1
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Sritharan K, Daamen L, Pathmanathan A, Schytte T, Pos F, Choudhury A, van der Voort van Zyp JR, Kerkmeijer LG, Hall W, Hall E, Verkooijen HM, Herbert T, Hafeez S, Mitchell A, Tree AC. MRI-guided radiotherapy in twenty fractions for localised prostate cancer; results from the MOMENTUM study. Clin Transl Radiat Oncol 2024; 46:100742. [PMID: 38440792 PMCID: PMC10909700 DOI: 10.1016/j.ctro.2024.100742] [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: 08/29/2023] [Revised: 01/30/2024] [Accepted: 02/03/2024] [Indexed: 03/06/2024] Open
Abstract
Background and purpose MRI-guided radiotherapy (MRIgRT) offers multiple potential advantages over CT-guidance. This study examines the potential clinical benefits of MRIgRT for men with localised prostate cancer, in the setting of moderately hypofractionated radiotherapy. We evaluate two-year toxicity outcomes, early biochemical response and patient-reported outcomes (PRO), using data obtained from a multicentre international registry study, for the first group of patients with prostate cancer who underwent treatment on a 1.5 T MR-Linac. Materials and methods Patients who were enrolled within the MOMENTUM study and received radical treatment with 60 Gy in 20 fractions were identified. PSA levels and CTCAE version 5.0 toxicity data were measured at follow-up visits. Those patients who consented to PRO data collection also completed EQ-5D-5L, EORTC QLQ-C30 and EORTC QLQ-PR25 questionnaires. Results Between November 2018 and June 2022, 146 patients who had MRIgRT for localised prostate cancer on the 1.5 T MR-Linac were eligible for this study. Grade 2 and worse gastro-intestinal (GI) toxicity was reported in 3 % of patients at three months whilst grade 2 and worse genitourinary (GU) toxicity was 7 % at three months. There was a significant decrease in the median PSA at 12 months. The results from both the EQ-5D-5L data and EORTC global health status scale indicate a decline in the quality of life (QoL) during the first six months. The mean change in score for the EORTC scale showed a decrease of 11.4 points, which is considered clinically important. QoL improved back to baseline by 24 months. Worsening of hormonal symptoms in the first six months was reported with a return to baseline by 24 months and sexual activity in all men worsened in the first three months and returned to baseline at 12 months. Conclusion This study establishes the feasibility of online-MRIgRT for localised prostate on a 1.5 T MR-Linac with low rates of toxicity, similar to that published in the literature. However, the clinical benefits of MRIgRT over conventional radiotherapy in the setting of moderate hypofractionation is not evident. Further research will focus on the delivery of ultrahypofractionated regimens, where the potential advantages of MRIgRT for prostate cancer may become more discernible.
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Affiliation(s)
- Kobika Sritharan
- The Royal Marsden NHS Foundation Trust, UK
- The Institute of Cancer Research, UK
| | - Lois Daamen
- Division of Imaging and Oncology, University Medical Center Utrecht, Utrecht, the Netherlands
| | | | | | - Floris Pos
- The Netherlands Cancer Institute, The Netherlands
| | - Ananya Choudhury
- Division of Cancer Sciences, University of Manchester and The Christie NHS Foundation Trust, UK
| | | | | | | | - Emma Hall
- The Institute of Cancer Research, UK
| | - Helena M. Verkooijen
- Division of Imaging and Oncology, University Medical Center Utrecht, Utrecht, the Netherlands
| | | | | | - Adam Mitchell
- The Royal Marsden NHS Foundation Trust, UK
- The Institute of Cancer Research, UK
| | - Alison C. Tree
- The Royal Marsden NHS Foundation Trust, UK
- The Institute of Cancer Research, UK
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2
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Courtney PT, Valle LF, Raldow AC, Steinberg ML. MRI-Guided Radiation Therapy-An Emerging and Disruptive Process of Care: Healthcare Economic and Policy Considerations. Semin Radiat Oncol 2024; 34:4-13. [PMID: 38105092 DOI: 10.1016/j.semradonc.2023.10.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2023]
Abstract
MRI-guided radiation therapy (MRgRT) is an emerging, innovative technology that provides opportunities to transform and improve the current clinical care process in radiation oncology. As with many new technologies in radiation oncology, careful evaluation from a healthcare economic and policy perspective is required for its successful implementation. In this review article, we describe the current evidence surrounding MRgRT, framing it within the context of value within the healthcare system. Additionally, we highlight areas in which MRgRT may disrupt the current process of care, and discuss the evidence thresholds and timeline required for the widespread adoption of this promising technology.
