True beyond belief. Where there are reasonable opportunities to reduce treatment, these should be pursued. It has morphed into a crusade about cutting radiation, just to cut it.
Hypofractionation for breast done in a reasonable, seasoned manner with long term results before adoption. Prostate hypofraction is the opposite. We took a scheme used in low risk disease, shook it up with some European trials that included a clear minority of high risk disease, included HYPRO (which showed 3.4 Gy fractions can control high grade disease, but also cause significantly worse side effects and should not be used on patients) and came out with a policy statement that every prostate should be hypofractionated. Period.
All previous evidence that dose escalation, including by brachytherapy, may be beneficial was not even considered. And I recall getting into this argument with Chartreuse or someone about the follow up. The RTOG 0415 study had a follow up of 5 years. And guess what came out recently? RTOG 9413. The curves started to separate at 7 years in that trial - it's almost as if there can be late recurrences in prostate cancer that mandate sufficient follow up to adequately report. But what did ASTRO do? Policy statement - hypofractionate every prostate. " Based on high-quality evidence, strong consensus was reached for offering moderate hypofractionation across risk groups to patients choosing external beam radiation therapy." I do not need to treat prostates in 39, 42, 48 fractions for my income. But how can one possibly look at the balance of evidence, those trials (including a negative one for toxicity!!!!!!) and conclude that the evidence supports that recommendation. It's garbage. It may be proven with time, it is absolutely not proven now. It's like some kind of weird and pathetic gimmick to prostrate ourselves to insurance companies prematurely.
70 yr old with breast cancer? Well those 3 weeks of radiation are just too terrible - take 5 years of hormonal therapy instead, so we can save society. Rather than advocating for a short treatment course that continually reduces the risk of LR in every single trial, and has very low grades of grade 2+ late effects, it's like we pat ourselves on the back for recommending 5 years of hormones which has inferior outcomes. But that's ok, why advocate for something that is short, well tolerated, and works?
I don't get it. We have pharmacy companies doing direct to consumer advertising, and instead of using our PAC money to do that and spread awareness of radiation, we are actively trying to cede our role at all costs. Even though we are the smallest of oncologic care spending.
