Paradigm shifting towards shorter radiation therapy schedules for men with prostate cancer

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First real-world study in Australia & New Zealand highlights rapid uptake across public & private settings

Radiotherapy is a safe and effective treatment for prostate cancer. Over the last decade we have witnessed significant advancements in the way radiation therapy is delivered and a paradigm shift from conventional radiation therapy to shorter treatment schedules, known as hypofractionated radiation therapy.

Modern advancements in treatment technology and planning software have led to the introduction of new highly focussed and accurate radiation therapy techniques, including intensity modulated radiation therapy (IMRT), image guided radiotherapy (IGRT) and hypofractionated radiation therapy (HypoRT).

HypoRT involves the use of advanced technologies to deliver fewer, larger doses of radiation therapy directly to the tumour, minimising exposure to surrounding healthy tissue. For prostate cancer, HypoRT is typically delivered over twenty sessions, compared to approximately forty sessions required with conventional radiation therapy, significantly reducing the number of visits patients need to make to hospital.

Globally, several randomised clinical trials have confirmed HypoRT is as effective as conventional radiation therapy for patients with localized prostate cancer.

In 2008, we launched an international clinical trial in Australia which looked at whether the standard eight-week radiation therapy treatment could be halved to four weeks with a slightly higher daily dose.

The trial confirmed that the shorter course of HypoRT achieved the same cure rates and comparable low rates of bladder and bowel side effects to the longer course of conventional radiation therapy.

On the back of this published data we began to sense an increasing uptake in HypoRT at radiation oncology centres across Australia in both public and private settings.

In order to get some definitive data, a coalition of researchers from across the country collaborated on the first real-world study into HypoRT in localized prostate cancer, analysing data from the Australian and New Zealand Prostate Cancer Outcomes Registry (PCOR-ANZ).

The results of the study, which were published earlier this month in the open access version of the Journal of the American Medical Association, found a substantial increase in the utilisation of HypoRT in the management of men with localized prostate cancer in Australia and New Zealand over a three year period from 2016 to 2019.

Of the 6368 men identified as receiving radiation therapy for prostate cancer, the use of HypoRT increased from 2.1% in the first half of 2016 to 52.7% in the second half of 2019.

The increase from 2.1% to 52.7% over a three year period is really remarkable as we know that behaviour change in medicine is challenging, and it can take many years to see meaningful changes in clinical practice.

While a substantial increase in the use of HRT was observed over the three year period, the registry data did highlight substantial variations in the uptake of HRT across jurisdictions, institutions and patient cohorts.

Rapid adoption was apparent from 2017 for New Zealand whereas year-on-year increases in hypofractionated RT proportions of approximately 15% were seen in NSW/ACT and Victoria/Tasmania with lower proportions in Queensland and SA/NT. While Australia and New Zealand’s health care systems share many similarities, funding models for radiation therapy differ substantially. In Australia, both private and public sectors retain a component of activity based and fee-for-service models proportionate to the number of fractions delivered, whereas public funding in New Zealand provides a global budget for all service by each facility. This is an area that warrants further analysis and exploration over the coming years, particularly in light of the current review of the Medicare Benefits Scheme taking place here in Australia.

In addition to tracking the utilisation of HypoRT across Australia and New Zealand, the study also recorded patient-reported outcomes (PRO) of men receiving either HRT or conventional radiation therapy. Patient reported outcomes included urinary control, bowel and sexual function.

Promisingly, the study found no clinically meaningfully differences in PROs between hypofractionated and conventional radiation therapy, which is consistent with previous international studies from the United Kingdom and the United States.

The COVID-19 pandemic has further accelerated the trend towards hypofractionation on a global scale.

During the COVID-19 pandemic, multiple international clinical practice guidelines have recommended doctors consider shorter courses of radiation therapy where clinically suitable to minimise the risk of transmission for patients and staff.

To bridge the gap between research and practice, a key priority is to identify current barriers to adopting HypoRT, and explore approaches to overcome any issues preventing wider deployment of this innovative treatment.

Looking to the future, we are now looking at compressing treatments even further down to just five radiation therapy sessions given over two weeks.

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About Author

Prof Jarad Martin is a GenesisCare radiation oncologist with strong research interests. He subspecialises in the multidisciplinary management of gastrointestinal tumours (including tumours of the rectum and anal canal) as well as genitourinary malignancies (including prostate and bladder cancers). A more recent interest is the use of low dose radiotherapy for conditions such as plantar fasciits, Dupuytren’s and Ledderhose diseases. Jarad attends and contributes to the Newcastle multidisciplinary meetings discussing patients with all of these disease, and has a leading role in helping organise specialist education events in the Hunter region. His technical knowledge is well recognized in areas including intensity modulated radiotherapy (IMRT), image guided radiotherapy (IGRT) and stereotactic radiotherapy (SBRT). Having worked in Victoria, Queensland and Canada prior to commencing practice in Newcastle, he is able to bring a broad perspective to his management of people with cancer. Jarad has authored more than 100 peer reviewed publications, being awarded more than $12 Million in competitive research funding and has won awards in both Canada and Australasia recognizing the quality of his research. He has held senior positions in several national bodies including the Trans-Tasman Radiation Oncology Group, for whom he was the convenor for their 2015 Annual Scientific Meeting. Professor Martin will be joining the specialist team at GenesisCare’s new integrated cancer centre in Maitland, NSW, which is set to open its doors in December 2021.

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