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Affiliation(s)
- P Travis Courtney
- Department of Radiation Oncology, University of California, Los Angeles, CA
| | - Luca F Valle
- Department of Radiation Oncology, University of California, Los Angeles, CA
| | - Ann C Raldow
- Department of Radiation Oncology, University of California, Los Angeles, CA
| | - Michael L Steinberg
- Department of Radiation Oncology, University of California, Los Angeles, CA.
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3
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Benitez CM, Steinberg ML, Cao M, Qi XS, Lamb JM, Kishan AU, Valle LF. MRI-Guided Radiation Therapy for Prostate Cancer: The Next Frontier in Ultrahypofractionation. Cancers (Basel) 2023; 15:4657. [PMID: 37760626 PMCID: PMC10526919 DOI: 10.3390/cancers15184657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Revised: 09/06/2023] [Accepted: 09/18/2023] [Indexed: 09/29/2023] Open
Abstract
Technological advances in MRI-guided radiation therapy (MRIgRT) have improved real-time visualization of the prostate and its surrounding structures over CT-guided radiation therapy. Seminal studies have demonstrated safe dose escalation achieved through ultrahypofractionation with MRIgRT due to planning target volume (PTV) margin reduction and treatment gating. On-table adaptation with MRI-based technologies can also incorporate real-time changes in target shape and volume and can reduce high doses of radiation to sensitive surrounding structures that may move into the treatment field. Ongoing clinical trials seek to refine ultrahypofractionated radiotherapy treatments for prostate cancer using MRIgRT. Though these studies have the potential to demonstrate improved biochemical control and reduced side effects, limitations concerning patient treatment times and operational workflows may preclude wide adoption of this technology outside of centers of excellence. In this review, we discuss the advantages and limitations of MRIgRT for prostate cancer, as well as clinical trials testing the efficacy and toxicity of ultrafractionation in patients with localized or post-prostatectomy recurrent prostate cancer.
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Affiliation(s)
| | | | | | | | | | | | - Luca F. Valle
- Department of Radiation Oncology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA 90095-6951, USA (X.S.Q.)
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De-Colle C, Kirby A, Russell N, Shaitelman S, Currey A, Donovan E, Hahn E, Han K, Anandadas C, Mahmood F, Lorenzen E, van den Bongard D, Groot Koerkamp M, Houweling A, Nachbar M, Thorwarth D, Zips D. Adaptive radiotherapy for breast cancer. Clin Transl Radiat Oncol 2023; 39:100564. [PMID: 36632056 PMCID: PMC9826896 DOI: 10.1016/j.ctro.2022.100564] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 12/07/2022] [Accepted: 12/14/2022] [Indexed: 12/24/2022] Open
Abstract
Research in the field of local and locoregional breast cancer radiotherapy aims to maintain excellent oncological outcomes while reducing treatment-related toxicity. Adaptive radiotherapy (ART) considers variations in target and organs at risk (OARs) anatomy occurring during the treatment course and integrates these in re-optimized treatment plans. Exploiting ART routinely in clinic may result in smaller target volumes and better OAR sparing, which may lead to reduction of acute as well as late toxicities. In this review MR-guided and CT-guided ART for breast cancer patients according to different clinical scenarios (neoadjuvant and adjuvant partial breast irradiation, whole breast, chest wall and regional nodal irradiation) are reviewed and their advantages as well as challenging aspects discussed.
