Expert Calls for Shorter Radiation Use in Prostate Cancer Treatment


“Men with prostate cancer can receive shorter courses of radiation therapy than what is currently considered standard, according to Justin Bekelman, MD, an associate professor of Radiation Oncology, Medical Ethics, and Health Policy at the University of Pennsylvania’s Perelman School of Medicine and Abramson Cancer Center. In his call for practice change, Bekelman cites research showing the shorter radiation treatment — known as moderate hypofractionation — is just as effective at treating cancer, while costing less and easing the burden on patients. The commentary was published online by the International Journal of Radiation Oncology Biology and Physics and was co-authored by W. Robert Lee, MD, MEd, MS, a professor of Radiation Oncology at the Duke University School of Medicine.”

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Hypofractionation May Be Poised to Become New Standard of Care for Prostate Cancer


“There has been an ongoing debate about which type of radiation therapy is preferable in the treatment of localized prostate cancer: hypofractionation (larger fractions given over 4–5 weeks) or conventional radiotherapy (given over 8–9 weeks). A new study presented at the 2016 ASCO Annual Meeting may help to resolve that debate.

“The large, randomized trial found that hypofractionation was not inferior to conventional radiation therapy in terms of efficacy or safety in men with localized intermediate-risk prostate cancer. This is the third large, randomized, contemporary study to demonstrate that both techniques have equivalent efficacy and safety.”

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HYPRO: Shorter RT Course No Better, Worse in Localized Prostate Cancer


“A randomized phase III trial found that a hypofractionated radiotherapy (RT) regimen was not superior to, but generally equivalent to a conventional RT scheme in men with localized prostate cancer. The study joins a growing body of literature on hypofractionation in this malignancy, generally showing that the shorter courses are a reasonable option.

“A low α-β ratio for prostate cancer has generated interest in hypofractionation, as it could increase the tumor dose without increasing toxicities. ‘Moreover, hypofractionated radiotherapy is delivered in fewer fractions, improving patients’ convenience, hospital logistics, and possibly reducing healthcare costs,’ wrote study authors led by Luca Incrocci, MD, PhD, of Erasmus Medical Center Cancer Institute in Rotterdam, the Netherlands.

“A study was presented at the 2016 American Society of Clinical Oncology (ASCO) Annual Meeting in Chicago that found a hypofractionated regimen of 60 Gy in 20 fractions was noninferior to conventional RT. Another, presented this past January at the ASCO Genitourinary Cancers Symposium, again found a 60 Gy/20 fractions regimen was noninferior to conventional RT and to another hypofractionated regimen of 57 Gy/19 fractions.”

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Hypofractionation Is Ready for Prime Time in Prostate Cancer, but Will It Be Adopted?

“Separate phase III trials presented at the 2016 Genitourinary Cancers Symposium demonstrated that modest hypofractionated radiotherapy is noninferior to conventional radiotherapy for men with intermediate- and low-risk prostate cancer and should be considered a new standard of care.1,2 However, it is not clear how widely adopted hypofractionation schedules will be.

“NRG Oncology RTOG 0415 was a randomized, phase III, noninferiority study comparing two fractionation schedules in men with low-risk prostate cancer: conventional radiotherapy (73 Gy in 41 fractions over 8.3 weeks) vs hypofractionation (70 Gy in 28 fractions over 5.6 weeks).1

“The study enrolled 1,115 patients with low-risk prostate cancer. No androgen suppression was given. Patients were stratified according to Gleason score 2–4 and Gleason score 5–6.”

Shorter-Course Radiation Non-Inferior to Conventional Therapy for Low-Risk Prostate Cancer

“Hypofractionated radiation therapy yielded a similar rate of DFS and toxicity profile as conventional radiotherapy among men with low-risk prostate cancer, according to results of a randomized phase 3 non-inferiority study presented at the ASTRO Annual Meeting.

“Given in larger doses over a shorter period, hypofractionated radiation therapy is being studied as a possible improved treatment option for some patients.

