials & Waste
exposure was responsible for an estimated 540,000 deaths in 2016.
Containers
It accounted for nearly 64 percent of the global burden of idiopathic • Design & Consultation Services
developmental intellectual disability as well as 3 percent and 3.1
percent of the global burden of ischemic heart disease and stroke,
respectively.
A few of the shielding companies have developed products
1.800.381.5335 | sales@marshield.com | www.MarShield.com
and come up with strategies to mitigate the risk of lead exposure.
ISO 9001:2015, CAN/CSA Z299.2-85 CERTIFIED QUALITY MANAGEMENT SYSTEM
MarShield sells lead bricks so that they can be painted to enclose the

Building Barriers
Rolling shields from MarShield
“A good shielding design by a qualified logistics, difficulty handing and especially the projecting how the caseload may increase
physicist should occur at the beginning of nature of radiation being shielded.” over the lifetime of the unit before installing
the process,” said Petrone. “An inexperi- For radiotherapy, Veritas usually uses any radiation equipment. By doing that, the
enced physicist may incorrectly calculate the its VeriShield system, which involves dry, initial design will never have to be revisited.
shielding needs and cost you down the line.” stacked shielding modules that interlock to “Most professionals would advise to proj-
form a leak-free therapy room. It’s structural ect the absolute maximum steady state aver-
What about radiotherapy? in terms of load bearing, consistent in com- age workload that would ever be reached
When it comes to radiotherapy, choosing the position, shape and density, uses space ef- during the life of the machine,” said Petrone.
right material isn’t as clean cut. NELCO and ficiently, attenuates a wide range of ionizing Martin agrees that new and/or growing fa-
Veritas don’t have a material of choice be- radiation and is modular in nature to provide cilities should always be looking 10 years down
cause they take into account each project’s design flexibility. the road to anticipate future growth. That can
unique needs. range from considering additional future pa-
“We’ll use a myriad materials to meet Shield for existing or tients in a single space to including extra space
the customer’s needs and budget require- future throughput? adjacent to the current bunker in a design to
ments,” said Miller. “We don’t try to jam a “Some may argue to shield for the existing easily add treatment rooms in the future.
product into every project and just say this is workload and if the workload increases, add “Adding extra layers of material to a
what we have and you live with it.” more shielding,” said Petrone. “Even if this room during initial construction is much
If the customer has space constraints, then would be possible, it is a dangerous selec- more cost-effective than having to add
they may use lead since it has the highest tion, analogous to being penny wise and shielding later,” he said. “Existing facilities
shielding value of any material. In other cases, pound foolish.” with multiple treatment spaces in operation
they may use a combination of lead and con- He added that the likelihood that a facil- are usually adding equipment for more stra-
crete or lead and the high-density concrete. ity will forget to redo their shielding design, tegic reasons and should consider the extra
“As with most things, there is no one- leaves them open to a noncompliance situa- shielding costs in conjunction with their abil-
size-fits-all solution,” said Martin. “The best tion, which could be dangerous for the sur- ity to split additional workload over multiple
shielding material depends on a number of rounding areas. treatment spaces.”
factors including raw material cost, project To prevent all of that, he recommends Share this story: dotmed.com/news/48328

Resource Guide: ASTRO
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Standing
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distributes medical de- BIODEX NEW 058-840 SUR-
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Dr’s Toy StoreXtension Medical, LLC • 866-534-4726 Midwest Medical LLC • 612-875-6030 239-454-9555 Artec Group Services, LLC • 305-884-4533
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BIODEX 058-726 ECONO ULTRA-
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ADVERTISER INDEX
ADVERTISER PAGE ADVERTISER PAGE ADVERTISER PAGE
ACE Summit & Expo Hitachi Nationwide Imaging Services

