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Rasmussen ME, Akbarov K, Titovich E, Nijkamp JA, Van Elmpt W, Primdahl H, Lassen P, Cacicedo J, Cordero-Mendez L, Uddin AFMK, Mohamed A, Prajogi B, Brohet KE, Nyongesa C, Lomidze D, Prasiko G, Ferraris G, Mahmood H, Stojkovski I, Isayev I, Mohamad I, Shirley L, Kochbati L, Eftodiev L, Piatkevich M, Bonilla Jara MM, Spahiu O, Aralbayev R, Zakirova R, Subramaniam S, Kibudde S, Tsegmed U, Korreman SS, Eriksen JG. Potential of E-Learning Interventions and Artificial Intelligence-Assisted Contouring Skills in Radiotherapy: The ELAISA Study. JCO Glob Oncol 2024; 10:e2400173. [PMID: 39236283 DOI: 10.1200/go.24.00173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2024] [Revised: 06/19/2024] [Accepted: 07/10/2024] [Indexed: 09/07/2024] Open
Abstract
PURPOSE Most research on artificial intelligence-based auto-contouring as template (AI-assisted contouring) for organs-at-risk (OARs) stem from high-income countries. The effect and safety are, however, likely to depend on local factors. This study aimed to investigate the effects of AI-assisted contouring and teaching on contouring time and contour quality among radiation oncologists (ROs) working in low- and middle-income countries (LMICs). MATERIALS AND METHODS Ninety-seven ROs were randomly assigned to either manual or AI-assisted contouring of eight OARs for two head-and-neck cancer cases with an in-between teaching session on contouring guidelines. Thereby, the effect of teaching (yes/no) and AI-assisted contouring (yes/no) was quantified. Second, ROs completed short-term and long-term follow-up cases all using AI assistance. Contour quality was quantified with Dice Similarity Coefficient (DSC) between ROs' contours and expert consensus contours. Groups were compared using absolute differences in medians with 95% CIs. RESULTS AI-assisted contouring without previous teaching increased absolute DSC for optic nerve (by 0.05 [0.01; 0.10]), oral cavity (0.10 [0.06; 0.13]), parotid (0.07 [0.05; 0.12]), spinal cord (0.04 [0.01; 0.06]), and mandible (0.02 [0.01; 0.03]). Contouring time decreased for brain stem (-1.41 [-2.44; -0.25]), mandible (-6.60 [-8.09; -3.35]), optic nerve (-0.19 [-0.47; -0.02]), parotid (-1.80 [-2.66; -0.32]), and thyroid (-1.03 [-2.18; -0.05]). Without AI-assisted contouring, teaching increased DSC for oral cavity (0.05 [0.01; 0.09]) and thyroid (0.04 [0.02; 0.07]), and contouring time increased for mandible (2.36 [-0.51; 5.14]), oral cavity (1.42 [-0.08; 4.14]), and thyroid (1.60 [-0.04; 2.22]). CONCLUSION The study suggested that AI-assisted contouring is safe and beneficial to ROs working in LMICs. Prospective clinical trials on AI-assisted contouring should, however, be conducted upon clinical implementation to confirm the effects.
