Even though cancer is among the leading causes of death in the United States, due to an aging population and unhealthy environmental factors and lifestyle habits, many materials management professionals may find oncology devices and equipment something of a mystery.

That should come as no surprise. Faced with a confusing array of technological terms that seem like a semantic stew, coupled with the infrequency of capital buys and the belief (or excuse) that clinician preference drives oncology purchasing patterns, materials managers logically limit their exposure to and time spent on cancer treatment technology.

But increased clinician and patient demand for cancer treatment beyond chemotherapy and the high costs of new radiation surgery and therapy technologies is taxing the budgetary controls of hospitals and healthcare facilities to the point that administration turns to materials management for their expertise. And because oncology represents such a lucrative potential revenue stream for healthcare facilities materials managers no longer have the luxury of rubber-stamping clinical decisions and moving on.

Instead, they have to find balance and restore order to two opposing forces: Clinicians that want to treat more patients with the best technology (that typically is more expensive than a facility can afford) vs. administrators that strive to grow and protect the revenue stream while keeping expenses in check.

It’s a familiar dilemma, emerging in such areas as orthopedics, diagnostic imaging (radiology) and cardiology. But the key difference is that materials management’s influence in those areas has been rising. And oncology is shaping up to be the next big budgetary battleground in materials management’s war plan. For that reason, materials managers should acquaint themselves with some basic intelligence on cancer treatment technology before they sit across the conference room table from the oncology team.

What to buy

If the oncology department wants to have as much of the latest technology at its disposal as possible, then what basic equipment needs to be on the initial shopping list and what can be considered optional and can wait until the department can cost justify adding it to the routine?

If anything, it’s important for a facility to make realistic decisions based on demographics, location and financial support.

"Linear accelerators are probably one of the early technologies to bring in," said Susan Levine, DVM, Ph.D., vice president, technology assessment and editor in chief, Hayes Inc., Lansdale, PA. "A linac can be used for external beam therapy and stereotactic radiosurgery. The field is moving toward image-guided technology that links diagnosis to therapy.

"But it depends so much on the type of hospital and the patient load," Levine continued. "Certainly, the right equipment can attract referrals and patients. This applies more to the strategic planning of the hospital and the potential patient population you want to reach." Also, such decisions allow the facility to determine how closely imaging and radiation therapy will work together, as well as relationships between the clinical laboratory and radiology. With all three departments working together – imaging to find the tumor, pathology to test the tumor and oncology to treat the tumor – they can cost justify bringing in certain types of equipment. Of course, a facility must be sited properly to support all this equipment, she added.

A fully equipped radiation therapy department probably contains linear accelerators, image-guided radiation therapy systems, radiation oncology information systems, radiation treatment planning systems and computed tomography (CT) simulation systems, according to Robert Maliff, associate director of ECRI’s Health Systems Group, Plymouth Meeting, PA. However, the essential platform includes [intensity modulated radiation therapy]-capable linear accelerators, a treatment planning system and CT simulation, he noted.

"Image-guided radiation therapy (IGRT) can wait, but is quickly advancing care applications," Maliff noted. "And radiation oncology information systems are necessary for completely smooth operations, but are not truly necessary to deliver care. Brachytherapy is nice, but volumes indicate that only major providers should really be doing this, let alone the physics, dosimetrist and radiation oncologist support necessary."

Furthermore, the radiation therapy equipment should be DICOM-compliant, and that means finding out at least how each device complies with at least DICOM RT Image, DICOM RT Dose, DICOM RT Plan, DICOM RT Structure Set and DICOM RT Treatment Record. The information systems and CT simulator should also comply with DICOM CT Store for simulation images, he added. DICOM is an acronym for digital imaging and communications in medicine and is a standard of communication and connectivity protocols for exchanging digital information between imaging equipment and other systems.

Jan Dragotta, clinical director, radiation oncology, CentraState Medical Center, Freehold, NJ, unveiled a basic device and equipment list that can be costly. Atop the list is a linear accelerator that includes multileaf collimators and electron beam capabilities; a CT simulator, including a laser positioning device and a laser printer; a film processor, even though many departments are moving toward electronic portal imaging; a treatment planning computer system capable of supporting IMRT, which may require a separate system or additional software; immobilization devices, which are dependant on user preference but the initial outlay can add up; physics devices, including a water tank, which is costly, and [quality assurance] devices that include daily, weekly and annual checks and calibrations; and some form of block cutter, either manual or computerized.

"Currently, we treat approximately 20-25 percent of our cases with IMRT," she said. "These treatments are very well reimbursed, and as patients become better educated they are demanding more advanced treatment modalities." However, imaging-based treatment systems, radiosurgery and high-dose rate brachytherapy can wait until they’re justified, she said.

With 16 years of experience in private practice, including the last 13 as medical director of the Cancer Institute of Carolina, Aiken, SC, and director of radiation oncology at Aiken (SC) Regional Medical Centers, oncologist Paul Goetowski, M.D., who joined the Carolina Regional Cancer Center, Myrtle Beach, SC, last year, offers a glimpse into the clinician’s mindset for technology. "1. What you have to have, 2. What you want to have, 3. What you wish you had," he said. "Seriously, there are lots of ‘bells and whistles’ available, but the bottom line is that you ultimately have to pay for what you buy or nothing works. For example, a small satellite or rural facility will only need the basics, with the bells/whistles at the ‘mother’ location or a referral facility, such as a university medical school. The next concern is what you are competing with. If you are out in the middle of Wyoming, and are 100 miles closer than your nearest competitor, then your decisions are largely based on what you can generate enough patient volume to afford.

