Working Title:

A Dosimetric Comparison of 3D Dynamic Conformal Arc Therapy vs. VMAT for Palliative
Liver Lesions
Problem Statement:
The problem is that insurance companies deny the use of VMAT for palliative liver tumor
irradiation, due to the rising demand and costs of inverse planning methods.
Purpose Statement:
The purpose of this study is to determine if the sharpness of the dose gradient, conformity index,
integral dose, and dose to organs at risk are equivalent or improved with the use of 3D dynamic
conformal arc therapy as an alternative method of treatment when compared to standard VMAT
for liver lesions.
Hypotheses Statements:
H1A: 3D dynamic conformal arc therapy for liver lesions will achieve a mean heart dose ≤ the
mean heart dose produced by VMAT.
H10: 3D dynamic conformal arc therapy for liver lesions will not achieve a mean heart dose ≤ the
mean heart dose produced by VMAT.
H2A: 3D dynamic conformal arc therapy for liver lesions will achieve a V20 for the lungs ≤ the
V20 for the lungs produced by VMAT.
H20: 3D dynamic conformal arc therapy for liver lesions will not achieve a V20 for the lungs ≤
the V20 for the lungs produced by VMAT.
H3A: 3D dynamic conformal arc therapy for liver lesions will achieve a mean kidney dose ≤ the
mean kidney dose produced by VMAT.
H30: 3D dynamic conformal arc therapy for liver lesions will not achieve a mean kidney dose ≤
the mean kidney dose produced by VMAT.
H4A: 3D dynamic conformal arc therapy for liver lesions will achieve a mean large bowel dose ≤
the mean large bowel dose produced by VMAT.
H40: 3D dynamic conformal arc therapy for liver lesions will not achieve a mean large bowel
dose ≤ the mean large bowel dose produced by VMAT.
H5A: 3D dynamic conformal arc therapy for liver lesions will achieve V15 < 700 cc to the normal
liver.
H50: 3D dynamic conformal arc therapy for liver lesions will not achieve V15 < 700 cc to the
normal liver.
H6A: 3D dynamic conformal arc therapy for liver lesions will result in at least 95% coverage of
the prescription dose to 100% of the PTV.
H60: 3D dynamic conformal arc therapy for liver lesions will not result in 95% coverage of the
prescription dose to 100% of the PTV.
H7A: 3D dynamic conformal arc therapy for liver lesions will achieve a mean small bowel dose ≤
the mean small bowel dose produced by VMAT.
H70: 3D dynamic conformal arc therapy for liver lesions will not achieve a mean small bowel
dose ≤ the mean small bowel dose produced by VMAT.
Literature Review:
An evaluation of all cancer statistics from 2020 shows that the incidence for liver cancer
continues to increase in the United States. From 2007 to 2016 incidence of liver cancer has been
consistently increased 2-3% every year. In addition, liver cancer has one of the lowest survival
rates for cancer patients, with death rates continually increasing year to year. 1 The liver is also
one of the most common sites for metastasis, predominantly contributed by colorectal cancer, the
third most common cancer diagnosed among men and women. In recent years, stereotactic body
radiation therapy (SBRT) has become a good treatment option for patients with liver lesions,
specifically for palliative cases. However, insurance companies have denied volumetric
modulated arc therapy (VMAT) and intensity-modulated radiation therapy (IMRT) plans for
palliative liver plans, due to the cost of treatment. Instead, insurance companies will approve 3D
conformal plans more readily for palliative treatments. The high cost of treatment and limited
accessibility to VMAT for these patients can present as a challenge for delivery of timely care
and desired clinical outcome. With insurance posing the primary challenge for treatment
authorization of the type of treatment technique, it is important to discuss the background of
insurance authorization for IMRT/VMAT and the rising costs of cancer care.
Among the most prominent insurance companies in the United States, there exists no real
consensus on what is deemed medically necessary to allow coverage of palliative VMAT liver
treatments. For medically inoperable tumors within the liver without definitive intent, it does not
meet the requirements for IMRT coverage for certain insurances.2 Although IMRT for liver
should be covered per ASTRO guidelines, these discrepancies among insurance can pose a
challenge for many radiation oncology departments. In a survey completed by North American
radiation oncologists in National Cancer Institute-designated cancer centers, the majority had
responded that SBRT clinical investigation is limited by insurance reimbursement in general.3
The same survey done by Canadian physicians did not yield the same result: 0% felt that
insurance was a limiting factor when prescribing SBRT.3 To add to the complexities of obtaining
insurance authorization for SBRT, many insurances do not make their policies public or readily
accessible which results in delayed treatment, lowered ability for patient advocacy, and
degradation of desired clinical effects.4 The rising costs of cancer care in the United States and
specifically IMRT can be rooted to the method in which it was coded. According to the ASCO
post,5 IMRT was coded based on a resource-based value system during a time when the cost-
effectiveness of IMRT was yet to be analyzed. Since IMRT requires more resource/time for
radiation oncology departments, it is much more expensive compared to 3D conformal radiation
therapy (3DCRT). As optimization for IMRT and VMAT increasingly become the standard
method of treatment for many sites, the cost of IMRT further increases.5 Since VMAT plans
have proven to be much less accessible due to the differences in the value-based price and can
hinder efficiency in workflow to ensure timely treatments, the clinical effect of VMAT vs. 3D
dynamic conformal arc plans must be further evaluated.
