Hypofractionation, $$$, and data

[Gfunk6]

Since our threads regarding hypofractionation for prostate cancer and standard of care for limited stage SCLC ultimately devolved into the topic of "hypofractionation, $$$, and data," I took the liberty of creating this additional thread so that everyone can work out their angst.

My firm belief is that hypofractionation is the future of Radiation Oncology. You can be a first adopter, only change your practice when you are pressured to do so by peers/payors, or ultimately be dragged kicking and screaming into the future.

We all know that if you want large numbers of people to do something you have to either give incentivization to do it or disincentivization to do the opposite. In the case of hypofractionation in a fee for service environment, MDs are perversely incentivized to increase the length off treatment. Obviously, nobody will say in public that, "yes, I treat 70 year old women with low-grade invasive ductal carcinoma with 7 weeks of radiation because it increases my profit." Such an admission would be crass, unprofessional and (I would content) unethical. Instead a variety of excuses are adopted;

1. There is not enough follow-up in randomized trials comparing conventional to hypofractionation
2. Hypofractionation (in some cases) have minimally increased acute toxicity
3. My patients don't want to be treated with "socialist medicine" (I sincerely apologize to my European colleagues but seriously I am quoting that ad verbatim)
4. People who hypofractionate either don't care about data or they operate in a system (e.g. salaried) that incentivizes them to finish patients quicker (this last piece is especially ironic)
5. Let's ignore randomized Phase III data in 100s of patients because of an archaic mathematical equation we learned in residency

At the end of the day, when CMS pays a case rate we all know that conventional fractionation will die a quick and painless death. All the nay-sayers will "come to Jesus" suddenly being convinced of the data that has been there for years. So, I say, judge them not harshly.

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[John Rattan]

In the Red Journal Online First today... an article literally showing that fractionation decisions are based on reimbursement concerns:

Abstract Purpose/Objective(s): European data suggest that 8 fraction stereotactic body radiotherapy (SBRT) regimens may be similar in efficacy with less toxicity than ≤5 fraction SBRT for central lung lesions. However, under current Centers for Medicare & Medicaid Services guidelines, SBRT in the United States (US) is only reimbursed for ≤5 fractions, whereas there are no such restrictions for reimbursement in Canada. We hypothesize that US-specific SBRT reimbursement policies influence utilization of ≥5 fraction SBRT in US academic centers when compared to comparable Canadian centers.

Materials/Methods: A 15 question electronic survey was distributed to radiation oncologists at National Cancer Institute-designated cancer centers in the US and the ten highest research funded cancer centers in Canada. Fisher exact test or exact logistic regression if applicable was used, where p<.05 was considered statistically different from neutral.

Results: Of the 143 radiation oncologists from 60 US and 6 Canadian cancer centers who completed the survey (17.6% response rate), 125 routinely prescribe SBRT. Fifty percent of US vs 0% of Canadian physicians indicated that there are instances where they would like to prescribe >5 fraction SBRT but prescribe ≤5 fractions due to insurance reimbursement (p=.076 and p=.001, respectively). Seventy percent (p=.006) of US vs 0% (p=.001) of Canadian radiation oncologists report that SBRT clinical investigation is constrained by the insurance reimbursement. The most common reported deterrent to prescribing >5 fraction SBRT in the US was insurance reimbursement (49.5%).

Conclusion: US radiation oncologists are more likely than those in Canada to report that SBRT clinical investigation and >5 fraction SBRT use may be negatively influenced by health insurance reimbursement; this perception was not held by physicians in Canada. Healthcare environment may significantly affect radiation therapy decision-making and practice patterns.

 

[medgator]

At the end of the day, when CMS pays a case rate we all know that conventional fractionation will die a quick and painless death. All the nay-sayers will "come to Jesus" suddenly being convinced of the data that has been there for years. So, I say, judge them not harshly.

Case based reimbursement is going to come with sovereign immunity? CMS is going to have the hypo-fx legal team on retainer for us? Sign me up!

 

[Gfunk6]

Case based reimbursement is going to come with sovereign immunity? CMS is going to have the htpo-fx legal team on retainer for us? Sign me up!

It will be the usual mantra that payors give us. As clinicians we obviously want the best for our patients but payors are generally ok with letting them die if it saves them money. So the excuse is always, "Oh no, you are the doctor. We don't make clinical decisions. All we are saying is that we will not cover what you are trying to do." In other words, unless the patient is independently wealthy, payors dictate care.

As you know, they do this all the time. I can't tell you how many times I have gotten red-faced explaining to some bureaucrat or partially-senile, retired family medicine doctor why my patient needs IMRT for lung or rectal cancer only to be rebuffed. Obviously, in those cases I suck it up and go with 3D. The liability, as always, is on me - where it belongs.

 

[seper]

For SBRT study quoted above, "Europenan" 7.5 Gy X 8 is a pretty poor treatment regimen. I've seen it used (billed as IMRT) in the recent past, with high relapse rates.