“Howard Sandler, MD, MS, FASTRO, professor and chair of the department of radiation oncology at Cedars Sinai Medical Center in New York, and colleagues sought to evaluate whether the hypofractionated therapy schedule — or 70 Gy in 28 fractions over 5.6 weeks — resulted in a 5-year DFS that was not lower than that of the conventional schedule, or 73.8 Gy in 41 fractions over 8.2 weeks, by more than 7%.”

Prostate Cancer Study Shows Hypofractionation Comparable to Standard Radiation in Low-risk Patients

“Hypofractionated radiotherapy can achieve similar cure rates with similar side effects compared with conventional radiotherapy for men with low-risk, early prostate cancer, according to follow-up RTOG 0415 study data presented October 20, 2015, during a scientific session at the 2015 ASTRO Annual Meeting.

“Hypofractionated radiotherapy is delivered in larger doses over 5.5 weeks whereas conventional radiotherapy requires 8 weeks of treatment. ‘Results of our study demonstrate that for men with low-risk prostate cancer, hypofractionated radiotherapy offers a shorter, more convenient treatment schedule without compromising cure or causing additional side effects,’ said lead author W. Robert Lee, MD, professor of radiation oncology at Duke University School of Medicine, Durham, NC.”

Hypofractionation of Breast Radiotherapy Associated With Reduced Acute Toxicity

“In an analysis reported in JAMA Oncology, Jagsi et al found that hypofractionation of whole-breast radiotherapy was associated with reduced acute toxicity compared with conventional fractionation.

“The study involved data on physician-assessed toxic effects and patient-reported outcomes in 2,309 patients who received adjuvant whole-breast radiotherapy after lumpectomy for unilateral breast cancer at Michigan Radiation Oncology Quality Consortium sites from October 2011 through June 2014. Patients had to have a comprehensive physician toxicity evaluation within 1 week of completing radiotherapy and at least 1 weekly evaluation during treatment.”

Shorter, Cheaper Radiation Treatment Not given to Most Breast Cancer Patients

“In 2011, expert guidelines endorsed shorter whole breast radiation for early-stage breast cancer patients. However, a new study finds that this less costly treatment has not reached many patients who meet guidelines to receive it.

“The study – led by Dr. Justin E. Bekelman, of the University of Pennsylvania Perelman School of Medicine in Philadelphia – is published in JAMA and is released to coincide with the San Antonio Breast Cancer Symposium.

“The researchers explain that breast conservation therapy is the most common treatment for early-stage breast cancer, with whole breast irradiation (WBI) recommended for most women after surgery, as it reduces recurrence and improves overall survival.

“Conventional WBI has been the ‘mainstay’ of treatment in the US and consists of 5-7 weeks of daily radiation treatments. However, hypofractionated WBI is a shorter alternative to conventional WBI, consisting of fewer higher-dose treatments over 3 weeks.

” ‘Hypofractionated WBI increases convenience, reduces treatment burden and lowers health care costs,’ note the authors, ‘while offering similar cancer control and cosmesis (cosmetic outcomes) to conventional WBI.’ They also note that patients naturally prefer shorter radiation treatments.”

Prostate Cancer and the Hypofractionation Hypothesis

“ ‘Hypotheses are scaffoldings erected in front of a building and then dismantled when the building is finished. They are indispensable for the workman; but you mustn’t mistake the scaffolding for the building.’—Goethe. Nearly 15 years ago, Brenner and Hall authored a provocative paper that claimed that the fractionation sensitivity of prostate cancer was different from most tumors and, as a consequence, radiation oncologists should treat this cancer with hypofractionation (fewer, larger daily fractions). The optimal fractionation schedule for specific cancers has been the subject of argument for more than a century. In the first three decades of the 20th century, two methods of practice evolved. One method (popularized by Seitz and Wintz) involved large single-dose treatments. Advocates of this approach believed that fractionation of treatment would ‘favor the tumor.’ The other method, advocated by Regaud and Coutard, called for treatment to be fractionated. By the late 1930s, the fractionated approach would be adopted by most radiotherapists. del Regato, in the Regaud lecture in 1968, would claim that this was ‘the last time in radiotherapy where consensus is reached.’ As del Regato anticipated, the arguments about optimal fractionation continue to this day. As most readers will be unfamiliar with the  underlying theory of fractionation, a brief primer is in order.”