Incidence of radiodermatitis in breast cancer patients during hypofractionated radiotherapy / Incidencia de radiodermatitis en pacientes con cáncer de mama durante la radioterapia hipofraccionada / Incidência de radiodermatite em pacientes com câncer de mama durante a radioterapia hipofracionada

ABSTRACT Objective: To analyze the incidence, dose of occurrence, grade, severity, and associated risk factors for the development of radiodermatitis, by area of the irradiated breast, in women with breast cancer, during hypofractionated radiotherapy. Method: Observational, prospective, and longitudinal study, according to the guidelines of the Strengthening the Reporting of Observational studies in Epidemiology, carried out between May 2019 and May 2021. Results: A total of 104 women participated in the study, and 73.1% (95%CI: 64-82) developed signs of radiodermatitis during treatment. The majority (63.5%, 95%CI: 54-73) developed erythema in the axillary region with about 36.5 Grays. Women with large breasts and statin users are more likely to develop radiodermatitis. However, women with Phototype III skin color classification (light brown skin) are less likely to develop radiodermatitis, with skin color being a protective factor. Conclusion: The incidence of radiodermatitis in women with breast cancer during hypofractionated radiotherapy is significant. Therefore, the development of protocols for the management of this radiotoxicity is suggested, considering the cumulative dose and associated risk factors.

RESUMEN Objectivo: Analizar la incidencia, dosis de ocurrencia, grado, severidad y factores de riesgo asociados para el desarrollo de radiodermatitis, por área de la mama irradiada, en mujeres con cáncer de mama, durante radioterapia hipofraccionada. Método: Estudio observacional, prospectivo y longitudinal, según las directrices del Strengthening the Reporting of Observational studies in Epidemiology, realizado entre mayo de 2019 y mayo de 2021. Resultados: Participaron del estudio 104 mujeres, el 73,1% (IC 95%: 64-82) desarrollaron signos de radiodermatitis durante el tratamiento. La mayoría (63,5%, IC95%: 54-73) desarrolló eritema en la región axilar con alrededor de 36,5 Grays. Las mujeres con senos grandes y usuarias de estatinas tienen más probabilidades de desarrollar radiodermatitis. Sin embargo, las mujeres con color de piel clasificado como Fototipo III (piel morena clara) tienen menos probabilidades de desarrollar radiodermatitis, siendo el color de piel un factor protector. Conclusión: La incidencia de radiodermatitis en mujeres con cáncer de mama durante la radioterapia hipofraccionada es significativa. Por lo tanto, se sugiere el desarrollo de protocolos para el manejo de esta radiotoxicidad, considerando la dosis acumulada y los factores de riesgo asociados.

RESUMO Objetivo: Analisar a incidência, a dose de ocorrência, o grau, a severidade e os fatores de risco associados para o desenvolvimento de radiodermatite, por área da mama irradiada, em mulheres com câncer de mama, durante a radioterapia hipofracionada. Método: Estudo observacional, prospectivo e longitudinal, conforme diretrizes do Strengthening the Reporting of Observational studies in Epidemiology, realizado entre maio de 2019 e maio de 2021. Resultados: Participaram do estudo 104 mulheres, 73,1% (IC95%: 64-82) desenvolveram sinais de radiodermatite durante o tratamento. A maioria (63,5%, IC95%: 54-73) desenvolveu eritema na região axilar com cerca de 36,5 Grays. Mulheres com mamas volumosas e usuárias de estatinas possuem maior chance de desenvolver radiodermatite. Entretanto, mulheres com a cor da pele classificada como Fototipo III (pele morena clara) possuem menor chance de desenvolver radiodermatite, sendo a cor da pele um fator protetor. Conclusão A incidência de radiodermatite em mulheres com câncer de mama durante a radioterapia hipofracionada é expressiva. Sugere-se, portanto, o desenvolvimento de protocolos para o manejo desta radiotoxicidade, considerando a dose cumulativa e fatores de risco associados.

Radioterapia hipofraccionada para cáncer de próstata localizado ¿Menos tiempo de tratamiento es mejor? / Hypofractionated radiotherapy for localized prostate cancer ¿Is less treatment time better?