 

[John Rattan]

For SBRT study quoted above, "Europenan" 7.5 Gy X 8 is a pretty poor treatment regimen. I've seen it used (billed as IMRT) in the recent past, with high relapse rates.

Yeah, man I saw one recur. And I saw one guy got real sick. Data, man, amirite?

 

[seper]

More like 3/5 recurred 🙂 Do they have 5 year follow data like Timmerman? Dunno.

 

[John Rattan]

The only thing I hate more than unsubstantiated analogy driven medicine is the Dutch. It's very reasonable, and even used at US institutions.
Our Socialist colleague, @Palex80 (just kidding buddy, take it easy), can probably let us know how commonly it's used in Europe.

 

[scarbrtj]

Insurance company guys & CMS just need to read the Student Doctor Network to figure out everything that's wrong with radiation oncology and the secret maneuvers hiding our base avariciousness. We sound awful! I need a shower.

 

[seper]

Retrospective, 3 years data - not good enough to consider replacing standard US/Japanese regimens

The only thing I hate more than unsubstantiated analogy driven medicine is the Dutch. It's very reasonable, and even used at US institutions.
Our Socialist colleague, @Palex80 (just kidding buddy, take it easy), can probably let us know how commonly it's used in Europe.

 

[John Rattan]

Retrospective, 3 years data - not good enough to consider replacing standard US/Japanese regimens

Huh? The Timmerman paper showed that 3 fractions were dangerous for central tumors. There are no 4-5 fraction "standard US/Japanese regimens" with 5 year follow up that I'm aware of. I may just be missing the series. 0813 median follow up was 30-33 months when presented at ASTRO in 2016, so "not good enough to consider". Or is there an update I'm just not aware of? 0915 was were peripheral tumors. 0618 used 3 fractions. NCCN reports it as treatment option for central tumors.

I think missing the point - did you see the above abstract? Clinical decisions are being made based on reimbursements. Can argue about that scheme all you want.

 

[Palex80]

For SBRT study quoted above, "Europenan" 7.5 Gy X 8 is a pretty poor treatment regimen. I've seen it used (billed as IMRT) in the recent past, with high relapse rates.

I do not agree. 3 x 15 Gy or 5 x 8 Gy schedules are quite popular here, but these doses are usually 60%-PTV-encompassing isodoses.
The ITV is generally in 90% area, meaning that the tumor is actually treated with about 3 x 22 Gy or 5 x 12 Gy.
Here's an open access paper describing what's going one in Europe in terms of SBRT.
http://www.jto.org/article/S1556-0864(15)33445-6/pdf


I never quite understood why in the US SBRT dose is prescribed on the 95% encompassing isodose. You are basically treating then quite a large part of healthy lung which may harbor some microscopic disease with ablative doses.

 

[Palex80]

The only thing I hate more than unsubstantiated analogy driven medicine is the Dutch. It's very reasonable, and even used at US institutions.
Our Socialist colleague, @Palex80 (just kidding buddy, take it easy), can probably let us know how commonly it's used in Europe.

Our "new" schedule for centrally located tumors adopted just a few months ago in our clinic is 10 x 5 Gy o 60% isodose. That's 10 x 8.33 Gy as maximum dose. I think it works charming for centrally located tumors. My esophagus constraint is 10 x 3.5 Gy. Minimum toxicity so far.

We still do 3 x 15 Gy to the 60% isodose for peripheral tumors. That's comparable to the Timmermann schedule in terms of dose. Of the lesion is on the chest wall however, we tend to fractionate more. And honestly, I do not like the 1 x 34 Gy RTOG-regime. I've only done it once for a patient with poor PS who wanted his metastatic lung nodule zapped. I'd never do it in a curative-intent NSCLC treatment.

 

[Gfunk6]

Seize the means of irradiation!


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[scarbrtj]

http://www.redjournal.org/article/S0360-3016(17)30274-2/abstract

 

[Burt Radnolds]

http://www.redjournal.org/article/S0360-3016(17)30274-2/abstract

Old news...

First results of the randomised UK FAST Trial of radiotherapy hypofractionation for treatment of early breast cancer (CRUKE/04/015). - PubMed - NCBI

 

[Phantom1]

Old news...

First results of the randomised UK FAST Trial of radiotherapy hypofractionation for treatment of early breast cancer (CRUKE/04/015). - PubMed - NCBI

Kinda scary that 30cGy per day (1.5Gy total) resulted in such a dramatic increase in toxicity... seems like close to a "tolerance" dose? Cosmesis is very important in breast cancer and is tied to psychosocial health. I'm a proponent of hypofractionation but dont take it too far and cause toxicity that is unnecessary just so that you can get treatment done in 5 days instead of 15...

 

[Palex80]

Kinda scary that 30cGy per day (1.5Gy total) resulted in such a dramatic increase in toxicity... seems like close to a "tolerance" dose? Cosmesis is very important in breast cancer and is tied to psychosocial health. I'm a proponent of hypofractionation but dont take it too far and cause toxicity that is unnecessary just so that you can get treatment done in 5 days instead of 15...