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Affiliation(s)
- C. De-Colle
- Department of Radiation Oncology, University Hospital and Medical Faculty, Eberhard Karls University Tübingen, Tübingen, Germany
| | - A. Kirby
- Department of Radiotherapy, Royal Marsden NHS Foundation Trust and Institute of Cancer Research, Sutton, United Kingdom
| | - N. Russell
- Department of Radiotherapy, The Netherlands Cancer Institute–Antoni van Leeuwenhoek Hospital, Amsterdam, Netherlands
| | - S.F. Shaitelman
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - A. Currey
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI, United States
| | - E. Donovan
- Department of Radiation Oncology, Odette Cancer Centre - Sunnybrook Health Sciences Centre, Toronto, Canada
| | - E. Hahn
- Department of Radiation Oncology, Princess Margaret Cancer Centre, Toronto, Canada
| | - K. Han
- Department of Radiation Oncology, Princess Margaret Cancer Centre, Toronto, Canada
| | - C.N. Anandadas
- Department of Clinical Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - F. Mahmood
- Department of Oncology, Odense University Hospital, Odense, Denmark
| | - E.L. Lorenzen
- Department of Oncology, Odense University Hospital, Odense, Denmark
| | | | - M.L. Groot Koerkamp
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, Netherlands
| | - A.C. Houweling
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, Netherlands
| | - M. Nachbar
- Section for Biomedical Physics, Department of Radiation Oncology. University Hospital and Medical Faculty, Eberhard Karls University Tübingen, Tübingen, Germany
| | - D. Thorwarth
- Section for Biomedical Physics, Department of Radiation Oncology. University Hospital and Medical Faculty, Eberhard Karls University Tübingen, Tübingen, Germany
- German Cancer Consortium (DKTK), partner site Tübingen; and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - D. Zips
- Department of Radiation Oncology, University Hospital and Medical Faculty, Eberhard Karls University Tübingen, Tübingen, Germany
- German Cancer Consortium (DKTK), partner site Tübingen; and German Cancer Research Center (DKFZ), Heidelberg, Germany
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Chen S, Peng Y, Qin A, Liu Y, Zhao C, Deng X, Deraniyagala R, Stevens C, Ding X. MR-based synthetic CT image for intensity-modulated proton treatment planning of nasopharyngeal carcinoma patients. Acta Oncol 2022; 61:1417-1424. [DOI: 10.1080/0284186x.2022.2140017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Affiliation(s)
- Shupeng Chen
- Department of Radiation Oncology, William Beaumont Hospital, Royal Oak, MI, USA
| | - Yinglin Peng
- Department of Radiation Oncology, Sun Yat-Sen University, Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, PR China
- School of Biomedical Engineering, Sun Yat-Sen University, Guangzhou, PR China
| | - An Qin
- Department of Radiation Oncology, William Beaumont Hospital, Royal Oak, MI, USA
| | - Yimei Liu
- Department of Radiation Oncology, Sun Yat-Sen University, Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, PR China
| | - Chong Zhao
- Department of Radiation Oncology, Sun Yat-Sen University, Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, PR China
| | - Xiaowu Deng
- Department of Radiation Oncology, Sun Yat-Sen University, Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, PR China
| | - Rohan Deraniyagala
- Department of Radiation Oncology, William Beaumont Hospital, Royal Oak, MI, USA
| | - Craig Stevens
- Department of Radiation Oncology, William Beaumont Hospital, Royal Oak, MI, USA
| | - Xuanfeng Ding
- Department of Radiation Oncology, William Beaumont Hospital, Royal Oak, MI, USA
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6
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Castelluccia A, Mincarone P, Tumolo MR, Sabina S, Colella R, Bodini A, Tramacere F, Portaluri M, Leo CG. Economic Evaluations of Magnetic Resonance Image-Guided Radiotherapy (MRIgRT): A Systematic Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph191710800. [PMID: 36078513 PMCID: PMC9517760 DOI: 10.3390/ijerph191710800] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 08/17/2022] [Accepted: 08/20/2022] [Indexed: 05/06/2023]
Abstract
OBJECTIVES This review systematically summarizes the evidence on the economic impact of magnetic resonance image-guided RT (MRIgRT). METHODS We systematically searched INAHTA, MEDLINE, and Scopus up to March 2022 to retrieve health economic studies. Relevant data were extracted on study type, model inputs, modeling methods and economic results. RESULTS Five studies were included. Two studies performed a full economic assessment to compare the cost-effectiveness of MRIgRT with other forms of image-guided radiation therapy. One study performed a cost minimization analysis and two studies performed an activity-based costing, all comparing MRIgRT with X-ray computed tomography image-guided radiation therapy (CTIgRT). Prostate cancer was the target condition in four studies and hepatocellular carcinoma in one. Considering the studies with a full economic assessment, MR-guided stereotactic body radiation therapy was found to be cost effective with respect to CTIgRT or conventional or moderate hypofractionated RT, even with a low reduction in toxicity. Conversely, a greater reduction in toxicity is required to compete with extreme hypofractionated RT without MR guidance. CONCLUSIONS This review highlights the great potential of MRIgRT but also the need for further evidence, especially for late toxicity, whose reduction is expected to be the real added value of this technology.
