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Electronic surface brachytherapy is a low-energy radiation treatment for skin cancer. Radiologists are required to administer the treatment, which is controversial in terms of reimbursement and collaborative requirements.
Radiotherapy has been a part of the dermatologist’s therapeutic armamentarium for over 70 years. With the emergence of excellent surgical options and the logistic problems of administering radiation therapy (RT) in the office, this form of treatment has almost completely disappeared over the past 30 years.
Now there is a new technology which has been designed to be a practical alternative to the old-fashioned RT, namely electronic surface brachytherapy (EBT). Unlike its predecessor, which used radioactive isotopes, EBT delivers low-energy radiation at a high dose rate through an applicator placed directly on the skin. Thus, there is less shielding needed and no requirement for a dedicated lead-lined room.
There is one major drawback of EBT from the point of view of the dermatologist: A radiation oncologist must be the person to actually administer the treatment, which is given twice weekly for four weeks to non-melanoma skin cancers.
The dermatologist becomes the “middle man” between his patients and the radiation therapist. In spite of the fact that he is not actually giving the treatments, he is taking a substantial percentage of the reimbursement from third-party payers. Apparently this can be quite lucrative. There is an “urban legend” that one dermatologist in a large city near where I practice has billed over one million dollars in one year from this procedure alone.
Maybe I am being ultra-sensitive, but this procedure as performed in the dermatologist’s office has the distinct scent of a major conflict of interest. The proponents of EBT argue that this is a part of offering “a comprehensive spectrum of skin cancer care.” It gives the patient an additional choice of therapy, and most importantly, it protects the dermatologist’s turf from interlopers like free-standing radiation oncologists and others.
I have a much different take on this situation. In my view, this is all about the money. With EBT, an office can find a new source of revenue without so much as touching the patient. It begins to look very attractive. From the purely medical standpoint, we routinely collaborate with other physicians without concern about “losing our turf.” When I refer a patient to the excellent head and neck surgeon in our community for the excision of a squamous cell carcinoma of the lip, I never feel as if I have lost anything, and I know the patient is better served by him than by me. Likewise, if I think that a patient would benefit from EBT, there would be no problem with referring directly to a radiation oncologist, thus eliminating any taint of a conflict of interest.
This brings us to the issue of the usefulness or need for EBT. In my 35 years of practice in both an academic and private practice environment, I have cared for many thousands of patients with skin cancer. I can count on one hand the number of those patients who would benefit from EBT rather than surgery. In fact, in a recent review of the subject, the authors suggested that EBT was really best for tumors less than 2 mm in depth and less than 2 cm in diameter. These would be the exact tumors which are well treated by electrodessication and curettage, surgical excision, or Mohs micrographic surgery.
Is this technology more effective than surgery? There is scant published data to address this question. The only study that I could find, reported by a paid consultant to the manufacturer of the EBT equipment, showed that in 46 lesions treated, there were no recurrences after one year. If someone out there knows of any controlled trials conducted by disinterested parties with data which extends to five years, please let me know; otherwise EBT appears to be in the early investigational stages of development. There is at least one major health insurance carrier that has decided that it will not cover the cost of the procedure because of the determination that the procedure should be classified as investigational/experimental.
In conclusion, I can safely predict that if reimbursement for EBT evolves to be the same as that of other skin cancer treatment modalities, it would soon be gone from the face of the earth. Furthermore, I would like to ask the users of this form of therapy whether they would continue to recommend this modality if only the radiation oncologists in their communities owned the machines. Our patients do not need this as a treatment option. We dermatologists will continue to be the major providers of care for those with skin cancer, with or without this technology.
What are your thoughts on EBT? Comment below to continue the discussion.