Implementation of hypofractionated prostate radiation therapy in the United States: A National Cancer Database analysis: Beyond the Abstract

External-beam radiation has an established role as a non-invasive treatment for prostate cancer. Traditionally, this treatment has consisted of conventional fractionation, which entails roughly 8-9 weeks of treatment delivered 5 days per week. While many patients tolerate this regimen quite well, it can impose significant logistical burdens on patients and families.

Advances in radiation treatment planning and delivery have enabled the development of hypofractionation, which entails a shorter, and therefore less burdensome, treatment course. At the University of Colorado, we are proud to have been early adopters of a 5½-week course. Similar schedules of so-called moderate hypofractionation typically range from 4-6 weeks in duration while maintaining 5 treatments per week. Several large randomized controlled trials have compared these shorter courses with the tried-and-true conventional fractionation approach, with each supporting the use of moderate hypofractionation.

Other investigators have pushed the limits of hypofractionation even further to arrive at extreme fractionation, which entails only 5 treatments. In contrast to the solid track record supporting moderate hypofractionation, randomized evidence comparing extreme hypofractionation with other schedules is only starting to emerge. However, several smaller studies support the safety and efficacy of this approach.

Providers therefore have a variety of fractionation schedules to use in treating prostate cancer with radiation. We used a large national dataset, the National Cancer Database, to characterize the use of these approaches in the United States.

We found that use of shorter treatment schedules increased from 2004 through 2013 but remained low, reaching 14.2% of patients by the end of the period. Remarkably, this growth appears to have come from the less-well-studied extreme hypofractionation, rather than from the better-explored moderate hypofractionation. 

While extreme hypofractionation certainly offers greater convenience to patients, we find the rapid adoption of these courses to be somewhat concerning given the limited randomized data to support them. We eagerly await the results of randomized studies comparing this approach to others.

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Written By: William A Stokes, Brian D Kavanagh, David Raben, Thomas J Pugh