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  • Choosing between conventional and hypofractionated RT

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    Old 01-21-2020, 07:59 AM   #1
    DjinTonic
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    Choosing between conventional and hypofractionated RT

    This is a recent Australian study on using a decision aid to help patients choose between the two. (Hypofractionation is administering the same total radiation dose over fewer sessions (fractions) by increasing the dose per session. The advantage is convenience. The downside may be increased toxicities and the lack of long-term data.)

    Choosing between conventional and hypofractionated prostate cancer radiation therapy: results from a study of shared decision-making [2020]

    https://www.sciencedirect.com/science/article/abs/pii/S1507136720300031

    Quote:
    Abstract

    Aim
    To evaluate patient choice of prostate cancer radiotherapy fractionation, using a decision aid.

    Background
    Recent ASTRO guidelines recommend patients with localised prostate cancer be offered moderately hypofractionated radiation therapy after discussing increased acute toxicity and uncertainty of long-term results compared to conventional fractionation.

    Materials and methods
    A decision aid was designed to outline the benefits and potential downsides of conventionally and moderately hypofractionated radiation therapy. The aid incorporated the ASTRO guideline to outline risks and benefits.

    Results
    In all, 124 patients with localised prostate cancer were seen from June-December 2018. Median age was 72 (range 50-90), 49.6% were intermediate risk (50.4% high risk). All except three patients made a choice using the aid; the three undecided patients were hypofractionated. In all, 33.9% of patients chose hypofractionation: falling to 25.3% for patients under 75 years, 24.3% for patients living within 30 miles of the cancer centre, and 14.3% for patients with baseline gastrointestinal symptoms. On multivariate analysis, younger age, proximity to the centre, and having baseline gastrointestinal symptoms significantly predicted for choosing conventional fractionation. Insurance status, attending clinician, baseline genitourinary symptoms, work/carer status, ECOG, cancer risk group and driving status did not impact choice. Reasons for choosing conventional fractionation were certainty of long-term results (84%) and lower acute bowel toxicity (51%).

    Conclusions
    Most patients declined the convenience of moderate hypofractionation due to potentially increased acute toxicity, and the uncertainty of long-term outcomes. We advocate that no patient should be offered hypofractionation without a thorough discussion of uncertainty and acute toxicity.

    ECOG is a widely used performance scale that evaluates how well the patient can take care of themselves and perform daily activities and functions.

    ASTRO is the American Society for Radiation Oncology.


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    Old 01-21-2020, 08:33 AM   #2
    guitarhillbilly
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    Re: Choosing between conventional and hypofractionated RT

    "A recent Australian study on using a decision aid to help patients choose between the two. (Hypofractionation is administering the same total radiation dose over fewer sessions (fractions) by increasing the dose per session. The advantage is convenience. The downside may be increased toxicities and the lack of long-term data.)"

    Thanks for the posting.

    My UR discussed all the radiation options for me and let me decide.
    I did ask him about Cyberknife specifically and he told me he has patients that have chosen that with good short term results. He did place emphasis on lack of LONG TERM data concerning secondary issues with Cyberknife.
    After a lot of research on IMRT - Proton - Cyberknife - I chose IMRT because of logistics and the experience of my radiologist. If I lived in a city that had proton therapy I would have probably chosen that method.I still work and cannot be gone out of town for 8-9 weeks and the expense related to that choice.

    Regardless of which EBRT method is chosen my UR injects the SpaceOAR Gel and fiducial markers before the CT simulation.

    The reality is many factors go into making a choice about which Radiation treatment to choose.

     
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    Old 01-21-2020, 02:30 PM   #3
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    Re: Choosing between conventional and hypofractionated RT

    Quote:
    Originally Posted by DjinTonic View Post
    This is a recent Australian study on using a decision aid to help patients choose between the two. (Hypofractionation is administering the same total radiation dose over fewer sessions (fractions) by increasing the dose per session. The advantage is convenience. The downside may be increased toxicities and the lack of long-term data.)

    Choosing between conventional and hypofractionated prostate cancer radiation therapy: results from a study of shared decision-making [2020]

    https://www.sciencedirect.com/science/article/abs/pii/S1507136720300031




    ECOG is a widely used performance scale that evaluates how well the patient can take care of themselves and perform daily activities and functions.

    ASTRO is the American Society for Radiation Oncology.


    Djin
    This article simply reports that lower numbers of patients chose a treatment after being told that if MAY increase toxicities and lacked long term data.

    Umm, isn't that a common sense outcome? If you scare somebody about a choice, that they are then less likely to choose it?

