Radiotherapy is a cost-effective palliative treatment for patients with bone metastasis from prostate cancer

International variations in radiotherapy fractionation for bone metastases: geographic borders define practice patterns?

Although it may be argued that single fraction (SF) radiotherapy (RT) should be regarded as the standard palliative treatment for pain due to uncomplicated bone metastases, its widespread clinical use is still underexploited. In this chapter, the authors discuss a number of surveys investigating doctors and patients' preferences for palliative RT schedules, discuss the possible reasons for this phenomenon, and suggest potential strategies to increase the use of SF.

Economic analysis of radiation therapy oncology group 97-14: multiple versus single fraction radiation treatment of patients with bone metastases

INTRODUCTION

Radiation Therapy Oncology Group 97-14 concluded that a single fraction of radiation was as effective in relieving pain as multiple fractions in the treatment of patients with bone metastases. A statistically significant higher retreatment rate, however, was noted in patients undergoing a single fraction treatment. The purpose of the analysis was to determine whether multiple fraction treatment is cost-effective in treating patients with bone metastasis, by preventing further retreatment.

METHODS AND MATERIAL

A Markov model was used to evaluate the cost-effectiveness of 30 Gy in 10 fractions in comparison with 8 Gy in 1 fraction. Transition probabilities, cost, and utilities were obtained from the clinical trial. Costs and outcomes were not discounted because of the short time line for the study.

RESULTS

The expected mean cost and quality-adjusted survival in months for patients receiving 8 Gy in 1 fraction and 30 Gy in 10 fractions was 998 US dollars and 7.26 months and 2316 US dollars and 9.53 months, respectively. The incremental cost-effectiveness ratio was 6973 US dollars/quality-adjusted life year. The results were sensitive to the utility of the posttreatment state for both single and multiple fraction treatments.

CONCLUSION

Single fraction treatment was the less expensive treatment in the treatment of patients with bone metastasis treated on Radiation Therapy Oncology Group 97-14.

Palliative radiotherapy in Medicare-certified freestanding hospices

Hospice care is designed to provide a variety of services, including pain and symptom management, to terminally ill patients. Although palliative radiotherapy (PRT) has been shown to be effective in reducing pain and other symptoms related to tumor growth, only a few hospice patients receive this therapy. This analysis identifies Medicare-certified freestanding hospices that report use of radiotherapy using Medicare's Healthcare Cost Report Information System (HCRIS) dataset. Any reported cost for radiotherapy services was used to indicate provision of PRT because of the population served. The relationship of provider characteristics (ownership, profit status, percent of patients with a cancer diagnosis, geographic location, and size) with provision of PRT was analyzed. Overall, 23.8% of Medicare-certified freestanding hospices in the study population provided radiotherapy services in fiscal year 2002. Provision of radiotherapy services was associated with larger size (measured by total number of hospice days reported in the HCRIS), longer length of Medicare certification, not-for-profit status, and a higher proportion of patients surviving more than seven days after admission. The finding that size, length of Medicare certification, and profit status are associated with provision of radiotherapy services lends credence to suggestions that current reimbursement practices discourage the use of PRT in hospice care, particularly for low-volume hospices.

National survey of perspectives of palliative radiation therapy: role, barriers, and needs

PURPOSE

Despite growth of palliative care programs and evidence on the effectiveness of radiotherapy in palliating cancer symptoms, radiotherapy is probably underused in this setting. Radiation and medical oncologists and palliative medicine specialists were surveyed regarding the perceived role of palliative radiotherapy and barriers to its use.

METHODS

The survey was sent electronically to all physician members of the American Society for Therapeutic Radiology and Oncology (ASTRO) and the American Academy of Hospice and Palliative Medicine (AAHPM) and a random sample of American Society of Clinical Oncology (ASCO) members, with known e-mail addresses.

RESULTS

Response rates were 27%, 14% and 26% for ASTRO, ASCO, and AAHPM respondents, respectively. Although most felt radiotherapy is an effective and important option for palliation of some common cancer symptoms, referrals for such therapy may be declining. Most agreed that radiation oncologists should be more involved in palliative care; however, multiple barriers were identified, such as poor reimbursement, emotional burden of care, insufficient training/knowledge, and the sense of unwillingness of others to share delivery of such services.

CONCLUSIONS

Although multiple barriers limit optimal integration, most agree that there should be greater national and professional society efforts to promote the advancement of radiation oncology in the area of palliative care.