Introducción: El hipofraccionamiento moderado (hRt) en cáncer de próstata, consisten en dismi-nuir el tiempo total de tratamiento con radioterapia, lo que mejora la adherencia terapéutica y opti-miza recursos tecnológicos. En cáncer de próstata, existe evidencia robusta con datos maduros a 5 años de seguimiento, donde se evidenció que hRtno es inferior al tratamiento con fraccionamiento estándar en control oncológico, con menor o igual toxicidad aguda y tardía. Se hace una revisión de la evidencia, dosis de tolerancia, contorneo de volúmenes objetivo (GTV-CTV-PTV) / órganos de ries-go, planificación y reproducibilidad del hRt en cáncer de próstata localizado.

Introduction: Moderate hypofractionation (hRt) in prostate cancer consists of reducing the total time of treatment with radiotherapy, which improves therapeutic adherence and optimizes technolog-ical resources. In prostate cancer, there is robust evidence with mature data at 5 years of follow-up, where it was evidenced that hRt is not inferior to treatment with standard fractionation in oncological control, with less or equal acute and late toxicity. A review of the evidence, tolerance dose, contouring of target volumes (GTV-CTV-PTV) / organs at risk, planning and reproducibility of hRt in localized prostate cancer is made.

Hypofractionated radiotherapy recommendations for localized prostate cancer in Brasil

SUMMARY OBJECTIVE: Several prospective randomized trials have shown that hypofractionation has the same efficacy and safety as the conventional fractionation in the treatment of localized prostate cancer. There are many benefits of hypofractionation, including a more convenient schedule for the patients and better use of resources, which is especially important in low- and middle-income countries like Brasil. Based on these data, the Brazilian Society of Radiotherapy (Sociedade Brasileira de Radioterapia) organized this consensus to guide and support the use of hypofractionated radiotherapy for localized prostate cancer in Brasil. METHODS: The relevant literature regarding moderate hypofractionation (mHypo) and ultra-hypofractionation (uHypo) was reviewed and discussed by a group of experts from public and private centers of different parts of Brasil. Several key questions concerning clinical indications, outcomes and technological requirements for hypofractionation were discussed and voted. For each question, consensus was reached if there was an agreement of at least 75% of the panel members. RESULTS: The recommendations are described in this article. CONCLUSION: This initiative will assist Brazilian radiation oncologists and medical physicists to safely treat localized prostate cancer patients with hypofractionation.

Hypofractionated and hyper-hypofractionated radiation therapy in postoperative breast cancer treatment

SUMMARY INTRODUCTION: Radiation therapy is widely used as adjuvant treatment in breast cancer patients. In the last decades, several studies have been designed to evaluate the safety and efficacy of hypofractionated breast radiation therapy. More recently, even shorter regimens with doses above 4 Gy (hyper-hypofractionation) have also been proposed. This study aims to present a narrative review of the various hypofractionation protocols used to treat breast cancer patients with a focus on clinical application. RESULTS: Long-term results from several phase III randomized controlled trials demonstrated the safety and efficacy of hypofractionated breast radiation therapy using 15 or 16 fractions for early and locally advanced disease. The results of the initial clinical trials of hyper-hypofractionation are also encouraging and it is believed that these regimens may become routine in the indication of adjuvant radiation therapy treatment after the ongoing studies on this subject have matured. CONCLUSIONS: The idea that normal tissues could present high toxicity at doses above 2 Gy was opposed by clinical trials that demonstrated that moderate hypofractionation had similar results regarding oncological and cosmetic outcomes compared to conventional fractionation. Cosmetic and toxicity results from hyper-fractionation studies are in principle favorable. However, the long-term oncological results of studies that used hyper-hypofractionation for the treatment of breast cancer patients are still awaited.

