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Nakai Y, Tanaka N, Asakawa I, Ohnishi K, Miyake M, Yamaki K, Torimoto K, Fujimoto K. Efficacy of a hydrogel spacer for improving quality of life in patients with prostate cancer undergoing low-dose-rate brachytherapy alone or in combination with intensity-modulated radiotherapy: An observational study using propensity score matching. Prostate 2024. [PMID: 38734992 DOI: 10.1002/pros.24744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Revised: 04/22/2024] [Accepted: 05/03/2024] [Indexed: 05/13/2024]
Abstract
BACKGROUND It is unclear whether a hydrogel spacer can improve quality of life (QOL) in patients undergoing low-dose-rate brachytherapy (LDR-BT) alone or in combination with intensity-modulated radiotherapy (IMRT). METHODS We enrolled patients with prostate cancer who underwent LDR-BT alone with (n = 186) or without (n = 348) a hydrogel spacer, or underwent LDR-BT in combination with IMRT with (n = 70) or without (n = 217) a hydrogel spacer. QOL was evaluated using Expanded Prostate Cancer Index Composite (EPIC) questionnaires at baseline and 1, 3, 6, 12, and 24 months after implantation. The groups were compared using propensity score matching analysis. RESULTS Among patients who underwent LDR-BT alone, there were no differences regarding changes in urinary, bowel, sexual, or hormonal domain scores between the spacer and no-spacer groups; however, the dose at the bowel was significantly lower in the spacer group than in the no-spacer group. Among patients who underwent LDR-BT in combination with IMRT, there were no differences regarding changes in urinary, sexual, or hormonal domain scores between the spacer and no-spacer groups. However, the changes in the bowel domain score were significantly lower in the spacer group than in the no-spacer group (p < 0.001). CONCLUSIONS A hydrogel spacer may not improve impaired urinary, bowel, or sexual QOL in patients undergoing LDR-BT alone. However, in patients undergoing LDR-BT in combination with IMRT, a hydrogel spacer can improve impaired bowel QOL but not sexual or urinary QOL.
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Affiliation(s)
- Yasushi Nakai
- Department of Urology, Nara Medical University, Nara, Kashihara, Japan
- Department of Prostate Brachytherapy, Nara Medical University, Nara, Kashihara, Japan
| | - Nobumichi Tanaka
- Department of Urology, Nara Medical University, Nara, Kashihara, Japan
- Department of Prostate Brachytherapy, Nara Medical University, Nara, Kashihara, Japan
| | - Isao Asakawa
- Department of Prostate Brachytherapy, Nara Medical University, Nara, Kashihara, Japan
- Department of Radiation Oncology, Nara Medical University, Nara, Kashihara, Japan
| | - Kenta Ohnishi
- Department of Urology, Nara Medical University, Nara, Kashihara, Japan
| | - Makito Miyake
- Department of Urology, Nara Medical University, Nara, Kashihara, Japan
| | - Kaori Yamaki
- Department of Radiation Oncology, Nara Medical University, Nara, Kashihara, Japan
| | - Kazumasa Torimoto
- Department of Urology, Nara Medical University, Nara, Kashihara, Japan
| | - Kiyohide Fujimoto
- Department of Urology, Nara Medical University, Nara, Kashihara, Japan
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Harvey M, Ong WL, Chao M, Udovicich C, McBride S, Bolton D, Eastham J, Perera M. Comprehensive review of the use of hydrogel spacers prior to radiation therapy for prostate cancer. BJU Int 2023; 131:280-287. [PMID: 35689413 PMCID: PMC9734283 DOI: 10.1111/bju.15821] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES To provide a comprehensive narrative review of the published data on the impact of hydrogel spacers on rectal dosimetry and toxicity and to outline the practicalities of inserting hydrogel spacers. RESULTS A growing body of evidence suggests that the administration of hydrogel spacers is safe and is associated with limited peri-operative morbidity. The impact on rectal dosimetry has been clearly established and use of hydrogel spacers is associated with reduced rectal morbidity. These results have been corroborated by several Phase II and III clinical trials and subsequent meta-analysis. There are several areas for future research, including the role of hydrogel spacers in prostate stereotactic beam radiotherapy and post-radiotherapy local recurrence. CONCLUSIONS Hydrogel spacers provide a low-morbidity method to potential reduce rectal toxicity after radiation therapy in men with prostate cancer. Data outlining sexual function and oncological outcomes are limited to date. Future studies, currently being conducted, may provide further clarification of the role of hydrogel spacers in prostate cancer management.
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Affiliation(s)
- Michael Harvey
- Urology Department, Austin Health, Melbourne, Victoria 3000, Australia
| | - Wee Loon Ong
- Department of Radiation Oncology, Alfred Health, Melbourne, 3004, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne 3000 Victoria
| | - Michael Chao
- Department of Radiation Oncology, Olivia Newton John Cancer Wellness and Research Centre, Austin Health, Melbourne, Victoria 3000, Australia
- Genesis Cancer Care Victoria, Ringwood East, Victoria 3135, Australia
| | - Cristian Udovicich
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria 3000, Australia
- Sir Peter MacCallum Department of Oncology, The University of Melbourne, Victoria 3010, Australia
| | - Sean McBride
- Radiation Oncology Service, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Damien Bolton
- Urology Department, Austin Health, Melbourne, Victoria 3000, Australia
| | - James Eastham
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Marlon Perera
- Urology Department, Austin Health, Melbourne, Victoria 3000, Australia
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, USA
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Björeland U, Notstam K, Fransson P, Söderkvist K, Beckman L, Jonsson J, Nyholm T, Widmark A, Thellenberg Karlsson C. Hyaluronic acid spacer in prostate cancer radiotherapy: dosimetric effects, spacer stability and long-term toxicity and PRO in a phase II study. Radiat Oncol 2023; 18:1. [PMID: 36593460 PMCID: PMC9809044 DOI: 10.1186/s13014-022-02197-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 12/30/2022] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Perirectal spacers may be beneficial to reduce rectal side effects from radiotherapy (RT). Here, we present the impact of a hyaluronic acid (HA) perirectal spacer on rectal dose as well as spacer stability, long-term gastrointestinal (GI) and genitourinary (GU) toxicity and patient-reported outcome (PRO). METHODS In this phase II study 81 patients with low- and intermediate-risk prostate cancer received transrectal injections with HA before external beam RT (78 Gy in 39 fractions). The HA spacer was evaluated with MRI four times; before (MR0) and after HA-injection (MR1), at the middle (MR2) and at the end (MR3) of RT. GI and GU toxicity was assessed by physician for up to five years according to the RTOG scale. PROs were collected using the Swedish National Prostate Cancer Registry and Prostate cancer symptom scale questionnaires. RESULTS There was a significant reduction in rectal V70% (54.6 Gy) and V90% (70.2 Gy) between MR0 and MR1, as well as between MR0 to MR2 and MR3. From MR1 to MR2/MR3, HA thickness decreased with 28%/32% and CTV-rectum space with 19%/17% in the middle level. The cumulative late grade ≥ 2 GI toxicity at 5 years was 5% and the proportion of PRO moderate or severe overall bowel problems at 5 years follow-up was 12%. Cumulative late grade ≥ 2 GU toxicity at 5 years was 12% and moderate or severe overall urinary problems at 5 years were 10%. CONCLUSION We show that the HA spacer reduced rectal dose and long-term toxicity.