www.acesummitandexpo.com 25 https://www.hitachimed.com/ www.nationwideimaging.com 2
particletherapy/singleroomsolution/ 47
AHRMM Oxford Instrument Healthcare
www.ahrmm.org/asset Inside Back Cover IBA www.oxinst.com/healthcare 1
www.iba-worldwide.com 45
Altima Diagnostic Imaging Solutions Radiology Oncology Systems
www.altimadis.com 11 iCRco www.oncologysystems.com 41
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Beekley Medical
www.beekley.com/ifix 63 Injector Support and Service Richardson Healthcare
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BR+A Consulting Engineers
www.brplusa.com 51 LG Business Solutions Sun Nuclear Corporation
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Complete Medical Services display/it-products/medical-monitors 9
www.completemedicalservices.com 15 Varex Imaging
MarShield www.vareximaging.com Inside Front Cover
CryoSRV www.marshield.com 71
www.cryosrv.com 59 Varian
MEDICA 2019 www.varian.com/intelligent 49
Elsmed www.medica.de 17
www.elsmed.com 57 West Physics
Midmark www.westphysics.com/
Health Connect Partners www.midmark.com/HBNsep Back Cover CTdoseNavigator 53
hlthcp.com 29
79
The Future of Healthcare
Future of radiotherapy:
Efficiency and accessibility
By Dr. Deepak “Dee” Khuntia
While the future of radiotherapy will lar basis, clinicians can look at physiological to countries around the world won’t achieve
continuously evolve through the dili- changes (e.g., bladder fluctuations, changes meaningful outcomes. The technology is
gence of passionate physicians and re- in weight, changes in tumor size) in the pa- appreciated, but without the appropriately
searchers, one thing remains constant: tient to account for macro fluctuations in the trained personnel to manage the machines
advancements in radiation oncology tumor’s shape and position due to changes in — which can be sparse in developing coun-
will be designed and developed to al- nearby organs. The approach allows clinicians tries and communities — the ability to treat
low clinicians to put patients’ needs first, to reassess, adjust, and adapt the treatment patients will still be limited. The industry is
always. Two such approaches — adaptive plan. Today, this can be completed for certain being challenged to develop treatment tools
radiotherapy and FLASH therapy — will, patients, but the treatment adjustment process that decrease the time it takes to learn and
when commercialized, prioritize treatment is a lengthy and laborious one. Aggressive and understand the technology. This will stream-
efficiency and accessibility to do just that. innovative work is currently being done to turn line training and ultimately boost access to
this 2 – 3-day long process into a treatment de- care. Knowledge-based learnings tools, or
Where are we today? signed to enable adaptive treatments in a stan- artificial intelligence, has the power to move
We define FLASH therapy as a noninvasive dard radiotherapy timeslot. If we can achieve the needle as well.
treatment that relies on external beam ra- this, the process will be easier on the patient Artificial intelligence tools have been in the
diation delivered in ultra-high doses, at ultra- and clinics will be able to treat more patients in market for several years and, looking ahead,
high speeds (less than one second), typically the abbreviated period of time. The future of the next step is to bring this type of technol-
in one to three sessions. It will empower clini- adaptive radiotherapy leverages artificial intel- ogy into radiation oncology even more. Le-
cians to treat and target cells in seconds, ver- ligence in order to segment and map out the veraging AI to better understand where the
sus minutes. Initial preclinical research on the anatomy, target where the tumor is, and opti- tumor is, which tissue needs to be avoided,
value of ultra-high dose rate FLASH therapy mize quality assurance of the treatment plan. etc., is an example of the near-term applica-
conducted by Varian and two of its clinical tions of intelligent radiation technology.
partners (Maryland Proton Treatment Center Accessibility + intelligent The future of radiotherapy will offer a
and Cincinnati Children’s/UC Health Proton advancement = adoption personalized, flexible, and dynamic long-
Therapy Center), has been promising. To fur- Once these modalities leap relevant regu- term treatment strategy that can offer better
ther study such ultra-high dose rate cancer latory hurdles, treatment and real-world experiences to clinics large and small — and
treatments with protons, the Varian FlashFor- scalability still will be imperative to clinical to patients around the globe.
ward Consortium was announced last year. adoption of these approaches, and the mod- About the author: Deepak “Dee” Khuntia,
If we look at adaptive therapy, it is a treat- ern-day reality is that the time, resources, M.D., is the senior vice president and chief
ment approach that evolves over time in re- and training needed to implement new ap- medical officer at Varian Medical Systems.
sponse to the temporal and spatial variability of proaches also are obstacles. Currently, just Share this story: dotmed.com/news/48329
the patient’s anatomy. On an increasingly regu- “airdropping” linear accelerators (LINACs)

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Raising The Profile of Radiation Oncology: Q&A With Astro President Dr. Theodore Deweese

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The future of radiotherapy: Efficiency and accessibility p.

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HealthCare Business News I september 2019 3

PUBLISHER DOTmed.com, Inc.

KEY ACCOUNT Susan Minotillo

Our online news is getting a makeover

Knitting raises thousands for Scottish MR scanner

6 HealthCare Business News I september 2019 www.dotmed.com/news

First scan in US performed with

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2019-05-24 Medica 2019_USA_MEDICA_86 x 224mm_DOTMED_4c_7198

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