RESUMO INTRODUÇÃO: A radioterapia é amplamente utilizada como tratamento adjuvante nas pacientes com câncer de mama. Nas últimas décadas, diversos estudos foram desenhados para avaliar a segurança e a eficácia da radioterapia hipofracionada moderada de mama. Mais recentemente, esquemas ainda mais curtos, com doses acima de 4 Gy (hiper-hipofracionamento), foram também propostos. Este estudo tem o objetivo de apresentar uma revisão narrativa dos diversos protocolos de hipofracionamento utilizados no tratamento do câncer de mama com o foco na aplicação clínica. RESULTADOS: Os resultados de longo prazo de diversos ensaios clínicos randomizados fase III demonstraram a segurança e a eficácia da radioterapia hipofracionada moderada utilizando 15 ou 16 frações para doença inicial e localmente avançada. Os resultados dos ensaios clínicos iniciais de hiper-hipofracionamento são também animadores e acredita-se que esses esquemas poderão se tornar rotina na indicação do tratamento adjuvante com radioterapia após a maturação dos estudos em andamento sobre esse tema. CONCLUSÕES: A ideia de que os tecidos normais poderiam apresentar toxicidade elevada com doses acima de 2 Gy foi pioneiramente contraposta por ensaios clínicos que comprovaram que o hipofracionado moderado apresentava resultados semelhantes em relação aos desfechos oncológicos e cosméticos quando comparados ao fracionamento convencional. Os resultados cosméticos e de toxicidade dos estudos de hiper-hipofracionamento são, em princípio, favoráveis. Todavia, ainda se aguardam os resultados oncológicos de longo prazo dos estudos que aplicaram o hiper-hipofracionamento para o tratamento das pacientes com câncer de mama.

Is moderate hypofractionation accepted as a new standard of care in north america for prostate cancer patients treated with external beam radiotherapy? Survey of genitourinary expert radiation oncologists

ABSTRACT Introduction: Several recent randomized clinical trials have evaluated hypofractionated regimens against conventionally fractionated EBRT and shown similar effectiveness with conflicting toxicity results. The current view regarding hypofractionation compared to conventional EBRT among North American genitourinary experts for management of prostate cancer has not been investigated. Materials and Methods: A survey was distributed to 88 practicing North American GU physicians serving on decision - making committees of cooperative group research organizations. Questions pertained to opinions regarding the default EBRT dose and fractionation for a hypothetical example of a favorable intermediate - risk prostate cancer (Gleason 3 + 4). Treatment recommendations were correlated with practice patterns using Fisher's exact test. Results: Forty - two respondents (48%) completed the survey. We excluded from analysis two respondents who selected radical hypofractionation with 5 - 12 fractions as a preferred treatment modality. Among the 40 analyzed respondents, 23 (57.5%) recommend conventional fractionation and 17 (42.5%) recommended moderate hypofractionation. No demographic factors were found to be associated with preference for a fractionation regimen. Support for brachytherapy as a first choice treatment modality for low - risk prostate cancer was borderline significantly associated with support for moderate hypofractionated EBRT treatment modality (p = 0.089). Conclusions: There is an almost equal split among North American GU expert radiation oncologists regarding the appropriateness to consider moderately hypofractionated EBRT as a new standard of care in management of patients with prostate cancer. Physicians who embrace brachytherapy may be more inclined to support moderate hypofractionated regimen for EBRT. It is unclear whether reports with longer follow-ups will impact this balance, or whether national care and reimbursement policies will drive the clinical decisions. In the day and age of patient - centered care delivery, patients should receive an objective recommendation based on available clinical evidence. The stark division among GU experts may influence the design of future clinical trials utilizing EBRT for patients with prostate cancer.

Cosmetic outcome of hypofractionated whole-breast irradiation with concomitant boost in breast cancer

Background: Breast cancer is the most common cancer in women worldwide, second most common malignancy in Egypt.Methods: 60 early-stage breast cancer patients who underwent breast-conserving surgery were clusterized into 2 groups: Arm A hypofractionation with concomitant boost and Arm B conventional fractionation, each compromising 30 early stage breast cancer patients. Assessment of cosmetic outcome after breast irradiation was recorded in both groups in 4 intervals to correlate cosmesis in relation to different irradiation schedules and boost dosage and timing. The study was conducted from April 2016 till December 2018, 32 months were obtained to assure that all patients completed their irradiation schedule and 12 months follow-up period.Results: Lowest cosmetic outcome was recorded immediately after completion of breast irradiation with excellent/good in 66.7% and 73.3% of patients and fair/poor in 33.3% and 26.7% in Arm A and B, respectively. Improvement in cosmesis after 12 months of breast irradiation reaching excellent/good in 83.4% and fair/poor in 16.7% in both Arm A and B.Conclusion: An abbreviated 4-week hypofractionated schedule with a concomitant boost is as effective as conventional irradiation with comparable cosmesis and may be a reasonable alternative following breast conserving surgery

Cosmesis in patients with breast neoplasia submitted to the hypofractionated radiotherapy with of intensity-modulated beam