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Affiliation(s)
- Ulrika Björeland
- grid.12650.300000 0001 1034 3451Department of Radiation Sciences, Radiation Physics, Umeå University, 901 87 Umeå, Sweden
| | - Kristina Notstam
- grid.12650.300000 0001 1034 3451Department of Radiation Sciences, Oncology, Umeå University, 901 87 Umeå, Sweden
| | - Per Fransson
- grid.12650.300000 0001 1034 3451Department of Nursing, Umeå University, 901 87 Umeå, Sweden
| | - Karin Söderkvist
- grid.12650.300000 0001 1034 3451Department of Radiation Sciences, Oncology, Umeå University, 901 87 Umeå, Sweden
| | - Lars Beckman
- grid.12650.300000 0001 1034 3451Department of Radiation Sciences, Oncology, Umeå University, 901 87 Umeå, Sweden
| | - Joakim Jonsson
- grid.12650.300000 0001 1034 3451Department of Radiation Sciences, Radiation Physics, Umeå University, 901 87 Umeå, Sweden
| | - Tufve Nyholm
- grid.12650.300000 0001 1034 3451Department of Radiation Sciences, Radiation Physics, Umeå University, 901 87 Umeå, Sweden
| | - Anders Widmark
- grid.12650.300000 0001 1034 3451Department of Radiation Sciences, Oncology, Umeå University, 901 87 Umeå, Sweden
| | - Camilla Thellenberg Karlsson
- grid.12650.300000 0001 1034 3451Department of Radiation Sciences, Oncology, Umeå University, 901 87 Umeå, Sweden
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Hadigal SR, Gupta AK. Application of Hydrogel Spacer SpaceOAR Vue for Prostate Radiotherapy. Tomography 2022; 8:2648-2661. [PMID: 36412680 PMCID: PMC9680261 DOI: 10.3390/tomography8060221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 10/18/2022] [Accepted: 10/22/2022] [Indexed: 11/07/2022] Open
Abstract
Damage in the surrounding structures, including the rectum, due to unintended exposure to radiation is a large burden to bear for patients who undergo radiation therapy for prostate cancer. The use of injectable rectal spacers to distance the anterior rectum from the prostate is a potential strategy to reduce the dose of unintended radiation to the rectum. Hydrogel spacers are gaining increasing popularity in the treatment regimen for prostate cancer. After FDA approval of SpaceOAR, specialists are receiving an increasing number of referrals for hydrogel placements. In this paper, we review hydrogel spacers, the supporting clinical data, the best practices for hydrogel placement, and the risk of adverse events.
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Affiliation(s)
| | - Atul K. Gupta
- Department of Radiology, Rochester General Hospital, 1425 Portland Ave, Rochester, NY 14621, USA
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Payne HA, Jain S, Peedell C, Edwards A, Thomas JA, Das P, Hansson Hedblom A, Woodward E, Saunders R, Bahl A. Delphi study to identify consensus on patient selection for hydrogel rectal spacer use during radiation therapy for prostate cancer in the UK. BMJ Open 2022; 12:e060506. [PMID: 35858729 PMCID: PMC9305805 DOI: 10.1136/bmjopen-2021-060506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES To identify consensus on patient prioritisation for rectal hydrogel spacer use during radiation therapy for the treatment of prostate cancer in the UK. DESIGN Delphi study consisting of two rounds of online questionnaires, two virtual advisory board meetings and a final online questionnaire. SETTING Radical radiation therapy for localised and locally advanced prostate cancer in the UK. PARTICIPANTS Six leading clinical oncologists and one urologist from across the UK. INTERVENTIONS Rectal hydrogel spacer. PRIMARY AND SECONDARY OUTCOME MEASURES None reported. RESULTS The panel reached consensus on the importance of minimising toxicity for treatments with curative intent and that even low-grade toxicity-related adverse events can significantly impact quality of life. There was agreement that despite meeting rectal dose constraints, too many patients experience rectal toxicity and that rectal hydrogel spacers in eligible patients significantly reduces toxicity-related adverse events. However, as a consequence of funding limitations, patients need to be prioritised for spacer use. A higher benefit of spacers can be expected in patients on anticoagulation and in patients with diabetes or inflammatory bowel disease, but consensus could not be reached regarding patient groups expected to benefit less. While radiation therapy regimen is not a main factor determining prioritisation, higher benefit is expected in ultrahypofractionated regimens. CONCLUSION There is a strong and general agreement that all patients with prostate cancer undergoing radical radiation therapy have the potential to benefit from hydrogel spacers. Currently, not all patients who could potentially benefit can access hydrogel spacers, and access is unequal. Implementation of the consensus recommendations would likely help prioritise and equalise access to rectal spacers for patients in the UK.
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Affiliation(s)
- Heather Ann Payne
- Department of Oncology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Suneil Jain
- School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK
| | - Clive Peedell
- Department of Radiotherapy and Oncology, James Cook University Hospital, Middlesbrough, UK
| | | | | | - Prantik Das
- Department of Oncology, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | | | - Emily Woodward
- Health Economics, Boston Scientific AG, Solothurn, Switzerland
| | | | - Amit Bahl
- Bristol Haematology and Oncology Centre, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
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Medical Resource Use and Medical Costs for Radiotherapy-Related Adverse Effects: A Systematic Review. Cancers (Basel) 2022; 14:cancers14102444. [PMID: 35626049 PMCID: PMC9139402 DOI: 10.3390/cancers14102444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 05/09/2022] [Accepted: 05/11/2022] [Indexed: 12/03/2022] Open
Abstract
Simple Summary Cancer patients who receive radiotherapy often suffer from adverse effects that require healthcare resources to manage. This study summarized evidence of healthcare resource use and costs related to radiotherapy-induced adverse effects and provided recommendations for including this evidence in economic evaluations. Our findings revealed unignorable differences for the same adverse effects, which implied that the potential for the economic burden of adverse effects was overestimated or underestimated. Abstract Background: Despite the need for a proper economic evaluation of new radiotherapies, the economic burden of radiotherapy-induced adverse effects remains unclear. A systematic review has been conducted to identify the existing evidence of healthcare resource use and costs related to radiotherapy-induced adverse effects and also to provide recommendations for including this evidence in economic evaluations. Methods: This systematic review of healthcare resource use and/or medical costs related to radiotherapy-induced adverse effects was performed up until 2020, focusing on patients with head and neck cancer, brain cancer, prostate cancer, eye cancer and breast cancer. Results: Resource use for treating the same adverse effects varied considerably across studies; for instance, the cost for mucositis ranged from USD 2949 to USD 17,244. This broad range could be related to differences in (1) severity of adverse effects in the study population, (2) study design, (3) cost estimation approach and (4) country and clinical practice. Conclusions: Our findings revealed unignorable differences for the same adverse effects, which implied that the potential for the economic burden of adverse effects was being overestimated or underestimated in economic evaluation for radiotherapy.
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Jones S, White N, Holt T, Graves N. Cost-effectiveness analysis of hydrogel spacer for rectal toxicity reduction in prostate external beam radiotherapy. J Med Imaging Radiat Oncol 2021; 65:931-939. [PMID: 34397158 DOI: 10.1111/1754-9485.13311] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 07/16/2021] [Accepted: 07/31/2021] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Contemporary methods of external beam radiotherapy for prostate cancer have reduced toxicity rates through beam modulation and image guidance, however, rectal injury has not been eliminated completely in this population. For patients at greatest risk of developing rectal toxicities, hydrogel spacers are a viable option for risk reduction. Translation of clinical trial results into routine clinical practice relies on an understanding of the economic implications. This study completed a cost-effectiveness analysis of hydrogel spacers in the Australian healthcare setting. METHOD Simulation of possible health states following treatment was performed using a Markov model. Model outcomes included the incremental cost-effectiveness ratio and the net monetary benefit (NMB) at three published willingness-to-pay thresholds derived from literature. Probabilistic sensitivity analyses were provided on these results. A baseline cohort without hydrogel spacer use was compared to treat all and selective use cohorts. Cost variation scenarios were also investigated to assess the impact of hydrogel spacer cost on outcomes. RESULTS Using hydrogel spacers in a selective cohort was more likely to be cost-effective than giving to all patients (NMB -$43 versus -$997, respectively); however, the incremental cost-effectiveness ratio was not below the $28 000 willingness-to-pay threshold for a healthcare provider perspective. These outcomes were influenced by large parameter uncertainty. Cost variation strategies are worth investigating further as a method to achieve willingness-to-pay threshold targets. CONCLUSION The influence of parameter uncertainty currently limits the cost-effectiveness of this intervention in the Australian public health setting. However, a cost variation solution has been demonstrated to improve cost-effectiveness estimates for selected patients and should be examined further.