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Affiliation(s)
- Alessandra Castelluccia
- Radiation Oncology, Department of Radiotherapy, Hospital “A. Perrino”, ASL Brindisi, 72100 Brindisi, Italy
| | - Pierpaolo Mincarone
- Institute for Research on Population and Social Policies, National Research Council, 72100 Brindisi, Italy
- MOVE-Mentis s.r.l., 47522 Cesena, Italy
- Correspondence: ; Tel.: +39-3289168745
| | - Maria Rosaria Tumolo
- Department of Biological and Environmental Sciences and Technology, University of Salento, 73100 Lecce, Italy
| | - Saverio Sabina
- MOVE-Mentis s.r.l., 47522 Cesena, Italy
- Institute of Clinical Physiology, National Research Council, 73100 Lecce, Italy
| | - Riccardo Colella
- Department of Engineering for Innovation, University of Salento, 73100 Lecce, Italy
| | - Antonella Bodini
- Institute for Applied Mathematics and Information Technologies “E. Magenes”, National Research Council, 20133 Milan, Italy
| | - Francesco Tramacere
- Radiation Oncology, Department of Radiotherapy, Hospital “A. Perrino”, ASL Brindisi, 72100 Brindisi, Italy
| | - Maurizio Portaluri
- Radiation Oncology, Department of Radiotherapy, Hospital “A. Perrino”, ASL Brindisi, 72100 Brindisi, Italy
| | - Carlo Giacomo Leo
- MOVE-Mentis s.r.l., 47522 Cesena, Italy
- Institute of Clinical Physiology, National Research Council, 73100 Lecce, Italy
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7
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The Economic Burden of Localized Prostate Cancer and Insights Derived from Cost-Effectiveness Studies of the Different Treatments. Cancers (Basel) 2022; 14:cancers14174088. [PMID: 36077625 PMCID: PMC9454560 DOI: 10.3390/cancers14174088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Revised: 08/09/2022] [Accepted: 08/16/2022] [Indexed: 11/17/2022] Open
Abstract
Prostate cancer has huge health and societal impacts, and there is no clear consensus on the most effective and efficient treatment strategy for this disease, particularly for localized prostate cancer. We have reviewed the scientific literature describing the economic burden and cost-effectiveness of different treatment strategies for localized prostate cancer in OECD countries. We initially identified 315 articles, studying 13 of them in depth (those that met the inclusion criteria), comparing the social perspectives of cost, time period, geographical area, and severity. The economic burden arising from prostate cancer due to losses in productivity and increased caregiver load is noticeable, but clinical decision-making is carried out with more subjective variability than would be advisable. The direct cost of the intervention was the main driver for the treatment of less severe cases of prostate cancer, whereas for more severe cases, the most important determinant was the loss in productivity. Newer, more affordable radiotherapy strategies may play a crucial role in the future treatment of early prostate cancer. The interpretation of our results depends on conducting thorough sensitivity analyses. This approach may help better understand parameter uncertainty and the methodological choices discussed in health economics studies. Future results of ongoing clinical trials that are considering genetic characteristics in assessing treatment response of patients with localized prostate cancer may shed new light on important clinical and pharmacoeconomic decisions.