SUMMARY OBJECTIVE: To assess the cosmetic satisfaction of patients diagnosed with breast cancer submitted to the hypofractionated radiotherapy with IMRT (hIMRT) technique and its correlation with dosimetric data of the radiotherapy planning. MATERIALS AND METHODS: The retrospective cohort study that assessed women with a diagnosis of malignant breast neoplasia submitted to the conservative treatment or radical mastectomy and treated with hIMRT. In the period between August 2007 to December 2014, in a philanthropic / private institution, 170 records were selected. The cosmetic assessment was carried out by means of the Harvard/RTOG/NSABP scale with one-year minimum range after treatment. The collected dosimetric data were: breast / chest wall volume, volume that received 95% (V95%) and 107% (V107%) of the prescribed dose. RESULTS: The volume of the treated breasts ranged from 169 to 2.103 ml (median = 702; IQR: 535 to 914 ml). Median V95% was 86.7% (54.6-96.6%; IQR: 80.0% to 90.6%); eight (5.7%) patients had V95% higher than 95%. Median V107% was 0% (0%-16.3%; IQR: 0.0% to 0.3% and 13); 9.3% patients had V107% higher than 2%. One hundred and thirty-three (78.2%) patients responded to the cosmetic assessment: 99 (74.4%) considered the cosmetic results excellent. Significant associations between cosmetic assessment and breast volume (p=0.875), V95% (p=0.294) e V107% (p=0.301) were not found. CONCLUSION: The cosmetic results showed favorable when using hIMRT, and the lack of correlation with usual the dosimetric data illustrates the capacity of hIMRT to minimize the heterogeneity of the dose in this endpoint, even in voluminous breasts.

RESUMO OBJETIVO: Avaliar a satisfação cosmética de pacientes diagnosticadas com câncer de mama submetidas à radioterapia hipofracionada com técnica IMRT (hIMRT) e sua correlação com dados dosimétricos do planejamento radioterápico. MATERIAIS E MÉTODOS: Estudo de coorte retrospectivo que avaliou mulheres com diagnóstico de neoplasia maligna de mama submetidas a tratamento conservador ou mastectomia radical e tratadas com hIMRT. No período de agosto de 2007 a dezembro de 2014, em uma instituição filantrópica/particular, foram selecionados 170 prontuários. A avaliação cosmética foi feita por meio da escala de Harvard/RTOG/NSABP com um intervalo mínimo de um ano após o tratamento. Dados dosimétricos coletados foram: volume da mama/plastrão, volume que recebeu 95% (V95%) e 107% (V107%) da dose prescrita. RESULTADOS: O volume das mamas tratadas variou de 169 a 2.103 ml (mediana = 702; IQR: 535 a 914 ml). O V95% mediano foi 86,7% (54,6-96,6%; IQR: 80,0% a 90,6%); oito (5,7%) pacientes tiveram o V95% superior a 95%. O V107% mediano foi 0% (0%-16,3%; IQR: 0,0% a 0,3% e 13); 9,3% pacientes tiveram o V107% superior a 2%. Cento e trinta e três (78,2%) pacientes responderam à avaliação cosmética: 99 (74,4%) consideraram o resultado cosmético excelente. Não foram encontradas associações significativas entre a avaliação cosmética e o volume da mama (p=0,875), V95% (p=0,294) e V107% (p=0,301). CONCLUSÕES: Os resultados cosméticos mostraram-se favoráveis com o uso de hIMRT, e a ausência de correlação com os dados dosimétricos usuais ilustra a capacidade do hIMRT em minimizar a heterogeneidade da dose neste desfecho, mesmo em mamas volumosas.

Recommendations for hypofractionated whole-breast irradiation

SUMMARY This recommendation consensus for hypofractionated whole-breast radiotherapy (RT) was organized by the Brazilian Society of Radiotherapy (SBRT) considering the optimal scenario for indication and safety in the technology applied. All controversies and contraindication matters (hypofractionated RT in patients who underwent chemotherapy [CT], hypofractionated RT in lymphatic drainage, hypofractionated RT after mastectomy with or without immediate reconstruction, boost during surgery, hypofractionated RT in patients under 50 years old, hypofractionated RT in large breasts, hypofractionated RT in histology of carcinoma in situ [DCIS]) was discussed during a meeting in person, and a consensus was reached when there was an agreement of at least 75% among panel members. The grade for recommendation was also suggested according to the level of scientific evidence available, qualified as weak, medium, or strong. Thus, this consensus will aid Brazilian radiotherapy experts regarding indications and particularities of this technique as a viable and safe alternative for the national reality.