It's a bit like the CHHiP trial results.
57/3 were worse than 60/3 in terms of tumor control. Kind of surprising how one fraction can make such a difference, isn't it?

 

[radiaterMike]

Old news...

First results of the randomised UK FAST Trial of radiotherapy hypofractionation for treatment of early breast cancer (CRUKE/04/015). - PubMed - NCBI

You don't have to read past the first few words of either abstract or title to know that these are preliminary results


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[Mandelin Rain]

Even if the point of this thread is completely true, and I think it likely is to some extent, in a day of completely arbitrary reimbursement rules sometimes you have to play the game to keep the lights on. I'm not going to feel too bad about it. It allows me to pay down my exorbitant school loans, while providing a comfortable (read: not extravagant, though that is a matter of prospective) life for my family. It allows me to treat the people who don't pay anything without ever turning anyone away. It allows my staff to have a full time pay check. It allows my patients who work, the ability to come at 7 AM or 4 PM rather than some administrator mandating half days due to low census. It allows me to meet ROI, so the system will pay for the next great $3 million way to hypofractionate people that Varian offers, when the time comes.

As the departmental leader, you have to consider many things.

Full disclosure: I hypofractionate nearly every early stage breast cancer I see. I'll flip them prone to try to hypofractionate them if the dosimetry isn't working supine. I offer women over 70 observation vs hypofrationated XRT routinely, and many select observation. I use 3 fraction SBRT lung when appropriate, 5 when central, 4 if touching a rib/chestwall (no science to this approach, just what I've settled on). I use 44 fractions for prostate off-study, as it is the standard arm of RTOG protocols, and I haven't seen any compelling reason not to other than cost (which if you're arguing we shouldn't be making treatment decision based on cost becomes highly ironic). I recommend active surveillance frequently, but men are less likely to observe than women are with breast cancer. I usually use 10 fractions to treat bone mets, mainly because of an admittedly small number of anecdotal experiences I had with terrible esophagitis, nausea, and diarrhea. I IMRT a lot of stuff. I cone beam a lot of stuff. That's how I trained, and I think it's better (and again, if the argument is no treatment decision based on cost...). I don't think I've ever given a patient a bad, substandard, or more toxic treatment based on reimbursement issues. I sleep okay at night.

 

[medgator]

I use 44 fractions for prostate off-study, as it is the standard arm of RTOG protocols, and I haven't seen any compelling reason not to other than cost (which if you're arguing we shouldn't be making treatment decision based on cost becomes highly ironic).

Zing!

 

[John Rattan]

Just some thoughts, b/c of the nifty "zing" posted (huh?) ..

Do you think in the current era of American health care that physicians should never utilize cost at all as a factor in medical decision making?

Do you think that this sort of thinking might be one reason our costs our higher than other Western countries?

Are doctors that think that way "more correct" then other service providers that do not completely neglect cost in their recommendations (mechanics, dentists, hair stylists, lawyers being some examples)?

Should clinicians be the economic stewards of American medicine or should we continue to leave that to the government and to insurers?

Do you think "Choosing Wisely" is a good campaign or just another "schoolmarm"/"bean counter" trying to make you do things you don't want to do?

NPR had a podcast regarding pharmaceutical companies. They offer coupons to waive the higher co-pays for more expensive non-generic medicines that are not found to be better. Basically, medicine A costs $50 and co-pay is $5. Medicine B costs $1000, co-pay is $20, but the pharma company offers the patient a $20 coupon for the co-pay. It costs the system>$900 more. The clinician interviewed said it wasn't her job to consider cost, and she didn't have time to think about any of that. Do you agree with that?

When clinicians and patients have no idea about cost nor do they care about it nor do they feel it should be valued at any point in the clinical decision making process, the cost curve will never bend. And, we are a rich country, so maybe that's okay to have health care costs continue to grow (from 16% of GDP 15 years ago to nearly 20% now). I do think cost should play a role in decision making. Not the most important factor, but certainly something to consider. A lot of patients, especially Medicare, are responsible for 20% of the bill. When you choose a $40,000 treatment that may or may not be better than a $10,000 patient, that inflicts financial toxicity.

Anyway, there is certainly a rift. Some people never want to consider it. Some people think it's important and it should be considered. I don't think the two sides will come to agreement. The argument essentially above from certain members is that no marginal cost is too high, if a treatment is marginally better or marginally less toxic. I.e. if 1% less toxicity, than $50,000 extra is fine. Others think that we have to weigh the cost vs benefit.

Zing!

Even if the point of this thread is completely true, and I think it likely is to some extent, in a day of completely arbitrary reimbursement rules sometimes you have to play the game to keep the lights on. I'm not going to feel too bad about it. It allows me to pay down my exorbitant school loans, while providing a comfortable (read: not extravagant, though that is a matter of prospective) life for my family. It allows me to treat the people who don't pay anything without ever turning anyone away. It allows my staff to have a full time pay check. It allows my patients who work, the ability to come at 7 AM or 4 PM rather than some administrator mandating half days due to low census. It allows me to meet ROI, so the system will pay for the next great $3 million way to hypofractionate people that Varian offers, when the time comes.