A study conducted by Yong et al6 helped to demonstrate the cost analysis of IMRT
versus 3D conformal treatments. The researchers utilized an activity-based costing method to
estimate the cost of both treatment methods.6 The costs for each treatment were calculated by
factoring in the amount of time all health care professionals worked on a patient case, annual
cost of equipment and upkeep, and the length of patients’ treatment times. The researchers
evaluated prostate, breast, and head and neck cancers, but this activity-based costing method can
be applied to any disease site. In addition, for all treatment sites, IMRT was more costly due to
increased treatment complexity and inclusion of QA processes.6 Another study conducted by
Kale et al7 demonstrated how IMRT is usually readily chosen over 3D conformal for elderly
patients with later stage lung cancer. After performing a cost analysis, it was found that IMRT
treatment costs were significantly higher than 3D conformal; however, IMRT did not show any
increase in survival or decreased toxicity. This cost analysis further supports that IMRT was
adopted as a standard treatment modality quickly without using randomized trials and data to
support the treatment, and consideration of specific populations.7 Based on this evidence, and in
addition to the rising costs and complexities in VMAT treatment authorization, there needs to be
a dosimetric re-evaluation of possible constraint-based radiation toxicity for modified 3D plans
such as DCA plans in comparison to VMAT plans.
A study performed by Pokhrel et al8 showed advantages of using DCA for early-stage
lung cancer. When compared to the original VMAT plan, the DCA plan was able to show similar
conformity and coverage to the tumor. It was noticed was that dose-spillage was lower for the
DCA plans and the 50% isodose line was better conformed to the target volume. Dosimetrically,
there was no significant difference between doses to the OAR - however, they were slightly
decreased with DCA, specifically the lung V20 dose. In addition, the primary advantage of DCA
was the decrease in monitor units and beam-on time.8 The reduction in treatment time could
improve patient comfort and decrease the risk of target miss due to tumor motion during
treatment delivery. Although the Pokhrel et al8 study involves using DCA for lung tumors, the
same concept of applying DCA to small lesions can be used for liver tumors since both sites
have multiple critical structures that are considered during treatment planning. As DCA is used
both for early stage and palliative lung tumors due to the physical similarity in size, research is
needed to achieve a similar conclusion by planning DCA versus VMAT for small metastatic
lesions in the liver as well as early-stage primary liver tumors. The problem is that insurance
companies deny the use of VMAT for palliative liver tumor irradiation, due to the rising demand
and costs of inverse planning methods. This rise in demand for optimization and inverse
planning contributes towards a trend of increasing price tags of IMRT utilization, and further
cost discrepancies between VMAT planning and 3D planning. Lack of access to insurance
policies further exacerbate the authorization process for palliative VMAT liver treatments. The
purpose of this study is to determine if the sharpness of the dose gradient, conformity index,
integral dose, and dose to organs at risk are equivalent or improved with the use of 3D dynamic
conformal arc therapy as an alternative method of treatment when compared to standard VMAT
for liver lesions. Researchers tested the hypotheses that 3D dynamic conformal arc therapy for
liver lesions will achieve a mean (H1A) heart, (H3A) kidney, (H7A) small bowel, and (H4A) large
bowel ≤ to those created with VMAT; (H2A) V20 for the lungs ≤ to those created by VMAT;
(H5A) V15< 700 cc to the normal liver; and (H6A) at least 95% coverage of the prescription dose
to 100% of the PTV.
 References
1. Siegel RL, Miller KD, Jemal A. Cancer statistics, 2020. CA Cancer J Clin. 2020;70(1):7-30.
http://doi.org/10.3322/caac.21590
2. Verma V, Ludmir EB, Mesko SM, et al. Commercial insurance coverage of advanced
radiation therapy techniques compared with American society for radiation oncology model
policies. Pract Radiat Oncol. 2020;10(5):324-329. http://doi.org/10.1016/j.prro.2019.08.005
3. Guo J, Kim H, Kalchman I, Dan TD, Zhan T, Werner-Wasik M. The influence of health
insurance policy on radiation oncology physician SBRT/SABR use practices: a north
american survey. Int J Radiat Oncol Biol Phys. 2017;99(3):524-529.
http://doi.org/10.1016/j.ijrobp.2017.06.2447
4. Roach MC, Thomas TO, Paravati AJ, Mahajan A. Differences in United States insurance
payer policies and American society for radiation oncology's (ASTRO) model policy on
stereotactic body radiation therapy (SBRT). Int J Radiat Oncol Biol Phys. 2019;104(4):740-
744. http://doi.org/10.1016/j.ijrobp.2019.01.005
5. Piana R. Rising costs in radiation oncology linked to medicare coverage. The ASCO Post
website: https://ascopost.com/issues/march-15-2012/rising-costs-in-radiation-oncology-
linked-to-medicare-coverage/. March 12, 2020. Accessed April 1, 2021.
6. Yong JH, McGowan T, Redmond-Misner R, et al. Estimating the costs of intensity-
modulated and 3-dimensional conformal radiotherapy in Ontario. Curr Oncol.
2016;23(3):e228-e238. http://doi.org/10.3747/co.23.2998
7. Kale MS, Mhango G, Bonomi M, et al. Cost of intensity-modulated radiation therapy for
older patients with stage III lung cancer. Ann Am Thorac Soc. 2016;13(9):1593-1599.
http://doi.org/10.1513/AnnalsATS.201603-156OC
8. Pokhrel D, Visak J, Sanford L. A novel and clinically useful dynamic conformal arc (DCA)‐
based VMAT planning technique for lung SBRT. American Association of Physicists in
Medicine (AAPM) website: https://aapm.onlinelibrary.wiley.com/doi/10.1002/acm2.12878.
Published April 19, 2020. Accessed April 10, 2021.