Oncology clinical technology compendium

PUBLISHED BY

Oncology clinical

technology compendium

Technology trends overview

Service Line Strategy Advisor

IMPLEMENTATION RESOURCE

advisory.com2© 2020 Advisory Board • All rights reserved

Oncology technology adoption landscape

Source: Service Line Strategy Advisor research and analysis. 1. Not profiled in Technology Compendium.

Subspecialty Conservative Late Majority Early Majority Early Adopter Progressive

Cancer

screening

and

diagnosis

• Breast coil

• Fecal occult

blood test

• Flexible

sigmoidoscopy

• Capsule video

endoscopy

• Optical

colonoscopy

• Dedicated

breast MRI

• Cologuard stool

DNA test

• Fecal

immunochemical

test

• Low-dose CT

lung screening

• Automated

breast

ultrasound

• CT colonography

• Endobronchial

ultrasound

• Electromagnetic

navigation

bronchoscopy

• Hyperthermic

intraperitoneal

chemotherapy

• Molecular breast

imaging

Interventional

and surgical

oncology

• Tumor

resection1

• Mohs

micrographic

surgery

• Laparoscopic

resection1

• Robotic

surgery

• Embolization

• Ablation

• Electronic

brachytherapy

• Hyperthermia

• Intraoperative

molecular

imaging

• Non-wire tumor

localization

• MR-guided

focused

ultrasound

• Drug eluting

beads

• Irreversible

electroporation

• High-intensity

focused

ultrasound

Medical

oncology

• Chemotherapy

infusion1

• Genetic testing

• Oral

chemotherapy

• Targeted cancer

therapies

• Immunotherapy

• Bone marrow

transplantation

• CAR T-cell

therapy

• Next-generation

sequencing

• Radiomics

• Liquid biopsy

• Companion

diagnostics

• Functional and

molecular imaging

• Pharmacogenics

• CDK4 inhibitors

Radiation

oncology

• CT simulation

• Low-dose

radiation

brachytherapy

• High-dose

radiation

brachytherapy

• Image-guided

radiation

therapy

• Three-

dimensional

conformal

radiation

therapy

• Intensity-

modulated

radiation

therapy

• Stereotactic

radiosurgery

• Stereotactic

body radiation

therapy

• Volumetric-

modulated arc

therapy

• Multi-functional

LINAC

• AccuBoost

breast

radiotherapy

• Intra-operative

radiation therapy

• Surface-guided

radiation therapy

• SpaceOAR

Hydrogel

• MRI-guided

radiation therapy

• Proton beam

therapy

• Single-room

proton beam

therapy

• Real-time

adaptive radiation

therapy

• Radiosensitivity

testing

• Respiratory gating

• 4D localization

(Calypso)

• Carbon ion

therapy

https://www.advisory.com/


Road map

Cancer screening and diagnosis



6M

8M

2018 2023

Automated Breast UltrasoundABUS unlikely to increase competitiveness, but can improve efficiency

Source: Giuliano et al., Improved Breast Cancer Detection in

Asymptomatic Women Using 3DAutomated Breast Ultrasound

in Mammographically Dense Breasts, Clinical Imaging, 2013;

Service Line Strategy Advisor research and analysis.

1. http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/DeviceApprovalsandClearances/Recently-

ApprovedDevices/ucm320724.htm


This document does not constitute professional legal advice. Advisory Board does not endorse any companies, organizations or their products as

identified or mentioned herein. Advisory Board strongly recommends consulting legal counsel before implementing any practices contained in this

document or making any decisions regarding suppliers and providers.

What is it?

Automated breast ultrasound (ABUS) is a dedicated ultrasound platform equipped with an ultrasound

transducer that automatically acquires standardized breast images from different angles with minimal

sonographer intervention required.

Adoption status: Early Adopter

FDA status: FDA approved for diagnosis in 2008; approved for screening with U-Systems (GE) ABUS

device in September 20121

Major vendors: GE Healthcare (Invenia ABUS), Siemens (Acuson S2000 ABVS), Sonociné (Adjunctive

Breast Ultrasound System)

Competing products: 2D ultrasound, elastography, digital breast tomosynthesis, molecular

breast imaging, breast MRI

Key facts

CPT Description2019

Rate

2020

Rate

Percent

Change

76641Breast

Ultrasound$112 $111 -1%

Financial outlook National market estimatesBreast Ultrasound; Outpatient Imaging Market Estimator

Who should invest?

Investment in ABUS may be favorable for organizations that want to reduce image variation and improve

efficiency by uncoupling the image acquisition from interpretation. Further, given increased diagnostic

sensitivity for women with dense breasts, programs looking to be comprehensive breast centers should

consider ABUS.

Clinical considerations: ABUS increases diagnostic sensitivity for women with dense breasts



802K

1M

2018 2023

Breast MRIBreast MRI important for high risk patients and secondary screenings

Source: Kelly, et al. Positron Emission Mammography

For the Diagnosis of Breast Cancer in Young Women:

a Literature Review. Internal Medicine, 2014; Service

Line Strategy Advisor research and analysis.


What is it?

Breast MRI is the imaging of breast tissue involving either a whole-body MRI scanner or a dedicated unit

engineered specifically for breast imaging. Breast MRI requires a specialized coil optimized for breast imaging.

Software then processes images into three-dimensional renderings. Alternatively, a small number of vendors

offer breast-only MRI units.

Adoption status: Breast Coil – Late Majority; Dedicated Breast MRI – Early Adopter

FDA status: Approved

Major vendors: Aurora, GE, Phillips, Siemens, Toshiba

Competing products: Breast ultrasound, molecular breast imaging, tomosynthesis,

positron emission mammography (PEM)

Key facts

CPT Description2019

Rate

2020

Rate

Percent

Change

77046 /

77047

One or two

breast without

contrast

$230 $231 0%

National market estimatesBreast MRI; Outpatient Imaging Market Estimator

Who should invest?

Investment in breast MRI is best suited for organizations that have developed or attempting to develop a

comprehensive breast program, particularly those that see a lot of women at high risk for breast cancer.

Prior to investment, assess current patient volumes to determine the sustainability of purchasing a

breast MRI coil or a dedicated breast MRI unit.

Financial outlookMedicare HOPPS1 reimbursement

1. Hospital Outpatient Prospective Payment System.

This document does not constitute professional legal advice. Advisory Board does not endorse any companies, organizations or their products as identified or mentioned herein.

Advisory Board strongly recommends consulting legal counsel before implementing any practices contained in this document or making any decisions regarding suppliers and providers.

Clinical considerations: Breast MRI is often recommended to be used as a screening tool

alongside an annual mammogram for certain women at high risk for breast cancer



Capsule Video EndoscopyGood investment for programs looking to increase endoscopy volumes

Source: Advisory Board Outpatient Market Estimator;

Service Line Strategy Advisor research and analysis.1. Hospital Outpatient Prospective Payment System.



What is it?

A capsule endoscopy is a screening and diagnostic procedure that uses a tiny wireless camera to take pictures

of the digestive tract. A capsule endoscopy camera sits inside a vitamin-size capsule that is swallowed. As the

capsule travels through the digestive tract, thousands of photos are transmitted to a recorder the patient wears

on a belt around the waist.

FDA status: Currently three FDA approved

Payer coverage: Covered by Medicare and private payers

Adoption status: Late majority

Competing products: Optical colonoscopy, virtual CT colonoscopy, Epi proColonblood test,

Cologuard Stool DNA test, flexible sigmoidoscopy, fecal occult blood test

Key facts

Clinical considerations: A useful tool in evaluation of the small bowel for tumors such as lymphoma,

carcinomas or carcinoids, as it allows providers to view even the most inaccessible parts of the GI tract.

The procedure does not require sedation, has fewer potential complications, and is less likely to cause

discomfort.

HCPCS Description2019

rate

2020

rate

Percent

change

0355T

GI tract

capsule

endoscopy

through

colon

$1483 $1557 5%


National market estimatesCapsule endoscopy volumes

Who should invest?

Capsule video endoscopy is a suitable investment for most AMCs and community centers, especially

those dealing with low uptake of colonoscopy or flexible sigmoidoscopy due to patient reluctance to

undergo invasive procedures.


83K

115K

2018 2023

+39.3%



Cologuard Stool DNA TestGood investment for programs with low screening volumes



1. Clinical Lab Fee Schedule.



What is it?

Cologuard is a non-invasive screening test for cancer that detects the presence of mutated DNA in stool.

Cologuard is an improvement on existing stool-based colon cancer screening tests because it detects pre-

cancerous lesions as well as the presence of cancer. Patients are prescribed a kit to use at home to collect the

stool sample. Positive results are followed by a diagnostic colonoscopy.

FDA status: Approved in 2014

Payer coverage: Covered by all major private payers and Medicare

Adoption status: Early majority; adoption increasing over time as awareness of test increases

Competing products: Colonoscopy, Virtual CT colonoscopy, fecal immunochemical tests (FIT),

Epi proColonblood test, FOBT, flexible sigmoidoscopy, capsule video endoscopy

Key facts

Clinical considerations: Colorectal cancer is often curable if detected early; however, many patients do

not receive colonoscopies at recommended intervals due to invasiveness of the test. Cologuard’s non-

invasive nature could potentially increase screening compliance and reduce colorectal cancer mortality


Rate

2020

Rate

Percent

change

81528

Oncology

colorectal

screening

$509 $509 0%

Financial outlookMedicare CLFS1 reimbursement

National market estimatesNational outpatient colonoscopy and sigmoidoscopy volumes

Who should invest?

As a potential lever to improve screening rates and ultimately outcomes, Cologuard is a strong investment

option for most organizations, especially those that are currently prioritizing population health or have low

screening colonoscopy volumes. However, organizations with moderate or high screening colonoscopy

volumes that still receive fee-for-service reimbursement should be wary of the potential negative impact

this could have on those volumes, although it may increase diagnostic colonoscopy volumes.


7.0M

7.6M

297K 286K

2018 2023

+10%

Colonoscopy -

Diagnostic

-4%

Sigmoidoscopy

- Diagnostic



87K

186K

2018 2023

CT ColonographyReasonable investment for comprehensive GI programs

Source: Johnson CD, Radiology, 2012. Service

Line Strategy Advisory research and analysis.


This document does not constitute professional legal advice. Advisory Board does not endorse any companies, organizations

or their products as identified or mentioned herein. Advisory Board strongly recommends consulting legal counsel before

implementing any practices contained in this document or making any decisions regarding suppliers and providers.

What is it?

CT Colonography (CTC), also referred to as “virtual colonoscopy” (VC), is a somewhat less invasive alternative

to traditional endoscopic colonoscopy. CTC utilizes CT imaging in place of optical endoscopy to visualize both

the interior and exterior of the colon.

Adoption status: Early adopter

FDA status: FDA approved

Major vendors: GE, Philips, Siemens, Toshiba; CAD available from iCAD, Viatronix, Vital Images,

Medicsight

Competing products: Optical/standard colonoscopy, flexible sigmoidoscopy, MR colonography,

barium enema, fecal immuno-histological testing

Key facts

CPT Description2019

Rate

2020

Rate

Percent

Change

74261Diagnostic CT

Colonography$112 $111 -1%

74262Diagnostic CT

Colonography

with contrast

$201 $179 -12%

74263Screening CT

ColonographyNot paid Not paid N/A

Financial outlook National market estimatesCT Colonography; Outpatient Imaging Market Estimator

Who should invest?

CTC is a suitable investment for GI programs that are seeking to differentiate themselves by offering a

noninvasive alternative to traditional endoscopic colonoscopy. Organizations looking to use CTC for both

screening and diagnostic purposes should ensure they see more commercially insured patients than

Medicare patients since Medicare does not cover screening CTC.

Payer coverage: Medicare covers diagnostic CTC, but not screening CTC; many private payers cover

both applications. Nearly half of states mandate coverage for screening CTC for appropriate patients.



Electromagnetic Navigation BronchoscopyPotential to help capture downstream revenue in radiotherapy and radiosurgery






What is it?

Electromagnetic navigation bronchoscopy (ENB) is a visual guidance method that combines a flexible catheter

with image navigation to extend the diagnostic and therapeutic reach of conventional bronchoscopy to

peripheral regions of the lungs. Guides pulmonologists to suspicious lesions previously available only through

open procedure, allowing minimally-invasive diagnostic and therapeutic applications in a larger patient pool.

FDA status: FDA Approved

Payer coverage: Private payers still do not offer additional payment for use of a navigation system;

Medicare covers and reimburses at the APC level when considered medically necessary


Competing products: Computed tomography (CT), ultrasound, fluoroscopy

Key facts

Clinical considerations: Although the technology is not currently approved for use outside the lung,

researchers see a potential role in gynecologic and gastrointestinal disease. ENB is best viewed as one

component of a multi-modality screening program, as ENB is a niche technology used for a subset of at-

risk patients, specifically those with small lesions in peripheral nodules

APC Description2019

rate

2020

rate

Percent

change

5153

Level 3

Airway

Endoscopy

$1369 $1430 5%

5154

Level 4

Airway

Endoscopy

$2740 $2936 7%

5155

Level 5

Airway

Endoscopy

$5147 $5439 6%


National market estimatesNational OP bronchoscopy volumes

Who should invest?

AMCs will likely find greater utilization with this technology as it is the gold standard for fiducial marker

placement and downstream radiotherapy or radiosurgical services. However, community hospitals may

find increasing value in ENB systems as a critical component to lung cancer screening programs, though

it may not be “need to have” technology.


149K173K

348K

455K

2018 2023

+31%

Procedural

Bronchoscopy

+15.9%

Diagnostic

Bronchoscopy



Endobronchial UltrasoundCritical for thoracic centers of excellence





What is it?

Endobronchial ultrasound (EBUS) is a noninvasive imaging modality that locally visualizes lesions in the lungs

and mediastinal lymph nodes for real-time staging of lung cancer, lung infections, and other conditions that

result in enlarged lymph nodes or masses in the chest. EBUS utilizes an ultrasound transducer affixed to a

specially-designed bronchoscope that is inserted into the lungs to locally visualize lesion depth and size for

lung cancer detection and staging. EBUS can also be utilized with trans-bronchial needle aspiration (TBNA) to

acquire tissue specimens for testing, or in some cases, to deliver targeted neoadjuvant therapy.