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Affiliation(s)
| | | | | | | | - Wouter Van Elmpt
- MAASTRO clinic, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Hanne Primdahl
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Pernille Lassen
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Jon Cacicedo
- Department of Radiation Oncology, Cruces University Hospital, Bilbao, Spain
| | | | - A F M Kamal Uddin
- Labaid Cancer Hospital and Super Speciality Centre, Dhaka, Bangladesh
| | - Ahmed Mohamed
- National Cancer Institute, University of Gezira, Wad Madani, Sudan
| | - Ben Prajogi
- Cipto Mangunkusumo Hospital, Jakarta, Indonesia
| | | | | | - Darejan Lomidze
- Tbilisi State Medical University and Ingorokva High Medical Technology University Clinic, Tbilisi, Georgia
| | | | | | | | - Igor Stojkovski
- University Clinic of Radiotherapy and Oncology, Skopje, Macedonia
| | - Isa Isayev
- National Center of Oncology, Baku, Azerbaijan
| | | | - Leivon Shirley
- Christian Institute of Health Science and Research, Dimapur, India
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McCullum LB, Karagoz A, Dede C, Garcia R, Nosrat F, Hemmati M, Hosseinian S, Schaefer AJ, Fuller CD. Markov models for clinical decision-making in radiation oncology: A systematic review. J Med Imaging Radiat Oncol 2024. [PMID: 38766899 DOI: 10.1111/1754-9485.13656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 04/03/2024] [Indexed: 05/22/2024]
Abstract
The intrinsic stochasticity of patients' response to treatment is a major consideration for clinical decision-making in radiation therapy. Markov models are powerful tools to capture this stochasticity and render effective treatment decisions. This paper provides an overview of the Markov models for clinical decision analysis in radiation oncology. A comprehensive literature search was conducted within MEDLINE using PubMed, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Only studies published from 2000 to 2023 were considered. Selected publications were summarized in two categories: (i) studies that compare two (or more) fixed treatment policies using Monte Carlo simulation and (ii) studies that seek an optimal treatment policy through Markov Decision Processes (MDPs). Relevant to the scope of this study, 61 publications were selected for detailed review. The majority of these publications (n = 56) focused on comparative analysis of two or more fixed treatment policies using Monte Carlo simulation. Classifications based on cancer site, utility measures and the type of sensitivity analysis are presented. Five publications considered MDPs with the aim of computing an optimal treatment policy; a detailed statement of the analysis and results is provided for each work. As an extension of Markov model-based simulation analysis, MDP offers a flexible framework to identify an optimal treatment policy among a possibly large set of treatment policies. However, the applications of MDPs to oncological decision-making have been understudied, and the full capacity of this framework to render complex optimal treatment decisions warrants further consideration.
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Affiliation(s)
- Lucas B McCullum
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Aysenur Karagoz
- Department of Computational Applied Mathematics & Operations Research, Rice University, Houston, Texas, USA
| | - Cem Dede
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Raul Garcia
- Department of Computational Applied Mathematics & Operations Research, Rice University, Houston, Texas, USA
| | - Fatemeh Nosrat
- Department of Computational Applied Mathematics & Operations Research, Rice University, Houston, Texas, USA
| | - Mehdi Hemmati
- School of Industrial and Systems Engineering, The University of Oklahoma, Norman, Oklahoma, USA
| | | | - Andrew J Schaefer
- Department of Computational Applied Mathematics & Operations Research, Rice University, Houston, Texas, USA
| | - Clifton D Fuller
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
- Department of Computational Applied Mathematics & Operations Research, Rice University, Houston, Texas, USA
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Adel A, Rezapour A, Aboutorabi A, Taghizadeh Kermani A, Ghorbani H. Economical Evaluation of Prostate Cancer Treatment Using Intensity-Modulated Radiation Therapy, 3-Dimensional Conformal Radiation Therapy and Radical Prostatectomy: A Systematic Review. Value Health Reg Issues 2024; 39:57-65. [PMID: 37979544 DOI: 10.1016/j.vhri.2023.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Revised: 06/23/2023] [Accepted: 08/01/2023] [Indexed: 11/20/2023]
Abstract
OBJECTIVES Prostate cancer is a common form of cancer among men worldwide. The objective of this study was to conduct a systematic review of the economic evaluations of prostate cancer treatment strategies. METHODS This systematic review was conducted using multiple electronic databases up to May 2021. English-language economic evaluation studies that compared intensity-modulated radiation therapy (IMRT), 3-dimensional conformal radiation therapy (3DCRT), and radical prostatectomy (RP) were included. The studies were evaluated using the Consolidated Health Economic Evaluation Reporting Standards checklist. The search yielded 1151 potentially relevant publications, which were screened based on the title and abstract. After the removal of duplicates, 55 studies remained, and 9 studies were screened in full text. Finally, textual data were analyzed manually using by-content analysis method. RESULTS All studies were cost-effective and evaluated quality-adjusted life year as the efficacy indicator. The studies were conducted from either payers' or health systems' perspectives, and the time horizon varied from 5 to 20 years. We included only full economic evaluation studies. The use of IMRT in comparison with 3DCRT was evaluated in 6 studies, based on which IMRT increased health and reduced side effects of treatment. According to incremental cost-effectiveness ratio (ICER) results, IMRT was more cost-effective than 3DCRT. Three studies evaluated the use of RP in comparison with radiotherapy. Based on these studies, radiotherapy was more effective than RP. CONCLUSION IMRT was found to be more cost-effective than 3DCRT in all 6 studies compared with the threshold. Radiotherapy was found to be more effective than RP. However, long-term clinical trial studies are needed to confirm these findings and to provide more definitive conclusions.