As the departmental leader, you have to consider many things.

Full disclosure: I hypofractionate nearly every early stage breast cancer I see. I'll flip them prone to try to hypofractionate them if the dosimetry isn't working supine. I offer women over 70 observation vs hypofrationated XRT routinely, and many select observation. I use 3 fraction SBRT lung when appropriate, 5 when central, 4 if touching a rib/chestwall (no science to this approach, just what I've settled on). I use 44 fractions for prostate off-study, as it is the standard arm of RTOG protocols, and I haven't seen any compelling reason not to other than cost (which if you're arguing we shouldn't be making treatment decision based on cost becomes highly ironic). I recommend active surveillance frequently, but men are less likely to observe than women are with breast cancer. I usually use 10 fractions to treat bone mets, mainly because of an admittedly small number of anecdotal experiences I had with terrible esophagitis, nausea, and diarrhea. I IMRT a lot of stuff. I cone beam a lot of stuff. That's how I trained, and I think it's better (and again, if the argument is no treatment decision based on cost...). I don't think I've ever given a patient a bad, substandard, or more toxic treatment based on reimbursement issues. I sleep okay at night.

 

[Mandelin Rain]

I don't believe that patients should bear the brunt of medical cost savings. No.

There are much better targets for such. However, these targets contribute vast sums of money to political campaigns so....

I also don't think the clinic is the place to have existential discussions of health care's increase as a percentage of GDP when weighing treatment options. Just me though. Feel free to have the GDP talk with your patients if you think it's the right thing to do.

 

[medgator]

It's sad when there is infighting among physicians (some of whom are completely naive to the reality of our system).

The real culprits of increasing healthcare expenditures are the six-figure novel therapies that continue to come out from big pharma, and the administrative expenses associated with the delivery of healthcare. I guarantee we could hypofx till the cows come home and it would be far outweighed by the above in absolute dollars.

Insurance company and hospital CEOs far outearn most physicians in income, specialists or otherwise. And the US patient essentially subsidizes drug development costs for the rest of the world by paying the most for drugs, even compared to much of the rest of the developed world including Canada and countries in western Europe.

Administrative costs are killing U.S. healthcare

U.S. health care admin costs are double the global average

Why Chemotherapy That Costs $70,000 in the U.S. Costs $2,500 in India

https://www.economist.com/blogs/economist-explains/2016/09/economist-explains-2

A curative course of head and neck xrt barely buys a few months of a PD-L1 inhibitor. Some people on this forum need to think about that long and hard.

 

[John Rattan]

I don't believe that patients should bear the brunt of medical cost savings. No.

There are much better targets for such. However, these targets contribute vast sums of money to political campaigns so....

I also don't think the clinic is the place to have existential discussions of health care's increase as a percentage of GDP when weighing treatment options. Just me though. Feel free to have the GDP talk with your patients if you think it's the right thing to do.

Yep. That's exactly what I said. Talk about GDP with patients. That will solve everything. It's even quoted. Spend 15 minutes on health care economics with patients and then bill for that separately.

 

[John Rattan]

I don't believe that patients should bear the brunt of medical cost savings. No.

There are much better targets for such. However, these targets contribute vast sums of money to political campaigns so....

I also don't think the clinic is the place to have existential discussions of health care's increase as a percentage of GDP when weighing treatment options. Just me though. Feel free to have the GDP talk with your patients if you think it's the right thing to do.

Medicare patients that don't have a secondary plan have to pay 20% of the cost. They would save a few $1000 out of pocket when treated with 70/28 vs 77.4/43. If patients are presented the bill at consultation and are clear that they may have more diarrhea during treatments, do you still think all patients would choose the 43 fractions? But, we don't discuss financial toxicity. That's where disagreement lies. I do think that patients should be the ones that save money, if they so choose. But, in most cases, 1) the information is completely asymmetric and 2) they don't even get the opportunity to have any agency in the decision.

 

[nkmiami]

Also on the surgical side the robot...It looses money, has no better outcomes and hospitals are forced to purchase them- this is a really eye opening editorial

Robotic-Assisted Radical Prostatectomy: Who Is Benefiting? | Cancer Network

 

[medgator]

Also on the surgical side the robot...It looses money, has no better outcomes and hospitals are forced to purchase them- this is a really eye opening editorial

Robotic-Assisted Radical Prostatectomy: Who Is Benefiting? | Cancer Network

A different variation/flavor of the proton/photon argument, albeit probably not at the same level financially as protons have been

 

[nkmiami]

a medline search on robot vs other forms of laparascopic surgery for any body site, the robot has equal/worse results but significantly more expensive- this is going on at almost every hospital in the country.

Is da Vinci Robotic Surgery a Revolution or a Rip-off?

thyroid surgery:
"Open surgery is an effective surgery in terms of oncologic control and has low complication rates. However, it leaves a prominent neck scar. Surgeons, predominantly in Asia, are now using the da Vinci Surgical System to perform thyroidectomies entering the body from the axilla in order to avoid the visible scar on the neck.”