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8
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Keall PJ, Brighi C, Glide-Hurst C, Liney G, Liu PZY, Lydiard S, Paganelli C, Pham T, Shan S, Tree AC, van der Heide UA, Waddington DEJ, Whelan B. Integrated MRI-guided radiotherapy - opportunities and challenges. Nat Rev Clin Oncol 2022; 19:458-470. [PMID: 35440773 DOI: 10.1038/s41571-022-00631-3] [Citation(s) in RCA: 40] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/31/2022] [Indexed: 12/25/2022]
Abstract
MRI can help to categorize tissues as malignant or non-malignant both anatomically and functionally, with a high level of spatial and temporal resolution. This non-invasive imaging modality has been integrated with radiotherapy in devices that can differentially target the most aggressive and resistant regions of tumours. The past decade has seen the clinical deployment of treatment devices that combine imaging with targeted irradiation, making the aspiration of integrated MRI-guided radiotherapy (MRIgRT) a reality. The two main clinical drivers for the adoption of MRIgRT are the ability to image anatomical changes that occur before and during treatment in order to adapt the treatment approach, and to image and target the biological features of each tumour. Using motion management and biological targeting, the radiation dose delivered to the tumour can be adjusted during treatment to improve the probability of tumour control, while simultaneously reducing the radiation delivered to non-malignant tissues, thereby reducing the risk of treatment-related toxicities. The benefits of this approach are expected to increase survival and quality of life. In this Review, we describe the current state of MRIgRT, and the opportunities and challenges of this new radiotherapy approach.
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Affiliation(s)
- Paul J Keall
- ACRF Image X Institute, The University of Sydney, Sydney, New South Wales, Australia.
| | - Caterina Brighi
- ACRF Image X Institute, The University of Sydney, Sydney, New South Wales, Australia
| | - Carri Glide-Hurst
- Department of Human Oncology, University of Wisconsin, Madison, WI, USA
| | - Gary Liney
- Ingham Institute of Applied Medical Research, Sydney, New South Wales, Australia
| | - Paul Z Y Liu
- ACRF Image X Institute, The University of Sydney, Sydney, New South Wales, Australia
| | - Suzanne Lydiard
- ACRF Image X Institute, The University of Sydney, Sydney, New South Wales, Australia
| | - Chiara Paganelli
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, Milan, Italy
| | - Trang Pham
- Faculty of Medicine and Health, The University of New South Wales, Sydney, New South Wales, Australia
| | - Shanshan Shan
- ACRF Image X Institute, The University of Sydney, Sydney, New South Wales, Australia
| | - Alison C Tree
- The Royal Marsden NHS Foundation Trust and the Institute of Cancer Research, London, UK
| | - Uulke A van der Heide
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, Netherlands
| | - David E J Waddington
- ACRF Image X Institute, The University of Sydney, Sydney, New South Wales, Australia
| | - Brendan Whelan
- ACRF Image X Institute, The University of Sydney, Sydney, New South Wales, Australia
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Assessment of MRI-Linac Economics under the RO-APM. J Clin Med 2021; 10:jcm10204706. [PMID: 34682829 PMCID: PMC8539760 DOI: 10.3390/jcm10204706] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 10/08/2021] [Indexed: 01/16/2023] Open
Abstract
The implementation of the radiation oncology alternative payment model (RO-APM) has raised concerns regarding the development of MRI-guided adaptive radiotherapy (MRgART). We sought to compare technical fee reimbursement under Fee-For-Service (FFS) to the proposed RO-APM for a typical MRI-Linac (MRL) patient load and distribution of 200 patients. In an exploratory aim, a modifier was added to the RO-APM (mRO-APM) to account for the resources necessary to provide this care. Traditional Medicare FFS reimbursement rates were compared to the diagnosis-based reimbursement in the RO-APM. Reimbursement for all selected diagnoses were lower in the RO-APM compared to FFS, with the largest differences in the adaptive treatments for lung cancer (−89%) and pancreatic cancer (−83%). The total annual reimbursement discrepancy amounted to −78%. Without implementation of adaptive replanning there was no difference in reimbursement in breast, colorectal and prostate cancer between RO-APM and mRO-APM. Accommodating online adaptive treatments in the mRO-APM would result in a reimbursement difference from the FFS model of −47% for lung cancer and −46% for pancreatic cancer, mitigating the overall annual reimbursement difference to −54%. Even with adjustment, the implementation of MRgART as a new treatment strategy is susceptible under the RO-APM.