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Affiliation(s)
- Amin Adel
- School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran
| | - Aziz Rezapour
- Health Management and Economics Research Center, Health Management Research Institute, Iran University of Medical Sciences, Tehran, Iran.
| | - Ali Aboutorabi
- Health Management and Economics Research Center, Health Management Research Institute, Iran University of Medical Sciences, Tehran, Iran
| | | | - Hamidreza Ghorbani
- Kidney Transplantation Complication Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
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Health Care Costs Attributable to Prostate Cancer in British Columbia, Canada: A Population-Based Cohort Study. Curr Oncol 2023; 30:3176-3188. [PMID: 36975453 PMCID: PMC10047657 DOI: 10.3390/curroncol30030240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Revised: 03/01/2023] [Accepted: 03/04/2023] [Indexed: 03/10/2023] Open
Abstract
We aimed to estimate the total health care costs attributable to prostate cancer (PCa) during care phases by age, cancer stage, tumor grade, and primary treatment in the first year in British Columbia (BC), Canada. Using linked administrative health data, we followed a cohort of men aged ≥ 50 years at diagnosis with PCa between 2010 and 2017 (Cohort 1) from the diagnosis date until the date of death, the last date of observation, or 31 December 2019. Patients who died from PCa after 1 January 2010, were selected for Cohort 2. PCa attributable costs were estimated by comparing costs in patients to matched controls. Cohort 1 (n = 22,672) had a mean age of 69.9 years (SD = 8.9) and a median follow-up time of 5.2 years. Cohort 2 included 6942 patients. Mean PCa attributable costs were the highest during the first year after diagnosis ($14,307.9 [95% CI: $13,970.0, $14,645.8]) and the year before death ($9959.7 [$8738.8, $11,181.0]). Primary treatment with radiation therapy had significantly higher costs each year after diagnosis than a radical prostatectomy or other surgeries in advanced-stage PCa. Androgen deprivation therapy (and/or chemotherapy) had the highest cost for high-grade and early-stage cancer during the three years after diagnosis. No treatment group had the lowest cost. Updated cost estimates could inform economic evaluations and decision-making.
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Sun S, Jonsson H, Salén KG, Andén M, Beckman L, Fransson P. Is ultra-hypo-fractionated radiotherapy more cost-effective relative to conventional fractionation in treatment of prostate cancer? A cost-utility analysis alongside a randomized HYPO-RT-PC trial. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2023; 24:237-246. [PMID: 35587847 PMCID: PMC9985558 DOI: 10.1007/s10198-022-01467-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Accepted: 04/12/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Economic evidence for comparing low fraction with ultra-hypo fractionated (UHF) radiation therapy in the treatment of intermediate-to-high-risk prostate cancer (PC) is lacking, especially in Europe. This study presents an economic evaluation performed alongside an ongoing clinical trial. AIM To investigate up to 6 years' follow-up whether conventional fractionation (CF, 78.0 Gy in 39 fractions, 5 days per week for 8 weeks) is more cost-effective than UHF (42.7 Gy in 7 fractions, 3 days per week for 2.5 weeks inclusive of 2 weekends) radiotherapy in treatment for patients with intermediate-to-high-risk PC. METHOD HYPO-RT-PC trial is an open-label, randomized, multicenter (10 in Sweden; 2 in Denmark) phase-3 trial. Patients from Sweden (CF 434; UHF 445) were included in this study. The trial database was linked to the National Patient Registry (NPR). Costs for inpatient/non-primary outpatient care for each episode were retrieved. For calculating Quality-adjusted life years (QALYs), the EORTC QLQ-C30 questionnaire was mapped to the EQ-5D-3L index. Multivariable regression analyses were used to compare the difference in costs and QALYs, adjusting for age and baseline costs, and health status. The confidence interval for the difference in costs, QALYs and incremental cost-effectiveness ratio effectiveness ratio (ICER) was estimated by the bootstrap percentile method. RESULTS No significant differences were found in ICER between the two arms after 6 years of follow-up. CONCLUSION The current study did not support that the ultra-hypo-fractionated treatment was more cost-effective than the conventional fraction treatment up to the sixth year of the trial.