A review of hypofractionated palliative radiotherapy

Radiotherapy commonly is employed to address symptoms in patients with symptoms caused by cancer. For this article, the authors reviewed data supporting the use of hypofractionated palliative radiotherapy. In addition to single-fraction treatment for painful bony metastasis, the available literature suggested that courses of 2 to 14 external-beam fractions may provide equivalent relief to longer course treatment in patients with a poor prognosis who have primary cancers of the lung, rectum, bladder, prostate, head and neck, spleen, and gynecologic system. Hypofractionated treatment delivers palliation that is time efficient, cost effective, and minimally toxic. Evidence suggests that the reluctance of radiation oncologists to provide single-fraction treatment acts as a barrier to referrals from palliative care professionals. Collaboration in education, research, and patient advocacy will advance the common objectives of the 2 specialties and lead to an appropriate increase in the use of palliative hypofractionated radiotherapy.

The role of external beam radiotherapy in the management of bone metastases

External beam radiotherapy is effective in the management of bone metastases for both local and more widespread pain. It is effective in spinal canal compression and pathological fracture where it also may have a prophylactic role. Single dose radiotherapy for bone metastases is a highly cost effective palliative treatment.

Pharmacoeconomics of available treatment options for metastatic prostate cancer

The resources devoted to managing metastatic prostate cancer are enormous, yet little attention has been given to directly measuring the economic consequences of treatment alternatives. The purpose of this article was to evaluate the pharmacoeconomics of available treatments for metastatic prostate cancer, including hormone-sensitive disease, androgen-independent prostate cancer and locally advanced/progressive disease. We identified 58 articles addressing economic issues related to metastatic prostate cancer. Treatment alternatives with considerably different costs are available in many areas of disease management, most notably, medical androgen deprivation therapy (ADT) versus surgical castration; combined androgen blockage (CAB) versus monotherapy for initial treatment of hormone-sensitive disease; as well as bisphosphonates and bone-targeted radioisotopes for palliation. The few available pharmacoeconomic studies indicate that the additional costs are not supported by clear and compelling evidence of differences in survival or quality-of-life (QOL) outcomes. Our review revealed that authors often use considerably different assumptions about efficacy and survival outcomes in their analyses, which may be due to the inconsistency of available clinical evidence. Although there have been many clinical trials comparing various therapies, we identified only three trials that included economic assessments. Thus, few sources of economic data are available and most pharmacoeconomic studies rely on information mined from indirect sources. We note that, while there has been considerable enthusiasm about the role of docetaxel regimens in the past 2 years, no study has yet examined the costs of these therapies. Survival remains poor for metastatic disease, thus QOL is the primary consideration for many therapies. However, QOL for treatment of metastatic disease is poorly measured and, in most analyses, the impact of therapy on QOL was inferred based on speculation by the authors. Given the large cost burdens of these treatments, it is essential that we more fully understand the true QOL gains potentially offered by more expensive therapies. The economic studies of advanced prostate cancer highlight several aspects of clinical care that are filled with considerable uncertainty and remain guided by forces other than optimal resource allocation. It is essential that we address the weaknesses in our understanding of the economic consequences of therapies for prostate cancer, and find ways to include economic information into the process of determining optimal therapy.

Primer: using decision analysis to improve clinical decision making in urology

Many clinical decisions in urology involve uncertainty about the course of disease or the effectiveness of treatment. Many decisions also involve trade-offs; for example, an improvement in patient survival at the cost of an increased risk of treatment-related adverse effects. Decision analysis is a formal, quantitative method for systematically comparing the benefits and harms of alternative clinical strategies under circumstances of uncertainty. The basic steps in performing a decision analysis are to define the clinical scenario or problem, identify the clinical strategies to be considered in the decision, enumerate all of the important sequelae of each strategy and their associated probabilities, define the outcome of interest, and assign a value to each possible outcome. Health outcomes can be defined in a number of ways, including quality-adjusted survival. A key aspect of decision analysis is allowing the values of particular health outcomes to vary from patient to patient, depending on individual preferences. Decision analysis has already been used to assess a variety of prevention, screening and treatment decisions in urology, and there is much potential for its future application. Greater incorporation of decision-analytic techniques into urology research and clinical practice might improve decision making, and thereby improve patient outcomes.