 

[scarbrtj]

Medicare patients that don't have a secondary plan have to pay 20% of the cost. They would save a few $1000 out of pocket when treated with 70/28 vs 77.4/43. If patients are presented the bill at consultation and are clear that they may have more diarrhea during treatments, do you still think all patients would choose the 43 fractions? But, we don't discuss financial toxicity. That's where disagreement lies. I do think that patients should be the ones that save money, if they so choose. But, in most cases, 1) the information is completely asymmetric and 2) they don't even get the opportunity to have any agency in the decision.

We really need to go deeper than just the pecuniary imponderables of 70/28 vs 77.4/43 for prostate CA. Why should we even treat prostate cancer? I read on the Internet that most people die "with it" versus "from it." Should we even screen for it? Should we treat ANY cancer, or is it just a natural part of aging? (I like the movie 'Logan's Run.') How do we get rid of informational symmetry? How can we TRULY know if a patient has "agency?" I actually have been thinking about making my patients write a sort of executive summary essay after our initial consultation wherein they reiterate to me their diagnosis, prognosis, estimated societal costs and burdens of their particular cancer, opportunity costs of treatment(s) vs. non-treatment, and a brief economic analysis of the pros and cons of Medicare's sustainable growth rate schema.

This is sarcasm... sorta. I'm not sure we are debating best medical care anymore! This almost devolves into a political argument or religious squabble. Like the people who can brag about being the true and honest hypofractionators are like what Isaiah wrote about as being "wrapped in a robe of righteousness." 🙂

 

[scarbrtj]

a medline search on robot vs other forms of laparascopic surgery for any body site, the robot has equal/worse results but significantly more expensive- this is going on at almost every hospital in the country.

Do the roboticists get on forums on the Internet and rend their intellectual raiments like we do, or are they smart? Would be interesting to know.

 

[Phantom1]

....
A curative course of head and neck xrt barely buys a few months of a PD-L1 inhibitor. Some people on this forum need to think about that long and hard.

This is such a good point and so key. We get all worked up about our specialty when in fact we have to realize that the entire billing of radiation oncology is a tiny fraction compared to medical oncology or cardiology for example. So we should not be too hard on ourselves as in most cases we are delivering treatment with curative intent...

 

[seper]

45 treatment fractions is just such an unreasonable amount of therapeutic sessions, IMHO. I do know of a case of an elderly man dying in car crash with his wife, driving on Michigan highway to his daily prostate XRT..

 

[John Rattan]

Well, information asymmetry is corrected by ... um .. providing information. Decision-aid tools. Societal and patient costs. Comparison tables.

The standard example, and it is a very fair example, is LASIK surgery. Very detailed information about the treatments, transparent pricing structure, etc. You can find oodles of very helpful information on it. People make very informed decisions when they get LASIK, and the satisfaction rates are extremely high. There is decision regret in patients treated with prostate cancer, and a lot of times they just don't know their options. But, yeah, we can stick with keeping people in the dark, not offering choices, and not allowing anyone but insurers worry about costs of care (be it to patients or society). Seems like it works just fine.

We really need to go deeper than just the pecuniary imponderables of 70/28 vs 77.4/43 for prostate CA. Why should we even treat prostate cancer? I read on the Internet that most people die "with it" versus "from it." Should we even screen for it? Should we treat ANY cancer, or is it just a natural part of aging? (I like the movie 'Logan's Run.') How do we get rid of informational symmetry? How can we TRULY know if a patient has "agency?" I actually have been thinking about making my patients write a sort of executive summary essay after our initial consultation wherein they reiterate to me their diagnosis, prognosis, estimated societal costs and burdens of their particular cancer, opportunity costs of treatment(s) vs. non-treatment, and a brief economic analysis of the pros and cons of Medicare's sustainable growth rate schema.

This is sarcasm... sorta. I'm not sure we are debating best medical care anymore! This almost devolves into a political argument or religious squabble. Like the people who can brag about being the true and honest hypofractionators are like what Isaiah wrote about as being "wrapped in a robe of righteousness." 🙂

 

[John Rattan]

9 weeks is nuts. But, it's standard, it pays better, and almost no one gives the option of shorter treatments. Whatever. It's only another $60k on a disease that arguably shouldn't be treated. People gotta get their kids to private school, their significant others pretty Yurman stuff, and vacations to Bali aren't cheap either.

On the other hand, people drive fast in Michigan. I'm not sure if I'm about to caution prostate cancer patients about treatment being related to a higher risk of motor vehicle related death. That seems to be a stretch, bro.

45 treatment fractions is just such an unreasonable amount of therapeutic sessions, IMHO. I do know of a case of an elderly man dying in car crash with his wife, driving on Michigan highway to his daily prostate XRT..