    The researchers' time would have been better spent analyzing patient data to determine relative toxicities of the two treatments being compared.
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    Old 01-21-2020, 02:53 PM   #4
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    Re: Choosing between conventional and hypofractionated RT

    I have to get the full text. I presume the decision aid provided study results and association guidelines. Decision aids are supposed to present pros and cons. As the study reports, we also want to know which factor(s) influenced the choice.

    Why do you say that providing data is intending to scare patients? A good portion of them chose hypofractionation.

    Djin
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    Old 01-21-2020, 03:32 PM   #5
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    Re: Choosing between conventional and hypofractionated RT

    Quote:
    Originally Posted by DjinTonic View Post
    I have to get the full text. I presume the decision aid provided study results and association guidelines. Decision aids are supposed to present pros and cons. As the study reports, we also want to know which factor(s) influenced the choice.

    Why do you say that providing data is intending to scare patients? A good portion of them chose hypofractionation.

    Djin

    The article did not mention data. It mentioned a discussion and later, a decision making aid.

    Perhaps the full text will provide a more balanced picture of what the participants were shown.
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    Old 01-21-2020, 06:24 PM   #6
    Terry G
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    Re: Choosing between conventional and hypofractionated RT

    From the “Conclusions” it sounds like the Australian study has already made it’s mind as to what treatment was safer. It would be interesting to see the actual data. The most challenging part of a PCa diagnosis is treatment choice. Every choice including AS carries risks. Unfortunately medicine is not always the science we would like it to be. Bias does exist.
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    Old 01-22-2020, 05:28 AM   #7
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    Re: Choosing between conventional and hypofractionated RT

    It is endlessly fascinating how people insert meaning into what happens.

     
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    Old 01-22-2020, 07:52 AM   #8
    BlueHeron2020
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    Re: Choosing between conventional and hypofractionated RT

    Most patients declined the convenience of moderate hypofractionation due to potentially increased acute toxicity, and the uncertainty of long-term outcomes.

    I think that sums it up well, if the data was available, it would (Should) have been presented.
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    Old 01-22-2020, 07:55 AM   #9
    BlueHeron2020
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    Re: Choosing between conventional and hypofractionated RT

    Quote:
    Originally Posted by guitarhillbilly View Post
    "

    My UR discussed all the radiation options for me and let me decide.
    I did ask him about Cyberknife specifically and he told me he has patients that have chosen that with good short term results. He did place emphasis on lack of LONG TERM data concerning secondary issues with Cyberknife.
    After a lot of research on IMRT - Proton - Cyberknife - I chose IMRT because of logistics and the experience of my radiologist. If I lived in a city that had proton therapy I would have probably chosen that method.I still work and cannot be gone out of town for 8-9 weeks and the expense related to that choice.

    Regardless of which EBRT method is chosen my UR injects the SpaceOAR Gel and fiducial markers before the CT simulation.

    The reality is many factors go into making a choice about which Radiation treatment to choose.
    I was glad to read of your thoughts on this, I am in a similar situation and feel the same way. Thanks for posting.
    __________________
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    Hope to live 20+ more years
    2012-2019 linear PSA progression 2-6.9
    Oct 2019 3T MRI Two areas pirad 4 identified
    Dec 2019 MRI US fusion biopsy
    4/27 cores positive
    GS 6(3+3) 10% core volume random area
    GS 7(3+4) 30-40% core volume random area
    2/7 cores GS 7(3+4) core vol 10-20% target area
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    Radiologist recommends: TBD

     
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    Old 01-22-2020, 10:40 AM   #10
    DjinTonic
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    Re: Choosing between conventional and hypofractionated RT

    The Full Text of the paper (still in the publication phases) makes clear the nature of the study.

    Quote:
    Background
    ASTRO recently published a position statement recommending all patients with localised prostate cancer be offered moderately hypofractionated radiation therapy as an alternative to conventional fractionation (1). From a patient perspective the benefit lies in convenience, with fewer visits for radiation. The downsides, as outlined by ASTRO, are the potential for a small increased risk of acute toxicity, and the uncertainty of results beyond 5 years. Many patients are now being offered moderate hypofractionation (2), however the choice of fractionation may often be made by the radiation oncologist without significant input from patients. The authors of the ASTRO statement suggest that the limitations of available evidence “underscore the importance of shared decision making between clinicians and patients.”
    In order to facilitate shared decision-making with our patients, we developed a decision aid outlining the two fractionation choices based on the ASTRO consensus statement. We aimed to evaluate our experience using the decision aid, and report on the proportion of patients selecting the two fractionation schedules.