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Affiliation(s)
- Scott Jones
- Radiation Oncology, Princess Alexandra Hospital, Raymond Terrace, Brisbane, Queensland, Australia.,Science and Engineering Faculty, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Nicole White
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Tanya Holt
- Radiation Oncology, Princess Alexandra Hospital, Raymond Terrace, Brisbane, Queensland, Australia.,University of Queensland, Brisbane, Queensland, Australia
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Byrne JD, Young CC, Chu JN, Pursley J, Chen MX, Wentworth AJ, Feng A, Kirtane AR, Remillard KA, Hancox CI, Bhagwat MS, Machado N, Hua T, Tamang SM, Collins JE, Ishida K, Hayward A, Becker SL, Edgington SK, Schoenfeld JD, Jeck WR, Hur C, Traverso G. Personalized Radiation Attenuating Materials for Gastrointestinal Mucosal Protection. ADVANCED SCIENCE (WEINHEIM, BADEN-WURTTEMBERG, GERMANY) 2021; 8:2100510. [PMID: 34194950 PMCID: PMC8224439 DOI: 10.1002/advs.202100510] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Revised: 03/07/2021] [Indexed: 05/11/2023]
Abstract
Cancer patients undergoing therapeutic radiation routinely develop injury of the adjacent gastrointestinal (GI) tract mucosa due to treatment. To reduce radiation dose to critical GI structures including the rectum and oral mucosa, 3D-printed GI radioprotective devices composed of high-Z materials are generated from patient CT scans. In a radiation proctitis rat model, a significant reduction in crypt injury is demonstrated with the device compared to without (p < 0.0087). Optimal device placement for radiation attenuation is further confirmed in a swine model. Dosimetric modeling in oral cavity cancer patients demonstrates a 30% radiation dose reduction to the normal buccal mucosa and a 15.2% dose reduction in the rectum for prostate cancer patients with the radioprotectant material in place compared to without. Finally, it is found that the rectal radioprotectant device is more cost-effective compared to a hydrogel rectal spacer. Taken together, these data suggest that personalized radioprotectant devices may be used to reduce GI tissue injury in cancer patients undergoing therapeutic radiation.
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Affiliation(s)
- James D. Byrne
- Division of GastroenterologyBrigham and Women's HospitalHarvard Medical School75 Francis St.BostonMA02115USA
- Harvard Radiation Oncology Program55 Fruit StreetBostonMA02114USA
- David H. Koch Institute for Integrative Cancer ResearchMassachusetts Institute of Technology500 Main St Building 76CambridgeMA02142USA
- Department of Mechanical EngineeringMassachusetts Institute of Technology77 Massachusetts AveCambridgeMA02139USA
- Department of Radiation OncologyDana‐Farber Cancer Institute/Brigham and Women's Hospital44 Binney St.BostonMA02115USA
| | - Cameron C. Young
- Division of GastroenterologyBrigham and Women's HospitalHarvard Medical School75 Francis St.BostonMA02115USA
| | - Jacqueline N. Chu
- David H. Koch Institute for Integrative Cancer ResearchMassachusetts Institute of Technology500 Main St Building 76CambridgeMA02142USA
- Department of Mechanical EngineeringMassachusetts Institute of Technology77 Massachusetts AveCambridgeMA02139USA
- Division of GastroenterologyMassachusetts General Hospital55 Fruit St.BostonMA02114USA
| | - Jennifer Pursley
- Division of Medical PhysicsDepartment of Radiation OncologyMassachusetts General Hospital450 Brookline AvenueBostonMA02115USA
| | - Mu Xian Chen
- Division of GastroenterologyBrigham and Women's HospitalHarvard Medical School75 Francis St.BostonMA02115USA
| | - Adam J. Wentworth
- Division of GastroenterologyBrigham and Women's HospitalHarvard Medical School75 Francis St.BostonMA02115USA
- David H. Koch Institute for Integrative Cancer ResearchMassachusetts Institute of Technology500 Main St Building 76CambridgeMA02142USA
- Department of Mechanical EngineeringMassachusetts Institute of Technology77 Massachusetts AveCambridgeMA02139USA
| | - Annie Feng
- David H. Koch Institute for Integrative Cancer ResearchMassachusetts Institute of Technology500 Main St Building 76CambridgeMA02142USA
| | - Ameya R. Kirtane
- David H. Koch Institute for Integrative Cancer ResearchMassachusetts Institute of Technology500 Main St Building 76CambridgeMA02142USA
- Department of Mechanical EngineeringMassachusetts Institute of Technology77 Massachusetts AveCambridgeMA02139USA
| | - Kyla A. Remillard
- Division of Medical PhysicsDepartment of Radiation OncologyMassachusetts General Hospital450 Brookline AvenueBostonMA02115USA
| | - Cindy I. Hancox
- Department of Radiation OncologyDana‐Farber Cancer Institute/Brigham and Women's Hospital44 Binney St.BostonMA02115USA
| | - Mandar S. Bhagwat
- Division of Medical PhysicsDepartment of Radiation OncologyMassachusetts General Hospital450 Brookline AvenueBostonMA02115USA
| | - Nicole Machado
- David H. Koch Institute for Integrative Cancer ResearchMassachusetts Institute of Technology500 Main St Building 76CambridgeMA02142USA
| | - Tiffany Hua
- David H. Koch Institute for Integrative Cancer ResearchMassachusetts Institute of Technology500 Main St Building 76CambridgeMA02142USA
| | - Siddartha M. Tamang
- David H. Koch Institute for Integrative Cancer ResearchMassachusetts Institute of Technology500 Main St Building 76CambridgeMA02142USA
| | - Joy E. Collins
- David H. Koch Institute for Integrative Cancer ResearchMassachusetts Institute of Technology500 Main St Building 76CambridgeMA02142USA
| | - Keiko Ishida
- David H. Koch Institute for Integrative Cancer ResearchMassachusetts Institute of Technology500 Main St Building 76CambridgeMA02142USA
| | - Alison Hayward
- David H. Koch Institute for Integrative Cancer ResearchMassachusetts Institute of Technology500 Main St Building 76CambridgeMA02142USA
- Division of Comparative MedicineMassachusetts Institute of TechnologyBuilding 16‐825, 77 Massachusetts AveCambridgeMA02139USA
| | - Sarah L. Becker
- Division of GastroenterologyBrigham and Women's HospitalHarvard Medical School75 Francis St.BostonMA02115USA
| | - Samantha K. Edgington
- Division of Medical PhysicsDepartment of Radiation OncologyMassachusetts General Hospital450 Brookline AvenueBostonMA02115USA
| | - Jonathan D. Schoenfeld
- Department of Radiation OncologyDana‐Farber Cancer Institute/Brigham and Women's Hospital44 Binney St.BostonMA02115USA
| | | | - Chin Hur
- Department of MedicineColumbia University Medical Center622 West 168th Street, PH 9‐105New YorkNY10032USA
- Department of EpidemiologyMailman School of Public Health and Herbert Irving Comprehensive Cancer CenterColumbia University Medical Center722 West 168th St.New YorkNY10032USA
| | - Giovanni Traverso
- Division of GastroenterologyBrigham and Women's HospitalHarvard Medical School75 Francis St.BostonMA02115USA
- Department of Mechanical EngineeringMassachusetts Institute of Technology77 Massachusetts AveCambridgeMA02139USA
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9
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Armstrong N, Bahl A, Pinkawa M, Ryder S, Ahmadu C, Ross J, Bhattacharyya S, Woodward E, Battaglia S, Binns J, Payne H. SpaceOAR Hydrogel Spacer for Reducing Radiation Toxicity During Radiotherapy for Prostate Cancer. A Systematic Review. Urology 2021; 156:e74-e85. [PMID: 34029607 DOI: 10.1016/j.urology.2021.05.013] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 05/04/2021] [Accepted: 05/07/2021] [Indexed: 12/25/2022]
Abstract
OBJECTIVE To evaluate the association between SpaceOAR and radiation dosing, toxicity and quality-of-life vs no spacer across all radiotherapy modalities for prostate cancer. METHODS A systematic search of the Cochrane Central Register of Controlled Trials, MEDLINE, and Embase was performed from database inception through May 2020. Two reviewers independently screened titles/abstracts and full papers. Data extraction was performed, and quality assessed by 1 reviewer and checked by a second, using a third reviewer as required. The synthesis was narrative. RESULTS 19 studies (3,622 patients) were included (only 1 randomized controlled trial, in image-guided intensity-modulated radiotherapy (IG-IMRT), 18 comparatives non-randomized controlled trials in external-beam radiotherapy (EBRT), brachytherapy, and combinations thereof). No hypofractionation studies were found. Regardless of radiotherapy type, SpaceOAR significantly reduced rectal radiation dose (eg, V40 average difference -6.1% in high dose-rate brachytherapy plus IG-IMRT to -9.1% in IG-IMRT) and reduced gastrointestinal and genitourinary toxicities (eg, late gastrointestinal toxicity 1% vs 6% (P = .01), late genitourinary toxicity of 15% vs 32% (P < .001) in stereotactic body radiotherapy). Improvements were observed in most Expanded Prostate Cancer Index Composite quality-of-life domains (eg, bowel function score decrease at 3 and 6 months: Average change of zero vs -6.25 and -3.57 respectively in low dose-rate brachytherapy plus EBRT). CONCLUSION The randomized controlled trial in IG-IMRT demonstrated that SpaceOAR reduces rectal radiation dose and late gastrointestinal and genitourinary toxicities, with urinary, bowel, and sexual quality-of-life improvement. These advantages were verified in observational studies in various radiotherapy types. Further research is required in hypofractionation.
