Exploring Value From the Patient's Perspective Between Modern Radiation Therapy Modalities for Localized Prostate Cancer: Beyond the Abstract

There is a growing emphasis to deliver value-based cancer care. Often when value is measured the focus is only on costs and cure. However, when treatments are all equally curative, evaluating a patient’s full treatment experience becomes necessary. This premise led to our study question:  Are all modern radiation treatments for localized prostate cancer equal from the patient’s point of view? 

We compared the treatment experience between dose-escalated intensity-modulated radiation therapy (IMRT), high-dose rate brachytherapy (HDR) and stereotactic body radiation therapy (SBRT) among a cohort of men with favorable risk prostate cancer. Importantly, all the men in our study would have been eligible for active surveillance. 

We evaluated treatment regret, a validated well-studied patient centered outcome associated with poor health-related post-treatment quality of life, as well as patient perceptions of their short- and long-term toxicities. 

We found that the majority of patients did not regret receiving treatment. However, 13% of men did endorse regret and the incidence of regret was significantly different between treatment modalities: 19% for IMRT, 18% for HDR and 5% for SBRT (p <0.01). Of the men with regret, 72% now wished they had received active surveillance. 

Additionally, we found that more men treated with IMRT and SBRT found their short-term toxicities to be less than what they had originally had anticipated (IMRT 56% and SBRT 55% vs. HDR 25%, p<0.01) and more importantly, significantly more patients treated with SBRT selected that their long-term toxicities were better than they had originally expected (SBRT 43% vs. IMRT 20% and HDR 10%, p<0.01).

When adjusting for toxicities, and patient related factors, men treated with IMRT vs. SBRT were 11x more likely to regret their treatment and men treated with HDR vs. SBRT were 7x more likely to have regret. What also predicted for regret was a poor treatment decision-making experience characterized by not believing that one had learned enough about all treatment options and not agreeing that one worked mutually with their physician. Patients that selected that either their short-term or long-term toxicities were worse than expected, regardless of the actual severity, were significantly more likely to endorse regret highlighting the importance of providing in-depth and honest upfront counseling. 

While all modern radiation therapies produce high-rates of cure with minimal toxicities in men with favorable-risk prostate cancer, this data highlights the significant differences between these treatments from the patient’s perspective.

Written By: Narek Shaverdian, M.D., Michael L. Steinberg, M.D., Christopher R. King, M.D., Ph.D.
Department of Radiation Oncology, David Geffen School of Medicine at UCLA, Los Angeles, California