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10
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Parikh NR. Time-Driven Activity-Based Costing of CT-Guided vs MR-Guided Prostate SBRT. APPLIED RADIATION ONCOLOGY 2021; 10:33-40. [PMID: 34671700 PMCID: PMC8525878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND AND PURPOSE Stereotactic body radiation therapy (SBRT) has become a standard-of-care option for localized prostate cancer. While prostate SBRT has traditionally been delivered using computed-tomography-guided radiation therapy (CTgRT), MR-imaging-guided radiation therapy (MRgRT) is now available. MRgRT offers real-time soft-tissue visualization and ease of adaptive planning, obviating the need for fiducial markers, and potentially allowing for smaller planning target volume (PTV) margins. Although prior studies have focused on evaluating the cost-effectiveness of MRgRT vs CTgRT from a payor perspective, the difference in provider costs to deliver such treatments remains unknown. This study thus used time-driven activity-based costing (TDABC) to determine the difference in provider resources consumed by delivering prostate SBRT via MRgRT vs CTgRT. METHODS Data was collected from a single academic institution where prostate SBRT is routinely performed using both CTgRT and MRgRT. Five-fraction SBRT (40 Gy total dose) was assumed to be delivered through volumetric-modulated arc therapy for CTgRT patients, and through step-and-shoot, fixed-gantry intensity-modulated radiation therapy for MRgRT patients. Process maps were constructed for each portion of the radiation delivery process via interviews/surveys with departmental personnel and by measuring CTgRT and MRgRT treatment times. Prior to simulation, only CTgRT patients underwent placement of three gold fiducial markers. Personnel capacity cost rates were calculated by dividing total personnel costs by the annual minutes worked by a given personnel. Equipment costs included both an annualized purchase price and annual maintenance costs. Ultimately, the total costs of care encompassing personnel, space/equipment, and materials were aggregated across the entire chain of care for both CTgRT and MRgRT patients in a base case. RESULTS Direct costs associated with delivering a 5-fraction course of prostate SBRT were $1,497 higher with MRgRT than with CTgRT - comprised of personnel costs ($210 higher with MRgRT), space/equipment ($1,542 higher with MRgRT), and materials ($255 higher with CTgRT). Only CTgRT patients underwent fiducial placement, which accounted for $591. MRgRT patients were assumed to undergo both CT simulation (for electron density calculation) and MRI simulation, with the former accounting for $168. Mean time spent by patients in the treatment vault per fraction was 20 minutes (range 15-26 minutes) for CTgRT, and 31 minutes (range 30-34 minutes) for MRgRT. Patient time spent during fiducial placement (CTgRT only) was 60 minutes. Modifying the number of fractions treated would result in the cost difference of $1,497 (5 fractions) changing to $441 (1 fraction) or to $2,025 (7 fractions). CONCLUSION This study provides an approximate comparison of the direct resources required for a radiation oncology provider to deliver prostate SBRT with CTgRT vs MRgRT. We await findings from the currently accruing phase III MIRAGE trial, which is comparing these modalities, and will subsequently measure acute and late genitourinary/gastrointestinal (GU/GI) toxicities, temporal change in quality-of-life outcomes, and 5-year biochemical, recurrence-free survival. Results from studies comparing the efficacy and safety of MRgRT vs CTgRT will ultimately allow us to put this cost difference into context.
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11
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Shelley CE, Barraclough LH, Nelder CL, Otter SJ, Stewart AJ. Adaptive Radiotherapy in the Management of Cervical Cancer: Review of Strategies and Clinical Implementation. Clin Oncol (R Coll Radiol) 2021; 33:579-590. [PMID: 34247890 DOI: 10.1016/j.clon.2021.06.007] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 05/19/2021] [Accepted: 06/11/2021] [Indexed: 02/08/2023]
Abstract
The complex and varied motion of the cervix-uterus target during external beam radiotherapy (EBRT) underscores the clinical benefits afforded by adaptive radiotherapy (ART) techniques. These gains have already been realised in the implementation of image-guided adaptive brachytherapy, where adapting to anatomy at each fraction has seen improvements in clinical outcomes and a reduction in treatment toxicity. With regards to EBRT, multiple adaptive strategies have been implemented, including a personalised internal target volume, offline replanning and a plan of the day approach. With technological advances, there is now the ability for real-time online ART using both magnetic resonance imaging and computed tomography-guided imaging. However, multiple challenges remain in the widespread dissemination of ART. This review investigates the ART strategies and their clinical implementation in EBRT delivery for cervical cancer.