Payer coverage: Three CPT codes created in 2016 for EBUS; previously considered a packaged

service with standard endoscopic ultrasound. CMS/commercial coverage provided when proven

advantageous to standard bronchoscopy.

Adoption status: Early adopter; limited to large oncology programs or institutions with extensive

interventional pulmonology programs

Competing products: Computed tomography (CT), ENB, ultrasound, fluoroscopy

Key facts

Clinical considerations: Especially useful for the diagnosis of non-small cell lung cancer (NSCLC), which

accounts for approximately 80% of all lung cancers. When combined with endoscopic ultrasound (EUS),

EBUS establishes accurate mediastinal staging thus replacing more invasive and costly procedures like

mediastinoscopy


rate

2020

rate

Percent

change

31652

Bronch ebus

sampling ½

node

$2740 $2936 7%

31653

Bronch ebus

sampling 3/>

node

$2740 $2936 7%

31654

Bronch ebus

ivntj perph

les

n/a n/a n/a


National market estimatesNational OP bronchoscopy volumes

Who should invest?

EBUS is a sound investment for thoracic centers of excellence and other large oncology programs.

However, it requires physicians to be highly skilled in both bronchoscopy and ultrasound, which can be a

limiting factor when investing and is a major reason for limited availability. Even so, while there is

possibly a low case-load in first years of adoption as physicians acclimate to the technology, it is

important for distinguishing a thoracic center of excellence.


149K173K

348K

455K

2018 2023

+31%

Procedural

Bronchoscopy

+15.9%

Diagnostic

Bronchoscopy



Fecal Immunochemical TestNon-invasive exam worth the investment for most programs

Source: “Important Information Regarding Reimbursement for

Fecal Occult Blood Testing” , https://www.ndc-inc.com/vendor-

spotlight/what-your-accounts-need-to-know-about-reimbursement-

of-ifob; Advisory Board Outpatient Market Estimator;





What is it?

The fecal immunochemical test (FIT), also known as an immunochemical fecal occult blood test (iFOBT), is a

colorectal cancer screening test that checks for hidden blood in stool. The test reacts to part of the human

hemoglobin protein, which is found in red blood cells. Done in the privacy of the home, stool is collected in a

special collection tube or card and sent off for testing.


Payer coverage: Covered by Medicare and private payers; Medicare covers one FOBT (either iFOBT or

gFOBT) per year for the early detection of colorectal cancer

Adoption status: Early majority

Competing products: Optical colonoscopy, virtual CT colonoscopy, Epi proColon blood test,

Cologuard Stool DNA test, gFOBT, capsule video endoscopy, flexible sigmoidoscopy

Key facts

Clinical considerations: Colorectal cancer is often curable if detected early, however, many patients do

not receive colonoscopies at recommended time intervals due to the invasiveness of the test. The FIT test

could increase screening compliance and reduce colorectal cancer mortality, and is more sensitive than

other tests like gFOBT, though it can occasionally give false positives.


rate

2020

rate

Percent

change

G0328

Blood, occult by

fecal

hemoglobin

determination

by

immunoassay

$18 $18 0%


National market estimatesOutpatient fecal occult blood test volumes

Who should invest?

Despite it’s risk of false positives, FIT’s inexpensiveness and increased specificity compared to gFOBT

tests make it a worthwhile investment for all organizations, especially those prioritizing population health

or experiencing low uptake of screening colonoscopy among their patient population.


3.6M

4.8M

2018 2023

+33.1%



Fecal Occult Blood TestCheap and insensitive, can still improve mortality rates for colorectal cancer

Source: Advisory Board Outpatient Market

Estimator; Service Line Strategy Advisor

research and analysis.1. Clinical Lab Fee Schedule.



What is it?

The fecal occult blood test, or guaiac fecal occult blood test (gFOBT), is a colorectal cancer test that checks for

hidden blood in stool. The test uses guaiac paper and hydrogen peroxide to react to any traces of blood. Done

in the privacy of the home or doctor’s office, stool is collected on a special collection card and sent off for

testing.


Payer coverage: Covered by Medicare and private payers, Medicare covers one screening FOBT (either

iFOBT or gFOBT) per year for the early detection of colorectal cancer.


Competing products: Optical colonoscopy, Virtual CT colonoscopy, Epi proColonblood test,

Cologuard stool DNA test, FIT, capsule video endoscopy, flexible sigmoidoscopy

Key facts


not receive colonoscopies at recommended time intervals due to the invasiveness of the test. The gFOBT

could increase screening compliance and reduce colorectal cancer mortality, as it is one of the cheapest

options for colorectal cancer screening, though it is less sensitive than FIT and can occasionally give false

positives.


rate

2020

rate

Percent

change

82270Occult blood

feces$4 $4 0%


National market estimatesOutpatient fecal occult blood test volumes

Who should invest?

gFOBT, while less sensitive than FIT, is still a worthwhile investment for organizations prioritizing

population health or experiencing low uptake of screening colonoscopy among their patient population.


3.6M

4.8M

2018 2023

+33.1%



Flexible SigmoidoscopyLess invasive procedure an easy investment for any cancer center

Source: Advisory Board Outpatient Market


research and analysis.1. Hospital Outpatient Prospective Payment System.



What is it?

Flexible sigmoidoscopy allows a doctor to look at part of the colon and rectum with a sigmoidoscope (a flexible,

lighted tube about the thickness of a finger with a small video camera on the end). It’s put in through the anus

and into the rectum and moved into the lower part of the colon. Images from the scope are seen on a video

screen. It is used as a general screening tool for colon cancer as well as a diagnosis tool for various bowel

symptoms; suspicious findings may require a follow-up full colonoscopy as it cannot be used to remove polyps.




Competing products: Optical colonoscopy, Virtual CT colonoscopy, Epi proColon blood test,

Cologuard Stool DNA test, FIT, capsule video endoscopy, FOBT

Key facts


not receive colonoscopies at recommended time intervals due to the invasiveness of the test. Flexible

sigmoidoscopy could increase screening compliance and reduce colorectal cancer mortality, as it is a less

invasive procedure (checking less of the colon than a full colonoscopy), does not require sedation, and has

a lower risk of direct harm due to perforation.


rate

2020

rate

Percent

change

45330Diagnostic

sigmoidoscopy$745 $764 3%


National market estimatesOutpatient sigmoidoscopy diagnostic/screening volumes

Who should invest?

Although not a complete replacement for colonoscopy, flexible sigmoidoscopy is a worthwhile investment

for any organization looking to increase screening compliance by offering a less invasive option to

traditional screening colonoscopy.


297K 286K

2018 2023

-3.8%



2018 2023

This document does not constitute professional legal advice. Advisory Board does not endorse any companies, organizations

or their products as identified or mentioned herein. Advisory Board strongly recommends consulting legal counsel before

implementing any practices contained in this document or making any decisions regarding suppliers and providers.

Low-Dose CT Lung ScreeningCritical investment for all organizations with robust lung cancer programs

What is it?

Low-dose CT (LDCT) lung screening is an FDA-approved, non-invasive imaging modality used for the detection of lung

cancer. This exam has proven promising due to the high sensitivity of CT in detecting smaller lung lesions, though

adoption is limited. Unlike conventional 2D chest x-ray, lung screening with CT uses a multi-detecter CT scanner

(commonly 16-slice or greater) to capture 2D images and aggregate them into a 3D reconstruction of the pulmonary

structures and visualize potentially cancerous nodules.

Key facts

Who should invest?

Source: Harry J. de Koning, M.D., et al. “Reduced Lung-Cancer Mortality with Volume CT Screening in a

Randomized Trial”, New England Journal of Medicine. https://www.nejm.org/doi/full/10.1056/NEJMoa1911793.

National Lung Screening Trial Research Team, “Reduced lung-cancer mortality with low-dose computed tomographic

screening,” New England Journal of Medicine. https://www.nejm.org/doi/full/10.1056/NEJMoa1102873. Cancer

Incidence Estimator. Service Line Strategy Advisor research and analysis.


Financial outlookEstimated HOPPS1 reimbursement

National market estimatesEstimated lung cancer incidence


Major vendors: Low-dose CT vendors; GE, Philips, Siemens, Toshiba

Competing products: Digital x-ray tomosynthesis (screening and diagnosis), hybrid PET/CT (staging, re-staging, and

treatment planning)

Clinical considerations: Early results from the National Lung Screening Trial (NLST) suggest a 20% reduction in lung

cancer-related mortality with CT lung screening. Some studies show mortality reductions from 36%-64%; however,

other trials have suggested a propensity toward over-diagnosis. Results from the Dutch-Belgian Randomized Lung

Cancer Screening trial found a 24% reduction in lung cancer-related mortality for men and 33% reduction for women

with CT lung screening versus no screening. The US Preventative Services Task Force (USPSTF) advises that those at

highest lung cancer risk receive low-dose scans annually. CT vendors have been developing scanning protocols that

can reduce radiation dose dramatically, as receiving multiple low-dose CT exams over time could increase the lifetime

attributable risk for lung cancer.

Low-dose CT screening is a necessary investment for any organization with a comprehensive lung cancer

program. Organizations located in markets with high smoking rates are also strong candidates for investment.

However, given the strong clinical evidence supporting positive outcomes for patients, advice from USPSTF,

and growing lung cancer incidence rates, LCDT is a suitable investment for most cancer programs.

263K

233K


rate

2020

rate

Percent

change

G0296Visit to determine

ldct eligibility$76 $79 5%

G0297Ldct for lung

cancer screening$62 $80 29%

+13%



https://www.nejm.org/doi/full/10.1056/NEJMoa1911793

https://www.nejm.org/doi/full/10.1056/NEJMoa1102873


Molecular Breast ImagingImproved specificity, sensitivity give AMCs opportunity to differentiate themselves






What is it?

Molecular breast imaging (MBI) represents a class of novel nuclear medicine imaging modalities designed to

provide high-resolution functional imaging of breast tissue. A secondary screening tool for breast cancer, it

captures the increased metabolism present in cancerous cells through the use of targeted radiotracers. MBI

utilizes technetium-99 to target breast lesions.

FDA status: FDA ApprovedPayer coverage: Covered by all major private payers and CMS

Adoption status: Progressive; limited to leading breast imaging facilities, centers seeking to differentiate

from competitionCompeting products: Breast ultrasound, contrast-enhanced spectral mammography, magnetic

resonance imaging (MRI), tomosynthesis

Key facts

Clinical considerations: With improved specificity over breast MRI, MBI helps physicians to better

understand lesion malignancy. Provides similar results to breast MRI for pre-surgical planning and to

mammography for high risk or dense-breasted screening. MBI also has potential to replace MRI in pre-

surgical planning for women with contraindications to MRI


rate

2020

rate

Percent

change

78800,

78801

Tumor

imaging,

limited,

multiple

$353 $368 4%


National market estimatesNational OP breast imaging volumes

Who should invest?

For AMCs, MBI is a differentiating technology and provides another breast screening option for select

patient groups. It is a good option for organizations with a high number of patients interested in

alternatives to a breast MRI exam. For community hospitals, MBI is not yet seen as a must-have for

majority of breast centers due to limited volume and numerous other competing technologies.


2.1M

2.4M

766K982K

2018 2023

+15%

3D Diagnostic

Mammography

+28%

Breast MRI



Optical ColonoscopyMost effective colorectal screening also the most invasive





What is it?

An optical colonoscopy allows a provider to look at the entire length of the colon and rectum with a

colonoscope, a flexible tube about the width of a finger with a light and small video camera on the end. It’s put

in through the anus and into the rectum and colon to look for any abnormal areas that might be cancer or

polyps. It can be used for screening and diagnosis, and any identified polyps can be removed immediately

during the procedure.



Adoption status: Late majority; colonoscopies are currently the most common screening test for colorectal

cancer in the US

Competing products: Virtual CT colonoscopy, Epi proColon blood test, Cologuard stool DNA

test, flexible sigmoidoscopy, fecal occult blood test, FIT, capsule video endoscopy

Key facts

Clinical considerations: A full colonoscopy requires bowel cleaning and sedation, which can be

uncomfortable for patients and lead to lower rates of screening. It has the highest cost of other screening

methods. However, a colonoscopy is the most thorough colorectal screening exam, negative results clear

patients for 10 years due to the thorough nature of the exam, and it can even serve as treatment during the

same procedure.


rate

2020

rate

Percent

change

G0105

Colorectal

cancer

screening;

colonoscopy on

individual with

high risk

$745 $764 3%

G0121

Colorectal

cancer

screening;

colonoscopy on

individual not

meeting criteria

for high risk

$745 $764 3%


National market estimatesColonoscopy diagnostic/screening volumes

Who should invest?

As the most common screening test for colorectal cancer in the US, it is likely that most organizations will

have already invested in this procedure. Since it is used as a follow-up for positive results from most other

colorectal screening modalities, this is a must-have for any organizations that have not yet invested.


7.0M

7.6M

2018 2023

+10%



Road map

Surgical oncology





Da Vinci Surgical SystemSurgical robots are now cost of doing business and less of a market differentiator

What is it?

The da Vinci Robotic Surgery System from Intuitive Surgical, Inc. is a minimally invasive alternative to

traditional open and laparoscopic surgery. The surgeon performs surgery from a seated position at a console

away from the patient. Robotic arms allow the surgeon to manipulate the endoscope and surgical tools with

greater ease, more precision, and enhanced visualization.

Key facts

Who should invest?

Source: “Annual Report 2018”, Intuitive

Surgical, Inc. Retrieved from:

http://www.annualreports.com/HostedData/Ann

ualReports/PDF/NASDAQ_ISRG_2018.pdf

Market Scenario Planner. Advisory Board

research and analysis.

1. All costs are estimates and will vary by institution.

National inpatient market estimatesService lines with highest robotic surgery adoption

2018 2023

Gynecology Urology General Surgery

Cost description Cost

da Vinci robot $2M

Training $6K per surgeon

Proctoring $3K per surgeon

Annual marketing $25K

Instrumentation $2K per procedure

Annual contract fee $170K

Adoption status: Late majority for urology & gynecology; early majority for other services lines


Operational needs: due to da Vinci’s size, it must be placed in a large OR; adoption of robotic technology initially slows

throughput and also requires a trained OR care team including anesthesiologist, nurse, and assistant.