RESUMO Este consenso de recomendações para a radioterapia (RT) hipofracionada de toda a mama foi organizado pela Sociedade Brasileira de Radioterapia (SBRT) considerando o cenário ideal para indicação e segurança na tecnologia aplicada. Questões de controvérsias e contraindicações (RT hipofracionada em pacientes submetidas à quimioterapia [QT], RT hipofracionada nas drenagens linfáticas, RT hipofracionada após mastectomia com ou sem reconstrução imediata, a realização de reforço de dose em leito cirúrgico [ou boost], RT hipofracionada em pacientes com idade menor que 50 anos, RT hipofracionada em mamas volumosas, RT hipofracionada em histologia de carcinoma in situ [CDIS]) foram discutidas em encontro presencial, sendo o consenso atingido quando existisse concordância de pelo menos 75% dos panelistas. O grau de recomendação foi também sugerido de acordo com o nível de evidência científico disponível, qualificado entre fraco, médio ou forte. Assim, este consenso deverá servir para auxiliar os especialistas da radioterapia brasileira em relação às indicações e particularidades dessa técnica, como uma alternativa segura e viável para a realidade nacional.

Fractionated Gamma Knife Radiosurgery as Initial Treatment for Large Skull Base Meningioma

We present our experience on the hypofractionated Gamma Knife radiosurgery (FGKS) for large skull base meningioma as an initial treatment. We retrospectively reviewed 23 patients with large skull base meningioma ≥10 cm³ who underwent FGKS as the initial treatment option. The mean volume of tumors prior to radiosurgery was 21.2±15.63 cm³ (range, 10.09~71.42). The median total margin dose and marginal dose per fraction were 18 Gy (range, 15~20) and 6 Gy (range, 5~6), respectively. Patients underwent three or four fractionations in consecutive days with the same Leksell® frame. The mean follow-up duration was 38 months (range, 17~78). There was no mortality. At the last follow-up, the tumor volume was stationary in 15 patients (65.2%) and had decreased in 8 patients (34.8%). Six patients who had cranial neuropathy at the time of FGKS showed improvement at the last clinical follow-up. Following FGKS, 4 patients (17%) had new cranial neuropathy. The trigeminal neuropathy was the most common and all were transient. The mean Karnofsky Performance Status score at pre-FGKS and the last clinical follow-up was 97.0±10.4 points (median, 100) and 98.6±6.9 (median, 100) points, respectively. FGKS has showed satisfactory tumor control with functional preservation for large skull base meningiomas. Further prospective studies of large cohorts with long term follow-up are required to clarify the efficacy in the tumor control and functional outcome as well as radiation toxicity.

Hypofractionated Re-irradiation after Maximal Surgical Resection for Recurrent Glioblastoma: Therapeutic Adequacy and Its Prognosticators of Survival

PURPOSE: To evaluate the adequacy of retreatment, including hypofractionated re-irradiation (HFReRT), after surgery for recurrent glioblastoma (GBM) and related prognosticators of outcomes. MATERIALS AND METHODS: From 2011 to 2014, 25 consecutive patients with recurrent (n=17) or secondary (n=7) disease underwent maximal surgery and subsequent HFReRT after meeting the following conditions: 1) confirmation of recurrent or secondary GBM after salvage surgery; 2) Karnofsky performance score (KPS) ≥60; and 3) interval of ≥12 months between initial radiotherapy and HFReRT. HFReRT was delivered using a simultaneous integrated boost technique, with total dose of 45 Gy in 15 fractions to the gross tumor volume (GTV) and 37.5 Gy in 15 fractions to the clinical target volume. RESULTS: During a median follow-up of 13 months, the median progression-free and overall survival (OS) were 13 and 16 months, respectively. A better KPS (p=0.026), no involvement of the eloquent area at recurrence (p=0.030), and a smaller GTV (p=0.005) were associated with better OS. Additionally, OS differed significantly between risk groups stratified by the National Institutes of Health Recurrent GBM Scale (low-risk vs. high-risk, p=0.025). Radiologically suspected radiation necrosis (RN) was observed in 16 patients (64%) at a median of 9 months after HFReRT, and 8 patients developed grade 3 RN requiring hospitalization. CONCLUSION: HFReRT after maximal surgery prolonged survival in selected patients with recurrent GBM, especially those with small-sized recurrences in non-eloquent areas and good performance.