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Affiliation(s)
- C E Shelley
- Department of Clinical Oncology, St. Luke's Cancer Centre, Royal Surrey County Hospital, Guildford, UK.
| | - L H Barraclough
- Department of Clinical Oncology, The Christie NHS Foundation Trust, Manchester, UK
| | - C L Nelder
- Department of Radiotherapy, The Christie NHS Foundation Trust, Manchester, UK
| | - S J Otter
- Department of Clinical Oncology, St. Luke's Cancer Centre, Royal Surrey County Hospital, Guildford, UK
| | - A J Stewart
- Department of Clinical Oncology, St. Luke's Cancer Centre, Royal Surrey County Hospital, Guildford, UK; University of Surrey, Guildford, UK
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12
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Hehakaya C, van der Voort van Zyp JRN, Vanneste BGL, Grutters JPC, Grobbee DE, Verkooijen HM, Frederix GWJ. Early health economic analysis of 1.5 T MRI-guided radiotherapy for localized prostate cancer: Decision analytic modelling. Radiother Oncol 2021; 161:74-82. [PMID: 34089754 DOI: 10.1016/j.radonc.2021.05.022] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 05/21/2021] [Accepted: 05/23/2021] [Indexed: 12/27/2022]
Abstract
BACKGROUND AND PURPOSE 1.5 Tesla magnetic resonance imaging radiotherapy linear accelerator (MR-Linac) is gaining interest for treatment of localized prostate cancer. Clinical evidence is lacking and it therefore remains uncertain whether MR-Linac is cost-effective. An early health economic analysis was performed to calculate the necessary relative reduction in complications and the maximum price of MR-Linac (5 fractions) to be cost-effective compared to 5, 20 and 39 fractionation schedules of external beam radiotherapy (EBRT) and low-dose-rate (LDR) brachytherapy. MATERIALS AND METHODS A state transition model was developed for men with localized prostate cancer. Complication rates such as grade ≥2 urinary, grade ≥2 bowel and sexual complications, and utilities were based on systematic literature searches. Costs were estimated from a Dutch healthcare perspective. Threshold analyses were performed to identify the thresholds of complications and costs for MR-Linac to be cost-effective, while holding other outcomes such as biochemical progression and mortality constant. One-way sensitivity analyses were performed to outline uncertainty outcomes. RESULTS At €6460 per patient, no reductions in complications were needed to consider MR-Linac cost-effective compared to EBRT 20 and 39 fractions. Compared to EBRT 5 fractions and LDR brachytherapy, MR-Linac was found to be cost-effective when complications are relatively reduced by 54% and 66% respectively. Results are highly sensitive to the utilities of urinary, bowel and sexual complications and the probability of biochemical progression. CONCLUSIONS MR-Linac is found to be cost-effective compared to 20 and 39 fractions EBRT at baseline. For MR-Linac to become cost-effective over 5 fractions EBRT and LDR brachytherapy, it has to reduce complications substantially or be offered at lower costs.
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Affiliation(s)
- Charisma Hehakaya
- Division of Imaging & Oncology, University Medical Center Utrecht, The Netherlands; Julius Clinical, Zeist, The Netherlands.
