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In Regard to Butala et al

      To the Editor:
      A recent Brief Opinion piece by Butala et al begins with a Rahm Emanuel quote: “You never want a serious crisis to go to waste.”

      Butala AA, Williams GR, Fontanilla HP, et al. Making the most of a crisis: A proposal for network-based palliative radiotherapy to reduce travel toxicity. Adv Radiat Oncol. doi: https://doi.org/10.1016/j.adro.2020.07.013.

      Whether Rahm’s worldview is wise or not, who is to say? However, he does mail people dead fish.
      • Kass J.
      Rahm once sent a man a dead fish. The dish is returned, served cold.
      Pardon the pun, but Butala et al’s proposal for a palliative radiation therapy (PRT) network seems fishy, too.
      Per the authors, “the current pandemic provides additional impetus to improve patient-centered care by coordinating access to PRT closer to home or in less endemic regions.” However, American Society for Radiation Oncology has promulgated guidelines previously (“Choosing Wisely,” guideline updates
      ASTRO choosing wisely: Ten things physicians and patients should question.
      ,
      • Lutz S.
      • Balboni T.
      • Jones J.
      • et al.
      Palliative radiation therapy for bone metastases: Update of an ASTRO evidence-based guideline.
      ), and PRT comprises ~40% or more of the treatments in a typical community center. Thus, delivering PRT “closer to home” should be a priority of academicians regardless of a once-in-a-lifetime pandemic. Furthermore, PRT is an integral component of residency training. Residents become adept at PRT early in their 4 years of graduate medical education. Residents must pass 4 separate examinations (3 written, 1 oral) before becoming board certified. If we believe residency and board certification produce competent physicians then we cannot also believe that extraneous certifications—whether by a “PRT provider network” or Accreditation Program for Excellence, American College of Radiology accreditation, and so forth (which are temporally and financially burdensome for smaller community centers particularly during coronavirus disease 2019)—add anything to “low-complexity” PRT delivered in few-to-single, brief outpatient visits. A phone call about the case to the community doctor would just as likely promote high quality “patient-centered care.”
      And how will we know the academic centers are practicing what they preach? As Juvenal said, “Who watches the watchmen?”
      Juvenal
      The Satires: A New Translation by Niall Rudd.
      Data do not indicate that academic centers are necessarily providing cost-effective care; Prospective Payment System exemption academic hospitals have recently been shown to charge higher prices than others, particularly compared with community sites.
      • Merkow R.
      • Yang A.
      • Pavey E.
      • et al.
      Comparison of hospitals affiliated with PPS-exempt cancer centers, other hospitals affiliated with NCI-designated cancer centers, and other hospitals that provide cancer care.
      Shifting lower-reimbursement patients to the community while keeping complex, higher-reimbursement patients at the academic center smacks of cherry-picking.
      We need to get past the idea that “academic” equals good quality and “community” equals suspect quality—or quality that needs an academic stamp of approval. But, inexplicably, our field produces articles and opinion pieces regarding these false premises. An additional certification for palliative radiation oncology is superfluous at best and insulting at worst. There is no need for a “PRT network.” It already exists. It is every community radiation oncologist and the centers in which they work.

      References

      1. Butala AA, Williams GR, Fontanilla HP, et al. Making the most of a crisis: A proposal for network-based palliative radiotherapy to reduce travel toxicity. Adv Radiat Oncol. doi: https://doi.org/10.1016/j.adro.2020.07.013.

        • Kass J.
        Rahm once sent a man a dead fish. The dish is returned, served cold.
        (Available at:)
      2. ASTRO choosing wisely: Ten things physicians and patients should question.
        (Available at:)
        • Lutz S.
        • Balboni T.
        • Jones J.
        • et al.
        Palliative radiation therapy for bone metastases: Update of an ASTRO evidence-based guideline.
        Pract Radiat Oncol. 2017; 7: 4-12
      3. COVID-19's Impact on Radiation Oncology.
        (Available at:)
        • Juvenal
        The Satires: A New Translation by Niall Rudd.
        Clarendon Press, Oxford, UK1991
        • Merkow R.
        • Yang A.
        • Pavey E.
        • et al.
        Comparison of hospitals affiliated with PPS-exempt cancer centers, other hospitals affiliated with NCI-designated cancer centers, and other hospitals that provide cancer care.
        JAMA Intern Med. 2019; 179: 1043-1051