    Methods and Materials
    The Faculty of Radiation Oncology Genitourinary Group endorsed the ASTRO Consensus statement in June 2018. As a result, our department developed a decision aid based on the statement to guide our patients in their choice of fractionation schedule. All patients with localised prostate cancer from mid-June 2018 are now asked to choose their fractionation schedule using the decision aid. The decision aid was developed using specific recommendations and statements within the ASTRO document (1), and is shown in Figure 1. The aid is based on decision aids we have previously developed to help patients decide on fractionation for the treatment of bone metastases and the palliation of lung primaries (3,4). The ASTRO consensus guidelines made the following statements which were incorporated into the aid:

    ...[statements based on previous study results and guidelines]

    Consults with patients were structured normally, with an initial history and examination, followed by a discussion of their treatment choices. Treatment options potentially included active surveillance, surgery, EBRT, brachytherapy and androgen deprivation therapy (ADT). EBRT was to be delivered using our usual program of prostate-specific membrane antigen positron emission tomography (PSMA PET) staging of high risk patients (6), intensity-modulated radiation therapy (IMRT) (7,8), fiducial marker insertion, spacer hydrogel insertion (9), MRI-CT fusion (10). During treatment we follow a bladder and bowel regime (8), with daily cone beam computed tomography (CBCT). Patients on treatment with a change in bowel anatomy in the high dose area were replanned.
    When discussing treatment options, the initial discussion mentioned that there was a one month or two month option of IMRT which would be discussed in more depth should the patient be interested in pursuing radiation. At the initial or subsequent consultation, once the patient had decided they wished to have IMRT, an in depth discussion of the 20 vs 45 fraction options occurred. This discussion was facilitated using the decision aid (Figure 1). If patients were unsure they were given the aid to take home, and a further appointment was made to obtain the decision. In order to ensure the discussion was understood and the choice was valid, patients were asked why they had made their decision, with multiple reasons allowed. We also asked patients whether they were happy being involved in the process. If patients were unhappy, or wished the specialist to decide for them, the radiation oncologist decided on the fractionation schedule.
    Univariate and multivariate analyses (using binomial logistic regression) of the effect of age, ECOG, cancer risk group, distance from the cancer centre, work/carer status, baseline GI and genitourinary (GU) symptoms, insurance status, driving status, and doctor facilitating the discussion on fractionation decision were undertaken using SPSS (IBM Corp, Version 21.0. Armonk, NY). This work was reviewed by the applicable HREC and was deemed to be a quality assurance activity. ...
    [Results and Discussion sections follow]

    [Emphasis mine]

    These were radiologists imparting RT information to their patients, not surgery vs. RT discussions. Study aids are seen as ways to ensure all patients are exposed to relevant, evidenced-based information. There follows a discussion with the patient's doctor's.

    Djin

     
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    Old 01-22-2020, 11:32 AM   #11
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    Re: Choosing between conventional and hypofractionated RT

    Quote:
    Originally Posted by DjinTonic View Post
    The Full Text of the paper (still in the publication phases) makes clear the nature of the study.



    [Results and Discussion sections follow]

    [Emphasis mine]

    These were radiologists imparting RT information to their patients, not surgery vs. RT discussions. Study aids are seen as ways to ensure all patients are exposed to relevant, evidenced-based information. There follows a discussion with the patient's doctor's.

    Djin
    Here is actual statement from ASTRO, AUA, and others:

    "Statement KQ1E: Men should be counseled about the small increased risk of acute gastrointestinal (GI) toxicity with moderate hypofractionation. Moderately hypofractionated EBRT has a similar risk of acute and late genitourinary and late GI toxicity compared with conventionally fractionated EBRT. However, physicians should discuss the limited follow-up beyond 5 years for most existing RCTs evaluating moderate hypofractionation."

    https://www.practicalradonc.org/article/S1879-8500(18)30247-9/fulltext
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    Old 01-22-2020, 11:49 AM   #12
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    Re: Choosing between conventional and hypofractionated RT

    Yes, that statement is one of the ASTRO statements quoted in the Decision Aid; in fact, it continues...

    Quote:
    ...The only applicable statistics given comparing conventionally and
    hypofractionated radiation were based on Aluwini et al. (5), who found that grade ≥2 GI toxicity up to 120 days post-RT in the HYPRO trial was more common with hypofractionation (42% versus 31%, OR 1.6, 95% CI: 1.19-2.14). Grade ≥3 toxicity was uncommon (~6%) and was similar between hypofractionated and conventional fractionation.
    So the patient can see one example of what "small" means in terms of the increased risk, at least in one study. The statement concludes that very serious toxicities were the same for hypo- and conventional fractionation.

    My point is that the Decision Aid is based on ASTRO statements and is not material developed to dissuade hypofractionation. Perhaps one day today's conventional fractionation will not longer be offered, and current hypofractionation will be standard of care. But I see nothing wrong with ROs wanting to be fair in their joint decision making with patients.