| | | | - Ben G L Vanneste
- Department of Radiation Oncology, MAASTRO Clinic, GROW School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Janneke P C Grutters
- Department for Health Evidence, Radboud Institute for Health Sciences, Radboudumc, Nijmegen, The Netherlands
| | - Diederick E Grobbee
- Julius Clinical, Zeist, The Netherlands; Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, The Netherlands; Utrecht University, The Netherlands
| | - Helena M Verkooijen
- Division of Imaging & Oncology, University Medical Center Utrecht, The Netherlands; Utrecht University, The Netherlands
| | - Geert W J Frederix
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, The Netherlands
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13
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Lee J, Kim WC, Yoon WS, Rim CH. Implications of Radiotherapy Utilization in Korea from 2010 to 2019. J Korean Med Sci 2021; 36:e117. [PMID: 33975394 PMCID: PMC8111041 DOI: 10.3346/jkms.2021.36.e117] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Accepted: 03/18/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND This study was to assess the rate of radiotherapy (RT) utilization according to the modality in South Korea to identify the implications of contemporary RT patterns. METHODS We collected information from claims and reimbursement records of the National Health Insurance Service from 2010 to 2019. We classified the location of each institution as capital (Seoul, Incheon, and Gyeonggi-do) and non-capital areas. RESULTS The rate of RT utilization in total cancer patients nationwide was 24.5% in 2010, which consistently has increased to 36.1% in 2019 (annual increase estimate [AIE], 4.5%). There was an abrupt increase in patients receiving intensity-modulated RT (IMRT), with an AIE of 33.5%, and a steady decline in patients receiving three-dimensional conformal RT (3DCRT), with an AIE of -7.1%. The commonest RT modality was IMRT (44.5%), followed by 3DCRT and stereotactic RT (SRT) (37.2% and 13.5%) in 2019. An increasing trend of advanced RT (such as IMRT and SRT) utilization was observed regardless of the region, although the AIE in the capital areas was slightly higher than that in non-capital areas. CONCLUSION The utilization of overall RT application and especially of advanced modalities remarkably increased from 2010 to 2019. We also found gaps in their AIEs between capital and non-capital areas. We should ensure that advanced RT is accessible to all cancer patients across South Korea.
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Affiliation(s)
- Jeongshim Lee
- Department of Radiation Oncology, Inha University Hospital, Inha University College of Medicine, Incheon, Korea
- Department of Radiation Oncology, Yonsei University College of Medicine, Seoul, Korea
| | - Woo Chul Kim
- Department of Radiation Oncology, Inha University Hospital, Inha University College of Medicine, Incheon, Korea
| | - Won Sup Yoon
- Department of Radiation Oncology, Korea University Ansan Hospital, Ansan, Korea
| | - Chai Hong Rim
- Department of Radiation Oncology, Korea University Ansan Hospital, Ansan, Korea.
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MR-Guided Hypofractionated Radiotherapy: Current Emerging Data and Promising Perspectives for Localized Prostate Cancer. Cancers (Basel) 2021; 13:cancers13081791. [PMID: 33918650 PMCID: PMC8070332 DOI: 10.3390/cancers13081791] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 04/01/2021] [Accepted: 04/02/2021] [Indexed: 12/13/2022] Open
Abstract
Simple Summary The biological features of prostate cancer as a tumor with a low alpha beta ratio have led clinicians to consider the use of higher doses per fraction, thus gaining an advantage both in terms of clinical outcomes and of logistic opportunities. To date, moderate hypofractionated schedules are supported by several international clinical guidelines. The subsequent step was represented by the adoption of extreme hypofractionated schedules, for which recent literature data report non-inferiority results for the five-fractions regimens. In this scenario, the recent introduction of MR-guided daily adaptive radiotherapy is a potential paradigm shift, given the ability to increase the resolution of the pelvis anatomy and to take into account of the daily variations in shape and size of the nearby healthy structures. Abstract In this review we summarize the currently available evidence about the role of hybrid machines for MR-guided radiotherapy for prostate stereotactic body radiotherapy. Given the novelty of this technology, to date few data are accessible, but they all report very promising results in terms of tolerability and preliminary clinical outcomes. Most of the studies highlight the favorable impact of on-board magnetic resonance imaging as a means to improve target and organs at risk identification with a consequent advantage in terms of dosimetric results, which is expected to relate to a more favorable toxicity pattern. Still, the longer treatment time per session may potentially affect the patient’s compliance to the treatment, although first quality of life assessment studies have reported substantial tolerability and no major impact on quality of life. Finally, in this review we hypothesize some future scenarios of further investigation, based on the possibility to explore the superior anatomy visualization and the role of daily adapted treatments provided by hybrid MR-Linacs.
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