 

[evilbooyaa]

9 weeks is nuts. But, it's standard, it pays better, and almost no one gives the option of shorter treatments. Whatever. It's only another $60k on a disease that arguably shouldn't be treated. People gotta get their kids to private school, their significant others pretty Yurman stuff, and vacations to Bali aren't cheap either.

On the other hand, people drive fast in Michigan. I'm not sure if I'm about to caution prostate cancer patients about treatment being related to a higher risk of motor vehicle related death. That seems to be a stretch, bro.

With multiple studies showing less toxicity in the standard regimen than the hypofractionated regimens. Sure, there are some which show no difference in toxicity, but you can't publish 10 studies comparing hypofrac to standard, then throw out 8 that show worse toxicity in hypofractionation, and claim that it's all the same. If an institution wants to hypofrac prostate, that's fine, and go for it, but I disagree with the idea that if you don't offer hypofractionated prostate, you're an unethical scumbag who only cares about his wallet and not the patient.

My counter-argument would be that if you're perversely incentivized to hypofractionate (like in the Kaiser system), it's unethical to do that, without offering standard fractionation (while discussing the potential toxicity risk of hypofrac).

I don't commonly treat intact prostate, because urology just cuts everything and everyone at my institution, regardless of indications, so as someone who has no dog in this fight on prostate RT and hypofractionation (and seeing the vitriol it brings out from both sides of the argument), there appears to be a toxicity difference between hypofractionated versus standard fractionation for prostate cancer. This isn't getting into whether patients should have active surveillance or not. That decision is frequently made before a consultation to radiation oncology is made at my institution.

Hypofrac for early stage breast, on the other hand, is pretty widely accepted, with documented no worsening of toxicity, and thus I agree that doing 6 weeks on every (or even most) early stage breast cancers where you're not covering nodes isn't super defensible, IMO.

Can't we all just get along as radiation oncologists, let folks do both standard of care AND hypofractionation, depending on personal preference, and focus on the real enemy, Urologists? (I kid, but seriously, both bladder and prostate cancer both have guidelines that make 0 sense to me).

Agree wholeheartedly with the bolded. That's the worst argument against standard fractionation I've seen.

 

[Mandelin Rain]

I heard of a guy who died in a car crash who wasn't even getting radiation! Crazy world.

 

[seper]

tell that to the doc who prescribed the old man 45 fractions - he has to live with this for the rest of his life

 

[Burt Radnolds]

tell that to the doc who prescribed the old man 45 fractions - he has to live with this for the rest of his life

What fraction was he on when he died?

 

[Mandelin Rain]

So now rad oncs aren't just responsible for our country's lagging GDP growth relative to the rate of health expenditures growth, but we are now responsible for being at the vanguard of lowering speed limits from 70 to 60 MPH?

I can't do all that from Bali.

 

[John Rattan]

So now rad oncs aren't just responsible for our country's lagging GDP growth relative to the rate of health expenditures growth, but we are now responsible for being at the vanguard of lowering speed limits from 70 to 60 MPH?

I can't do all that from Bali.

In the Upper Peninsula, the speed limit has increased on some highways to 80 MPH. Every radonc in Marquette, MI supported this bill. You do the math.

 

[medgator]

Hypofrac for early stage breast, on the other hand, is pretty widely accepted, with documented no worsening of toxicity, and thus I agree that doing 6 weeks on every (or even most) early stage breast cancers where you're not covering nodes isn't super defensible,

Some studies actually suggest it is better in terms of short term side effects and long term cosmesis.

It's just mind boggling that people equate the breast and prostate hypofx data.... totally different outcomes and median follow up periods. And bottom line, hypofx for breast actually might be better, along with being cheaper

Can't we all just get along as radiation oncologists, let folks do both standard of care AND hypofractionation, depending on personal preference, and focus on the real enemy, Urologists? (I kid, but seriously, both bladder and prostate cancer both have guidelines that make 0 sense to me).

Amen

Agree wholeheartedly with the bolded. That's the worst argument against standard fractionation I've seen.

??

 

[evilbooyaa]

Some studies actually suggest it is better in terms of short term side effects and long term cosmesis.

It's just mind boggling that people equate the breast and prostate hypofx data.... totally different outcomes and median follow up periods. And bottom line, hypofx for breast actually might be better, along with being cheaper

I'm aware, but again, that's like one, maybe two studies out of all of them? My point was that taking breast hypofrac data as a whole, there isn't much to suggest that moderate hypofractionation will ever be shown to have WORSE toxicity or outcomes. I wouldn't hang my hat that hypofractionation definitively 'improves cosmesis', despite the results of 1 trial.

??

Was stating that seper's argument about a guy dying of MVA while driving to his prostate radiation was a dumb argument against standard fractionation. Although, perhaps my sarcasm meter is off right now. This forum used to be super respectful, but in the past month it seems to have been inflicted by the same curse back when Damn_Daniel was riling people up. People have become a lot more hostile against people who don't treat exactly the same way as them, as well.