Management of the Spectrum of Hormone Refractory Prostate Cancer

INTRODUCTION

In its advanced stages, hormone refractory prostate cancer (HRPC) is an incurable condition which consists of a spectrum of disease. This requires an integrated multidisciplinary approach by an uro-oncologic team supported by radiologists, skeletal surgeons and palliative care. Aim of this review was to critically evaluate the current and potential approaches to patients affected by HRPC.

MATERIALS AND METHODS

A comprehensive evaluation of available published data included analysis of published full-length papers that were identified with Medline and Cancerlit from January 1981 to January 2006. Official proceedings of internationally known scientific societies held in the same time period were also assessed.

RESULTS

Most men with hormone refractory prostate cancer will die of their disease in the absence of intercurrent illness, and the various conditions arising as a consequence of local and distal cancer progression commonly lead to a spectrum of morbidity requiring treatment. Recent data regarding docetaxel-based chemotherapy have shown small but significant improvements in survival and improvement in quality of life in men receiving treatment. However, this therapy may not be suitable for all patients. New agents used alone or in combination with docetaxel currently are under trial in an attempt to provide much needed improvements in outcome. Bone-targeted treatments, particularly late-generation bisphosphonates, have added to the range of options, reducing the incidence of skeletal complications in some men. Further work is needed to target their use more effectively, to explore their efficacy in combination with existing proven therapies and to develop new approaches to treat bone metastases. Complications arising as a consequence of upper and lower tract dysfunction, haematologic, neurologic and psychologic disorders are common. These complications often are amenable to effective treatment, but interventions may engender difficult clinical and ethical decisions.

CONCLUSIONS

Although HRPC is incurable, it is not untreatable, and that the clinical management embraces not just chemotherapy, but many interventional and supportive therapies. A holistic and supportive approach to patient care is vital for optimal management, and is best provided by a coordinated, multidisciplinary team including urologists and oncologists.

Role of radiotherapy in cancer control in low-income and middle-income countries

More than half the cases of cancer in the world arise in people in low-income and middle-income countries. This proportion will rise to 70% by 2020. These are regions where the annual gross national income per person is less than 9386 US dollars. Radiotherapy is an essential part of the treatment of cancer. In high-income countries, 52% of new cases of cancer should receive radiotherapy at least once and up to 25% might receive a second course. Because of the different distribution of tumour types worldwide and of the advanced stage at presentation, patients with cancer in low-income and middle-income regions could have a greater need for radiotherapy than those in high-income countries. Radiotherapy for cure or palliation has been shown to be cost effective. Many countries of low or middle income have limited access to radiotherapy, and 22 African and Asian countries have no service at all. In Africa in 2002, the actual supply of megavoltage radiotherapy machines (cobalt or linear accelerator) was only 155, 18% of the estimated need. In the Asia-Pacific region, nearly 4 million cases of cancer arose in 2002. In 12 countries with available data, 1147 megavoltage machines were available for an estimated demand of nearly 4000 megavoltage machines. Eastern Europe and Latin America showed similar shortages. Strategies for developing services need planning at a national level and substantial investment for staff training and equipment. Safe and effective development of services would benefit from: links with established facilities in other countries, particularly those within the same region; access to information, such as free online journal access; and better education of all medical staff about the roles and benefits of radiotherapy.

Radiation Therapy and Radio-nuclides for Palliation of Bone Pain

Bone pain from metastatic prostate cancer can be effectively palliated by a single fraction of 8 Gy with no increase in toxicity, which can occur with more protracted fractionation schemes. Re-treatment, if required, is simple and effective. For multiple painful sites on the same side of the diaphragm, hemi-body radiotherapy is rapidly effective; pre-medication with odanstetron and steroids has markedly improved tolerance. For multiple painful sites on both sides of the diaphragm, radiopharmaceuticals can be considered but will not treat adjacent soft tissue disease or neurologic compromise.

Évaluation économique de la radiothérapie : méthodes et résultats

The cost of radiotherapy, which concerns 150,000 new patients yearly in France has been estimated 1700 euros per patients in this country, 50% lower than the European average. Economic evaluations of radiotherapy have related the cost of either curative or palliative treatment to the medical outcome. For lung, rectal, breast cancer and bone metastases of prostate cancer, radiation therapy prolongs life by an estimated 6 to 10 months. The cost effectiveness ranges from 5,000 to 25,000 euros per life year gained.