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Affiliation(s)
- Nigel Armstrong
- Kleijnen Systematic Reviews Ltd, Escrick, YO, United Kingdom.
| | - Amit Bahl
- University Hospitals Bristol, Bristol, United Kingdom
| | - Michael Pinkawa
- Department of Radiation Oncology, MediClin Robert Janker Klinik, Bonn, Germany
| | - Steve Ryder
- Kleijnen Systematic Reviews Ltd, Escrick, YO, United Kingdom
| | | | - Janine Ross
- Kleijnen Systematic Reviews Ltd, Escrick, YO, United Kingdom
| | | | | | | | - Jean Binns
- Boston Scientific Corporation, United States
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10
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Sanei M, Ghaffari H, Ardekani MA, Mahdavi SR, Mofid B, Abdollahi H, Rostami A. Effectiveness of rectal displacement devices during prostate external-beam radiation therapy: A review. J Cancer Res Ther 2021; 17:303-310. [PMID: 34121672 DOI: 10.4103/jcrt.jcrt_841_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Dose-escalated prostate radiotherapy (RT) can improve treatment outcomes, but rectal toxicity is the main limiting factor for introducing dose-escalated RT. Pushing rectal wall away from the prostate reduces the volume of the rectum in high-dose region, which can decrease both short- and long-term rectal toxicities after RT. This review focuses on the literature using different rectal displacement devices such as endorectal balloons, tissue spacers, rectal retractor, and ProSpare during prostate External beam radiotherapy, with regard to dosimetric effects, clinical benefits, prostate motion, and postoperative RT setting.
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Affiliation(s)
- Mastaneh Sanei
- Department of Radiation Oncology, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Hamed Ghaffari
- Department of Medical Physics, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Mahdieh Afkhami Ardekani
- Department of Radiology, Faculty of Para-Medicine, Hormozgan University of Medical Sciences, Bandar-Abbas, Iran
| | - Seied Rabi Mahdavi
- Department of Medical Physics, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Bahram Mofid
- Department of Radiation Oncology, Shohada-e-Tajrish Medical Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Hamid Abdollahi
- Department of Radiologic Sciences and Medical Physics, Faculty of Allied Medicine, Kerman University of Medical Sciences, Kerman, Iran
| | - Aram Rostami
- Department of Medical Physics, School of Medicine, Iran University of Medical Sciences; Department of Medical Physics, Roshana Cancer Institute, Tehran, Iran
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11
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Yan M, Gouveia AG, Cury FL, Moideen N, Bratti VF, Patrocinio H, Berlin A, Mendez LC, Moraes FY. Practical considerations for prostate hypofractionation in the developing world. Nat Rev Urol 2021; 18:669-685. [PMID: 34389825 PMCID: PMC8361822 DOI: 10.1038/s41585-021-00498-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/23/2021] [Indexed: 02/06/2023]
Abstract
External beam radiotherapy is an effective curative treatment option for localized prostate cancer, the most common cancer in men worldwide. However, conventionally fractionated courses of curative external beam radiotherapy are usually 8-9 weeks long, resulting in a substantial burden to patients and the health-care system. This problem is exacerbated in low-income and middle-income countries where health-care resources might be scarce and patient funds limited. Trials have shown a clinical equipoise between hypofractionated schedules of radiotherapy and conventionally fractionated treatments, with the advantage of drastically shortening treatment durations with the use of hypofractionation. The hypofractionated schedules are supported by modern consensus guidelines for implementation in clinical practice. Furthermore, several economic evaluations have shown improved cost effectiveness of hypofractionated therapy compared with conventional schedules. However, these techniques demand complex infrastructure and advanced personnel training. Thus, a number of practical considerations must be borne in mind when implementing hypofractionation in low-income and middle-income countries, but the potential gain in the treatment of this patient population is substantial.
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Affiliation(s)
- Michael Yan
- grid.410356.50000 0004 1936 8331Division of Radiation Oncology, Cancer Centre of Southeastern Ontario, Queen’s University, Kingston, Canada
| | - Andre G. Gouveia
- Department of Radiation Oncology, Americas Centro de Oncologia Integrado, Rio de Janeiro, Brazil
| | - Fabio L. Cury
- grid.14709.3b0000 0004 1936 8649Department of Radiation Oncology, Cedars Cancer Centre, McGill University, Montreal, Canada
| | - Nikitha Moideen
- grid.410356.50000 0004 1936 8331Division of Radiation Oncology, Cancer Centre of Southeastern Ontario, Queen’s University, Kingston, Canada
| | - Vanessa F. Bratti
- grid.410356.50000 0004 1936 8331Queen’s University School of Medicine, Department of Public Health Sciences, Kingston, Canada
| | - Horacio Patrocinio
- grid.14709.3b0000 0004 1936 8649Department of Medical Physics, Cedars Cancer Centre, McGill University, Montreal, Canada
| | - Alejandro Berlin
- grid.17063.330000 0001 2157 2938Radiation Medicine Program, Princess Margaret Cancer Centre, University of Toronto, Toronto, Canada
| | - Lucas C. Mendez
- grid.39381.300000 0004 1936 8884Department of Radiation Oncology, London Regional Cancer Program, Western University, London, Canada
| | - Fabio Y. Moraes
- grid.410356.50000 0004 1936 8331Division of Radiation Oncology, Cancer Centre of Southeastern Ontario, Queen’s University, Kingston, Canada
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12
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Thompson AB, Hamstra DA. Rectal Spacer Usage with Proton Radiation Therapy for Prostate Cancer. Int J Radiat Oncol Biol Phys 2020; 108:644-648. [DOI: 10.1016/j.ijrobp.2020.05.034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 05/11/2020] [Accepted: 05/18/2020] [Indexed: 01/03/2023]
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13
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Schumacher LED, Dal Pra A, Hoffe SE, Mellon EA. Toxicity reduction required for MRI-guided radiotherapy to be cost-effective in the treatment of localized prostate cancer. Br J Radiol 2020; 93:20200028. [PMID: 32783629 DOI: 10.1259/bjr.20200028] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE To determine the toxicity reduction required to justify the added costs of MRI-guided radiotherapy (MR-IGRT) over CT-based image guided radiotherapy (CT-IGRT) for the treatment of localized prostate cancer. METHODS The costs of delivering prostate cancer radiotherapy with MR-IGRT and CT-IGRT in conventional 39 fractions and stereotactic body radiotherapy (SBRT) 5 fractions schedules were determined using literature values and cost accounting from two institutions. Gastrointestinal and genitourinary toxicity rates associated with CT-IGRT were summarized from 20 studies. Toxicity-related costs and utilities were obtained from literature values and cost databases. Markov modeling was used to determine the savings per patient for every 1% relative reduction in acute and chronic toxicities by MR-IGRT over 15 years. The costs and quality adjusted life years (QALYs) saved with toxicity reduction were juxtaposed with the cost increase of MR-IGRT to determine toxicity reduction thresholds for cost-effectiveness. One way sensitivity analyses were performed. Standard $100,000 and $50,000 per QALY ratios were used. RESULTS The added cost of MR-IGRT was $1,459 per course of SBRT and $10,129 per course of conventionally fractionated radiotherapy. Relative toxicity reductions of 7 and 14% are required for SBRT to be cost-effective using $100,000 and $50,000 per QALY, respectively. Conventional radiotherapy requires relative toxicity reductions of 50 and 94% to be cost-effective. CONCLUSION From a healthcare perspective, MR-IGRT can reasonably be expected to be cost-effective. Hypofractionated schedules, such a five fraction SBRT, are most likely to be cost-effective as they require only slight reductions in toxicity (7-14%). ADVANCES IN KNOWLEDGE This is the first detailed economic assessment of MR-IGRT, and it suggests that MR-IGRT can be cost-effective for prostate cancer treatment through toxicity reduction alone.
