By Thomas C. Lee, MD
As recently as a decade ago, insurance companies often required a peer-to-peer discussion for approval of head and neck ablations. Though these discussions usually led to approval, it was somewhat puzzling to have to justify why ablation of a tumor or lymph node metastasis in the neck would be as effective as ablating elsewhere in the body, particularly when body radiologists have been routinely ablating lesions for over three decades. One of the experienced ablation technicians at my institution told me that ablation of a small renal cell cancer is practically considered a standard of care in some situations as opposed to the past when one might expect a complete nephrectomy which then subsequently evolved to partial nephrectomy and now ablation. Within the past several years, however, there seem to have been fewer and fewer requests for peer-to-peer discussions to justify the rationale for ablation in the head and neck, presumably as ablation in the head and neck has become more mainstream.
Why has ablation in the head and neck been so slow in adoption compared to elsewhere in the body? Perhaps it is not so much a question of efficacy as a question of whether the benefits outweigh the risks in the more sensitive head and neck region where there is the potential for permanent neurologic complications such as carotid injury and stroke. Risk, however, is always relative. Extensive granulation from previous surgery or radiation can cause further surgery high risk for carotid dissection as opposed to an outpatient percutaneous ablation procedure. One might consider then that ablation in some circumstances may entail far less risk than the patient’s alternatives.
Perhaps the real question facing us, then, is whether adoption of head and neck ablation should be within the domain of radiologists. In many regards, radiologists are gatekeepers to imaging in the head and neck, and even to image guided needle biopsies. I attended an ultrasound workshop once at which the instructors mentioned that they would happily go a step further and ablate a thyroid lesion if their hospital would only let them. I think we’ve come to a time when safe techniques for ablation in the head and neck have been established. There are now surgical groups offering image guided ablation, as well as radiology groups. Should we as an association sit on the side lines and allow patient care and image guided ablation be absorbed by surgical practices?
Recently relative value unit designations have given more emphasis to evaluation and management (E/M) codes. Specialties such as family medicine, pediatrics and psychiatry have gained the most from this recent shift while procedural based specialties without E/M codes have suffered the most. This is likely not a one time event. This is a trend that will increase. Patients and referring providers are no longer satisfied with a statement that there is a nodule, or even that it is a benign nodule, particularly if that benign nodule is causing the patient symptoms. They want a one-stop shop where the provider who diagnoses the problem also takes responsibility for treating it.
At this time, imaging is to a large extent in the hands of radiologists. As imaging equipment becomes less expensive and more readily available this practice may change. Are we not at this time then the best equipped to offer image guided treatment? If we decline to do so and not step up our practices, we may face a time when our specialty is asked to step aside, not only from treatment but eventually from diagnosis.