Comparative Effectiveness Research in Radiation Oncology: Stereotactic Radiosurgery, Hypofractionation, and Brachytherapy

https://doi.org/10.1016/j.semradonc.2013.08.004Get rights and content

Radiation oncology encompasses a diverse spectrum of treatment modalities, including stereotactic radiosurgery, hypofractionated radiotherapy, and brachytherapy. Though all these modalities generally aim to do the same thing—treat cancer with therapeutic doses of radiation while relatively sparing normal tissue from excessive toxicity, the general radiobiology and physics underlying each modality are distinct enough that their equivalence is not a given. Given the continued innovation in radiation oncology, the comparative effectiveness of these modalities is important to review. Given the broad scope of radiation oncology, this article focuses on the 3 most common sites requiring radiation treatment: breast, prostate, and lung cancer.

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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    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.

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