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Affiliation(s)
- Leif-Erik D Schumacher
- Radiation Oncology, Sylvester Comprehensive Cancer Center, Miller School of Medicine, University of Miami, Miami, FL, United States
| | - Alan Dal Pra
- Radiation Oncology, Sylvester Comprehensive Cancer Center, Miller School of Medicine, University of Miami, Miami, FL, United States
| | - Sarah E Hoffe
- Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, United States
| | - Eric A Mellon
- Radiation Oncology and Bioengineering, Sylvester Comprehensive Cancer Center, Miller School of Medicine, University of Miami, Miami, FL, United States
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14
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Paetkau O, Gagne IM, Alexander A. SpaceOAR© hydrogel rectal dose reduction prediction model: a decision support tool. J Appl Clin Med Phys 2020; 21:15-25. [PMID: 32250042 PMCID: PMC7324696 DOI: 10.1002/acm2.12860] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Revised: 02/10/2020] [Accepted: 03/04/2020] [Indexed: 12/12/2022] Open
Abstract
Prostate cancer external beam radiation therapy can result in toxicity due to organ at risk (OAR) dose, potentially impairing quality of life. A polyethylene glycol-based spacer, SpaceOAR© hydrogel (SOH), implanted between prostate gland and rectum may significantly reduce dose received by the rectum and hence risk of rectal toxicity. SOH implant is not equally effective in all patients. Determining patients in which the implant will offer most benefit, in terms of rectal dose reduction, allows for effective management of SOH resources. Several factors have been shown to be correlated with reduction in rectal dose including distance between rectum and planning treatment volume (PTV), volume of rectum in the PTV, and change in rectum volume pre- to post-SOH. Several of these factors along with other pre-SOH CT metrics were able to predict reduction in rectal dose associated with SOH implant. Rectal V55Gy metric, was selected as the dose level of interest in the context of 60 Gy in 20 fraction treatment plans. Models were produced to predict change in RV55Gy and pre-SOH hydrogel RV55Gy. These models offered R-squared between 0.81 and 0.88 with statistical significance in each model. Applying an ω 1 = 3% lower limit of pre-SOH RV55 Gy and an ω 2 = 3.5% lower limit on change in RV55 Gy, retained 60% of patients experiencing the largest rectal dose reduction from the hydrogel. This may offer a clinically useful tool in deciding which patients should receive SOH implant given limited resources. Predictive models, nomograms, and a workflow diagram were produced for clinical management of SOH implant.
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Affiliation(s)
- Owen Paetkau
- Department of Physics and Astronomy, University of Victoria, Victoria, BC, Canada
| | - Isabelle M Gagne
- Department of Physics and Astronomy, University of Victoria, Victoria, BC, Canada.,Department of Medical Physics, BC Cancer - Victoria, Victoria, BC, Canada
| | - Abraham Alexander
- Department of Radiation Oncology, BC Cancer - Victoria, Victoria, BC, Canada.,Department of Surgery, University of British Columbia, Vancouver, BC, Canada
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15
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Aminsharifi A, Kotamarti S, Silver D, Schulman A. Major Complications and Adverse Events Related to the Injection of the SpaceOAR Hydrogel System Before Radiotherapy for Prostate Cancer: Review of the Manufacturer and User Facility Device Experience Database. J Endourol 2019; 33:868-871. [PMID: 31452385 DOI: 10.1089/end.2019.0431] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Purpose: SpaceOAR® is a Food and Drug Administration-approved hydrogel injection used to create space between the prostate and rectum during prostate radiotherapy. It has shown to significantly reduce the rectal radiation dose with lower rates of rectal toxicity. Despite a high safety performance in initial trials, SpaceOAR remains in early clinical use. Thus, we examined emerging safety reports as the system becomes more widely utilized. Methods: We reviewed the SpaceOAR manufacturer website for the safety profile and complications associated with the SpaceOAR hydrogel. We then compared this with reports submitted to the Manufacturer and User Facility Device Experience (MAUDE) database. Results: The manufacturer website reported risks including pain, needle penetration, and/or gel injection into a nearby organ or blood vessel, local inflammation, infection, urinary retention, and local rectal injury or symptoms. There were 22 unique reports discussing 25 patient cases in the MAUDE database from January 2015 to March 2019, with an increasing number of reports each year up through 2018. Unique major complications including acute pulmonary embolism, severe anaphylaxis, prostatic abscess and sepsis, purulent perineal drainage, rectal wall erosion, and rectourethral fistula were reported. Conclusion: Despite well-documented clinical benefits of the SpaceOAR System, there are a number of severe and debilitating complications recently reported in proximity to gel injection. This highlights the need for further study of device complications in light of its increasing clinical use.
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Affiliation(s)
- Alireza Aminsharifi
- Division of Urology, Duke Cancer Institute, Duke University Hospital, Durham, North Carolina.,Department of Urology, Shiraz University of Medical Sciences, Shiraz, Iran
| | | | - David Silver
- Division of Urology, Maimonides Medical Center, Brooklyn, New York
| | - Ariel Schulman
- Division of Urology, Maimonides Medical Center, Brooklyn, New York
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16
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Navaratnam A, Cumsky J, Abdul-Muhsin H, Gagneur J, Shen J, Kosiorek H, Golafshar M, Kawashima A, Wong W, Ferrigni R, Humphreys MR. Assessment of Polyethylene Glycol Hydrogel Spacer and Its Effect on Rectal Radiation Dose in Prostate Cancer Patients Receiving Proton Beam Radiation Therapy. Adv Radiat Oncol 2019; 5:92-100. [PMID: 32051895 PMCID: PMC7004937 DOI: 10.1016/j.adro.2019.08.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Revised: 07/15/2019] [Accepted: 08/13/2019] [Indexed: 12/31/2022] Open
Abstract
Purpose To assess the efficacy of placing a polyethylene glycol (PEG) spacing hydrogel in patients undergoing proton beam radiation therapy for prostate cancer. This study also aims to assess the effect on rectal radiation dose of prostate-rectum separation in various anatomic planes. Methods and Materials Seventy-two consecutive prostate cancer patients undergoing conventionally fractionated pencil beam scanning proton radiation therapy with and without hydrogel placement were compared. Magnetic resonance images taken after hydrogel placement measured prostate-rectum separation and were correlated to rectal dosing and rectal toxicity. Univariate analysis of clinical variables and radiation dosing was conducted using nonparametric Wilcoxon rank-sum test with continuity correction between groups (hydrogel spacer vs controls). Spearman's rank correlation coefficient assessed relationships between the various anatomic dimensions of perirectal space and rectal radiation dosing. Results Fifty-one patients had hydrogel placement before therapy and 21 did not. There was a 42.2% reduction in rectal dosing (mL3 rectum) in hydrogel patients (P < .001). Increasing midline sagittal lift resulted in a greater mitigation of total rectal dose (P = .031). The degree of prostate surface area coverage on coronal plane did not correlate with further reductions in rectal radiation dose (P = .673). Patients who had PEG hydrogels placed reported more rectal side effects during treatment compared with those patients who did not (35.3% vs 9.5%, P = .061). At median 9.5-month follow-up, there was no difference in reporting of grade ≤2 rectal toxicity between the 2 groups (7.7% vs 7.1%, P = .145). Conclusions Polyethylene glycol hydrogel placement before pencil proton beam radiation therapy for prostate cancer reduced rectal radiation dose. The most important factor reducing total rectal dose was the degree of sagittal midline separation created by the PEG hydrogel. This is the largest study with the longest follow-up to investigate hydrogel placement in the proton beam radiation setting.