Long-term cosmesis following a novel schedule of accelerated partial breast radiation in selected early stage breast cancer: result of a prospective clinical trial

PURPOSE: There is controversy regarding the cosmetic outcome after accelerated partial breast radiation (APBR). We report the cosmetic outcome from a single-arm prospective clinical trial of APBR delivered using intensity-modulated radiation therapy (IMRT) in elderly patients with stage I breast cancer (BC), using a novel fractionation schedule. MATERIALS AND METHODS: Forty-two patients aged ≥65, with Stage I BC who underwent breast-conserving surgery were enrolled in a phase I/II study evaluating a 2-week course of APBR. Thirty eligible patients received 40 Gy in 4 Gy daily fractions. Cosmetic outcome was assessed subjectively by physician/patient and objectively by using a computer program (BCCT.core) before APBR, during, and after completion of the treatment. RESULTS: The median age was 72 years, the median tumor size was 0.8 cm, and the median follow-up was 50.5 months. The 5-year locoregional control in this cohort was 97% and overall survival 87%. At the last follow-up, patients and physicians rated cosmesis as ‘excellent’ or ‘good’ in 100% and 91 %, respectively. The BCCT.core program scored the cosmesis as ‘excellent’ or ‘good’ in 87% of the patients at baseline and 81% at the last follow-up. The median V50 (20 Gy) of the whole breast volume (WBV) was 37.2%, with the median WBV V100 (40 Gy) of 10.9%. CONCLUSION: An excellent rate of tumor control was observed in this prospective trial. By using multiple assessment techniques, we are showing acceptable cosmesis, supporting the use of IMRT planned APBR with daily schedule in elderly patients with early stage BC.

A novel schedule of accelerated partial breast radiation using intensity-modulated radiation therapy in elderly patients: survival and toxicity analysis of a prospective clinical trial

PURPOSE: Several accelerated partial breast radiation (APBR) techniques have been investigated in patients with early-stage breast cancer (BC); however, the optimal treatment delivery techniques remain unclear. We evaluated the feasibility and toxicity of APBR delivered using intensity-modulated radiation therapy (IMRT) in elderly patients with stage I BC, using a novel fractionation schedule. MATERIALS AND METHODS: Forty-two patients aged ≥65 years, with stage I BC who underwent breast conserving surgery were enrolled in a phase I/II study evaluating APBR using IMRT. Forty eligible patients received 40 Gy in 4 Gy daily fractions. Patients were assessed for treatment related toxicities, and cosmesis, before APBR, during, and after completion of the treatment. RESULTS: The median age was 73 years, median tumor size 0.8 cm and the median follow-up was 54 months. The 5-year locoregional control was 97.5% and overall survival 90%. Erythema and skin pigmentation was the most common acute adverse event, reported by 27 patients (69%). Twenty-six patients (65%) reported mild pain, rated 1-4/10. This improved at last follow-up to only 2 (15%). Overall the patient and physician reported worst late toxicities were lower than the baseline and at last follow-up, patients and physicians rated cosmesis as excellent/good in 93% and 86 %, respectively. CONCLUSION: In this prospective trial, we observed an excellent rate of tumor control with daily APBR. The acceptable toxicity profile and cosmetic results of this study support the use of IMRT planned APBR with daily schedule in elderly patients with early stage BC.

Hypofractionated whole breast irradiation: new standard in early breast cancer after breast-conserving surgery

Hypofractionated whole breast irradiation (HF-WBI) has been proved effective and safe and even better for late or acute radiation toxicity for early breast cancer. Moreover, it improves patient convenience, quality of life and is expected to be advantageous in the medical care system by reducing overall cost. In this review, we examined key randomized trials of HF-WBI, focusing on adequate patient selection as suggested by the American Society of Therapeutic Radiology and Oncology (ASTRO) guideline and the radiobiologic aspects of HF-WBI in relation to its adoption into clinical settings. Further investigation to identify the current practice pattern or cost effectiveness is warranted under the national health insurance service system in Korea.