percentage of SBRT/SRS/moderate hypofractionation

[Kroll2013]

Dear colleagues,

I am interested to know, in your daily practice
how much do you estimate the percentage of SRS/SBRT/moderate hypofractionation treatment out of the total activity in your department ? (all included palliative + curative)
and are you aware of any published numbers so we can compare our activity ?

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[Bequerel]

Is 40/15 + 10/5 for a breast and 70.2/26 for prostate considered hypofraction for the percentage? If so, then I’d estimate >80% of my patients fall into this category.

 

[Gfunk6]

Agree with 80% plus. The only holdouts are:

1. Upper GI cancers
2. Lymphomas
3. H&N
4. Gyn
5. Occasional prostate, breast or rectum which is not hypofractionated

 

[medgator]

Agree with 80% plus. The only holdouts are:

1. Upper GI cancers
2. Lymphomas
3. H&N
4. Gyn
5. Occasional prostate, breast or rectum which is not hypofractionated

Stage 3 lung?

 

[Gfunk6]

Stage 3 lung?

Yes. A few more spring to mind:

6. Locally advanced lung
7. Sarcomas
8. Anal

 

[taserlaser]

2019 numbers (canadian centre):
Consults 42XX
F/u 86XX

CT sims 37XX
Fractions 32XXX

New starts
Linacs 30XX
Brachy ~100

Average ~11 fr/pt.

 

[Palex80]

I would say it's about 70% at my institution.
We have quite a few postoperative prostate cases, which are normofractionated. Without them, it would certainly be >80%.

Here are our fractions/patient statistics up until 2019
2016: 14,7
2017: 14,6
2018: 13,8
2019: 13,1

I have no idea what happened in 2020, but with COVID, I'm sure they dropped considerably again.


I'd add to the list

9. Fit Astro °III / GBM
10. Astro °II, large meningeomas

 

[medgator]

 

[ramsesthenice]

We are in line with everyone else. I personally lag behind because a significant portion of my patients have Rectal (80% long course vs 20% short course), Anal (no hypofrac), esophageal (no hypofrac), and cervical cancers (no hypofrac).

I treat a lot of prostate as well. Half are salvage and I don't hypofrac those at all. For intact, pretty much all get 70/28, SBRT, or brachy only. The only thing that really surprises me is how many men choose brachy over SBRT. Its probably a 2-3:1 ratio in my practice. I would have expected more men to want SBRT since its non-invasive but so in my region many had dads, uncles, etc. who had brachy in the past and were very happy.

The big change for me has been pancreas. I do very little long-course anymore. Once I got confident with the MR-linac, I am almost exclusively doing dose escalated hypofrac or SBRT. And I doubt I go back. Very happy with no just local control but also toxicity which is essentially none with either approach. And before anyone says anything, you don't need an MR-linac to do any of this. But my IR group doesn't routinely put in fiducials for pancreas and I don't love the cone beam quality for upper GI with our versa HDs. In my particular situation, the MR was a game changer with respect to pancreas patients.

 

[deleted1111261]

We are in line with everyone else. I personally lag behind because a significant portion of my patients have Rectal (80% long course vs 20% short course), Anal (no hypofrac), esophageal (no hypofrac), and cervical cancers (no hypofrac).

I treat a lot of prostate as well. Half are salvage and I don't hypofrac those at all. For intact, pretty much all get 70/28, SBRT, or brachy only. The only thing that really surprises me is how many men choose brachy over SBRT. Its probably a 2-3:1 ratio in my practice. I would have expected more men to want SBRT since its non-invasive but so in my region many had dads, uncles, etc. who had brachy in the past and were very happy.

The big change for me has been pancreas. I do very little long-course anymore. Once I got confident with the MR-linac, I am almost exclusively doing dose escalated hypofrac or SBRT. And I doubt I go back. Very happy with no just local control but also toxicity which is essentially none with either approach. And before anyone says anything, you don't need an MR-linac to do any of this. But my IR group doesn't routinely put in fiducials for pancreas and I don't love the cone beam quality for upper GI with our versa HDs. In my particular situation, the MR was a game changer with respect to pancreas patients.

Definitely CAN do with CT, but it is harrowing (for me). The imaging is just not great in that area. Any aberrant gas patterns or whatever really changes what is in field. I've done 3-5 in career and I don't know that I would do it at current site.

I have done it, but have a very low threshold for not doing it. The problem is then you have to send out and re-do everything. So, if I even get a tingle that it will be challenging, would send to MR Linac. This is one site that the machine is well designed for.

 

[TheWallnerus]

We are clearly on a downward trajectory in terms of fractions per patient, a roughly 30% decline over the last decade. Will be interesting to see “how low can it go.” The UK is now 5-fractioning about 70% of ALL their breast RT patients.

