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Does a patient who had PBI catheter radiation therapy for breast cancer more than 6 months ago and now has nonhealing wound at the site of catheter placement qualify for HBO therapy? I am not clear on whether brachytherapy qualifies since I don't have records which show radiation doses in Excess of 40 Gray.
Jan 1, 0001 by Beth Hirsch, Nurse Practitioner
4 replies
Eugene Worth
MD, M.Ed., FABA, ABPM/UHM
Hi, Beth! I know that Tiff picked this up, but I’ll add my $.02.

Brachytherapy is still radiation therapy. So, here’s what I would do ... and, yes, I’ve had patients with this complication ... I would get the record of treatment, dose, timing, etc from the radiation oncologist. Then, add in the length of time since radiation was complete until the wound opened.

This is the tricky part for reimbursement. You must tell the right story with a correct timeline in order for reimbursement. The HBOT part of this is ‘Yes, certainly.’ But, that also comes with some caveats. The problem with this type of brachytherapy is the location of the radioactive beads/catheter. Frequently these affect the underlying ribs as well, creating an osteoradionecrosis of the ribs as a complication. I suggest that you image the ribs to see if that is going to happen in your case. It did in mine. If the ribs are involved, the affected areas must be excised/removed in order to heal the wound. HBOT alone will NOT be effective without removing the dead bone.

And, you will likely end up having a plastic/breast reconstruction surgeon excise some of the radiated tissue and possibly the ribs before this will close.

Dose of HBOT ... 40 treatments. I recommend 30 prior to surgical resection then 10 after.

I realize this response is somewhat disjointed, so I will be happy to answer follow up questions.

Gene
Jan 1, 0001
Tiffany Hamm
BSN, ACHRN, CWS
Hi Beth,
Thank you for the question. In order to meet medical necessity requirements for the treatment of STRN, you will need to document the exact radiation dosage delivered by way of brachytherapy. The radiation delivered would need to be in excess of 40 Gray. It would be necessary to obtain the radiation oncology notes so that you have that information. Since radiation delivered through brachytherapy is typically slow-release and is not external beam, it would be important to biopsy the breast tissue to determine if there is radiation damage. From there, if the biopsy shows STRN, and the dosage is greater then 40 Gray and at least 6 months post-irradiation, you would have a case to begin a course of HBOT.

Information from Wound Reference Knowledge>Hyperbaric Oxygen>STRN
Non-healing wound on irradiated area with onset at least six months since last radiation exposure
History of radiation treatment (usually in excess of 40 Gray or 4,000 cGy) to the region of the documented injury
Wound that is non-responsive to conservative standard treatment

Thanks so much,
Tiffany
Jan 1, 0001
Eugene Worth
MD, M.Ed., FABA, ABPM/UHM
Just read your query again ... about the 40 Gy dose. For this type of brachytherapy (in my patient, called Mammosite), the problem is not the same as external beam radiotherapy, so dosage (per se) isn’t as important as location to ‘normal’ tissue. This is still classified as “late effects on normal tissue.” This is why telling the correct story in the history and documentation is so important. I would describe this as high-dose, short-duration radiotherapy. Ask the rad-one doc to estimate the local tissue radiation dose surrounding the catheter ... it’s high.
Jan 1, 0001
Beth Hirsch
Nurse Practitioner
Very helpful- thank you for the responses. I have the radiation oncology notes but there is no documentation of tissue radiation dose. I will ask for the estimate. The wound has never closed since the balloon was removed from the radiation site 10 months ago. We have made a small amount of progress with standard wound care but have not looked imaging of the ribs.
Jan 1, 0001
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