- A narrow scope of practices was surveyed. The survey was solely sent to VHA physicians at 38 active VHA radiation oncology centers out of 144 VHA hospitals. Therefore the practices at VHA medical centers without active VHA radiation was not acquired with this survey.
- This survey only addresses availability of these newer treatment technologies, not their actual use, in treating cancers predominant within the VHA.
- Literature comparison in this report is based on current use of these technologies for some of the reports cited, rather than availability as this report reflects. As such, direct comparisons could be misleading.
Discussion
Although the total number of veterans has been decreasing in recent years, the number of veterans enrolling into VHA-related programs has been increasing and is expected to expand increase further in years to come. 1,2 It is important for radiation oncologists to keep pace with new technologies to ensure their patients have access to the best possible treatments.
Advances in radiation oncology have allowed radiotherapy to evolve from the 2-dimensional treatments of the 1950s to the 1980s, to more targeted treatments that employ advanced imaging and complex planning. Modern techniques for delivery of radiotherapy are better at confining radiation dose to the tumor volume while minimizing the irradiation of normal structures. The use of cumbersome blocks, wedges, and tissue compensators has given way to treatment with internal collimation techniques such as IMRT, SBRT, and SRS. These techniques rely heavily on image guidance for tumor targeting. Four-dimensional planning and treatment allow radiation oncologists to track tumor and normal tissue motion, thereby increasing the accuracy and precision of radiation treatments.
As is true in the community, IMRT and IGRT are widely available within the VHA. According to a survey by Simpson and colleagues evaluating the use of IGRT in the U.S., 93% of radiation oncologists use IGRT. 7 Similarly, the survey presented here demonstrates that 91% of VHA radiation oncologists report availability of IGRT at their centers. All VHA radiation oncologists surveyed report access to IMRT.
Shen’s recent report evaluating radiotherapy patterns of practice from 2002 to 2010 examined volume of payments for treatment delivery by codes for office-based IMRT. 8 These authors noted an increase in the usage of IMRT as a percentage of external beam radiotherapy from 2002 to 2010 of 0% to 70%, respectively. They further noted during this period that IGRT use, based on total payments for treatment delivery, increased from 2.1% to 11.1%.
The reported use of onsite SBRT among VHA physicians is slightly less than that of community physicians. A survey study by Pan and colleagues demonstrated that 63.9% of U.S. radiation oncologists use SBRT, while in the survey study presented here, 53% of VHA radiation oncologists reported availability of onsite SBRT. 9 Of note, the lack of availability of onsite SBRT at VHA centers does not preclude treatment with SBRT when medically necessary. These cases can be referred to other VHA or community centers with the requisite accreditation credentials. Because of the increasing use of SBRT and related technologies in the treatment of some cancers, an improved availability of SBRT in the future within the VHA will allow for some centers to participate in the Veterans Affairs Lung Cancer Surgery or Stereotactic Radiotherapy (VALOR) trial, which was approved for open recruitment in 2015.