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Affiliation(s)
- Sun Sun
- Department of Epidemiology and Global Health, Umeå University, 90185, Umeå, Sweden.
- Research Group Health Outcomes and Economic Evaluation, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden.
- Center for Cancer Control and Policy Research, Shandong University, Jinan, Shandong Province, China.
| | - Håkan Jonsson
- Department of Epidemiology and Global Health, Umeå University, 90185, Umeå, Sweden
| | - Klas-Göran Salén
- Department of Epidemiology and Global Health, Umeå University, 90185, Umeå, Sweden
| | - Mats Andén
- Department of Oncology, Kalmar Hospital, Kalmar, Sweden
| | - Lars Beckman
- Department of Oncology, Sundsvall Hospital, Sundsvall, Sweden
| | - Per Fransson
- Department of Nursing, Umeå University, Umeå, Sweden
- Department of Radiation Sciences, Umeå University, Umeå, Sweden
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Ultrahypofractionation of localized prostate cancer : Statement from the DEGRO working group prostate cancer. Strahlenther Onkol 2020; 197:89-96. [PMID: 33301049 PMCID: PMC7726607 DOI: 10.1007/s00066-020-01723-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Accepted: 11/17/2020] [Indexed: 01/02/2023]
Abstract
Due to its low fractionation sensitivity, also known as “alpha/beta ratio,” in relation to its surrounding organs at risk, prostate cancer is predestined for hypofractionated radiation schedules assuming an increased therapeutic ratio compared to normofractionated regimens. While moderate hypofractionation (2.2–4 Gy) has been proven to be non-inferior to normal fractionation in several large randomized trials for localized prostate cancer, level I evidence for ultrahypofractionation (>4 Gy) was lacking until recently. An accumulating body of non-randomized evidence has recently been strengthened by the publication of two randomized studies comparing ultrahypofractionation with a normofractionated schedule, i.e., the Scandinavian HYPO-RT trial by Widmark et al. and the first toxicity results of the PACE‑B trial. In this review, we aim to give a brief overview of the current evidence of ultrahypofractionation, make an overall assessment of the level of evidence, and provide recommendations and requirements that should be followed before introducing ultrahypofractionation into routine clinical use.
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Gogineni E, Rana Z, Soberman D, Sidiqi B, D'Andrea V, Lee L, Potters L, Parashar B. Biochemical Control and Toxicity Outcomes of Stereotactic Body Radiation Therapy Versus Low-Dose-Rate Brachytherapy in the Treatment of Low- and Intermediate-Risk Prostate Cancer. Int J Radiat Oncol Biol Phys 2020; 109:1232-1242. [PMID: 33171199 DOI: 10.1016/j.ijrobp.2020.11.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 10/16/2020] [Accepted: 11/02/2020] [Indexed: 12/30/2022]
Abstract
PURPOSE Low-dose-rate (LDR) brachytherapy and stereotactic body radiation therapy (SBRT) have both shown acceptable outcomes in the treatment of low- and intermediate-risk prostate cancer. Minimal data have been published directly comparing rates of biochemical control and toxicity with these 2 modalities. We hypothesize that LDR and SBRT will provide similar rates of biochemical control. METHODS AND MATERIALS All low- and intermediate-risk patients with prostate cancer treated definitively with SBRT or LDR between 2010 and 2018 were captured. Phoenix definition was used for biochemical failure. Independent t tests were used to compare baseline characteristics, and repeated measure analysis of variance test was used to compare American Urologic Association (AUA) and the Expanded Prostate Cancer Index Composite (EPIC) scores between treatment arms over time. Biochemical control was estimated using the Kaplan-Meier method. Differences in acute and late toxicity were assessed via Pearson χ2. RESULTS In the study, 219 and 118 patients were treated with LDR and SBRT. Median follow-up was 4.3 years (interquartile range, 3.1-6.1). All patients treated with LDR received 125.0 Gy in a single fraction. SBRT consisted of 42.5 Gy in 5 fractions. Five-year biochemical control for LDR versus SBRT was 91.6% versus 97.6% (P = .108). LDR patients had a larger increase in mean AUA scores at 1 month (17.2 vs 10.3, P < .001) and 3 months posttreatment (14.0 vs 9.7, P < .001), and in mean EPIC scores at 1 month (15.7 vs 13.8, P < .001). There was no significant difference between LDR and SBRT in late grade 3 genitourinary toxicity (0.9% vs 2.5%, P = .238); however, LDR had lower rates of late grade 3 gastrointestinal toxicity (0.0% vs 2.5%, P = .018). CONCLUSIONS Our data show similar biochemical control and genitourinary toxicity rates at 5 years for both SBRT and LDR, with slightly higher gastrointestinal toxicity with SBRT and higher AUA and EPIC scores with LDR.