Clinical considerations: The majority of clinical literature suggests the robot can substantially decrease length-of-stay

(LOS) and blood loss for prostatectomy. While for most other procedures clinical results are mixed, the robot does offer

additional benefits over traditional laparoscopic approaches.

• Organizations with substantial surgeon interest, sufficient volumes of robotic eligible procedures, and

access to capital may be good candidates for investment.

• New physicians continue to drive demand for investment the da Vinci, as their training often includes

robotic procedures. The robotics market is growing though, as use of da Vinci robots increased 18%

overall and 32% in general surgery from 2017 to 2018.

2.40M 2.38M

454K375K

467K342K

Costs associated with da Vinci investment1

Surgical oncology


http://www.annualreports.com/HostedData/AnnualReports/PDF/NASDAQ_ISRG_2018.pdf


Hyperthermic Intraperitoneal ChemotherapyFewer side effects coupled with clinical benefit help alleviate cost

Source: Squires MH 3rd et al, “Association between hospital finances, payer mix, and complications after hyperthermic intraperitoneal chemotherapy:

deficinecies in the current healthcare reimbursement system and future implications, (https://www.ncbi.nlm.nih.gov/pubmed/25249258); Advisory

Board Cancer Incidence Estimator; Service Line Strategy Advisor research and analysis.

1. Inpatient Prospective Payment System.

2. Incidence represents the number of new cancer cases.



What is it?

Hyperthermic (or heated) intraperitoneal chemotherapy (HIPEC) is an abdominal surgical procedure wherein

after visible tumors are removed from the abdomen with cytoreductive surgery, a powerful dose of heated

chemotherapy is pumped inside the patient’s abdomen. The 41-42 degrees Celsius chemo bath circulates

through the peritoneal cavity, and after 90 minutes the chemo is washed out and incisions are closed.



Adoption status: Early adoption; over 115 centers in the US currently offer HIPEC

Competing products: Standard chemotherapy, targeted therapy, radiation therapy

Key facts

Clinical considerations: Fewer side effects than traditional chemotherapy because confining the

treatment to the stomach cavity allows for a higher dosage to be administered without causing adverse

effects elsewhere in the body; higher temperature of the chemicals cause blood vessels to expand, leading

to deeper penetration for better absorption

DRG/

CPTDescription

2019

rate

2020

rate

Percent

change

356

Oth. dig.

Sys. O.R.

proc w

MCC

$24,274 $25,539 5%

357

Oth. dig.

Sys. O.R.

proc w CC

$13,046 $14,096 8%

358

Oth. dig.

Sys. O.R

proc w/o

cc/MCC

$8,232 $8,591 4%

965

49

Unlist

chemo.

proc

$38 $38 0%

Financial outlookMedicare IPPS1 reimbursement

National market estimatesNational stomach cancer incidence2

Who should invest?

HIPEC could be a clinical differentiator for AMCs and community organizations with comprehensive

abdominal cancer programs. However, the financial case for investment is stronger for organizations that

treat more commercially insured patients than Medicare patients, as the procedure is only profitable with

private payer reimbursement rates.

Surgical oncology

25K

28K

2018 2023

+12%


https://www.ncbi.nlm.nih.gov/pubmed/25249258


Intraoperative Molecular ImagingBreast centers should invest to gain immediate feedback and better margins


2. Volumes represent number of unique treatment visits by patients with a primary diagnosis of cancer.



What is it?

Intraoperative molecular imaging uses to visualize remaining cancer cells via molecular probes targeting tumor

markers. There are many different imaging modalities that can be used for molecular imaging, but optical

imaging is most commonly used intraoperatively for cancer detection. Currently used in only breast surgeries,

tissue can be evaluated while still in the operating room, reducing the need for follow-up surgeries.


FDA status: MarginProbe, approved in 2012, is currently the only intraoperative imaging system with FDA

approval, but there are other systems of various stages of development in the pipeline; LightPath Imaging

System has a CE mark and is approved for sale in the European Union, but has not received FDA

approval yet

Payer coverage: MarginProbe is reimbursed for its use in cancer surgeries by Medicare and private payers

Competing products: Standard post-surgery pathology testing

Key facts


rate

2020

rate

Percent

change

19499

Unlisted procedure,

breast (when specified

as intraoperative

assessment of surgical

margins by

radiofrequency

spectroscopy)

$2,816 $3,029 8%


Who should invest?

Surgical oncology

Clinical considerations: The use of intraoperative molecular imaging systems allows for evaluation of

surgical tissue in the operating room, allowing surgeons to remove excess cancer cells in the margins

immediately without having to wait for a pathologist to examine the removed tissue. This reduces the need

for follow-up surgeries.

Intraoperative molecular imaging is a viable investment option for any institution looking to differentiate itself

as a breast center of excellence, though community programs may find the initial cost of a system

prohibitive. This technology may also have a unique appeal to institutions currently participating in or

preparing to participate in value-based payment models that are looking to decrease costs given its ability to

reduce the need for potentially costly follow-up surgeries.

Source: Advisory Board Oncology Market Estimator;


National market estimatesOutpatient oncology lumpectomy volumes2

144K131K

2018 2023

-9.1%



Non-Wire Tumor LocalizationLower patient pain and lower complications increase viability

Advisory Board Oncology Market Estimator;



2. Volumes are represented in the outpatient module by unique visits with a primary diagnosis of cancer.



What is it?

Tumor localization uses non-radioactive markers and detection probes to identify target tissue for surgical

removal. Using a small reflector or magnetic lesion marker detected by radar or a handheld magnetometer,

surgeons can precisely target the affected tissue to pinpoint its location. Currently used for lumpectomies in

breast cancer patients.

FDA status: SAVI SCOUT approved in 2014, Sentimag Magseed approved in 2016


Adoption status: Early adopter; over 125 centers currently use SAVI SCOUT

Competing products: MRI, wire localization

Key facts

Clinical considerations: Tumor localization allows surgeons to better visualize tumors, making it a useful

tool to optimize surgical planning, reduce surgical delays and the need for follow-up surgeries, and improve

patient satisfaction compared to a more painful wire localization.


rate

2020

rate

Percent

change

19081

Biopsy, breast, with

placement of breast

localization device(s)

(e.g., clip, metallic

pellet), when

performed, and

imaging of the

biopsy specimen,

when performed,

percutaneous; first

lesion, including

mammographic

guidance

$1,376 $1,372 -0%


National market estimatesOutpatient oncology lumpectomy volumes2

Who should invest?

Non-wire tumor localization is a viable investment option for any institution looking to differentiate itself

as a breast center of excellence. Although community programs may initially find the cost prohibitive, the

immediate significant impact that this technology can have on reducing OR delays presents an

opportunity to recoup some of the upfront costs.

Surgical oncology

144K131K

2018 2023

-9%



Road map

Interventional oncology



AblationMore progressive ablation techniques best suited to AMC investment



1. Hospital Outpatient Prospective Payment System

2. Volumes represent unique visits in the outpatient module with a primary diagnosis of cancer



What is it?

Ablations are minimally invasive procedures that use extreme temperatures or other energy sources to target

and destroy tumor cells. Common types of ablation include cryoablation, radiofrequency ablation (RFA),

microwave ablation (MWA), ethanol ablation, and laser ablation. These procedures are usually performed by

an interventional radiologist who will percutaneously guide a needle or probe to the tumor to apply the energy

source. Ablations can be curative treatments for small tumors (usually <3cm); they are also used in conjunction

with other therapies and palliative procedures.

FDA status: Several devices are cleared for marketing through 510(k) process

Payer coverage: RFA and cryoablation are covered by Medicare and most payers; MWA currently has

no specific cpt codes for reimbursement, and the American Medical Association recommends using CPT

codes for RFA

Adoption status: Early majority; use of cryoablation and RFA is more widespread, while use of microwave,

ethanol, and laser ablations is limited to research

Competing products: Transcatheter arterial chemoembolization, CT-guided high dose brachytherapy

Key facts

Clinical considerations: Cryoablation. RFA, and MWA are primarily used to treat liver, kidney,

bone, and lung tumors; RFA is usually the first option for hepatocellular carcinoma (HCC), but

cryoablation is preferred for recurrent cancers or those near blood vessels.


rate

2020

rate

Percent

change

47382Percute ablate

liver RF$4596 $4833 5%

47383Percute ablate

liver cryo$4596 $4833 5%

20982Ablate bone

tumor(s) perq$5700 $5981 5%

50593

Percute cryo

ablate liver

tumor

$7741 $8412 9%


National market estimatesOutpatient oncology ablation volumes2

Who should invest? Ablation is best suited for AMC investment or larger research institutions with a

highly specialized cancer program. Volumes are currently low but growing quickly, and these procedures

expand an institution’s interventional oncology program, which is an increasingly recognized component

of a comprehensive cancer program. Smaller, less well-funded programs should carefully weigh the

expected benefit to patients and number of eligible patients against the steep $25K-$30K-cost of these

systems when deciding whether to invest.


12K

16K

4K 4K3K 3K

2018 2023

+35%

RFA liver

volumes

+23%

Cryoablation

liver volumes

+18%

RFA bone

volumes



Drug-Eluting Beads Niche investment case for organizations developing liver cancer programs





What is it?

Drug-Eluting Beads (DEBs) are synthetic microspheres that are injected into the vessels that supply blood to a

tumor, where they release a chemotherapy agent and obstruct blood supply. DEBs are coated in a hydrogel

with molecular properties that allow them to attach to a chemotherapeutic agent. Once the beads have been

combined with the agent, they are admioniosteted int the arterioles feeding the tumor via a microcatheter

inserted throught the femoral artery. Once there, they release the chemotherapeutic agent and obstruct the

vessels supplying blood to the tumor.

FDA status: LC Beads and Quadraspheres were approved as embolization devices in 2006. However,

neither product is approved for chemo delivery in the US even though they are approved for this

indication in Europe

Payer coverage: FDA-approved indicators are generally reimbursed. Reimbursement for non-FDA

approved indications is largely limited to patients on clinical trials and may need to be secured on a

case-by-case basis.

Adoption status: Progressive; currently offered at 20-25 sites within the US

Competing products: Chemotherapy, conventional transarterial

chemoembolization,(cTACE), radiofrequency ablation, resection

Key facts

Clinical considerations: DEBs allow for targeted delivery of a chemotherapy agent to liver

tumors in patients ineligible for surgery. DEBs are also used for embolization of primary

hypervascular tumors and AVMs

HCSPCS Description2019

rate

2020

rate

Percent

change

37241

Vascular

embolizatio

n/

occlusion,

venous

$9669 $9907 3%

37242

Vascular

embolizatio

n/occlusion,

arterial

$9669 $9907 3%


National market estimatesOutpatient transcatheter embolization volumes

Who should invest?

Liver tumor chemoembolization is a potential niche offering for AMCs and centers with interventional

radiologists seeking to distinguish themselves in competitive markets, particularly those organizations

trying to develop and market liver cancer programs. However, the market opportunity for hepatocellular

carcinoma is relatively low as liver tumors are a low-volume malignancy.


+66.6%

23K

39K

2018 2023



EmbolizationsPotential niche offering to differentiate comprehensive liver cancer programs







What is it?

Embolizations are minimally invasive procedures that use embolic agents, delivered via a catheter, to block

blood flow to a certain area of the body. In oncology, providers block the hepatic artery, which primarily

supplies blood to the tumor cells, while the portal vein continues to supply blood to the liver. By cutting off the

tumor’s blood supply, embolizations aim to induce tumor necrosis to prolong patient survival.

FDA status: Drug-eluting bead transarterial chemoembolization (DEB-TACE) is not yet FDA approved

for chemotherapy, while bland transarterial embolization (TAE) is FDA approved.

Payer coverage: Routinely covered by payers including Medicare and Medicaid, reimbursement

continues to increase in the case of Y-90; however DEB-TACE is not reimbursed

Adoption status: While TAE and TACE are more widespread, DEB-TACE is still in the research phase;

progressive

Competing products: Surgery, chemotherapy, radiation therapy, and ablations

Key facts

Clinical considerations: Although TACE is currently the most popular standard treatment for HCC,

there is limited evidence demonstrating which modality yields the best outcomes for patients with

liver cancer. Most studies have not shown significant differences in overall survival when comparing

TACE and DEB-TACE, but studies have shown patients treated with DEB-TACE have fewer side

effects and require fewer treatments. Many recent studies have also demonstrated clinical

superiority of Y-90 over chemoembolization in reducing toxicity to HCC patients and increasing their

time to disease progression

HCPC

SDescription

2019

rate

2020

rate

Percent

change

37243

Vasc

embolize

organ

$9669 $9907 3%

C2616Addition of

Y-90$16625 $17089 3%


National market estimatesOutpatient transcatheter embolization volumes2

Who should invest?

Embolization procedures are best suited for AMCs and other progressive cancer programs are best

suited to invest in embolization procedures. Community centers should be wary about offering these

procedures until there is more robust clinical evidence on the superiority of each embolization modality

compared to each other and alternative treatments.


102K

170K

2018 2023

+66.6%



High-Intensity Focused UltrasoundStill in early stages, HIFU shows promising, yet expensive, results

Source: HIFU Prostate services, “HIFU reimbursement”,

https://www.hifuprostateservices.com/hifu-reimbursement/;



1. Due to lack of clinical evidence validating claims that HIFU has fewer side effects than

traditional cancer treatment


3. Prostatectomy DRGs included: 665, 666, 667



What is it?

High-intensity focused ultrasound (HIFU) is a non-invasive therapy that uses focused ultrasound waves to

thermally ablate a portion of tissue. The intense heat causes tissue coagulation, cavitation and heat shock in

the cells, meaning that the portion of tissue which is being abated is destroyed.

FDA status: Approved two types of HIFU treatments for prostate cancer in 2015

Payer coverage: Medicare covered a substantial part of the HIFU cost from mid-2017 through 2018, but

cut reimbursement for HIFU to less than the cost of the supplies needed to perform the procedure in

20191; not covered by private payers

Adoption status: Progressive, only a few sites within the US

Competing products: Drug therapy, surgery, radiotherapy

Key facts

Clinical considerations: Primarily performed by urologists as an alternative to radiation or

surgery for prostate cancer patients; requires shorter treatment time and early results

indicate fewer side effects than standard surgical or radiation therapies because HIFU only

targets diseased cells, minimizing the negative impact on the essential nerves, blood

vessels, and muscles surrounding the prostate that are critical for sexual function and

urinary continence


rate

2020

rate

Percent

change

C9747

Ablation,

HIFU,

Prostate

$4021 $4231 5%


National market estimatesOutpatient radiation therapy and inpatient prostatectomy volumes

Who should invest?