 

[medgator]

I'm aware, but again, that's like one, maybe two studies out of all of them? My point was that taking breast hypofrac data as a whole, there isn't much to suggest that moderate hypofractionation will ever be shown to have WORSE toxicity or outcomes. I wouldn't hang my hat that hypofractionation definitively 'improves cosmesis', despite the results of 1 trial.

Yeah. My point was that the breast data didn't look as bad as the prostate on the whole and it has longer follow up. A few studies suggest it might be a better treatment, while none of the prostate data shows that to be the case.

The argument for prostate hypofx is purely on the pt convenience and financial aspect. Rather than put pts through 19, 28, or 44 fx, I'd rather not treat them if they don't need to be treated and are OK with AS/WW. But if a patient needs to be treated, I'm going with the safest txwith the least amount of side effects

Was stating that seper's argument about a guy dying of MVA while driving to his prostate radiation was a dumb argument against standard fractionation. Although, perhaps my sarcasm meter is off right now. This forum used to be super respectful, but in the past month it seems to have been inflicted by the same curse back when Damn_Daniel was riling people up. People have become a lot more hostile against people who don't treat exactly the same way as them, as well

Ah gotcha. Yeah, it's unfortunate. I put a certain recently joined poster on my ignore list and he seems to remind me a lot of DD

 

[medgator]

tell that to the doc who prescribed the old man 45 fractions - he has to live with this for the rest of his life

Would it matter if the guy had high risk disease and was bleeding from the rectum because his PCa was clinically a T4 (I've seen it happen before as an initial presentation).

I'd feel guilty treating the guy in the first place if he was 82 with copd and a GS of 6 with a psa of 5, with or without the car crash hx

 

[Chartreuse Wombat]

With multiple studies showing less toxicity in the standard regimen than the hypofractionated regimens. Sure, there are some which show no difference in toxicity, but you can't publish 10 studies comparing hypofrac to standard, then throw out 8 that show worse toxicity in hypofractionation, and claim that it's all the same. If an institution wants to hypofrac prostate, that's fine, and go for it, but I disagree with the idea that if you don't offer hypofractionated prostate, you're an unethical scumbag who only cares about his wallet and not the patient.

My counter-argument would be that if you're perversely incentivized to hypofractionate (like in the Kaiser system), it's unethical to do that, without offering standard fractionation (while discussing the potential toxicity risk of hypofrac).

I don't commonly treat intact prostate, because urology just cuts everything and everyone at my institution, regardless of indications, so as someone who has no dog in this fight on prostate RT and hypofractionation (and seeing the vitriol it brings out from both sides of the argument), there appears to be a toxicity difference between hypofractionated versus standard fractionation for prostate cancer. This isn't getting into whether patients should have active surveillance or not. That decision is frequently made before a consultation to radiation oncology is made at my institution.

Hypofrac for early stage breast, on the other hand, is pretty widely accepted, with documented no worsening of toxicity, and thus I agree that doing 6 weeks on every (or even most) early stage breast cancers where you're not covering nodes isn't super defensible, IMO.

Can't we all just get along as radiation oncologists, let folks do both standard of care AND hypofractionation, depending on personal preference, and focus on the real enemy, Urologists? (I kid, but seriously, both bladder and prostate cancer both have guidelines that make 0 sense to me).

Agree wholeheartedly with the bolded. That's the worst argument against standard fractionation I've seen.

I agree that we should stop insulting each other but I must correct your categorization of 8 studies showing worse toxicity.

Here are the facts:
Three non-inferiority studies with >5000 patients all with at least 5 years of FU:
CHHiP (n=3200) NO DIFFERENCE in toxicity or patient reported outcomes
PROFIT (n=1200) NO DIFFERENCE in toxicity or patient reported outcomes (in fact late Grade 2 GI was less likely in hypo)
RTOG (n=1100) INCREASE in Grade 2 GI/GU but NO DIFFERENCE in Grade 3+

Four smaller superiority studies
Italian (n=168) No difference
Fox Chase (n=300) Overall no differences but in unplanned subgroup with high IPSS more GU toxicity
MDAnderson (n=200) No difference
HYPRO (n=800) More toxicity with the hypo regimen but no one is recommending that regimen; even the authors

All told 7 seven studies-no difference in the two largest including >4000 patients. In two studies there was an increase in overall toxicity with hypo.

I gave up telling people what to do a long time ago, and I don't question the motives of people that I don't know but it is simply not accurate to say that the majority of studies show more toxicity with hypo. The weight of the evidence is that there are no differences in late toxicity. Many will say that five years is not long enough. Perhaps, if so then how many people followed for how long will satisfy you that hypo is safe?

 

[Gfunk6]

Well to be fair - if we are being data driven . . .

If a statistically significant number of men receiving conventional fractionation for prostate cancer were dying in MVAs, it should show up on the survival curves. As far as I'm aware there is no survival difference between hypofrac and conventional frac 🙂

 

[RadOncDoc21]

I once knew a guy who died.

 

[evilbooyaa]

I agree that we should stop insulting each other but I must correct your categorization of 8 studies showing worse toxicity.