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Affiliation(s)
- Emile Gogineni
- Academic Department of Radiation Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
| | - Zaker Rana
- Academic Department of Radiation Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
| | - Danielle Soberman
- Academic Department of Radiation Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
| | - Baho Sidiqi
- Academic Department of Radiation Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
| | - Vincent D'Andrea
- Academic Department of Radiation Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
| | - Lucille Lee
- Academic Department of Radiation Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
| | - Louis Potters
- Academic Department of Radiation Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
| | - Bhupesh Parashar
- Academic Department of Radiation Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY.
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Hehakaya C, Van der Voort van Zyp JR, Lagendijk JJW, Grobbee DE, Verkooijen HM, Moors EHM. Problems and Promises of Introducing the Magnetic Resonance Imaging Linear Accelerator Into Routine Care: The Case of Prostate Cancer. Front Oncol 2020; 10:1741. [PMID: 32984058 PMCID: PMC7493635 DOI: 10.3389/fonc.2020.01741] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 08/04/2020] [Indexed: 01/17/2023] Open
Abstract
The new radiotherapy high field, 1.5 Tesla MRI-guided linear accelerator (MR-Linac) is being clinically introduced. Sensing and evaluating opportunities and barriers at an early stage will facilitate its eventual scale-up. This study investigates the opportunities and barriers to the implementation of MR-Linac into prostate cancer care based on 43 semi-structured interviews with Dutch oncology care professionals, hospital and division directors, patients, payers and industry. The analysis was guided by the Non-adoption, Abandonment, Scale-up, Spread, and Sustainability framework of new medical technologies and services. Opportunities included: the acquirement of (1) advanced MRI-guided radiotherapy technology with (2) the potential for improved patient outcomes and (3) economic benefits, as well as (4) professional development and (5) a higher hospital quality profile. Barriers included: (1) technical complexities, (2) substantial staffing and structural investments, (3) the current lack of empirical evidence of clinical benefits, (4) professional silos, and (5) the presence of patient referral patterns. While our study confirms the expected technical and clinical prospects from the literature, it also reveals economic, organizational, and socio-political challenges.
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Affiliation(s)
- Charisma Hehakaya
- Division of Imaging & Oncology, University Medical Center Utrecht, Utrecht, Netherlands
| | | | - Jan J. W. Lagendijk
- Division of Imaging & Oncology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Diederick E. Grobbee
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, Netherlands
| | - Helena M. Verkooijen
- Division of Imaging & Oncology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Ellen H. M. Moors
- Copernicus Institute of Sustainable Development, Utrecht University, Utrecht, Netherlands
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Tree AC, Dearnaley DP. Seven or less Fractions is Not the Standard of Care for Intermediate-Risk Prostate Cancer. Clin Oncol (R Coll Radiol) 2020; 32:175-180. [PMID: 31711737 DOI: 10.1016/j.clon.2019.10.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 09/20/2019] [Indexed: 01/09/2023]
Abstract
Evidence is accumulating for seven and less fractions in localised prostate cancer, including one large randomised trial. However, there is much more evidence yet to come and changing practice in advance of this may be premature. We review the reasons to persist with moderate hypofractionation for prostate cancer radiotherapy, until the results of further phase III studies are known.
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Affiliation(s)
- A C Tree
- The Royal Marsden NHS Foundation Trust, London, UK; The Institute of Cancer Research, London, UK.
| | - D P Dearnaley
- The Royal Marsden NHS Foundation Trust, London, UK; The Institute of Cancer Research, London, UK
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