Only major AMCs with a larger number of self-pay prostate cancer patients are currently well-positioned

to invest in HIFU given then limited payer coverage of the treatment.


3.4M

3.9M

937 8222018 2023

+26.1%

Outpatient

radiation

therapy

volumes

-12% Inpatient

Prostatectomy3

volumes


https://www.hifuprostateservices.com/hifu-reimbursement/


Hyperthermia Increased payer coverage and effectiveness make a compelling case for AMCs

Source: Oncology Market Estimator, Service

Line Strategy Advisor research and analysis





What is it?

Hyperthermia raises the temperature of a tumor to 108-113⁰ F for one hour to increase efficacy of radiation

therapy (RT) or chemotherapy. It may also be used as a stand alone treatment. Treatment can be delivered

locally or regionally. Local hyperthermia applies heat to a small area through microwave, radiofrequency, and

ultrasound. Regional hyperthermia applies heat to large tissue areas, such as an organ or limb, using

microwave or radiofrequency energy.

FDA status: Only a few FDA-approved hyperthermia systems on the market

Payer coverage: Covered by most private payers and Medicare

Adoption status: Early adopter stage; adoption growing as supporting clinical evidence emerges

Competing products: Surgery, radiation therapy, chemotherapy

Key facts

Clinical considerations: Utilized for palliative management of advanced or recurrent surface and

subsurface solid malignant tumors; used as adjuvant to radiation therapy and, less often, chemotherapy;

there is clinical evidence of effectiveness in increasing tumor response to RT, making it an additional

treatment option for patients with poor prognosis

HCSPCS Description2019

Rate

2020

Rate

Percent

change

77600Hyperthermia

treatment$224 $236 5%

77605Hyperthermia


77610,

15, 20

Hyperthermia



National market estimatesOutpatient oncology radiation treatment volumes2

Who should invest?

Major AMCs and other high-volume cancer centers are best positioned to offer hyperthermia as an

adjunctive or standalone treatment option. Although the high cost of the console is potentially prohibitive

for most lower-volume community hospitals, increasing reimbursement rates and leasing options may

pose solutions for mitigating risk.


-6.9% Outpatient

radiation treatment

- conventional

6.7M6.2M

2018 2023



Irreversible ElectroporationExpensive and experimental, IRE nonetheless shows promising results

Source: Advisory Board Oncology Market

Estimator; Advisory Board Interventional

Radiology Outpatient Estimator; Service Line

Strategy Advisor research and analysis.


2. Reimbursement for IRE projected to follow coding guidelines for RFA, but currently not

reimbursed because still experimental




What is it?

Irreversible electroporation (IRE) is a soft-tissue ablation technique using ultra short but strong electrical fields

to create permanent and hence lethal nanopores in the cell membrane to disrupt cellular homeostasis. The

resulting cell death results from apoptosis(controlled cell death) and not necrosis as in all other thermal or

radiation based ablation techniques.

FDA status: NanoKnife received 510(k) clearance in 2008 for ablation of soft-tissuePayer coverage: For virtually all patients, there is typically no coverage by commercial health insurers,

or Medicare for IRE at this time, considered investigational

Adoption status: Progressive; because IRE is currently only performed in clinical research trials for patients

who do not qualify for other ablative methods.

Competing products: Drug therapy, surgery, radiofrequency ablation, cryoablation

Key facts

Clinical considerations: IRE has the potential to be used for larger tumors and tumors close to other vital

organs or blood vessels because it destroys the tumor through controlled cell death instead of necrosis,

which can harm neighboring cells. IRE can be used to treat kidney, liver, pancreas, and lung tumors, but

new applications are emerging for prostate, eye, and brain tumors. IRE is not expected to replace other

ablative methods for most of these tumor sites because RFA and cryoablation are both faster and cheaper,

and there is little evidence to suggest the clinical superiority of IRE; however, treatment of pancreatic cancer

is a more promising potential use for IRE because other ablative methods are not recommended to treat it.


Rate

2020

Rate

Percent

change

47382

Percute

ablate liver

RF2

$4596 $4833 5%


National market estimatesOP ablation volumes3

Who should invest?

Currently, only AMCs and large research organizations, especially those with high pancreatic cancer

volumes, should invest in IRE. Considering the system’s high investment cost and lack of evidence

showing clinical superiority over other ablative methods, IRE is not a worthwhile investment for

community cancer programs at this time.


12K

16K

4K 4K

3K4K

2018 2023

+34%

Radiofrequency

tumor ablation -

liver

+23% Cryosurgical

tumor ablation -

liver

+11% Tumor

ablation (Cryo/RF) -

Kidney



2018 2023

Magnetic Resonance-guided Focused Ultrasound SurgeryPalliative treatment is good investment for centers with high volumes of bone

cancer patients


2. Volumes



What is it?

Magnetic resonance-guided focused ultrasound surgery (MRgFUS) is a non-invasive treatment used to

thermally destroy target tissue while sparing surrounding tissues and organs. MR imaging visualizes bone

metastasis or tumor margins and allows for real-time monitoring of focused ultrasound sonication. High-intensity

focused ultrasound pinpoints a specific target and is able to raise temperatures high enough to destroy that

tissue. MRgFUS is largely used for pain palliation for metastatic bone cancer, as it ablates the nerves at the

outermost layer of the affected bone, which causes nerve denervation and subsequent pain relief.

Adoption status: Progressive; around 20 U.S. sites currently offer MRgFUS

FDA status: Approved to treat cancer in 2012

Payer coverage: Medicare coverage of MRgFUS offered in select states; covered by some private payers

for pain palliation of metastatic bone cancer

Competing products: High-dose rate brachytherapy (HDR-B), low-dose rate brachytherapy (LDR-B),

external beam radiation therapy (EBRT), surgery

Key facts


rate

2020

rate

Percent

change

C9734

Focused ultrasound

ablation/therapeutic

intervention, other than

uterine leiomyomata, with

MR guidance

$10,714 $11,899 11.1%


National market estimatesOutpatient oncology radiation therapy volumes

Who should invest?


Clinical considerations: The noninvasive nature of MRgFUS allows for minimal pain, and it is considered

a conservative treatment as it does not use ionizing radiation. MRgFUS is primarily used as a palliative

treatment for pain from bone metastases, although it is being investigated as a curative treatment of

prostate, breast, kidney, lung, and desmoid tumors.

Source: “Magnetic Resonance-Guided Focused Ultrasound (MRgFUS).” Froedtert & the Medical College of

Wisconsin, 11 Mar. 2019, https://www.froedtert.com/mrgfus; Schlesinger, David et al. “MR-guided focused

ultrasound surgery, present and future.” Medical physics vol. 40,8 (2013): 080901. doi:10.1118/1.4811136;

Advisory Board Oncology Market Estimator; Service Line Strategy Advisor research and analysis.

13.0M

14.1M

AMCs and progressive community hospitals should consider investing in MRgFUS technology to stay

competitive. Radiation oncology departments with high volumes of patients suffering from bone metastases

may see highest utilization of the treatment. However, many payers do not yet cover focused ultrasound, and

CMS offers limited coverage, which could lead patients to chose other treatment options.

+8.6%



Mohs Micrographic Surgery Significant incremental costs may price out centers with low skin cancer volumes








What is it?

Mohs Micrographic Surgery (MMS) enables complete tumor resection with less removal of healthy skin and

tissue than traditional surgical excision (TSE) Accordingly, it is most commonly used to treat skin cancers

located in critical and high-visibility areas. The procedure removes individual layers of cancer tissue and

examines them one at a time under a microscope until all cancer tissue has been removed.


Payer coverage: Covered by private payers and Medicare; Medicare generally covers 80% of the cost

Adoption status: Late majority; more commonly performed in dermatologist’s office than by hospital based

programs

Competing products: TSE, radiation therapy for late stage melanoma

Key facts

Clinical considerations: Utilized primarily for non-malignant skin cancers, including basal cell carcinoma

and squamous cell carcinoma, but also for superficial malignant melanoma in some cases; specialists feel

that MMS is not well suited for treatment of melanoma due to its unconnected growth patterns and difficulty

of histologically identifying melanoma in the frozen skin sections used in MMS


Rate

2020

Rate

Percent

change

17311

Mohs

Micrographic

Technique,

head, neck,

hands, feet,

genitalia, first

stage, up to 5

tissue blocks

$483 $497 3%

17313

Mohs

Micrographic

Technique,

trunk arms

legs, first

stage, up to 5

tissue blocks

$483 $497 3%


National market estimatesOutpatient oncology Mohs surgery volumes2

Who should invest?

AMCs, larger community centers, and other organizations with high volumes of non-malignant skin cancer

patients are best positioned to invest in MMS. The significant incremental costs associated with the time

consuming nature of the procedure, the dedicated facility requirements, and the specialized physicians

needed to perform the procedure detract from its attractiveness for community centers with lower volumes.


+44%

1.6M

2.3M

2018 2023



Road map

Medical oncology



Bone Marrow TransplantationHigh costs and low volumes make investment most attractive for large AMCs





What is it?

Bone marrow is a spongy tissue found inside the breast bone, skull, hips, ribs, and spinal column that contains

small amounts of stem cells. Stem cells are rare cells that function as the building blocks for three types of

blood cells —red blood cells, white blood cells, and platelets —and can be replaced to treat a wide variety of

conditions, including leukemia, aplastic anemia, lymphomas, and solid tumor cancers. Patients with an eligible

condition can opt to have their diseased stem cells destroyed and healthy marrow infused into their

bloodstream. If the transplant is successful, the new stem cells will migrate to the cavities of the large bones,

engraft, and begin producing normal blood cells.

Adoption status: Early adopter; over 200 programs have FACT accreditation for transplant, collection, and

processing services

FDA status: Bone marrow transplantation is the only stem cell-based treatment approved by the FDA

Competing products: Chemotherapy, hormonal therapy, NiCord (single ex-vivo expanded cord blood unit

transplantation in patients with hematological malignancies following myeloablative therapy)

Key facts

Financial outlookMedicare IPPS1 reimbursement

Who should invest?

Medical oncology

Clinical considerations: BMT is primarily used to treat hematological malignancies, including some acute

and chronic leukemia, lymphoma, and myeloma

Complex care and regulatory requirements, high volume thresholds, and high startup and ongoing costs

make offering BMT treatment most attractive for AMCs. While these characteristics of BMT have

traditionally been prohibitive for community programs seeking to invest, it has recently become a more

viable option for progressive community cancer programs as outpatient management becomes more

feasible.

MS-DRG /

HCPCSDescription 2019 rate 2020 rate

Percent

change

14 Allogenic BMT $72,962 $79,893 10%

16Autologous BMT

w CC/MCC$39,926 $43,127 8%

17Autologous BMT

w/o CC/MCC$26,749 $27,857 4%

1. Inpatient Prospective Payment System.

2. DRGs representing bone marrow transplantation; 14, 16, 17


Payer coverage: To consistently obtain full coverage, programs must be identified by either local or national

payers as a BMT Center of Excellence and have a FACT accreditation. Reimbursement typically not

available for outpatient transplants

National market estimatesBone marrow transplantation2 volumes3

19K18K

2018 2023

-8%



CAR T-Cell TherapyImmunotherapies provide options where none previously existed


2. Incidence is the number of new cases.



What is it?

Chimeric antigen receptor T-cell (CAR-T) therapy reprograms a patient’s T-cells in a lab so they will attack and

kill cancer cells. T-cells are removed from the patient’s blood, and modified in the lab with a chimeric antigen

receptor. Large numbers of these CAR T-cells are grown in the lab and infused back into the patient.

Adoption status: Early adopter; available at 130 centers around the U.S.

FDA status: First two CAR T-cell therapies approved in 2017

Payer coverage: Medicare will cover 65% of the cost of CAR T-cell therapy when it is provided at healthcare

facilities enrolled in the FDA risk evaluation and mitigation strategies (REMS) for medically-accepted

indications; private payers typically pay separately for the cellular product and then negotiate a case rate

based on the autologous stem cell transplant rate and agree to a percentage of charges all on a case-by-

case basis

Competing products: Chemotherapy, radiation therapy, stem cell transplants, targeted therapies

Key facts

MS-DRG Description 2019 rate 2020 ratePercent

change

Q2041

Axicabtagene

ciloleucel, up to

200mil cells

(Yescarta)

$395,380 $395,380 0%

Q2042Tisagenlecleucel,

up to 600mil cells

(Kymriah)

$489,764 $441,508 -10%


Who should invest?

Medical oncology

Clinical considerations: For aggressive, refractory non-Hodgkin lymphoma and for with relapsed or

refractory acute lymphoblastic leukemia up to age 25, but with more than 50 ongoing trials in solid tumors in

the U.S., more indications are likely. Since CAR T also signals the T-cells to multiply, its effects are

remarkably long lasting for a one-time infusion. Instead of needing six months of chemotherapy, the

reprogrammed T-cells can recognize and attack cancer cells if there is a relapse

With the significant clinical benefit CAR T has been shown to provide, AMCs treating a large number of

complex hematologic cancer patients are best positioned to invest in first generation CAR T pioneers such

as Kymriah and Yescarta. Community cancer centers should wait for a second or third generation of CAR T

drugs to enter the market and either the cost to decrease or reimbursement to increase to match the full cost

of the drug (not to mention the cost of labor and supplies) before considering investing.

Source: Advisory Board Cancer Incidence Estimator;


National market estimatesIncidence2 of Non-Hodgkin Lymphoma and Leukemias

71K79K

50K 56K

2018 2023

+11.6%

+12.0%

Leukemias

Non-Hodgkin

Lymphoma



Genetic TestingStrong investment for AMCs or organizations with high breast volumes

Source: US Bureau of Labor Statistics

(https://www.bls.gov/ooh/healthcare/genetic-counselors.htm),






What is it?