Here are the facts:
Three non-inferiority studies with >5000 patients all with at least 5 years of FU:
CHHiP (n=3200) NO DIFFERENCE in toxicity or patient reported outcomes
PROFIT (n=1200) NO DIFFERENCE in toxicity or patient reported outcomes (in fact late Grade 2 GI was less likely in hypo)
RTOG (n=1100) INCREASE in Grade 2 GI/GU but NO DIFFERENCE in Grade 3+

Four smaller superiority studies
Italian (n=168) No difference
Fox Chase (n=300) Overall no differences but in unplanned subgroup with high IPSS more GU toxicity
MDAnderson (n=200) No difference
HYPRO (n=800) More toxicity with the hypo regimen but no one is recommending that regimen; even the authors

All told 7 seven studies-no difference in the two largest including >4000 patients. In two studies there was an increase in overall toxicity with hypo.

I gave up telling people what to do a long time ago, and I don't question the motives of people that I don't know but it is simply not accurate to say that the majority of studies show more toxicity with hypo. The weight of the evidence is that there are no differences in late toxicity. Many will say that five years is not long enough. Perhaps, if so then how many people followed for how long will satisfy you that hypo is safe?

Everyone is going on and on about late toxicity - For me, there is a question of acute toxicity, during and immediately after the treatment that everyone seems to gloss over. Just to reiterate, it's not that I'm NOT a believer in hypoFx, and I do personally agree that it should be offered to patients (although, like I stated previously, the amount of intact prostate treated at my institution is too damn low), but with the discussion that the risk of acute toxicity is higher. That is what I mean when I say worse toxicity. I've now gone through the papers, again, to make sure I wasn't talking out of my ass.

CHHiP - Grade 2 or worse bowel toxicity 25% in 74Gy arm vs 38% in both 60Gy and 57Gy hypoFx arms.
PROFIT - Increase in acute Grade 2 GI toxicity
RTOG 0415 - No difference in acute toxicity, but you said the late toxicity results yourself.

Radiation Oncology moved from 3D to IMRT for prostate immediately, and eventually there was a toxicity improvement which justified it. I don't think we should, as a field, be 'forced' to move again due to those who go on and on about prostate hypofractionation, while having worse toxicity in any setting. And to me, this includes the acute setting.

Do all adamant believers of hypofractionation offer standard fractionation, as an option, to their intact prostate patients? Do you tell them about the increased risk of acute GI toxicity, which is seen even in the two trials that proponents seem to want to hang their hat on?

Hypofrac for breast has shown that, at best, hypofrac is better for cosmesis than standard. At worst, it's equal to standard fractionation in toxicity while maintaining efficacy.

Hypofrac for prostate has shown, at best, that late toxicities are similar (I'm not really going to buy the PROFIT late GI toxicity result because it's out of line with all the other data). At worst, there are studies that show worsening of both acute and/or late toxicity. I think oncologic outcomes will remain the same.

 

[radtothebone]

Chartreuse Wombat is dead on here. To lump all hypofractionation studies together with equal weight is silly. CHHiP, PROFIT, and RTOG are the ones that I see as the most informative on the subject. PROFIT and CHHiP quite clearly show no disadvantage to hypofractionation, while RTOG did have slightly worse G2 toxicity. However, the standard dose of 73.8 is quite low and PROFIT compares favorably to a dose that I am guessing is mich more in line with what most do in 2017.

The subset analysis from the FOX Chase study about worse toxicity in those with existing iron art symptoms is questionable at best. I suspect Dearnaly and colleagues will test it within the CHHiP patients.

In the end it is not unreasonable to wait for more data, but I think the data for 60 Gy in 20 fractions is pretty compelling and it's my go to for most prostate cancer patients.

I agree that we should stop insulting each other but I must correct your categorization of 8 studies showing worse toxicity.

Here are the facts:
Three non-inferiority studies with >5000 patients all with at least 5 years of FU:
CHHiP (n=3200) NO DIFFERENCE in toxicity or patient reported outcomes
PROFIT (n=1200) NO DIFFERENCE in toxicity or patient reported outcomes (in fact late Grade 2 GI was less likely in hypo)
RTOG (n=1100) INCREASE in Grade 2 GI/GU but NO DIFFERENCE in Grade 3+

Four smaller superiority studies
Italian (n=168) No difference
Fox Chase (n=300) Overall no differences but in unplanned subgroup with high IPSS more GU toxicity
MDAnderson (n=200) No difference
HYPRO (n=800) More toxicity with the hypo regimen but no one is recommending that regimen; even the authors

All told 7 seven studies-no difference in the two largest including >4000 patients. In two studies there was an increase in overall toxicity with hypo.

I gave up telling people what to do a long time ago, and I don't question the motives of people that I don't know but it is simply not accurate to say that the majority of studies show more toxicity with hypo. The weight of the evidence is that there are no differences in late toxicity. Many will say that five years is not long enough. Perhaps, if so then how many people followed for how long will satisfy you that hypo is safe?