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Affiliation(s)
| | - Jameson Cumsky
- Department of Urology, Mayo Clinic in Arizona, Phoenix, Arizona
| | | | - Justin Gagneur
- Department of Radiation Oncology, Mayo Clinic in Arizona, Phoenix, Arizona
| | - Jiajian Shen
- Department of Radiation Oncology, Mayo Clinic in Arizona, Phoenix, Arizona
| | - Heidi Kosiorek
- Department of Biostatistics, Mayo Clinic in Arizona, Phoenix, Arizona
| | - Michael Golafshar
- Department of Biostatistics, Mayo Clinic in Arizona, Phoenix, Arizona
| | - Akira Kawashima
- Department of Radiology, Mayo Clinic in Arizona, Phoenix, Arizona
| | - William Wong
- Department of Radiation Oncology, Mayo Clinic in Arizona, Phoenix, Arizona
| | - Robert Ferrigni
- Department of Urology, Mayo Clinic in Arizona, Phoenix, Arizona
| | - Mitchell R. Humphreys
- Department of Urology, Mayo Clinic in Arizona, Phoenix, Arizona
- Corresponding author: Mitchell R. Humphreys, MD
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17
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Hwang ME, Mayeda M, Liz M, Goode-Marshall B, Gonzalez L, Elliston CD, Spina CS, Padilla OA, Wenske S, Deutsch I. Stereotactic body radiotherapy with periprostatic hydrogel spacer for localized prostate cancer: toxicity profile and early oncologic outcomes. Radiat Oncol 2019; 14:136. [PMID: 31375119 PMCID: PMC6679492 DOI: 10.1186/s13014-019-1346-5] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2019] [Accepted: 07/24/2019] [Indexed: 02/07/2023] Open
Abstract
Background Multiple phase I-II clinical trials have reported on the efficacy and safety of prostate stereotactic body radiotherapy (SBRT) for the treatment of prostate cancer. However, few have reported outcomes for prostate SBRT using periprostatic hydrogel spacer (SpaceOAR; Augmenix). Herein, we report safety and efficacy outcomes from our institutional prostate SBRT experience with SpaceOAR placement. Methods Fifty men with low- or intermediate-risk prostate cancer treated at a single institution with linear accelerator-based SBRT to 3625 cGy in 5 fractions, with or without androgen deprivation therapy (ADT) were included. All patients underwent SpaceOAR and fiducial marker placement followed by pre-treatment MRI. Toxicity assessments were conducted at least weekly while on treatment, 1 month after treatment, and every follow-up visit thereafter. Post-treatment PSA measurements were obtained 4 months after SBRT, followed by every 3–6 months thereafter. Acute toxicity was documented per RTOG criteria. Results Median follow up time was 20 (range 4–44) months. Median PSA at time of diagnosis was 7.4 (2.7–19.5) ng/ml. Eighteen men received 6 months of ADT for unfavorable intermediate risk disease. No PSA failures were recorded. Median PSA was 0.9 ng/mL at 20 months; 0.08 and 1.32 ng/mL in men who did and did not receive ADT, respectively. Mean prostate-rectum separation achieved with SpaceOAR was 9.6 ± 4 mm at the prostate midgland. No grade ≥ 3 GU or GI toxicity was recorded. During treatment, 30% of men developed new grade 2 GU toxicity (urgency or dysuria). These symptoms were present in 30% of men at 1 month and in 12% of men at 1 year post-treatment. During treatment, GI toxicity was limited to grade 1 symptoms (16%), although 4% of men developed grade 2 symptoms during the first 4 weeks after SBRT. All GI symptoms were resolving by the 1 month post-treatment assessment and no acute or late rectal toxicity was reported > 1 month after treatment. Conclusions Periprostatic hydrogel placement followed by prostate SBRT resulted in minimal GI toxicity, and favorable early oncologic outcomes. These results indicate that SBRT with periprostatic spacer is a well-tolerated, safe, and convenient treatment option for localized prostate cancer. Electronic supplementary material The online version of this article (10.1186/s13014-019-1346-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Mark E Hwang
- Department of Radiation Oncology, Columbia University Medical Center, New York, 10032, USA
| | - Mark Mayeda
- Department of Radiation Oncology, Columbia University Medical Center, New York, 10032, USA
| | - Maria Liz
- Department of Radiation Oncology, Columbia University Medical Center, New York, 10032, USA
| | - Brenda Goode-Marshall
- Department of Radiation Oncology, Columbia University Medical Center, New York, 10032, USA
| | - Lissette Gonzalez
- Department of Radiation Oncology, Columbia University Medical Center, New York, 10032, USA
| | - Carl D Elliston
- Department of Radiation Oncology, Columbia University Medical Center, New York, 10032, USA
| | - Catherine S Spina
- Department of Radiation Oncology, Columbia University Medical Center, New York, 10032, USA
| | - Oscar A Padilla
- Department of Radiation Oncology, Columbia University Medical Center, New York, 10032, USA
| | - Sven Wenske
- Department of Urology, Columbia University Medical Center, New York, 10032, USA
| | - Israel Deutsch
- Department of Radiation Oncology, Columbia University Medical Center, New York, 10032, USA.
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18
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Evaluating the Cost-Effectiveness of Hydrogel Rectal Spacer in Prostate Cancer Radiation Therapy. Pract Radiat Oncol 2018; 9:e172-e179. [PMID: 30342180 DOI: 10.1016/j.prro.2018.10.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Revised: 10/01/2018] [Accepted: 10/04/2018] [Indexed: 12/22/2022]
Abstract
PURPOSE A hydrogel rectal spacer (HRS) is a medical device that is approved by the U.S. Food and Drug Administration to increase the separation between the prostate and rectum. We conducted a cost-effectiveness analysis of HRS use for reduction in radiation therapy (RT) toxicities in patients with prostate cancer (PC) undergoing external beam RT (EBRT). METHODS AND MATERIALS A multistate Markov model was constructed from the U.S. payer perspective to examine the cost-effectiveness of HRS in men with localized PC receiving EBRT (EBRT alone vs EBRT + HRS). The subgroups analyzed included site of HRS placement (hospital outpatient, physician office, ambulatory surgery center) and proportion of patients with good baseline erectile function (EF). Data on EF, gastrointestinal and genitourinary toxicities incidence, and potential risks associated with HRS implantation were obtained from a recently published randomized clinical trial. Health utilities and costs were derived from the literature and the 2018 Physician Fee Schedule and were discounted 3% annually. Quality-adjusted life years (QALYs) and costs were modeled for a 5-year period from receipt of RT. Probabilistic sensitivity analysis and value-based threshold analyses were conducted. RESULTS The per-patient 5-year incremental cost for spacers administered in a hospital outpatient setting was $3578, and the incremental effectiveness was 0.0371 QALYs. The incremental cost-effectiveness ratio was $96,440/QALY for patients with PC undergoing HRS insertion in a hospital and $39,286/QALY for patients undergoing HRS insertion in an ambulatory facility. For men with good baseline EF, the incremental cost-effectiveness ratio was $35,548/QALY and $9627/QALY in hospital outpatient and ambulatory facility settings, respectively. CONCLUSIONS Based on the current Medicare Physician Fee Schedule, HRS is cost-effective at a willingness to pay threshold of $100,000. These results contain substantial uncertainty, suggesting more evidence is needed to refine future decision-making.
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19
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Hwang ME, Black PJ, Elliston CD, Wolthuis BA, Smith DR, Wu CC, Wenske S, Deutsch I. A novel model to correlate hydrogel spacer placement, perirectal space creation, and rectum dosimetry in prostate stereotactic body radiotherapy. Radiat Oncol 2018; 13:192. [PMID: 30285812 PMCID: PMC6167802 DOI: 10.1186/s13014-018-1135-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Accepted: 09/20/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The SpaceOAR hydrogel is employed to limit rectal radiation dose during prostate radiotherapy. We identified a novel parameter - the product of angle θ and hydrogel volume - to quantify hydrogel placement. This parameter predicted rectum dosimetry and acute rectal toxicity in prostate cancer patients treated with stereotactic body radiotherapy to 36.25 Gy in 5 fractions. METHODS Twenty men with low- and intermediate-risk prostate cancer underwent hydrogel placement from 2015 to 2017. Hydrogel symmetry was assessed on the CT simulation scan in 3 axial slices (midgland, 1 cm above midgland, 1 cm below midgland). Two novel parameters quantifying hydrogel placement - hydrogel volume and angle θ formed by the prostate, hydrogel, and rectum - were measured, and the normalized product of θ and hydrogel volume calculated. These were then correlated with perirectal distance, rectum maximum 1-3 cc point doses (rDmax 1-3 cc), and rectum volumes receiving 80-95% of the prescription dose (rV80-95%). Acute rectal toxicity was recorded per RTOG criteria. RESULTS In 50% of patients, hydrogel placement was symmetric bilaterally to within 1 cm of midline in all three CT simulation scan axial slices. Lateral hydrogel asymmetry < 2 cm in any one axial slice did not affect rectum dosimetry, but absence of hydrogel in the inferior axial slice resulted in a mean increase of 171 cGy in the rDmax 1 cc (p < 0.005). The perirectal distance measured at prostate midgland, midline (mean 9.1 ± 4.3 mm) correlated strongly with rV95 (R2 0.6, p < 0.001). The mean hydrogel volume and θ were 10.3 ± 4.5 cc and 70 ± 49°, respectively. Perirectal distance, rV95 and rDmax 1 cc correlated with hydrogel angle θ (p < 0.01), and yet more strongly with the novel metric θ*hydrogel volume (p < 0.001). With a median follow up of 14 months, no rectal toxicity >grade 2 was observed. Low grade rectal toxicity was observed in a third of men and resolved within 1 month of SBRT. Men who had these symptoms had higher rDmax 1 cc and smaller θ*hydrogel volume measurements. CONCLUSIONS Optimal hydrogel placement occurs at prostate midgland, midline. The novel parameter θ*hydrogel volume describes a large proportion of rectum dosimetric benefit derived from hydrogel placement, and can be used to assess the learning curve phenomenon for hydrogel placement.