Genetic testing involves the assessment of genetic traits to identify cancer-predisposing mutations, stage and

type tumors, and indicate appropriate targeted therapies based on predicted tumor response. Testing has the

potential to improve care by optimizing disease prevention, diagnosis and therapy selection.

FDA status: Varies; commercial test kits must receive FDA approval before going to market

Payer coverage: CMS covers most tests under Clinical Laboratory Fee Schedule (CLFS), where

national reimbursement limit is set, but payment varies by state. Private payers reimburse genetic testing

on case-by-case basis, though BRCA1 and 2 tests consistently covered. Reimbursement depends upon

ability of tests to garner cost-savings or prevent use of unnecessary therapies

Adoption status: Late majority; 500+ genetic testing clinics in the US, according to the American College of

Medical Genetics. There are ~74,000 genetic testing products(tests, kits) in the US

Competing products: Standard pathology for diagnosis and staging

Key facts

Clinical considerations: Breast, ovarian, and colorectal cancer risk profiling are common

applications; finer disease sub-classification through genetic testing can enable better

prognosis and therapy design, with optimization of clinical outcomes


rate

2020

rate

Percent

change

81201

Apc gene

full

sequence

$780 $780 -1%

81292

Mlh1 gene

full

sequence

$675 $675 0%

81321

Pten gene

full

sequence

$600 $600 0%


National market estimatesUS Bureau of Labor Statistics Genetic Counselor Job Outlook

Who should invest?

Highly complex laboratory capability requirements make investing in in-house genetic testing most

suitable for large AMCs, especially those looking to expand market presence via community outreach

programs focused on cancer risk assessment. However, progressive community hospitals that have high

genetic counseling volumes or high breast, ovarian, and colorectal cancer volumes should also consider

developing either in-house or off-site testing as a viable option.

Medical oncology

3K

4K

2018 2023

+27%


https://www.bls.gov/ooh/healthcare/genetic-counselors.htm


2017 2024

ImmunotherapyGrowth of immunotherapy revenue suggests progressive centers should invest




What is it?

Immunotherapy triggers the immune system to find and destroy cancer. It works by ether stimulating the immune

system to fight cancer or by boosting the immune system with man-made proteins. Therapeutic antibodies are

made in a lab and used to either destroy cancer cells directly or boost the immune response; checkpoint

inhibitors, which prevent cancer cells from halting the immune response prematurely; therapeutic vaccines,

which treat patients who already have cancer; and adoptive cell therapy, which involves taking a patient’s own

T-cells out of their body, growing and activating them in vitro, and reinfusing them back into the patient.

Adoption status: Early adopter; uptake of immunotherapy increasing rapidly

FDA status: Sipuleucel-T (Provenge) became the first FDA-approved immunotherapy in 2010; Yervoy

was approved in 2011; Opdivo and Keytruda were approved in 2014, Kymriah was approved in 2017

Payer coverage: Both Medicare and private payers cover FDA-approved immunotherapy drugs, but some

require prior-authorization

Key facts


Who should invest?

Immunotherapy is a critical offering for AMCs with comprehensive infusion therapy programs. Associated

costs and operational needs make it a less viable investment for the average community cancer center,

but progressive community cancer centers should still consider adoption.

Medical oncology

Clinical considerations: Currently used to treat prostate cancer and melanoma primarily, but research on

use for other cancers in progress; although controversial for high costs, immunotherapy in clinical trials have

better progression-free survival and overall survival rates than regular therapies. Limited to specific subsets

of patients now, but broader potential applications in the future. Patients often experience severe toxicities

with immunotherapies that look different from the traditional side effects of chemotherapy.

Competing products: Gene therapy, targeted therapies


rate

2020

rate

Percent

change

Q2043Sipuleucel-T (min 50 mil

cells; single infusion)$43,419 $46,374 7%

J9228Ipilimumab injection 10mg

(Yervoy)$151 $153 1.5%

J9271Pembrolizumab injection,

1 mg (Keytruda)$49 $49 0.1%

J9299Nivolumab injection 1mg

(Opdivo)$28 $28 1%

Source: “Global Cancer Immunotherapies Market to 2024 - Increased Uptake of Immune Checkpoint Inhibitors Driving

Growth, Supported by a Large, Robust Pipeline.” Research and Markets - Market Research Reports - Welcome, July 2018,

www.researchandmarkets.com/research/9rpwcx/global_cancer?w=4; Service Line Strategy Advisor research and analysis.

National market estimatesGlobal cancer immunotherapy revenue

$33.7B

$103.4B

+206.8%


http://www.researchandmarkets.com/research/9rpwcx/global_cancer?w=4


Liquid BiopsyResearch organizations should consider investing in the detection method

1. Clinical Laboratory Fee Schedule.

2. Types of biopsies include lip, skin, thyroid, eat, larynx, nose, tongue, mouth, pharynx, salivary gland, liver, abdomen, bone marrow,

breast, colorectal, lymphatic, gynecologic, upper GI, thoracic, and urologic biopsies.




What is it?

Liquid biopsies detect cancer from blood samples (or, more rarely, urine and saliva) rather than traditional

tissue samples. They have two applications: detection (to diagnose cancer and monitor disease

progression/recurrence) and molecular profiling (to identify actionable mutations and match patients with

appropriate therapies). There are three potential sources of liquid biopsies, each with its own benefits and

drawbacks: circulating tumor cell (CTC), circulating tumor DNA (ctDNA), and exosomes ejected by tumors.

Adoption status: Progressive; only a handful of liquid biopsies on the market today, as they remain

experimental while the evidence base is still being established

FDA status: Many commercially-available liquid biopsy tests are laboratory-developed tests, and so are

monitored by CMS’ Clinical Laboratory Improvement Amendments (CLIA) and not the FDA

Payer coverage: Not covered by Medicare or private payers beyond standard imaging tests

Key facts


Who should invest?

Because liquid biopsies are still in the research phase, investment is best suited for progressive

organizations with a focus on innovative cancer research. The low cost of liquid biopsies compared to

traditional biopsies (e.g., $5,800/patient for Guardant360 liquid biopsy vs. $14,000/patient for a lung cancer

tissue biopsy) make it a viable option for both AMCs and research-focused community organizations.

Medical oncology

Clinical considerations: Liquid biopsies are less expensive and minimally invasive, especially compared to

traditional surgical biopsies. They can facilitate earlier detection, particularly in hard-to-detect cancers that

are diagnosed through imaging, and can be performed frequently, which enables clinicians to monitor

treatment response and identify new mutations as the tumor evolves. However, there is mixed evidence that

liquid biopsies are reliable and comparable to traditional biopsies.

Competing products: Standard pathology for diagnosis and staging, screening, genetic testing


rate

2020

rate

Percent

change

81445Targeted genomic seq

analysis panel, solid organ

neoplasm, 5-50 genes

$598 $598 0%

81450

Targeted genomic seq

analysis panel,

hematolymphoid neoplasm

or disorder, 5-50 genes

$760 $760 0%

Source: NILA USA Final CLFS Payment Rates 2018, 2019, and 2020 (https://www.nila-

usa.org/images/nila/FINAL%20cy_2018_final_private_payor_ratebased_clfs_payment.pdf),


National market estimatesOutpatient oncology biopsy2 volumes3

2018 2023

14.0M

15.9M +13.6%



Next-Generation SequencingNext-generation sequencing large investment with increased flexibility

Source: “North America Next Generation Sequencing Market”,

https://www.marketdataforecast.com/market-reports/north-america-next-generation-sequencing-market;

Service Line Strategy Advisor research and analysis.1. Clinical Lab Fee Schedule.



What is it?

Next-generation sequencing (NGS) enables millions or billions of DNA strands to be sequenced in parallel,

yielding significantly higher throughput than traditional technologies. Cheaper and more efficient, it typically

targets the genome (i.e. alterations in the DNA sequence), although some NGS platforms and commercial

panels also look at epigenomics (i.e. changes in gene activity outside of the DNA sequence), and

transcriptiomics (i.e. RNA). Applications in oncology include cancer risk assessments and molecular profiling of

tumors to facilitate treatment decisions.

FDA status: Most NGS panels are lab-developed tests (LDTs), which are monitored by CMS’ CLIA

regulations and not the FDA

Payer coverage: Medicare currently covers NGS tests w/FDA approval as a companion diagnostic and

indication for use in patient’s cancer type for patients with recurrent, metastatic, or advanced-stage

disease; private payer coverage is more varied, with only one-third of managed care organizations

having policies to cover biomarker tests

Adoption status: Early adopter; available at only the most progressive centers

Competing products: Standard pathology for diagnosis and staging, standard genetic testing

Key facts

Clinical considerations: Capable of whole-genome sequencing (examining the entire genome for disease

associations), exome sequencing (exome represents less than 2% of the human genome but contains a

majority of disease-causing mutations), and targeted sequencing (examines a subset of genes or region of

the genome; enables providers to focus on specific areas of interest; can achieve increased accuracy)

CPT Description2019

Rate

2020

Rate

Percent

change

81425

Genome

seq

analysis

$5031 $5031 0%

81426

Genome

seq

analysis

$2710 $2710 0%


North American market estimatesNext generation sequencing market size(USD)

Who should invest?

With the flexibility to design custom NGS panels and potential revenue associated with NGS, internally

developing a next-generation sequencing lab is a sound decision for AMCs at the forefront of precision

medicine research with high volumes of patients receiving these treatments. With the high upfront costs

associated with developing an internal lab, partnering with an external lab for NGS may be a better option

for community centers despite potentially having to sacrifice flexibility, quality control, and turnaround time.

Medical oncology

1310M

2840M

2019 2024

+117%


https://www.marketdataforecast.com/market-reports/north-america-next-generation-sequencing-market


39.8M41.4M

25.3M 26.0M

2.3M 2.6M

2018 2023

Radiomics Decision Support SystemAMCs in personalized cancer medicine space should invest to differentiate





What is it?

The field of radiomics involves the conversion of tumor images to higher-dimensional data and the subsequent

mining of online databases of images, enabling improved decision support and more focused treatment

planning.

Adoption status: Progressive; this is a recently emerging field

FDA status: Not approved; still in research phase and not commercially available yet

Payer coverage: Not covered by Medicare or private payers beyond standard imaging tests

Key facts


Who should invest?

Medical oncology

Clinical considerations: Radiomics could help better classify tumors based on 3D shape, texture, intensity,

wavelet, and other characteristics, which could help predict treatment outcomes. Intra-tumor heterogeneity

challenges treatment and genetic testing efficacy, since different parts of a single tumor may vary wildly;

significant research is still needed before clinical use.

Radiomics could be a potential differentiator for AMCs looking for cutting-edge research opportunities in the

precision medicine space, and first mover advantage could be significant if radiomics proves to be effective.

However, potential investors must ensure they have sufficiently robust data processing and warehousing

capacity or the means to build it out. Also consider the long-term financial impact of reduced volumes due to

more tailored treatment plans.



National market estimatesOutpatient oncology imaging volumes2

2.8%

Competing products: Genetic testing, PET scans

APC Description 2019 rate 2020 ratePercent

change

5571Level 1 Imaging

with Contrast$202 $182 -10%

5572Level 2 Imaging

with Contrast$386 $382 -1%

5522Level 2 Imaging

w/o Contrast$113 $112 -0.4%

5523Level 3 Imaging

w/o Contrast$231 $233 1%

5593Level 3 Nuclear

Imaging$1229 $1272 4%

5594Level 3 Imaging

w/o Contrast$1376 $1443 5%

3.9%

9.5%



Targeted Cancer TherapiesLarge number of options allow centers to increase progression-free survival rates




2. Volumes represent unique visits in the outpatient module with a primary diagnosis of cancer.



What is it?

Targeted cancer therapies encompass many classes of infusion and oral chemotherapeutics that specifically

affect tumor cells, including hormone therapies, signal transduction inhibitors, gene expression modulators,

apoptosis inducers, angiogenesis inhibitors, immunotherapies, and toxin delivery molecules. They work by

blocking the growth of cancer by interfering with molecules that control tumor progression. They differ from

traditional chemotherapy because they are able to differentiate normal cells from cancer cells, enabling more

precise treatment with fewer side effects.

FDA status: Tamoxifen, the first targeted cancer therapy drug, was approved in 1990; since then more

than 100 targeted cancer therapy drugs have been approved; in May 2017, pembrolizumab (Keytruda)

became the first drug ever to receive FDA approval for all solid tumors with a specific genetic feature,

regardless of tumor site.Payer coverage: Medicare covers targeted therapies that are FDA-approved and private payers

typically follow suit, but some require prior authorizationAdoption status: Early majority; targeted therapies are available at most cancer centers

Competing products: Standard chemotherapies such as doxorubicin, radiation therapy

Key facts

Clinical considerations: Targeted cancer therapies may be used as adjuvant therapies, first-line therapies,

or last-resort therapies after cancer has progressed. Therapies have significantly increased progression-free

survival for patients with certain cancers over a wide range of tumor sites. However, combinations of

targeted therapies are not always effective, and can result in worse outcomes for some patients


rate

2020

rate

Percent

change

J9035

Bevacizumab

injection, 10mg

(Avastin)

$79 $81 2%

J9355

Trastuzumab

injection, 10 mg

(Herceptin)

$104 $107 2%

J9271

Pembrolizumab

injection, 1 mg

(Keytruda)

$49 $49 0.1%


National market estimatesOutpatient oncology chemotherapy volumes2

Who should invest?

Targeted therapies are increasingly seen as standard of care for both AMCs and community hospitals;

however, AMCs are leading the charge on research and patient accrual for clinical trials for new

targeted therapies. Wide payer coverage and positive patient outcomes make targeted therapies a

good investment for most cancer centers.

Medical oncology

957K979K

2018 2023

+2.3%



Road map

Radiation oncology



2018 2023

4D Localization (Calypso)Invest in high-precision therapy if you have high prostate cancer volumes





What is it?

Four-dimensional (4D) localization is a technique based on the detection of small electromagnetic markers,

called Beacon transponders, which are implanted in or near a target treatment site. The Calypso system

continuously monitors these markers during radiation delivery in order to detect movements of the prostate and

provide real-time feedback. If the tumor target moves and becomes improperly aligned with the radiation beam,

radiation is stopped until the tumor repositions into the target range.

