It’s not uncommon for breast cancer patients in the rural South to travel hundreds of miles to reach the medical practice run by Dr. Phillip Ley, a cancer surgeon in Jackson, Mississippi.
For those who are good candidates, Ley recommends a therapy that delivers a single, targeted radiation dose to a patient’s breast tissue immediately after surgery to remove a tumor. Known as intraoperative radiation therapy, or IORT, it costs patients less in both time and money than traditional radiation treatments, and it is far less grueling.
“For our patient population here, [IORT] has been such a boon because we have so many rural patients,” said Ley, who is the director of oncology services at Merit Health Surgical Oncology. “I have patients that don’t have enough gas money to go to radiation every day.”
But the treatment is not as widely available in the United States as it once was, according to interviews with a dozen breast surgeons. They contend that is because it cuts into the revenue of doctors and hospitals that rely on the far larger sums of money generated by traditional radiation treatments.
Radiation oncologists who perform IORT receive about $525 per treatment, Medicare estimates from 2022 show, far less than the $1,300 they receive performing whole breast radiation with five sessions and the $1,730 generated by 15 sessions. Hospitals also benefit from repeated radiation sessions, which generate facility fees every time a patient returns for care.
Breast cancer surgeons receive the same amount regardless of whether a patient gets IORT, whole breast irradiation or partial breast irradiation.
“This is about money and greed,” Ley said.
IORT, which the Food and Drug Administration approved in 1999, is not for every breast cancer patient. Ideal candidates are postmenopausal women with early-stage, very small tumors and no evidence of lymph node involvement.
In the decades since IORT was introduced, it has been the subject of extensive research showing slightly higher cancer recurrence rates than for whole breast irradiation. In addition, roughly 1 in 5 IORT patients wind up having to supplant the treatment with whole breast irradiation after subsequent pathology reports show cancer in their lymph nodes or near the removed tumors.
But IORT has similar long-term survival outcomes and lower mortality rates from other cancers, and it eliminates the potential for burns on the skin and life-threatening radiation damage to the lungs and heart, according to research studies and breast cancer surgeons.
The American Society for Radiation Oncology, or ASTRO, the medical society for professionals performing radiation therapy to treat cancer and other diseases, does not recommend IORT for patients outside of clinical trials, citing its higher recurrence rate.
Dr. Catheryn Yashar, the health policy chair and president-elect of ASTRO, said money is not a factor in its stance on IORT.
“ASTRO’s job is to evaluate the data objectively and give both physicians and patients a framework for decision-making,” said Yashar, who is chief medical officer of the University of California San Diego Health System. “We don’t make the decision for the patients.”
Dr. Alice Police, a breast surgeon who has set up three IORT programs in U.S. hospitals, says she believes ASTRO’s position on the innovative treatment reflects the view among many radiation oncologists that IORT is a disruptive technology whose lower costs and high levels of patient satisfaction threaten their revenues.
“Radiation oncologists are very powerful — they make so much money for the hospitals,” Police said. “Even though the [IORT] data is awesome and the benefit to the patient is just enormous, they call it experimental.”
The problem with that, Police said, is “insurance companies are not going to pay for it.”
Amy Slaton, 59, of Louisiana, discovered her breast cancer early and opted to receive IORT. Her employer’s insurance plan would not cover it, she told NBC News, so she and her husband decided to pay for the treatment out of pocket.
After the surgery, she said, she was back at work within two months — a feat that would not have occurred with whole breast irradiation.
“My employer got me back about five weeks to two months earlier than they would have,” Slaton said in an interview. “That’s why I do not understand why my insurance company would not cover it.”
Medicare and Medicaid do cover it, however.
NBC News asked AHIP, the lobbying organization representing U.S. health insurers, why some, including Medicare Advantage plans, deny coverage for IORT.
A spokesman said: “Health plans work to connect patients with safe, clinically appropriate care while promoting affordability for consumers and sustainability within our health care system.”
‘A valuable option’
Heidi Toplansky, 72, was diagnosed with two different cancers — one in each breast — in 2012. A mother of two living in California, Toplansky received traditional radiation to treat the tumor in one of her breasts because it was not a candidate for IORT. The tumor in the other one was, and she jumped at the chance to get the alternative treatment.
Even though her surgeon ended up detecting cancer cells near where her tumor had been, forcing her to undergo repeated bouts of whole breast radiation after the IORT, she is a huge proponent of the treatment.
“With IORT it’s 30 minutes with that device in the breast cavity,” Toplansky said. “With traditional radiation, this machine travels over your body 20 to 30 minutes every day for two months and you’re burning like a piece of meat on a barbecue grill.”
The treatment has been widely available overseas — in Europe, South America and Asia — for more than two decades.
The use of IORT grew significantly in the United States after ASTRO issued its first guideline on the treatment in 2009, studies show. While for select patients the technology might demonstrate “long term effectiveness and safety comparable to whole breast irradiation,” ASTRO said, those choosing IORT should be told that the traditional radiation treatment “has a much longer track record” for safety and efficacy.
As IORT gained acceptance in the 2010s, a worrisome trend was forming among radiation oncologists — their supply was growing faster than patient demand for their services, according to 2016 research in the International Journal of Radiation Oncology, Biology, Physics.
Last year, ASTRO issued a new, more emphatic IORT guideline to “reflect recent developments in the management of patients.”
It said “IORT alone is not recommended as treatment for early-stage invasive breast cancer” but “may be reasonable to perform on a prospective clinical trial or multi-institutional registry.”
Surgeons who spoke with NBC News said they noticed a decline in IORT’s availability following the updated ASTRO guidance.
Dr. Frederick Barker, a surgeon in Bluefield, Virginia, with privileges at Princeton Community Hospital/WVU Medicine, is a big believer in IORT.
“The bottom line on this is women, through what are professed to be the best intentions of the medical community, are being denied a valuable option that they’re not being denied in countries other than the U.S.,” he said. “I think we have scientists with an agenda.”
As U.S. health care costs spiral higher, IORT’s savings and convenience have become more compelling, proponents and patients say. An IORT treatment costs $8,000 to $10,000, breast surgeons say, compared with $30,000 and upward for whole breast irradiation. A 2018 article in Frontiers in Oncology cited research showing IORT could save $1.2 billion in the U.S. health care system over five years.
Dr. Sheldon Feldman, a breast surgeon who performs IORT at Montefiore Einstein Medical Center in the Bronx, New York, said he thinks patients need to get involved in pushing for IORT.
“It really requires advocacy, just like a lot of advances in breast cancer treatment,” Feldman said. “That’s what going to be required to make sure this is available.”
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