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Affiliation(s)
- Mark E Hwang
- Department of Radiation Oncology, Columbia University Medical Center, New York, New York, 10032, USA
| | - Paul J Black
- Department of Radiation Oncology, Columbia University Medical Center, New York, New York, 10032, USA
| | - Carl D Elliston
- Department of Radiation Oncology, Columbia University Medical Center, New York, New York, 10032, USA
| | - Brian A Wolthuis
- Department of Radiation Oncology, Columbia University Medical Center, New York, New York, 10032, USA
| | - Deborah R Smith
- Department of Radiation Oncology, Columbia University Medical Center, New York, New York, 10032, USA
| | - Cheng-Chia Wu
- Department of Radiation Oncology, Columbia University Medical Center, New York, New York, 10032, USA
| | - Sven Wenske
- Department of Urology, Columbia University Medical Center, New York, 10032, New York, USA
| | - Israel Deutsch
- Department of Radiation Oncology, Columbia University Medical Center, New York, New York, 10032, USA.
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20
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Leiker AJ, Desai NB, Folkert MR. Rectal radiation dose-reduction techniques in prostate cancer: a focus on the rectal spacer. Future Oncol 2018; 14:2773-2788. [PMID: 29939069 DOI: 10.2217/fon-2018-0286] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Prostate cancer is the most common cancer in men. External beam radiotherapy by a variety of methods is a standard treatment option with excellent disease control. However, acute and late rectal side effects remain a limiting concern in intensification of therapy in higher-risk patients and in efforts to reduce treatment burden in others. A number of techniques have emerged that allow for high-radiation dose delivery to the prostate with reduced risk of rectal toxicity, including image-guided intensity-modulated radiation therapy, endorectal balloons and various forms of rectal spacers. Image-guided radiation therapy, either intensity-modulated radiation therapy or stereotactic ablative radiation therapy, in conjunction with a rectal spacer, is an efficacious means to reduce acute and long-term rectal toxicity.
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Affiliation(s)
- Andrew J Leiker
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, 2280 Inwood Road, Dallas, TX 75390-9303, USA
| | - Neil B Desai
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, 2280 Inwood Road, Dallas, TX 75390-9303, USA
| | - Michael R Folkert
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, 2280 Inwood Road, Dallas, TX 75390-9303, USA
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21
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Abstract
The use of radiotherapy in the treatment of prostate cancer has evolved from treatments utilizing large fields with hand placed blocks to radiotherapy treatments given with a linear accelerator moving around the patient on a robotic arm. These technologic developments have allowed radiation dose escalations resulting in improvements in disease and patient reported outcomes with longer biochemical disease-free survival (DFS) as well as improved quality of life. Increased costs have accompanied these technologic improvements with some private payers questioning the increased cost of the newer treatments and in some instances refusing to pay for some treatment modalities such as intensity-modulated radiotherapy (IMRT) or proton beam therapy (PBT). Cost-effectiveness analysis have been used in an attempt to illustrate these new treatments were cost-effective when compared to the older treatments. Cost-effectiveness analyses will need to be adapted in the current health care environment to provide an assessment of value as many payers, including medicare, move to a value-based reimbursement system.
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Affiliation(s)
- Andre Konski
- Department of Radiation Oncology, University of Pennsylvania, Perelman School of Medicine, Pennsylvania, USA.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Pennsylvania, USA
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22
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King RB, Osman SO, Fairmichael C, Irvine DM, Lyons CA, Ravi A, O'Sullivan JM, Hounsell AR, Mitchell DM, McGarry CK, Jain S. Efficacy of a rectal spacer with prostate SABR-first UK experience. Br J Radiol 2018; 91:20170672. [PMID: 29182384 DOI: 10.1259/bjr.20170672] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
OBJECTIVE This study assessed the use of implanted hydrogel rectal spacers for stereotactic ablative radiotherapy-volumetric modulated arc therapy (SABR-VMAT) patients, investigating practicality, dosimetric impact, normal tissue complication probability (NTCP) and early toxicity. METHODS Data from the first 6 patients treated within a prostate SABR and rectal spacer trial were examined to determine spacer insertion tolerability, resultant changes in treatment planning and dosimetry and early toxicity effects. CT scans acquired prior to spacer insertion were used to generate SABR plans which were compared to post-insertion plans. Plans were evaluated for target coverage, conformity, and organs at risk doses with NTCPs also determined from resultant dose fluences. Early toxicity data were also collected. RESULTS All patients had successful spacer insertion under local anaesthetic with maximal Grade 1 toxicity. All plans were highly conformal, with no significant differences in clinical target volume dose coverage between pre- and post-spacer plans. Substantial improvements in rectal dose metrics were observed in post-spacer plans, e.g. rectal volume receiving 36 Gy reduced by ≥42% for all patients. Median NTCP for Grade 2 + rectal bleeding significantly decreased from 4.9 to 0.8% with the use of a rectal spacer (p = 0.031). To date, two episodes of acute Grade 1 proctitis have been reported following treatment. CONCLUSION The spacer resulted in clinically and statistically significant reduction in rectal doses for all patients. Advances in knowledge: This is one of the first studies to investigate the efficacy of a hydrogel spacer in prostate SABR treatments. Observed dose sparing of the rectum is predicted to result in meaningful clinical benefit.
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Affiliation(s)
- Raymond B King
- 1 Centre for Cancer Research and Cell Biology, Queen's University Belfast , Belfast , Ireland.,2 Radiotherapy Physics, Northern Ireland Cancer Centre, Belfast City Hospital , Belfast , Ireland
| | - Sarah Os Osman
- 1 Centre for Cancer Research and Cell Biology, Queen's University Belfast , Belfast , Ireland.,2 Radiotherapy Physics, Northern Ireland Cancer Centre, Belfast City Hospital , Belfast , Ireland
| | - Ciaran Fairmichael
- 1 Centre for Cancer Research and Cell Biology, Queen's University Belfast , Belfast , Ireland.,3 Department of Clinical Oncology, Northern Ireland Cancer Centre, Belfast City Hospital , Belfast , Ireland
| | - Denise M Irvine
- 2 Radiotherapy Physics, Northern Ireland Cancer Centre, Belfast City Hospital , Belfast , Ireland
| | - Ciara A Lyons
- 1 Centre for Cancer Research and Cell Biology, Queen's University Belfast , Belfast , Ireland.,3 Department of Clinical Oncology, Northern Ireland Cancer Centre, Belfast City Hospital , Belfast , Ireland.,4 Department of Clinical Oncology, North West Cancer Centre, Altnagelvin Area Hospital , Londonderry , Northern Ireland
| | - Ananth Ravi
- 5 Department of Medical Physics, Odette Cancer Centre, Sunnybrook Health Sciences Centre , Toronto , Canada
| | - Joe M O'Sullivan
- 1 Centre for Cancer Research and Cell Biology, Queen's University Belfast , Belfast , Ireland.,3 Department of Clinical Oncology, Northern Ireland Cancer Centre, Belfast City Hospital , Belfast , Ireland
| | - Alan R Hounsell
- 1 Centre for Cancer Research and Cell Biology, Queen's University Belfast , Belfast , Ireland.,2 Radiotherapy Physics, Northern Ireland Cancer Centre, Belfast City Hospital , Belfast , Ireland
| | - Darren M Mitchell
- 3 Department of Clinical Oncology, Northern Ireland Cancer Centre, Belfast City Hospital , Belfast , Ireland
| | - Conor K McGarry
- 1 Centre for Cancer Research and Cell Biology, Queen's University Belfast , Belfast , Ireland.,2 Radiotherapy Physics, Northern Ireland Cancer Centre, Belfast City Hospital , Belfast , Ireland
| | - Suneil Jain
- 1 Centre for Cancer Research and Cell Biology, Queen's University Belfast , Belfast , Ireland.,3 Department of Clinical Oncology, Northern Ireland Cancer Centre, Belfast City Hospital , Belfast , Ireland
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23
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Berlin A, Di Tomasso A, Ballantyne H, Patterson S, Lam T, Sundaramurthy A, Helou J, Bayley A, Chung P. Use of hydrogel spacer for improved rectal dose-sparing in patients undergoing radical radiotherapy for localized prostate cancer: First Canadian experience. Can Urol Assoc J 2017; 11:373-375. [PMID: 29257741 DOI: 10.5489/cuaj.4681] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
We describe the initial experience using a hydrogel spacer (SpaceOAR) to separate the prostate-rectum interspace in patients planned to undergo radical hypofractionated, image-guided, intensity-modulated radiotherapy (IG-IMRT). We depict and discuss the impact of SpaceOAR in the context of hypofractionated IG-IMRT, and the particular considerations for its applications in the Canadian setting.