Adoption status: Progressive

FDA status: Calypso 4D Localization System approved in 2006

Major vendors: Varian (Calypso)

Competing products: Real-time adaptive radiation therapy

Key facts


rate

2020

rate

Percent

change

A4648Tissue marker,

implantable, any typen/a n/a n/a


National market estimatesProstate cancer volumes2

Who should invest?

Consider offering treatment with the Calypso 4D Localization System if you see a large number of prostate

cancer patients, as the technology is an expensive investment. The system can be used with stereotactic

body radiation therapy (SBRT) to provide highly accurate radiation treatment, and may be a competitive

differentiator within prostate cancer care.

Radiation oncology

Clinical considerations: Calypso has only been used to treat prostate cancer patients thus far, but

possibility for use to treat lung and other soft tissue cancers in the future

574K

476K

Source: Quigley, Martin M., et al. “Prostate Tumor Alignment and Continuous, Real-Time

Adaptive Radiation Therapy Using Electromagnetic Fiducials: Clinical and Cost-Utility

Analyses.” Urologic Oncology: Seminars and Original Investigations, vol. 27, no. 5, 2009, pp.

473–482. ScienceDirect, doi:https://doi.org/10.1016/j.urolonc.2008.04.017; Advisory Board

Oncology Market Estimator; Service Line Strategy Advisor research and analysis.

-16.9%



2018 2023

AccuBoost Breast RadiotherapyWise investment for centers with high volumes of early stage breast patients




What is it?

AccuBoost is an image-guided radiation therapy technique designed to improve the efficacy of the “boost dose”

irradiation delivered to the tumor cavity of women following lumpectomy. Following breast immobilization,

radiographic images are taken immediately before every treatment fraction. Tungsten applicators are then

placed on the surface of the breast, to deliver high intensity Iridium-192 from a high-dose rate brachytherapy

(HDR-B) after-loader system to the target. Treatment is performed daily over 5-10 days, prior to or after 25

daily whole breast irradiation (WBI) sessions.

Adoption status: Early adopter; utilized at over 50 sites across the U.S.


Major vendors: Advanced Radiation Therapy

Competing products: scar-guided WBI following lumpectomy

Key facts


rate

2020

rate

Percent

change

19499 Breast surgery procedure $2,816 $3,029 7.6%

77771

Remote afterloading high

dose rate radionuclide

interstitial or intracavitary

brachytherapy, includes basic

dosimetry, when performed;

2-12 channels

$705 $740 5.0%


National market estimates

Who should invest?

Radiation oncology

Clinical considerations: AccuBoost breast radiotherapy is used to treat early stage breast cancer. It is

primarily used prior to WBI, and early results suggest it may be safe for accelerated partial breast irradiation.

AccuBoost allows for more precise and accurate delivery than standard methods of scar-guided

identification and delineation of the targeted lumpectomy cavity.

55.7K

66.7K

144K

131K

HDR-B,

breast tumor site

Lumpectomy

AccuBoost is a good investment for organizations with a large number of early-stage breast cancer patients.

The treatment can be a differentiator among comprehensive breast centers, providing patients with a less-

invasive treatment option that can improve both cosmetic and morbidity outcomes.




-9.1%

+19.7%



Carbon Ion TherapyAMCs and research institutions uniquely positioned to invest due to high costs

Source: Bortzfield, B, WJCT “Mayo Clinic To Build North America’s First Carbon Ion Therapy Unit In Jacksonville”,

“https://news.wjct.org/post/mayo-clinic-build-north-americas-first-carbon-ion-therapy-unit-Jacksonville”, Advisory Board Oncology Market Estimator;



2. Volumes represent unique visits for patients with a primary diagnosis of cancer. For radiation

therapy, each visit represents a treatment or fraction, not a whole course of therapy.



What is it?

Carbon ion therapy directs particularly heavy charged carbon nuclei at a tumor, irradiating and destroying the

cells. Similar to proton therapy, which uses the charged nuclei of hydrogen atoms, this is in contrast to

traditional radiation therapy carried out with much lighter photons.

FDA status: Not approved; Mayo plans to work closely with Hitachi, who makes the equipment, to gain

approval through research

Payer coverage: Treatment is not covered by Medicare or private payers in the US

Adoption status: While there are 13 carbon ion centers worldwide already serving 22,000 patients, there

are currently no sites performing carbon ion therapy in the US; the Mayo Clinic is currently building the first

carbon ion therapy treatment facility in the US, expected to be completed in 2023

Competing products: Drug therapy, surgery, traditional radiation therapy, proton therapy

Key facts

Clinical considerations: Carbon ion therapy is similarly precise to proton therapy, but as carbon ions are

heavier, they deliver more power than protons do. Accelerated particles deliver their energy in a delayed

burst, so that very little damage occurs to normal tissue as the beam enters the body and power is

concentrated at the tumor where the particle track stops. Carbon centers abroad have reported high survival

rates post treatment for a variety of tumor sites (including head and neck, lung, GI, etc.) but it is particularly

effective for hard-to-treat bone and soft-tissue cancers such as spinal tumors.


rate

2020

rate

Percent

change

77520

Proton trmt

simple w/o

comp

$520 $539 4%

77522

Proton trmt

simple w/

comp

$1,079 $1,247 16%

77525Proton trmt

complex$1,079 $1,247 16%


National market estimatesOutpatient proton beam treatment volumes2

Who should invest?

AMCs and research institutions are best suited to establish carbon ion centers. The $300 million price

tag of establishing such a center will price out community centers for years to come. Since there is

currently no coverage for this treatment, cancer centers with large populations of patients who can pay

out of pocket will be uniquely positioned to take advantage of this niche treatment.

Radiation oncology

233K

267K

2018 2023

+14.7%



CT SimulationDedicated simulator good investment for high-volume RT departments

1. Hospital Outpatient Prospective Payment System,.




What is it?

CT simulation uses a CT scanner to acquire 3D images of a tumor and surrounding anatomy that allows

providers to accurately plan for radiation therapy (RT). CT simulators include a CT scanner (usually 4- or 16-

slice), orthogonal wall or ceiling-mounted lasers for patient localization, and a simulation software to render the

CT slices as a 3D image, used to localize the tumor and plan the RT treatment.

Adoption status: Conservative; hundreds of institutions within the U.S. use CT simulations

FDA status: Various approved devices on the market

Major vendors: GE, Philips, Siemens, Toshiba

Competing products: Conventional two-dimensional (2D) simulation with kV x-rays

Key facts

APC Description2019

rate

2020

rate

Percent

change

5611

Level 1 Therapeutic

Radiation Treatment

Preparation: Set Radiation

Therapy Field

$124 $127 2.4%

5612

Level 2 Therapeutic

Radiation Treatment

Preparation: Set Radiation

Therapy Field

$322 $335 4.0%

5613

Level 3 Therapeutic

Radiation Treatment

Preparation: 3D

Radiotherapy Plan

$1,192 $1,245 4.4%


National market estimatesExternal beam radiation therapy volumes2

Who should invest?

Radiation oncology

Clinical considerations: CT simulation enables more dynamic visualization of the target and, thus, more

accurate placement of radiation beams and more conformal treatment as compared to conventional

simulation with 2D x-ray images

CT simulators are a viable investment for all organizations offering radiation therapy treatment, as CT

simulation is considered “standard of care”. However, investment in a dedicated CT simulator for the

radiation therapy department is best suited for organizations experiencing or anticipating capacity

constraints on CT scanners currently used for simulation; the increasing use of 3D and 4D CT for

dosimetry is also likely to justify investment in a dedicated CT simulator.



2018 2023

5.6M

7.1M

46K 63K

6.7M

6.2M

IMRT

SBRT

21.3K 21.4K

+26.1%

-6.9%

+37.4%

+0.5%

SRS



2018 2023

High-Dose Rate BrachytherapyHDR-B is a standard care offering for a comprehensive cancer center

Source: “New Clinical Brachytherapy Codes in 2016.” AAPC Knowledge

Center, 7 Mar. 2016, https://www.aapc.com/blog/33907-new-clinical-

brachytherapy-codes-in-2016/; Advisory Board Oncology Market

Estimator; Service Line Strategy Advisor research and analysis.





What is it?

High-dose rate brachytherapy (HDR-B) delivers radiation through catheters and applicators implanted directly

into the tumor site or tumor bed. Catheters (interstitial) or applicators (intracavitary) are inserted into the

treatment site. After treatment planning, the applicators are connected with wires to a remote afterloader, which

delivers the radioactive sources to the tumor sites.

Adoption status: Late majority; approximately 1,000 sites in the U.S.

FDA status: Nucletron microSelectron approved in 2004; Nucletron Flexitron approved in 2007; Varian

GammaMedplus and Varisource approved in 2007

Major vendors: Nucletron (acquired by Elekta in 2011); Varian Medical Systems

Competing products: External beam radiation therapy, surgery, low-dose rate brachytherapy (LDR-B)

Key facts

HCPCS Description 2019 rate 2020 ratePercent

change

0394THDR electronic

skin surface

brachytherapy

$224 $236 5.4%

77770,

77771,

77772

Remote

afterloading high

dose rate

radionuclide

interstitial or

intracavitary

brachytherapy

$705 $740 5.0%


National market estimatesOutpatient high-dose rate brachytherapy volumes2

Who should invest?

Although the use of HDR-B has declined substantially over the last decade as sophisticated (and better

reimbursed) surgical techniques and EBRT technologies have gained popularity, brachytherapy’s clinical

efficacy is well established, and the technology is essential for all comprehensive cancer centers.

Radiation oncology

Clinical considerations: Primarily used to treat prostate, gynecologic, breast, head and neck, and

esophageal cancers. HDR-B can be used not only as a supplement to surgery, but also as a standalone

therapy.

364K

304K

+19.7%



Image-Guided Radiation TherapyIGRT considered standard of care treatment offering

Source: Zelefsky et al., “Improved Clinical Outcomes with High–Dose Image Guided Radiotherapy Compared

with Non-IGRT for the Treatment of Clinically Localized Prostate Cancer,”Int J of Rad Onc. Biol. Phys. 2012

Simpson et al., “A Survey of Image-Guided Radiation Therapy Use In The United States,” Cancer, 2010;




What is it?

Image-guided radiation therapy (IGRT) involves systematically (often daily) imaging the patient on the

treatment table immediately prior to treatment delivery, in order to verify tumor location. Conventional IGRT

includes planar imaging and volumetric imaging; IGRT may be practiced with an array of imaging modalities,

including cone-beam CT, stereoscopic kV X-rays, MV port films, and fluoroscopy; it also may be used with

IMRT or 3D CRT.

Adoption status: Late majority; over 90% of RT programs in the U.S. use IGRT

FDA status: Multiple FDA-approved devices on the market

Major vendors: BrainLAB, Elekta, Siemens, TomoTherapy, Varian, ViewRay

Competing products: Three-dimensional conformal radiation therapy (3D CRT), intensity-modulated

radiation therapy (IMRT)

Key facts


change

5621Level 1 Radiation

Therapy$117 $123 5.1%


Therapy$224 $236 5.4%


Therapy$520 $539 3.7%


Who should invest?

Radiation oncology

Clinical considerations: Particularly effective for prostate, lung, head and neck lesions; confirms patient

and tumor position and enables treatment modification prior to RT. IGRT technology must be combined

with consistent high-quality treatment planning and delivery procedures in order to achieve superior results.

IGRT is a necessary investment for any facility offering radiation therapy as a treatment option, as it is

considered “standard of care”.

2018 2023

National market estimatesOutpatient oncology radiation therapy volumes2

13.0M

14.1M



+8.6%



2018 2023

5.6M

Intensity-Modulated Radiation TherapyIMRT widely regarded as standard offering for comprehensive cancer programs





What is it?

Intensity-modulated radiation therapy (IMRT) technology utilizes inverse treatment planning software and a

multileaf collimator (MLC) to produce a more optimal dose delivery plan and conformal radiation beam. Inverse

treatment planning uses a computer algorithm to calculate beam angles and doses for a given target. The MLC

is used to generate a beam according to the optimized treatment plan, creating a more conformal dose

distribution.

Adoption status: Late majority; clinical use of IMRT is widespread

Major vendors: LINAC technologies: Accuray, Elekta, Varian

Treatment planning software: Brainlab, ViewRay

Key facts


change

77338 MLC device for IMRT $322 $335 4.0%

77385Ntsty modul rad tx dlvr

simple$520 $539 3.7%


complex$520 $539 3.7%


National market estimatesOutpatient oncology IMRT volumes2

Who should invest?

Radiation oncology

IMRT is considered a standard offering for AMCs and community hospitals alike. Any institution hoping to boast

a comprehensive cancer center should invest in IMRT technology in order to be competitive.

Competing products: Three-dimensional conformal radiation therapy (3D CRT), image-guided radiation

therapy (IGRT)

FDA status: First IMRT system approved in the 1990s

7.1M

Clinical considerations: Allows for higher and more effective doses, reduced side effects, and improved

treatment outcomes over 3D CRT. Most commonly used in treating prostate, head and neck, and central

nervous system tumors; in limited situations, also used to treat breast, thyroid, lung, gastrointestinal, and

genitourinary tumors



+26.1%



2018 2023

Intraoperative Radiation TherapyInvest in IORT if you have high volumes of breast cancer patients



What is it?

Intraoperative radiation therapy (IORT) is the delivery of radiation directly to the tumor site during surgery.

IORT can be delivered via miniaturized or self-shielded platforms in the operating room, or by patient transport

to a shielded vault. During surgery, a radiation delivery platform, such as a LINAC or high-dose rate (HDR)

afterloader, is attached to an applicator to guide radiation delivery. The applicator is directed to the exposed

tumor bed while the surrounding tissue is shielded, allowing delivery of high-dose radiation.

Adoption status: Early adopter; 17 U.S. sites using Mobetron, ~50 sites using Intrabeam, 10-20 centers

using HDR IORT

FDA status: Mobetron approved in 1998, Intrabeam in 2005, Xoft electronic brachytherapy in 2009

Major vendors: IntraOp Medical Corporation (Mobetron), Carl Zeiss Meditech AG (Intrabeam), iCAD Inc.