"However, if you are competing with four other major facilities, then you may have to go for something more expensive to ‘stand out,’" he continued. "For instance, in Myrtle Beach, we are considering the ‘top of the line’ TomoTherapy, partially because it would blow anyone else out of the water (we are in a four-way fight for a certificate of need), and we can generate enough off the other two machines to partially subsidize the ‘luxury’ of a $3-million machine. The other reason is that it would allow us to do things that we couldn’t do on anything else. Would we have taken this step if we weren’t under pressure? Probably not, but we would wish we had."

Just to qualify for a certificate of need in South Carolina, a facility is expected to have a simulator, access to a CT scanner if you don’t have your own in-house, linac with two energy ranges to cover shallow and deep tumors or two fixed-energy machines, electrons or superficial X-rays for skin surface tumors, physics equipment to test and monitor the output and function of the machines, some type of blocking equipment (either able to make custom lead blocks or multileaf collimator in the machine), and a treatment planning system, either onsite or at a remote primary facility, according to Goetowski.

"Some places with satellite locations will do CT, simulation, treatment planning at the central ‘mother ship’ and have only the machine and physician/nurse exam space locally, and physics drags their equipment around. Optional is anything else," he said. "Some places (like Aiken) still have Cesium to do their own low-dose rate GYN brachytherapy, some will have a high-dose rate (HDR) device if they have enough cases to justify it, and others (like Myrtle Beach) will refer those on to a major place (like MUSC in Charleston) that do have the HDR equipment."

Houston-based US Oncology Inc. maintains a base platform that includes a linear accelerator, record-and-verify technologies and a solid infrastructure to ensure that all of the equipment is digitally interfaced for an efficient workflow, said Bill Herman, vice president and general manager of cancer care services. "With a solid foundation established, we then add advanced treatment technology as the demographics and physician commitment dictates," he noted. US Oncology is a healthcare services network dedicated to cancer treatment and research that is affiliated with more than 900 physicians practicing in approximately 460 locations, including 85 outpatient cancer centers in 32 states.

US Oncology groups equipment and technologies into three specific tiers, Herman noted. The first tier includes the linac, treatment planning, computed tomography (CT) simulation software and a networking information system that ties it together. All of US Oncology’s facilities are equipped with at least tier one technologies. The second tier includes electronic portal imaging, multislice CT, access to positron emission tomography (PET) imaging (not necessarily onsite), intensity modulated radiation therapy (IMRT) equipment and software and the appropriate quality assurance (QA) equipment and software. Roughly 60 percent of the company’s network is at a tier two level. The third tier includes high-dose radiation (HDR) capabilities, an on-board imager for image guidance therapies and access to stereotactic technologies. About 10 percent of the company’s facilities are at the third tier. Integrating radiation and imaging equipment is one of US Oncology’s key goals, noted with its RADMAP project.

Who decides what to buy?

Historically, oncologists have controlled the purchasing decisions with limited administrative influence. No longer. With budgetary concerns and return-on-investment targets, the business side has emerged as a key participant.

"Radiation oncology products, particularly the larger ticket items such as treatment machines, are very specific, and there are only a few vendors," Dragotta said. "It is important for the users to have an opportunity to investigate the product choices." She recommended that the process involve the physician, physicist and manager or chief therapist.

"Technology assessment is the first step," Levine said. "Materials managers should expect that clinicians have identified the technology most appropriate for their patients. If this is a new technology then what will adding it bring to the facility? Some of the image-guided technology can handle multiple applications, including performing diagnostic and therapeutic procedures, so there’s a key ROI factor. Two different departments may be able to share in the benefits and the expenses – oncology and radiology. That facilitates a relationship between the two.

"Once the need and efficacy are established then you can look at specifics about vendors," she continued. "This is where materials management’s ears perk up because they’re charged with this part of the process." That involves visiting other installations, evaluating vendor responsiveness, service and support, and examining service contract terms and costs. Uptime is important, she added.

"One of the dangers to be faced is that the next version is always coming along," Levine continued. "So the dilemma becomes which version do you buy? Does the newer version show a patient benefit or just incorporate additional bells and whistles?"

Although David Zimba, vice president, contracting division, West Penn Allegheny Health System, Pittsburgh, acknowledged that this is an "extremely clinical" process it should be dependent on the team that’s assembled. "The role of materials management is helping in the acquisition and contracting strategy and in understanding the marketplace," he said. "There should be joint expertise between the clinical and materials management staff. This should never be done in isolation. The most effective strategy builds off the knowledge of both the clinical personnel and the materials management personnel."

Zimba assigned one of his staff members to become an expert in the oncology marketplace. "Her job is to create an environment of competitive friction in this dynamic marketplace where vendors feel competitively at risk, whether they either have the business or want the business. You have to make sure there are enough attributes among the product that makes it competitive with others, even if it’s not the same product but a functional or therapeutic equivalent."

Using Zimba’s competitive friction strategy, West Penn recently acquired oncology equipment from TomoTherapy that slashed $500,000 from the price, even though the healthcare system is paying $1 million more than they expected for the technology. Even with the negotiated discount, the organization was willing to pay TomoTherapy’s price based on the timeliness of the installation and the expected ROI, he said. The hospital-based TomoTherapy unit will complement the interconnected network of Siemens equipment used by eight other facilities in the oncology group of the West Penn Allegheny system.