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.

Las nuevas tecnologías: necesidades y retos en radioterapia en América Latina / New technologies: needs and challenges in radiotherapy in Latin America

La experiencia acumulada en más de un siglo de práctica de radioterapia ha puesto de manifiesto su importancia no solamente para la atención paliativa de una parte de los casos de cáncer, sino principalmente para la curación de una proporción aun mayor de esos pacientes. Teniendo en cuenta la evolución tecnológica, el acceso cada vez mayor que tienen los países en desarrollo a estos métodos y la cobertura actual en América Latina, los esfuerzos en esta área se deben dirigir a mejorar la calidad de los servicios y de los centros de radioterapia ya instalados. Para ello se debe completar su parque tecnológico, ampliar los servicios que prestan y cumplir los requerimientos mínimos de calidad establecidos para instalaciones del nivel 2. Cada centro debe estar en condiciones de realizar todas las etapas del proceso de radioterapia -desde la simulación hasta la verificación del tratamiento y el seguimiento de los pacientes- con una calidad adecuada (nivel 2). Para ello deben contar con la tecnología necesaria y con el personal debidamente capacitado. Los esfuerzos cooperativos en la Región deben tener también como prioridad contribuir a que los países adopten guías nacionales de tratamiento que contemplen todas las etapas del proceso de radioterapia y fomentar la puesta en marcha de programas validados de garantía de la calidad.

The cumulative experience gathered over more than a century of practice of radiotherapy has demonstrated the latter's importance not only for the palliative treatment of a fraction of cancer cases, but mainly for the curative treatment of an even greater proportion of such cases. In light of the changes in technology, the ever-increasing access developing countries to such technology, and its current coverage in Latin America, any efforts in this area should be aimed at improving the quality of the radiotherapy services and centers that are already in place. This involves developing their technological assets to the fullest, expanding their services, and complying with the minimum quality requirements established for second-level facilities. Each center should be equipped to carry out all stages of the radiotherapy process, from simulation through treatment verification and patient follow-up, with a high level of quality (level 2). To achieve this, it should possess the necessary technology and properly-trained staff that are required for the purpose. Collaborative efforts in the Region should also prioritize helping countries implement national treatment standards for all stages of the radiotherapy process and promoting the implementation of validated quality assurance programs.

Postal dose audits for radiotherapy centers in Latin America and the Caribbean: trends in 1969-2003

Since 1969 the International Atomic Energy Agency and the World Health Organization (along with the Pan American Health Organization, working with countries in Latin America and the Caribbean) have operated postal dosimetry audits based on thermoluminescent dosimetry (TLD) for radiotherapy centers. The purpose of these audits is to provide an independent dosimetry check of radiation beams used to treat cancer patients. The success of radiotherapy treatment depends on accurate dosimetry. Over the period of 1969 through 2003 the calibration of approximately 5 200 photon beams in over 1 300 radiotherapy centers in 115 countries worldwide was checked. Of these audits, 36 percent were performed in Latin America and the Caribbean, with results improving greatly over the years. Unfortunately, in several instances large TLD deviations have confirmed clinical observations of inadequate dosimetry practices in hospitals in various parts of the world or even accidents in radiotherapy, such as the one that occurred in Costa Rica in 1996. Hospitals or centers that operate radiotherapy services without qualified medical physicists or without dosimetry equipment have poorer results than do hospitals or centers that are properly staffed and equipped. When centers have poor TLD results, a follow-up program can help them improve their dosimetry status. However, to achieve audit results that are comparable to those for centers in industrialized countries, additional strengthening of the radiotherapy infrastructure in Latin America and the Caribbean is needed.