Competing products: Whole breast irradiation (WBI), surgery, external beam radiation therapy (EBRT),

brachytherapy

Key facts


rate

2020

rate

Percent

change

77424Intraoperative radiation

treatment delivery, x-ray$7,644 $7,942 3.9%

77425Intraoperative radiation

treatment delivery,

electrons

$7,644 $7,942 3.9%


National market estimatesOutpatient lumpectomy volumes2

Who should invest?

Radiation oncology

Clinical considerations: IORT enables delivery of a higher dose, since the radiation does not need to pass

through surrounding structures. IORT is primarily used for breast cancer; also some use for gastric, head &

neck, rectal, prostate, and skin cancers



144K

131K

IORT is a suitable investment for organizations with comprehensive cancer programs seeking to offer

advanced radiation therapy treatment options, especially those that have a high volume of breast cancer

patients. Given IORT’s ability to potentially shorten the course of treatment, it could be an especially

attractive investment opportunity for programs looking to increase throughput and capacity. However, the

additional staffing costs associated with the fact that the procedure requires both radiation oncologist and

surgeon involvement may be prohibitive for some organizations.

-9.1%





2018 2023

Low-Dose Rate BrachytherapyGood investment for programs with high prostate cancer patient volumes







What is it?

Low-dose rate brachytherapy (LDR-B) involves the permanent placement of small radioactive “seeds” which

irradiate the entire tumor from within while minimizing radiation exposure to surrounding healthy tissue.

Typically, a computer-generated plan is used to calculate the optimal seed placement configuration and dose

distribution. Needles are then inserted into the tumor site using ultrasound guidance, through which the seeds

are deposited through the needles and immediately begin delivering radiation.

Adoption status: Conservative; LDR-B is a widely-accepted first-line treatment for early stage prostate

cancer

FDA status: Major contemporary products received approval in early 2000s

Major vendors: IsoRay Medical, Inc., MDS Nordion, Oncura Brachytherapy, Theragenics Corporation

Key facts


change

77789Surface application

of low dose rate

radionuclide

$117 $123 5.1%

77763

Intracavitary

radiation source

application;

complex

$704 $740 5.1%


National market estimatesOutpatient low-dose rate brachytherapy volumes2

Who should invest?

Radiation oncology

69K

60K

LDR-B is a sound investment for AMCs and community hospitals with high volumes of prostate cancer

patients, as both patients and clinicians often prefer LDR-B over EBRT due to its minimally invasive nature,

short treatment time, and superior dose conformity.

-12.9%

Competing products: External beam radiation therapy (EBRT), surgery, high-dose rate brachytherapy

(HDR-B), electronic brachytherapy

Clinical considerations: Primarily utilized for treatment of prostate cancer, but some use for lung, head

and neck, breast, cervix, and liver cancers; also used to treat resected brain metastases. LDR-B is often

used in concert with surgery.



2018 2023

Magnetic Resonance Image Guided-Radiation TherapyLarge investment in high precision therapy suitable for progressive centers

Source: Simpson et al., “A Survey of Image-Guided Radiation Therapy Use In The United States,” Cancer, 2010. Elekta. Elekta Unity, 2020,

https://www.elekta.com/radiotherapy/treatment-delivery-systems/unity/. “Mridian Locator - ViewRay - MRIdian MRI-Guided Linac.” ViewRay,

2018, https://viewray.com/mridian-locator/; Advisory Board Oncology Market Estimator; Service Line Strategy Advisor research and analysis.



What is it?

Magnetic resonance image (MRI)-guided radiation therapy is a newer, more precise form of image-guided

radiation therapy (IGRT). The system combines MRI technology with either a cobalt-60 or linear accelerator

radiation therapy machine; the captured images of anatomical structures can be used to improve the precision

and accuracy of the radiation beam and conduct in-the-moment changes to the treatment plan. MRI-guided

radiation therapy is advantageous because it creates images of anatomical structures without exposing

patients to additional radiation, so patients can be imaged more frequently. Additionally, MRI produces images

with greater detail than conventional imaging.

Adoption status: Progressive; ViewRay technology currently offered at 15 sites across the US, Elekta Unity

offered at 3 centers in the US and for research purposes in Europe

FDA status: ViewRay MRIdian MRI-Guided LINAC approved in 2017, Elekta Unity MR-LINAC approved in

2018

Competing products: Conventional IGRT, three-dimensional conformal radiation therapy (3D CRT),

intensity-modulated radiation therapy (IMRT), real-time adaptive radiation therapy

Key facts



Who should invest?

Radiation oncology

Clinical considerations: Greatest impact for tumor sites where anatomy is most complicated or dynamic,

such as abdomen, head and neck, lung, brain, and sites near soft tissue; produces images of actual

anatomy, not surrogates, with no additional radiation dose, confirms patient and tumor position, and enables

treatment modification prior to radiation therapy

13.0M

14.1M

Given the high cost and unproven clinical superiority, MRI-guided radiation therapy is an investment best

suited for progressive cancer programs seeking to use it for research or to differentiate themselves in a

competitive market. This technology may also be particularly attractive to cancer programs receiving or

preparing for value-based payment, as it has the potential to reduce the total of care by providing radiation

in a fewer number of fractions and reducing side effects by decreasing irradiation of normal tissue.


rate

2020

rate

Percent

change

77402 Radiation treatment delivery $117 $123 5.1%

77407, 77412 Radiation treatment delivery $224 $236 5.4%

773872

Guidance for localization of

target volume for delivery of

radiation treatment delivery

n/a n/a n/a


2. Not separately reimbursable but should be reported for tracking purposes.


+8.6%



Multi-Functional Linear Accelerator (LINAC)





What is it?

Multi-functional LINAC (MFL) platforms are optimized for the treatment of intra- and extracranial lesions with

stereotactic radiosurgery (SRS) and stereotactic body radiation therapy (SBRT), respectively, as well as

conventional and intensity-modulated therapy (IMRT) treatments. MFLs utilize a variety of integrated image-

guidance systems, including stereoscopic kV X-ray, MV X-ray, and cone-beam CT, in addition to high

resolution beam shaping capabilities and stereotactic coordinate-based tumor localization, to enable delivery of

single- and hypo-fractionated treatments to lesions located in close proximity to critical structures.


FDA status: First MFL platforms approved in 2000s

Competing products: Three dimensional conformal radiation therapy (3D CRT), intensity-modulated

radiation therapy (IMRT), image-guided radiation therapy (IGRT), SRS/SBRT on other platforms

Key facts


Who should invest?

Multi-functional LINAC platforms are increasingly viewed as a competitive imperative to retain a range of oncology

patients. Radiosurgery offerings typically require additional staff training, and investment in the technology should

follow neurosurgeon and radiation oncologist buy-in for performing SRS and SBRT on the platform. It is important

to evaluate the size of regional and local RT market, especially for SRS- and SBRT-eligible patient volumes, before

investing.

Radiation oncology

Invest in multi-functional LINAC platforms for range of advanced RT capabilities


change

5621Level 1

Radiation Therapy$117 $123 5.1%

5622Level 2


5623Level 3


5626Level 6

Radiation Therapy$1,691 $1,768 4.6%

5627Level 7

Radiation Therapy$7,644 $7,942 3.9%

National market estimatesExternal beam radiation therapy volumes2

Clinical considerations: MFL combines advanced imaging, highly accurate beam collimation, motion

management, and (typically) robotic patient positioning in a single, flexible platform

2018 2023

5.6M

7.1M

46K63K

6.7M

6.2M

IMRT

SBRT

21.3K21.4K

+26.1%

-6.9%

+37.4%

+0.5%



SRS

3D CRT

Major vendors: Varian (TrueBeam), Elekta (Infinity), Siemens (Oncor)



2018 2023

Proton Beam TherapyLarge investment, due to high costs, more suitable for AMCs


Service Line Strategy Advisor research and analysis. This document does not constitute professional legal advice. Advisory Board does not endorse any companies, organizations or their products as identified or mentioned herein.


What is it?

Proton beam therapy (PBT) is an external beam radiation treatment that delivers protons (as opposed to

electrons or photons) to a precise target in the body. A particle accelerator is used to manipulate a beam of

protons. The maximum energy dose is released at an adjustable depth in the body, achieved by varying the

speed of the particles.

Adoption status: Progressive; 30 centers currently operating in the U.S.

FDA status: Only certain large-scale and single-room models FDA approved at this time

Major vendors: IBA; Hitachi; Mevion Medical; Mitsubishi Electric; Optivus; Protom International; Varian;

Sumitomo Heavy Industries; CPAC

Competing products: Conventional radiation therapy, surgery, intensity-modulated radiation therapy,

(IMRT), image-guided radiation therapy (IGRT), stereotactic radiosurgery (SRS)/stereotactic body radiation

therapy (SBRT)

Key facts


change

77520Proton trmt

simple w/o comp$520 $539 3.7%

77522Proton trmt

simple w/comp$1,079 $1,247 15.6%

77523Proton trmt

intermediate$1,079 $1,247 15.6%

77525Proton trmt

complex$1,079 $1,247 15.6%


National market estimatesOutpatient oncology proton beam therapy volumes2

Who should invest?

AMCs are generally the best candidates for proton therapy investment due to the technology’s high cost,

though the advent of smaller scale models may make it more accessible to a broader market, including

community hospitals.

Radiation oncology

Clinical considerations: Recognized for equivalence or superiority to conventional radiation therapy in

treatment of pediatric, prostate, ocular tumors and skull-based chordomas

233K

267K +14.7%





Radiosensitivity TestingProgressive AMCs focused on personalized medicine should invest

Source: Advisory Board Oncology Market Estimator; Service

Line Strategy Advisor research and analysis.This document does not constitute professional legal advice. Advisory Board does not endorse any companies, organizations or their products as identified or mentioned herein.


What is it?

Radiosensitivity testing is a new approach to improving the effectiveness of radiation therapy while reducing

toxicity. It identifies genetic markers that provide information about how tumors are likely to respond to

radiation, using multi-gene expression assays. That information can then be used to calculate a radiosensitivity

index (RSI) to determine whether a particular patient is likely to benefit from radiation therapy, and, if so, refine

the treatment plan accordingly. The RSI score is used to identify the optimal radiation dose for a patient’s

specific tumor; a low RSI score indicates tumor cell is radiosensitive (i.e., unlikely to survive radiation therapy).


FDA status: Not yet FDA approved; assays still in research and development phase

Key facts

HCPCS2 Description 2019 rate 2020 ratePercent

change

81201Apc gene full

sequence$780 $780 -1%

81292Mlh1 gene

full sequence$675 $675 0%

81321Pten gene

full sequence$600 $600 0%


Who should invest?

Radiosensitivity testing could be a clinical differentiator for AMCs. Although the test is still in development,

progressive institutions interested in innovative research possibilities within precision medicine should

consider from investing in the technology. This test may also be an appealing investment for institutions

receiving or preparing for value-based payment that are looking for innovative ways to reduce costs

associated with unnecessary care utilization and improve outcomes.

Radiation oncology

Clinical considerations: The assay has been used to identify stage 2-3 rectal cancer patients who will not

benefit from pre-operative chemoradiation. Research shows promise for use in head & neck, non-small-cell

lung, and breast cancers, as well.

2018 2023


13.0M

14.1M

Major vendors: Cvergenx

+8.6%

1. Clinical Laboratory Fee Scheduling.

2. Reimbursement codes not specifically for radiosensitivity testing, but may give an idea of what those codes may look like in the future.


Payer coverage: Currently only covered for clinical trial patients



Real-Time Adaptive Radiation TherapyRelatively small invest to upgrade systems for centers currently offering IGRT

Sources: Simpson et al., “A Survey of Image-Guided Radiation Therapy Use In The United States,” Cancer, 2010.,

“Accuray Precision® Treatment Planning.” Accuray, Precise, Innovative Tumor Treatments | Accuray, 28 May 2019,

https://www.accuray.com/software/precision-treatment-planning/; Advisory Board Oncology Market Estimator;




What is it?

Real-time adaptive radiation therapy is an advanced form of image-guided radiation therapy (IGRT). The goal

is to adjust the radiation beam in response to small movements in the patient created by breathing or digestion.

The system’s software uses information produced by beacons implanted near the tumor to re-shape the beam.

Real-time adaptive software translates tumor motion into beam motion, and the result is a radiation beam that

changes shape with the tumor.

Adoption status: Progressive; still in research and development phase, but expected to become more

widely available within next few years

FDA status: Accuray software approved in 2016

Major vendors: Accuray (PreciseART software)

Key facts

Who should invest?

Radiation oncology

Clinical considerations: Greatest potential impact for tumor sites where anatomy is most complicated or

dynamic, such as prostate, abdomen, head and neck, lung, brain, and sites near soft tissue.

Any cancer program that already has IGRT should consider investing in real-time adaptive radiation

therapy, as it only requires a relatively low-cost software upgrade from conventional IGRT.


change

77402Radiation

treatment delivery$117 $123 5.1%

77407,

77412Radiation

treatment delivery$224 $236 5.4%

Competing products: MRI-guided radiation therapy

2018 2023


13.0M

14.1M +8.6%






2018 2023

Respiratory GatingSignificant clinical results justify relatively small investment for GI tumor programs





What is it?

Respiratory gating uses computer software to guide the delivery of radiation as a patient breathes. Respiratory

movements can sometimes shift tumor location, especially if located in the lungs, chest, or abdomen.

Respiratory gating works either through the use of external devices to predict or control the patient’s breathing,

or through specialized software, which allows radiation oncologists to define a treatment field and then deliver

radiation only when the tumor passes through the defined region. Four-dimensional CT simulation is used to

determine tumor motion.


FDA status: Real-time Position Management system from Varian approved in 2000s, Anzai system from

Siemens approved in 2019

Major vendors: Varian (Real-time Position Management), Siemens (Anzai), Elekta (Active Breathing

Coordinator), Dyn’R (SDX System)

Competing products: Real-time adaptive radiation therapy, deep inspiration breath hold technique

Key facts


rate

2020

rate

Percent

change

77387Guidance for radiation

treatment deliveryn/a n/a n/a


Who should invest?

Respiratory gating technology is a worthwhile investment for cancer programs with high volumes of lung,

stomach, pancreas, and liver cancer patients. However, each program will need to carefully weigh the

clinical benefits against the costs when deciding between investing in relatively low-cost respiratory gating

software that can be added to current radiation therapy platforms and higher-cost respiratory gating devices.

