No reason ever* to endure 40 IMRT treatments as primary therapy anymore

This is the eighth randomized clinical trial I've written up in the last few years on this subject. Doing it in 20 treatments is clearly not inferior on any dimension to doing it in 40 treatments (and 5 SBRT treatments is just fine too, imho). This was an Italian trial with 9 years of follow-up - the longest so far. They used 3D-CRT instead of IMRT and it was still just as good.

/pcnrv.blogspot.com/2017/06/eigthth-randomized-clinical-trial-of.html

I hope that any patient whose RO recommends IMRT as primary therapy in 38-44 treatments sends him the table at the end and asks for a response.

*"What never? Well, hardly ever." I can imagine the case where there are pre-existing urinary issues like a TURP or urinary obstruction where they might want to be a bit more cautious.

Re FreudM - mods, looks like the spammers are out en mass today

In the States, RO's are not motivated to cut their incomes in half by reducing the number of fractions..In most other countries where RO's work for the government at a fixed salary, newer more streamlined therapies are adopted much sooner as the patients well-being comes first and not their own...

Prat-

1. It is tempting to notice that all oncological outcomes are favored in the hypofractionated group, but statistical significance is a function of sample size. So, for example, the difference in overall survival was 11%. That was based on 75% in the Hypo group of 85 men, and 64% in the Conv group of 83 men. Statistically, one can have only 88% confidence that that difference would be non-zero in the entire population. 88% might sound pretty good, but, by convention, we all agree that 95% confidence is needed. The overall survival would have had to be at least 78% in the Hypo group to be statistically significant.

Here's an online calculator if you want to play with it:

/www.medcalc.org/calc/comparison_of_proportions.php

2. In the US, it's probably being done to some extent at the institutions where they did the trials: Fox Chase, Cleveland Clinic, MD Anderson, and the 300 or so institutions that participated in RTOG 0415. ASTRO has not issued a policy directive. NCCN makes the following statement:

"Moderately hypofractionated image-guided IMRT regimens (2.4–4 Gy per fraction over 4-6 weeks) have been tested in randomized trials, and its efficacy has been similar or non-inferior to conventionally fractionated IMRT. Toxicity was similar between moderately hypofractionated and conventional regimens in many, but not all of the trials. These RT techniques can be considered as an alternative to conventionally fractionated regimens when clinically indicated."

There have been a few trials of moderate hypofraction for SRT.

Thanks TA, for the explanation.

Sheepguy-

Take a look at the list of the institutions that participated in the RTOG 0415 RCT. Perhaps one of them is nearby.

/www.rtog.org/ClinicalTrials/ProtocolTable/StudyDetails.aspx?study=0415

Searchinginla, location,location,loction. The nearest SBRT center for me is MSK..260 milesaway. Possibly Roswell Park, although they are notkeen on SBRT...180 miles. Local IMRT 6 miles. A four hour drive one way even for 20 treatments is a lot.

TA Our local hospital Cayuga Medical Center was indeed part of the RTOG..the very study that failed to impress my RO. We'll talk about it more though.

One thing that amazed me was the Medicare reimbursement rate for SBRT vs. low dose imrt. For some reason, SBRT has a much higher reimbursement rate. Maybe because there are a lot fewer fractions?
Bob

Sheepguy: Yes, that would do the trick. Too bad that you're not closer to a SBRT facility.

Tall Allen said...
Bob- Yes - ROs bill insurance by the number of fractions. They have a financial incentive to do more fractions.

Yes they do -- in areas where there are few enough providers that competition is not in the equation. Here in the Chicago area, for example, my uro's practice group does offer IMRT but not SBRT. I was able, though, to find two SBRT providers within a 15-minute drive of my office.

location has a LOT to do with a man's options and how he exercises them, I think.

I certainly encourage anyone, if there is any way they can do it to at least check out SBRT at a center that is experienced with it. It's the wave of the future boys, as far as RT is concerned.

TA:
You're probably correct that more fractions equals more revenue, but Medicare pays many times more for SBRT than for imrt. My experience is that imrt reimbursement is < 25% whereas SBRT is 90%!! I sense that reimbursement is based on grays administered per fraction, so high dose is reimbursed way more than low dose. Makes sense since high dose is much more productive/efficient than low dose. I suppose that safety is a consideration was well ( collaterall Damage) , but it appears that high dose can be administered safely as well. This is a wonderful advancement for us patients!
Bob

I think I might twist my RO's arm a little about hypofractionation.