    Here are the ASTRO statements in the Decision Aid:

    Quote:
    1. In men with low-, intermediate- and high-risk prostate cancer receiving external beam radiation therapy (EBRT) to the prostate with or without radiation to the seminal vesicles, moderate hypofractionation should be offered. The task force recommended that moderately hypofractionated EBRT be offered to patients across all risk groups after a discussion of risks and benefits. In patients who are candidates for EBRT, moderate hypofractionation should be offered regardless of patient age, comorbidity, anatomy, or urinary function.

    2. To date, there are limited published outcomes beyond five years for moderate hypofractionation. Therefore, current evidence supports similar early cancer control with this approach. However, physicians should discuss the limited follow-up beyond five years. It is unknown whether moderate hypofractionation might have excess acute or late toxicity compared to conventional hypofractionation in, for example, elderly patients, those with larger gland volumes, or those with significant baseline voiding dysfunction.

    3. Men should be counselled about the small increased risk of acute gastrointestinal (GI) toxicity with moderate hypofractionation. Moderately hypofractionated EBRT has a similar risk of acute and late genitourinary and late GI toxicity compared to conventionally fractionated EBRT. However, physicians should discuss the limited follow-up beyond five years for most existing randomised clinical trials (RCTs) evaluating moderate hypofractionation. The only applicable statistics given comparing conventionally and hypofractionated radiation were based on Aluwini et al. (5), who found that grade ≥2 GI toxicity up to 120 days post-RT in the HYPRO trial was more common with hypofractionation (42% versus 31%, OR 1.6, 95% CI: 1.19-2.14). Grade ≥3 toxicity was uncommon (~6%) and was similar between hypofractionated and conventional fractionation.
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    Old 01-27-2020, 10:40 AM   #13
    Terry G
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    Re: Choosing between conventional and hypofractionated RT

    I try to encourage everyone with a prostate cancer diagnoses to make an informed decision regarding treatment choice. The challenge for most of us with PCa is we are fortunate to have so many treatment choices; however, physicians don't present them well enough. I think boards like this are so valuable to those willing to dig a little deeper to help understand those choices. My Urologist was ready to schedule surgery for me on the same day we sat down to discuss treatment even though I had only a small amount of Gleason 6. He was totally uninformed about most radiation options with the exception of seeds. I thank those on forms like this one for helping me make an informed decision. Here is another news release from Astro regarding SBRT.

    https://www.astro.org/News-and-Publications/News-and-Media-Center/News-Releases/2018/Men-with-low-and-intermediate-risk-prostate-cancer
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    Old 01-28-2020, 05:25 AM   #14
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    Re: Choosing between conventional and hypofractionated RT

    When I was deciding on a treatment path the RO I talked to at MD Anderson offered a chance at fractionated Proton Beam Therapy.
    They were letting patients choose to let the computer flip a coin and decide who would get it if they so desired.
    To me as a person already leary of radiation it seemed like the guys that won the coin toss were a little bit like guinea pigs.
    Didn't appeal to me even though it would have been quite a bit shorter treatment than normal.
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    Old 01-28-2020, 05:42 AM   #15
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    Re: Choosing between conventional and hypofractionated RT

    Quote:
    Originally Posted by djust View Post
    When I was deciding on a treatment path the RO I talked to at MD Anderson offered a chance at fractionated Proton Beam Therapy.
    They were letting patients choose to let the computer flip a coin and decide who would get it if they so desired.
    To me as a person already leary of radiation it seemed like the guys that won the coin toss were a little bit like guinea pigs.
    Didn't appeal to me even though it would have been quite a bit shorter treatment than normal.
    Looking at the limited study data, if this were me having to choose, and travelling wasn't a burden, I would choose the conventional treatment over hypofractionation, simply to cut down the risk of the (admittedly not severe) toxicities. Now, if hypofractionation proves to have better long-term oncological outcomes, that, plus the convenience, will probably mean it becomes the new standard.

    In any human randomized or patient's choice study, you can always draw the guinea pig analogy. But the short- and medium-term toxicities are known, so I think this factionation choice is ethical.

    There is much more risk with Phase I (safety in humans) trials of new drugs for advanced metastatic cancer -- here you are weighing the more serious risks against the chance of prolonging life by perhaps many months or longer.

    Djin
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    6-06-17 Nodule on R + PSA rise on finasteride: 3.6→4.3
    6-28-17 Bx #10: 2/14 cores: G10 (5+5) 50% RB, G9 (4+5) 3% RLM
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    8-7-17 Open RP, neg. frozen sections, Duke Regional Hosp.
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    Dry; ED OK with sildenafil
    11-10-17 Decipher 0.37 Low Risk; 5-yr met risk 2.4%, 10-yr PCa mortality 3.3%
    LabCorp uPSA: 0.010 (3 mo.)…0.015 (1 yr. 6 mo.)…0.015 (2 yr. 4 mo.)

     
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