Comparative Effectiveness Research in Radiation Oncology: Stereotactic Radiosurgery, Hypofractionation, and Brachytherapy
Introduction
This article focuses on comparative effectiveness research (CER) as applied to radiation oncology, specifically in the areas of stereotactic radiosurgery (SRS), hypofractionation, and brachytherapy. This article is distinct from the previous article by Chen et al, in reviewing radiation technologies that may represent “cost savings” to the health care system and to the patients. Given the broad scope of radiation oncology, we focus on the 3 most common areas of radiation cancer treatment: breast, prostate, and lung cancer. However, the issues raised in these 3 areas are applicable to radiation oncology as a whole.
Section snippets
Overview
SRS is the treatment of cancer using 2 general principles: stereotaxis (precise localization of the target in 3-dimensional [3D] space) and radiosurgery (delivery of high doses of radiation in 1-5 treatments). SRS is synonymous with “extreme hypofractionation” where only 1-5 total fractions of large doses of radiation are administered. SRS has been applied to clinical situations as diverse as brain metastases and prostate cancer. Since 2009, intensity-modulated radiation therapy (IMRT) was by
Overview
In addition to extreme hypofractionation using stereotactic technology, modest hypofractionation has also received recent interest in research and clinical use. Conventional, EBRT consists of radiation separated into 1.8-2 Gy doses (or “fractions”) given daily for the course of treatment. However, recent advances in RT technologies, imaging, and planning have stimulated interest in diverse fractionated treatment schedules.37 Specifically, radiation oncologists have been investigating the
Overview
Brachytherapy serves as a popular modality for RT.62 The focus on this section will be on the comparative effectiveness of brachytherapy specifically focusing on low-dose rate (LDR) prostate brachytherapy and high-dose rate (HDR) accelerated partial-breast irradiation (APBI) (or breast brachytherapy). Brachytherapy has the promise of limiting normal tissue irradiation given that the radiation is delivered internally and locally, with less concern for distant tissues that would otherwise be in
Conclusions
Although many newer treatment technologies in oncology represent added costs to the health care system, in this article we have described several technologies in radiation oncology that may provide cost savings not only in terms of dollars saved, but also reduced human costs by shortening treatment courses. In addition, these technologies may allow more patients to have access to necessary treatments. With the rapidity of technological development and diffusion in radiation oncology, there is a
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2016, Clinical Lung CancerCitation Excerpt :These results are consistent with observations from a study from Singapore, in which patients preferred hypofractionated RT over conventional RT owing to its shorter duration and lower cost.16 Furthermore, from a health services perspective, evidence has supported the cost-effectiveness of the shorter course of hypofractionated RT.17 For patients with NSCLC who otherwise lack effective and safe treatment options and at risk of symptomatic intrathoracic progression, hypofractionated IMRT is an appealing option that warrants further study.
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2015, Molecular ImmunologyCitation Excerpt :Interestingly, for radiation therapy, the fractionation of the dose into multiple smaller doses over a certain period of time has become standard practice. This approach was shown to result in comparable efficacy relative to more dose intense regimens, however, better safety profiles attributed to a reduction in toxicity in normal tissues were reported (Aneja and Yu, 2014). The dose fractionation studies conducted with calicheamicin conjugates in the clinic suggest that this basic principle may also apply to DNA damaging ADCs.
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2015, International Journal of Radiation Oncology Biology PhysicsCitation Excerpt :This issue is particularly relevant to RT, as the field has developed tumor targeting and beam delivery techniques with widely varying costs and hypothetical therapeutic ratios. However, although on the surface these advanced technologies may appear expensive in comparison to conventional RT, in fact several studies have shown that hypofractionated RT can be markedly cost effective (25) as the smaller number of fractions and potentially superior efficacy outweigh the higher per-fraction cost. In this case the Medicare reimbursements for precision hypofractionated thoracic RT, conventionally fractionated intensity modulated RT, and conventionally fractionated 3D-RT are $14,068, $22,693, and $12,659, respectively (Supplementary Table E3; available online at www.redjournal.com).
Stereotactic body radiation therapy for prostate cancer: Rational and reasonable
2015, Practical Radiation OncologyCitation Excerpt :With respect to cost, a comparison of SBRT versus IMRT in Medicare beneficiaries ≥ 66 years old treated between 2008 and 2011 documented lower treatment costs; mean treatment cost was $13,645 for SBRT versus $21,023 for IMRT. With respect to quality of life (QOL) after SBRT, given the convenience and efficacy of SBRT, patient-based QOL concerns have been the subject of much debate, especially with respect to late side effects.41 Initial clinical trials have shown favorable late gastrointestinal and genitourinary toxicity in the range of 1% to 3%.37
Considerations for observational research using large data sets in radiation oncology
2014, International Journal of Radiation Oncology Biology PhysicsCitation Excerpt :Given the low barriers to accessing certain sources of such data and the recent emphasis on understanding the “real-world” outcomes of medical interventions, studies relying on registry and/or claims data have proliferated in the International Journal of Radiation Oncology, Biology, Physics (Red Journal) and the general oncology literature in recent years. Although the literature of health services research contains detailed resources to guide the design and interpretation of such studies (1-13) and some reviews have considered specific topics of interest to the radiation oncologist (14-19), we are aware of no single, comprehensive overview specifically targeted toward the radiation oncologist who seeks to conduct or interpret such studies. Because observational research has unique features that distinguish it from clinical trials and other forms of traditional radiation oncology research, the Red Journal assembled a panel of experts in health services research to provide a concise and well-referenced overview, intended to be informative for the lay reader of the Red Journal, as well as for scholars who wish to embark on such research without prior experience.
Institution where the work reported was done: “Yale School of Medicine.”
Dr. Yu is supported by CTSA Grant Number KL2 RR024138 from the National Center for Research Resources (NCRR) and the National Center for Advancing Translational Science (NCATS), components of the National Institutes of Health (NIH), and NIH roadmap for Medical Research. The contents of this article are solely the responsibility of the authors and do not necessarily represent the official view of NIH.