 

[sirspamalot]

Can't wait for FLASH one shot radiation. Good luck with the pay model on that one.

 

[NotMattSpraker]

We are in line with everyone else. I personally lag behind because a significant portion of my patients have Rectal (80% long course vs 20% short course), Anal (no hypofrac), esophageal (no hypofrac), and cervical cancers (no hypofrac).

I treat a lot of prostate as well. Half are salvage and I don't hypofrac those at all. For intact, pretty much all get 70/28, SBRT, or brachy only. The only thing that really surprises me is how many men choose brachy over SBRT. Its probably a 2-3:1 ratio in my practice. I would have expected more men to want SBRT since its non-invasive but so in my region many had dads, uncles, etc. who had brachy in the past and were very happy.

The big change for me has been pancreas. I do very little long-course anymore. Once I got confident with the MR-linac, I am almost exclusively doing dose escalated hypofrac or SBRT. And I doubt I go back. Very happy with no just local control but also toxicity which is essentially none with either approach. And before anyone says anything, you don't need an MR-linac to do any of this. But my IR group doesn't routinely put in fiducials for pancreas and I don't love the cone beam quality for upper GI with our versa HDs. In my particular situation, the MR was a game changer with respect to pancreas patients.

Im busy with pancreas, all treated on a Truebeam breath hold. It's been a mix of SBRT w/wo nodes (usually with) and 25 fraction with SIB and cape. I really like the latter more than I thought I would! It feels a little more comprehensive. I know this is not based on prospective data.

I hope to have MR at some point, I do miss it for upper GI targets. But totally agree any of this can be done very safely with CBCT. We actually have an interventional GI group, it's nicer than working with IR haha. But its even nicer to not need fiducial placement at all.

 

[sirspamalot]

Haven't seen a pancreas in 3-4 years. Don't miss them either.

 

[thesauce]

Reduced fraction trials are the low-hanging fruit of research in our field - these trails are simple to write and accrue for and require virtually no actual thought or creativity (3 versus 5 fractions...come on now). The background sections of the trials can be essentially copied and pasted from one to another and one could easily write one over a weekend.

Others are too nice to tell them how meaningless it is so it proceeds.

If they truly think this is groundbreaking research, we have an even bigger problem, but truthfully I think they know in their hearts it is not and it's just the easiest path to academic promotion.

 

[radoncftw]

Reduced fraction trials are the low-hanging fruit of research in our field - these trails are simple to write and accrue for and require virtually no actual thought or creativity (3 versus 5 fractions...come on now). The background sections of the trials can be essentially copied and pasted from one to another and one could easily write it over a weekend.

Others are too nice to tell them how meaningless it is so it proceeds.

If they truly think this is groundbreaking research, we have an even bigger problem, but truthfully I think they know in their hearts it is not and it's just the easiest path to academic promotion.

completely agree.
10--5--3--1 for breast APBI for example.
think about how many visits required for chemo, IV iron, IVF, f/u visits, dexa, etc. it all adds up...but somehow 5-10 Fx APBI or 16 Fx of whole breast RT is too much.

 

[TheWallnerus]

completely agree.
10--5--3--1 for breast APBI for example.
think about how many visits required for chemo, IV iron, IVF, f/u visits, dexa, etc. it all adds up...but somehow 5-10 Fx APBI or 16 Fx of whole breast RT is too much.

The “too much fractions” phone call came from inside our own house. In the beginning of the Hypofract Era I recall some med oncs and general surgeons asking me “Is it safe?” to do such a drastic jump in fraction lowering (if the alpha/beta guesses were off, hypofractionation was dose de-escalation on the cancer). The other specialists seemed genuinely worried. Lots of rad oncs were too! And then, kind of overnight, the rad oncs were not.

 

[sirspamalot]

They really want us to go back in the closet (basement).

Not cool

 

[seper]

mainstream hypofrac came from UK and Canada

 

[TheWallnerus]

mainstream hypofrac came from UK and Canada

Totally. For the longest though when you brought up Canadian or UK data, in the US, you were quack-y, irresponsible, or a really misinformed person.

 

[Chartreuse Wombat]

Totally. For the longest though when you brought up Canadian or UK data, in the US, you were quack-y, irresponsible, or a really misinformed person.

UK and Canada are incentivized to use fewer fractions; US not so much

 

[medgator]

UK and Canada are incentivized to use fewer fractions; US not so much

Academic centers have definitely found the advantage of keeping patients for treatment at the mothership though with those regimens rather than referring out to satellites or community/PP'ers

 

[radoncftw]

Academic centers have definitely found the advantage of keeping patients for treatment at the mothership though with those regimens

i think its very interesting. we had a lot of hesitancy where i trained to move to hypofrac (we need long-term outcomes data!!!)...but seemed to really start adopting around when satellites started cropping up all over town.