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Affiliation(s)
- Alejandro Berlin
- Radiation Medicine Program, Princess Margaret Cancer Centre, Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Anne Di Tomasso
- Radiation Medicine Program, Princess Margaret Cancer Centre, Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Heather Ballantyne
- Radiation Medicine Program, Princess Margaret Cancer Centre, Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Susan Patterson
- Radiation Medicine Program, Princess Margaret Cancer Centre, Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Tony Lam
- Radiation Medicine Program, Princess Margaret Cancer Centre, Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Aravind Sundaramurthy
- Radiation Medicine Program, Princess Margaret Cancer Centre, Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Joelle Helou
- Radiation Medicine Program, Princess Margaret Cancer Centre, Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Andrew Bayley
- Radiation Medicine Program, Princess Margaret Cancer Centre, Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Peter Chung
- Radiation Medicine Program, Princess Margaret Cancer Centre, Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
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24
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Padmanabhan R, Pinkawa M, Song DY. Hydrogel spacers in prostate radiotherapy: a promising approach to decrease rectal toxicity. Future Oncol 2017; 13:2697-2708. [DOI: 10.2217/fon-2017-0073] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
High-dose radiation is a well-established method of treatment for prostate cancer. The main limiting structure for dose escalation is the rectum. The risk of rectal toxicity is related to dose received by the rectum. Several strategies for reducing dose to rectum have been explored; these include endorectal balloons as well as injection of rectal spacers like hydrogels. They create greater distance between rectal wall and prostate to confer a dosimetric advantage to the rectum. Early clinical studies with hydrogels have shown favorable outcomes. A low incidence of major procedural adverse effects with hydrogel use has been reported and it is well tolerated by patients. Hydrogel holds promise in establishing itself as an adjunct to standard of care in prostate radiation.
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Affiliation(s)
- Ranjani Padmanabhan
- Department of Radiation Oncology, INOVA Health System Fairfax, 3300 Gallows Road, Falls Church, VA 22042, USA
| | - Michael Pinkawa
- Department of Radiation Oncology, RWTH Aachen University, Pauwelsstrasse 30, 52057 Aachen, Germany
| | - Daniel Y Song
- Johns Hopkins Medicine, Department of Radiation Oncology & Molecular Radiation Sciences, Johns Hopkins University, 401 N Broadway, Baltimore, MD 21231, USA
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25
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Development of a virtual spacer to support the decision for the placement of an implantable rectum spacer for prostate cancer radiotherapy: Comparison of dose, toxicity and cost-effectiveness. Radiother Oncol 2017; 125:107-112. [DOI: 10.1016/j.radonc.2017.07.026] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Revised: 07/12/2017] [Accepted: 07/25/2017] [Indexed: 02/06/2023]
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26
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Pinkawa M, Berneking V, Schlenter M, Krenkel B, Eble MJ. Quality of Life After Radiation Therapy for Prostate Cancer With a Hydrogel Spacer: 5-Year Results. Int J Radiat Oncol Biol Phys 2017; 99:374-377. [PMID: 28871986 DOI: 10.1016/j.ijrobp.2017.05.035] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Revised: 05/16/2017] [Accepted: 05/22/2017] [Indexed: 12/19/2022]
Abstract
PURPOSE To evaluate quality of life changes up to 5 years after prostate cancer radiation therapy (RT) with a hydrogel spacer. METHODS AND MATERIALS In the years 2010 to 2011, 114 patients received external beam radiation therapy to the prostate; 54 patients were selected for a hydrogel injection before the beginning of RT. Treatment was performed applying fractions of 2 Gy up to a total dose of 76 Gy (n=96) or 78 Gy (n=18, all with hydrogel). Patients were surveyed before RT; at the last day of RT; and a median time of 2 months, 17 months, and 63 months after RT using a validated questionnaire (Expanded Prostate Cancer Index Composite). A mean score change of >5 points was defined as clinically relevant. RESULTS For patients treated with a hydrogel spacer, mean bowel function and bother score changes of >5 points in comparison with baseline levels were found only at the end of RT (10-15 points; P<.01). No spacer patient reported moderate or big problems with his bowel habits overall. Mean bother score changes of 21 points at the end of RT, 8 points at 2 months, 7 points at 17 months, and 6 points at 63 months after RT were found for patients treated without a spacer. A bowel bother score change >10 points was found in 6% versus 32% (P<.01) at 17 months and in 5% versus 14% (P=.2) at 63 months with versus without a spacer. CONCLUSIONS The first 5-year quality of life results in a group of prostate cancer patients treated with a hydrogel spacer demonstrate excellent treatment tolerability, in particular regarding bowel problems. Further studies with dose-escalated or re-irradiation concepts can be encouraged.
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Affiliation(s)
- Michael Pinkawa
- Department of Radiation Oncology, RWTH Aachen University, Aachen, Germany; Department of Radiation Oncology, MediClin Robert Janker Klinik, Bonn, Germany.
| | - Vanessa Berneking
- Department of Radiation Oncology, RWTH Aachen University, Aachen, Germany
| | - Marsha Schlenter
- Department of Radiation Oncology, RWTH Aachen University, Aachen, Germany
| | - Barbara Krenkel
- Department of Radiation Oncology, RWTH Aachen University, Aachen, Germany
| | - Michael J Eble
- Department of Radiation Oncology, RWTH Aachen University, Aachen, Germany
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27
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De Ruysscher D, Defraene G, Ramaekers BLT, Lambin P, Briers E, Stobart H, Ward T, Bentzen SM, Van Staa T, Azria D, Rosenstein B, Kerns S, West C. Optimal design and patient selection for interventional trials using radiogenomic biomarkers: A REQUITE and Radiogenomics consortium statement. Radiother Oncol 2016; 121:440-446. [PMID: 27979370 PMCID: PMC5557371 DOI: 10.1016/j.radonc.2016.11.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2016] [Revised: 10/25/2016] [Accepted: 11/01/2016] [Indexed: 12/25/2022]
Abstract
The optimal design and patient selection for interventional trials in radiogenomics seem trivial at first sight. However, radiogenomics do not give binary information like in e.g. targetable mutation biomarkers. Here, the risk to develop severe side effects is continuous, with increasing incidences of side effects with higher doses and/or volumes. In addition, a multi-SNP assay will produce a predicted probability of developing side effects and will require one or more cut-off thresholds for classifying risk into discrete categories. A classical biomarker trial design is therefore not optimal, whereas a risk factor stratification approach is more appropriate. Patient selection is crucial and this should be based on the dose-response relations for a specific endpoint. Alternatives to standard treatment should be available and this should take into account the preferences of patients. This will be discussed in detail.
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Affiliation(s)
- Dirk De Ruysscher
- Maastricht University Medical Center, Department of Radiation Oncology (MAASTRO Clinic), The Netherlands; KU Leuven, Radiation Oncology, Belgium.
| | | | - Bram L T Ramaekers
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre, The Netherlands
| | - Philippe Lambin
- Maastricht University Medical Center, Department of Radiation Oncology (MAASTRO Clinic), The Netherlands
| | | | | | - Tim Ward
- Patient Advocate, Manchester, UK
| | | | - Tjeerd Van Staa
- The University of Manchester, Manchester Academic Health Science Centre, UK
| | - David Azria
- Department of Radiation Oncology and Medical Physics, Institut Regional du Cancer Montpellier, France
| | - Barry Rosenstein
- Department of Radiation Oncology and Medical Physics, Institut Regional du Cancer Montpellier, France
| | | | - Catharine West
- The University of Manchester, Translational Radiobiology Group I Institute of Cancer Sciences, The Christie NHS Foundation Trust, UK
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