Radiation oncology

Clinical considerations: Shown to be most effective for tumors located in regions such as the lungs,

stomach, pancreas, and liver.

Source: Giraud, Philippe, and Annie Houle. “Respiratory Gating for Radiotherapy:

Main Technical Aspects and Clinical Benefits.” ISRN Pulmonology, vol. 2013, Jan.

2013, pp. 1–13., doi:10.1155/2013/519602; Advisory Board Oncology Market

Estimator; Service Line Strategy Advisor research and analysis.


+8.6%

13.0M

14.1M



2018 2023

Single-Room Proton Beam TherapySmaller-scale models may allow more community hospitals to offer PBT





What is it?

Single-room proton beam therapy (PBT) systems are compact, single-vault solutions for radiation that deliver

protons to a precise target in the body. Like the original multi-room proton therapy systems, a particle

accelerator is used to manipulate a beam of protons. The speed of the particles can be varied to deliver a

maximum energy dose at a specific depth in the body.

Adoption status: Progressive; offered at over 300 different sites around the U.S.

FDA status: Multiple devices approved, beginning in 2014

Major vendors: IBA (ProteusONE), Mevion Medical (S250), Varian (ProBeam), ProTom (Radiance 330)

Competing products: Chemotherapy, surgery, conventional radiation therapy, intensity-modulated

radiation therapy (IMRT), image-guided radiation therapy (IGRT), three-dimensional conformal radiation

therapy (3D CRT), stereotactic radiosurgery (SRS), stereotactic body radiation therapy (SBRT), multi-room

proton bream therapy systems

Key facts


rate

2020

rate

Percent

change

77522Proton treatment, simple

with compensation$1,079 $1,247 15.6%

77523Proton treatment,

intermediate$1,079 $1,247 15.6%

77525Proton treatment,

complex$1,079 $1,247 15.6%


National market estimatesOutpatient proton beam therapy volumes2

Who should invest?

Radiation oncology

Clinical considerations: Recognized for equivalence or superiority to conventional radiation therapy in

treatment of pediatric, prostate, ocular tumors and skull-based chordomas. Clinical trials for additional sites

are emerging and ongoing. The perceived benefits of PBT over conventional RT spurred clinical interest,

despite the lack of long-tem clinical studies

233K

267K

Although single-room proton beam therapy is still an investment best suited for AMCs, it’s lower cost

compared to multi-room proton beam therapy also makes it a viable option for progressive community

centers that see high volumes of patients eligible for this treatment. However, community centers evaluating

this technology should be sure to consider the specially trained clinical and physics staff required to operate

the technology as part of the investment cost.



+14.7%



2018 2023

SpaceOAR HydrogelCenters treating high numbers of prostate cancer patients should invest





What is it?

SpaceOAR Hydrogel minimizes rectal injury in men receiving radiation therapy for prostate cancer that is not

locally advanced. The spacer pushes the rectum away from the prostate, moving it out of the region affected by

high-dose radiation and thus preventing any damage to the cells in the rectum. Implantation of the spacer

should be done before the start of radiation treatment, and can be used with all types of radiation therapy,

including external beam radiation therapy (EBRT), brachytherapy, stereotactic body radiation therapy (SBRT),

and proton beam therapy. Hydrogel remains in the body for around 3 months and is then absorbed and cleared

in the patient’s urine within 6 months.



Major vendors: Boston Scientific

Payer coverage: Widely covered by most private payers

Key facts


rate

2020

rate

Percent

change

55874

Transperineal

placement of

biodegradable material,

peri-prostatic, single or

multiple injection(s),

including image

guidance, when

performed

$4,020 $4,231 5.2%


National market estimatesRadiation therapy volumes2 for prostate cancer patients

Who should invest?

Radiation oncology

Clinical considerations: SpaceOAR Hydrogel has been found to have multiple benefits for patients,

including reduced rectal toxicity rates, preserved sexual function post-treatment, and overall improved long-

term quality of life.

Comprehensive cancer programs that treat high volumes of prostate cancer patients should consider

investing in SpaceOAR Hydrogel. The many patient benefits give it the potential to be an effective

differentiator for prostate cancer centers of excellence in highly competitive markets.



3.4M

3.9M +15.4%



2018 2023

Stereotactic Body Radiation TherapyEnsuring physician support, identifying referral sources imperative for investment







What is it?

Stereotactic body radiation therapy (SBRT) involves the precise delivery of a high dose of ionizing radiation

over a few delivery sessions to a localized malignancy, in order to kill tumor cells and prevent future growth.

The therapy is most commonly delivered via use of a linear accelerator. Through the use of three-dimensional

coordinate-based treatment planning and dose delivery, a specific area encompassing the tumor receives high

dose radiation from multiple beams.

Adoption status: Early majority; offered at over 300 different sites around the U.S.

FDA status: Approved in the 2000s for major manufacturers

Major vendors: Accuray, BrainLAB, Elekta, Siemens, Varian

Competing products: Intensity-modulated radiation therapy (IMRT), three-dimensional conformal radiation

therapy (3D CRT)

Key facts


rate

2020

rate

Percent

change

77290 Set radiation field $322 $335 4.0%

77295 3-d radiotherapy plan $1,192 $1,245 4.4%

77373 SBRT delivery $1,691 $1,768 4.6%


National market estimatesOutpatient oncology SBRT volumes2

Who should invest?

Radiation oncology

Clinical considerations: Typically used to treat early-stage non-small cell lung tumors; other investigative

sites include small-to-medium size tumors in prostate, liver, abdomen, and spine. There is emerging clinical

evidence of effectiveness over competing modalities, though long-term studies are ongoing. SBRT may

attract referrals for patients with complex tumors or those who are poor candidates for surgery.

45.9K

63.0K

SBRT is still a worthwhile investment for AMCs treating complex tumor sites looking to differentiate

themselves in a competitive market. As clinical evidence of the benefits of SBRT grows, SBRT is becoming

the new normal at progressive AMCs. The number of private practices starting to use SBRT is also

increasing. Having a dedicated multidisciplinary team of radiation oncologists, other specialists, and

dosimetry support to manage SBRT utilization is an important key for investment success.

+37.4%



2018 2023

Stereotactic RadiosurgeryDedicated SRS system suited for strong brain tumor programs





What is it?

Stereotactic radiosurgery (SRS) involves the highly precise, 3D coordinate-based delivery of high-intensity

ionizing radiation to destroy malignant and benign intracranial tumors. SRS can be delivered by a variety of

radiation therapy machines, from a dedicated cobalt-based device — the Gamma Knife — to LINAC-based

platforms. A 3D coordinate-based localization and treatment planning system enables accurate tumor

localization and delivery of high-dose radiation to the tumor with minimal dose to surrounding tissues.

Adoption status: Early majority; over 110 Gamma Knife units and over 2,000 multifunctional LINAC

sites in the U.S.

FDA status: Numerous devices approved by FDA, since the 1980s

Major vendors: Accuray (CyberKnife), Elekta (Leksell GammaKnife) , Varian (Edge, HyperArc)

Competing products: Surgical resection, whole-brain radiation

Key facts


change

77371SRS,

multisource$7,644 $7,941 3.9%

77372SRS, linear

based$7,644 $7,941 3.9%


National market estimatesOutpatient oncology stereotactic radiosurgery volumes2

Who should invest?

Radiation oncology

Clinical considerations: Utilized in the treatment of primary and metastatic intracranial tumors,

arteriovenous malformations, and functional disorders; minimal fractionation (1-5 fractions) compared to

traditional radiation therapy

21.3K

21.4K

Due to the expensive and specialized nature of the platform, investing in a dedicated SRS machine is best

suited for organizations with a strong brain tumor program with high volumes looking to increase their

subspecialization. While the high cost of dedicated SRS machines is prohibitive for many organizations,

the option of delivering LINAC-based SRS by using lower-cost add-on components with an existing

LINAC removes some of the financial barriers to investment.

Source: Advisory Board Oncology Market Estimator; Service

Line Strategy Advisor research and analysis.

+0.5%



Surface-Guided Radiation TherapyModerate cost and high potential patient throughput makes for a wise investment

Source: Guo, B. et al. "Surface Guided Radiation Therapy (SGRT): The Sensitivity Of The Region Of Interest (ROI) Selection On

The Translational And Rotational Accuracy For Whole Breast Irradiation". International Journal Of Radiation Oncology *Biology*

Physics, vol 99, no. 2, 2017; Herron, E. et al. "Surface Guided Radiation Therapy As A Replacement For Patient Marks In

Treatment Of Breast Cancer". International Journal Of Radiation Oncology *Biology* Physics, vol 102, no. 3, 2018; Kügele, Malin et

al. "Surface Guided Radiotherapy (SGRT) Improves Breast Cancer Patient Setup Accuracy". Journal Of Applied Clinical Medical

Physics, vol 20, no. 9, 2019; Advisory Board Oncology Market Estimator; Service Line Strategy Advisor research and analysis.





What is it?

Surface-guided radiation therapy (SGRT) is a tattoo-free radiation therapy that uses stereo vision technology to

monitor a patient’s external surface to ensure they are in the correct position before and during their radiation

treatment. SGRT checks the surface position during treatment and matches with data captured in the planning

or simulation process. Using SGRT, as opposed to marker-based techniques, allows for improved accuracy,

patient satisfaction, and throughput.


Major vendors: Vision RT, C-RAD

FDA status: Vision RT device approved in 2006

Key facts


Who should invest?

Radiation oncology

Clinical considerations: Current use of SGRT for sites from head to toe, including, but not limited to,

brain, breast, and head & neck cancers. SGRT reduces need for immobilization and makes certain that

patients are in the required position for treatment in all six degrees of freedom.

The moderate cost of SGRT equipment, coupled with high potential patient throughput and thus low cost

per patient, makes the procedure a manageable investment for mid- to large-size programs. The added

benefits of SGRT compared to alternative methods means progressive centers have the opportunity to

differentiate themselves, but it is important to ensure patient volumes are high enough and there is

physician buy-in before investing.


Rate

2020

Rate

Percent

Change

77387

Guidance for

localization of target

volume for delivery

of radiation

treatment, includes

intrafraction tracking

n/a n/a n/a

Competing Products: Image-guided radiation therapy (IGRT), three-dimensional conformal radiation

therapy (3D CRT), intensity-modulated radiation therapy (IMRT)

2018 2023

National market estimatesOutpatient radiation therapy volumes3

13.0M

14.1M +8.6%



2018 2023

Three-Dimensional Conformal Radiation TherapyUseof 3D CRT technology considered standard care offering





What is it?

Three-dimensional conformal radiation therapy (3D CRT) incorporates the use of highly-detailed imaging

technologies to plan the delivery of concentrated radiation dosage to a tumor. Using the three-dimensional

(3D) images of a patient’s tumor and surrounding organs, a more precise and effective radiation dose is

delivered directly to cancerous cells, while sparing nearby normal tissue. 3D images can be created using

either CT, MRI, PET, or PET-CT imaging technologies.

Adoption status: Late majority; used extensively but being replaced by IMRT for complicated body sites

FDA status: Approved in early 2000s

Major vendors: LINAC technologies: Accuray, Elekta, Varian; treatment planning software: Brainlab,

ViewRay

Competing products: Intensity-modulated radiation therapy (IMRT)

Key facts


rate

2020

rate

Percent

change

77295 3D radiotherapy plan $1,192 $1,245 4.4%

77470Special radiation

treatment$520 $539 3.7%


National market estimatesOutpatient oncology intensity-modulated radiation therapy

volumes2

Who should invest?

Radiation oncology

Clinical considerations: 3D CRT is used to treat tumors that may have previously been considered too

close to vital organs; it allows for high and more effective doses. It is most commonly used in treating brain,

head and neck, prostate, breast, liver, lung, and central nervous system tumors

1.4M

1.8M

Source: “NCI Dictionary of Cancer Terms.” National Cancer Institute,

https://www.cancer.gov/publications/dictionaries/cancer-terms/def/3d-crt;

Advisory Board Oncology Market Estimator; Service Line Strategy

Advisor research and analysis.

3D CRT is a sound investment for AMCs and community hospitals alike, as it is considered a standard

care offering for any radiation therapy program. Although the system is costly, it has been proven more

cost-effective than conventional radiation therapy.

+26.1%



2018 2023

Volumetric-Modulated Arc TherapyCenters with IMRT already in-place should invest in VMAT for better outcomes





What is it?

Volumetric-modulated arc therapy (VMAT) utilizes LINAC control and treatment planning software to enable

the delivery of image-modulated radiation therapy in a continuous arc around the patient, as opposed to across

a number of finite gantry angles. Dose rate, multi-plane light conversion shape, and gantry speed are

modulated continuously throughout the treatment delivery arc. VMAT enables efficient delivery of a radiation

dose, and shortened treatment time may have clinical benefit.

Adoption status: Early majority; over 275 sites worldwide offer VMAT, with ~200 sites in the U.S.


Major vendors: Varian (RapidArc); Elekta (Infinity, Versa HD), Philips Healthcare, Siemens

Competing products: Intensity-modulated radiation therapy (IMRT), image-guided radiation therapy (IGRT)

Key facts


National market estimatesOutpatient oncology IMRT volumes2

Who should invest?

Radiation oncology

Clinical considerations: VMAT offers more elegant dose distribution, reducing the time required for

radiation dose as compared to IMRT. The time-savings associated VMAT minimize stray patient or tumor

motion during treatment. However, clinical superiority of VMAT relative to IMRT is still under investigation.

Clinical use of VMAT for SBRT has also recently begun, suggesting greater adoption of the treatment in the

near future.

5.6M

7.1M

VMAT is a sound investment for AMCs and community hospitals that already have an IMRT system in place

since it is simply an add-on software and is expected to supplant IMRT as the preferred delivery method for

EBRT in the future. Institutions operating at or approaching capacity for radiation therapy should also

consider investing in VMAT to increase efficiency and patient throughput.


Service Line Strategy research and analysis.

+26.1%


change

77338 MLC device for IMRT $322 $335 4.0%


simple$520 $539 3.7%


complex$520 $539 3.7%


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Documents

Oncology clinical technology compendium