Hypofractionated radiotherapy for organ-confined prostate cancer: is less more?

Abstract

Moderate hypofractionation of radiotherapy is widely considered a viable alternative to conventional fractionation for the treatment of patients with organ-confined prostate cancer, but stereotactic body radiotherapy (SBRT) is rapidly emerging as a novel treatment modality for this disease. Advances in treatment planning, image guidance, target position reproducibility and on-line tracking, coupled with a compelling radiobiological rationale, have promoted SBRT as a safe and effective treatment. Dose escalation to the tumour tissue through a decreased number of radiation fractions improves patient comfort and convenience, as well as treatment cost-effectiveness, compared with conventional radiotherapy regimens. Several clinical trials have investigated moderate and extreme hypofractionation of radiotherapy in patients with prostate cancer. Evidence is accumulating which suggests that the use of moderately hypofractionated radiotherapy can be recommended regardless of cancer risk group. Regimens of extremely hypofractionated radiotherapy have shown very good short-term efficacy and safety outcomes, but appropriately designed trials with extended follow-up monitoring are required to confirm long-term outcomes.

Neoadjuvant long‐course chemoradiation remains strongly favored over short‐course radiotherapy by radiation oncologists in the United States

“…Current reimbursement policies in the US and many countries in Western Europe incentivize longer RT courses. [28][29][30][31] Practice changes that are viewed as "doing less" also may face greater resistance 32 ; however, shorter RT courses currently are under investigation for several malignancies 22,33,34 Interestingly, patterns-of-care studies have suggested that nonclinical factors such as insurance status and institutional characteristics are influential in the selection of RT fractionation regimens. 21,[23][24][25][26][27] Potential barriers to implementing new evidence-based practices include workplace culture, lack of training, knowledge gaps, limited skills in applying research findings to individual patient situations, unwillingness to change, patient preferences, administrative policies, and poor generalizability of study results.…”

“…21,[23][24][25][26][27] Potential barriers to implementing new evidence-based practices include workplace culture, lack of training, knowledge gaps, limited skills in applying research findings to individual patient situations, unwillingness to change, patient preferences, administrative policies, and poor generalizability of study results. [28][29][30][31] Practice changes that are viewed as "doing less" also may face greater resistance 32 ; however, shorter RT courses currently are under investigation for several malignancies 22,33,34 Interestingly, patterns-of-care studies have suggested that nonclinical factors such as insurance status and institutional characteristics are influential in the selection of RT fractionation regimens. 25,35,36 Approximately 20% of respondents in the current survey indicated that a capitated payment system would affect their selection of SC-RT versus LC-CRT for patients with rectal cancer.…”

Smart Radiation Therapy Biomaterials

“…Some like Baumann et al [98] suggest that with recent technological advances in radiotherapy, new research and developments should focus less on improving the dose distribution and more on reducing treatment times [99]. If the use of SRBs for radiation boosting or priming the abscopal effect can lead to hypofractionation, the anticipated benefit of reducing treatment times would resonate with this suggestion.…”

Effects of interruptions of external beam radiation therapy on outcomes in patients with prostate cancer

“…Additionally, we did not evaluate the impact of NTDR among hypofractionated schedules, which are increasingly used among prostate cancer patients . Extremely hypofractionated schedules may have mechanisms for cellular death similar to brachytherapy, and it is unclear if treatment breaks of days would have significant impact on patient outcomes.…”