Cost Effectiveness Of Prostate Cancer Radiotherapy
1Department of Radiation Oncology, University of Pennsylvania, Perelman School of Medicine, Pennsylvania, USA 2Leonard Davis Institute of Health Economics, University of Pennsylvania, Pennsylvania, USA
Abstract: The use of radiotherapy in the treatment of prostate cancer has evolved from treatments utilizing large fields with hand placed blocks to radiotherapy treatments given with a linear accelerator moving around the patient on a robotic arm. These technologic developments have allowed radiation dose escalations resulting in improvements in disease and patient reported outcomes with longer biochemical disease-free survival as well as improved quality of life. Increased costs have accompanied these technologic improvements with some private payers questioning the increased cost of the newer treatments and in some instances refusing to pay for some treatment modalities such as intensity-modulated radiotherapy or proton beam therapy . Cost-effectiveness analysis have been used in an attempt to illustrate these new treatments were cost-effective when compared to the older treatments. Cost-effectiveness analyses will need to be adapted in the current health care environment to provide an assessment of value as many payers, including medicare, move to a value-based reimbursement system.
Keywords: Prostate cancer radiotherapy cost-effective
Submitted Nov 14, 2017. Accepted for publication Dec 27, 2017.
What Is Radiation Therapy
Radiation is the strategic use of ionizing radiation or photons to kill cancer cells. It works by damaging the cancer cells DNA .The targeted cells die without growing or replicating themselves. Radiation therapy, like surgery, is very effective at killing localized or locally advanced prostate cancer and has the same cure rate as surgery.
Just as surgical skill can play an important role in determining outcomes from prostatectomy, the technical skill of your radiation oncologist can play an important role in radiation outcomes. When choosing a radiation oncologist, look for a physician who has broad experience with an assortment of approaches and can objectively help you decide on the best course of treatment.
Can Surgery And Radiation Be Used Together
If both surgery and radiation are in the treatment plan for prostate cancer, surgery is usually done before radiation. Radiation may be given to the area around the prostate after removal to help reduce the risk of cancer returning.
This is often done proactively in people in whom staging after surgery shows high-grade disease with a high risk for recurrence.
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What Happens During Radiation Therapy
Radiation therapy uses high-energy x-rays or a stream of particles . High doses of radiation can destroy abnormal cancer cells. Each treatment destroys some of the cancer cells at a microscopic level. Patients do not feel the radiation during treatment. They will only hear some electrical noise and may see light from the machine.
Do We Know Which Treatment Is Best For Prostate Cancer Brachytherapy Or External Beam Radiation
Its not a question of which type of radiation therapy is best in general, but rather which therapy is best for the patients specific disease and quality-of-life concerns. We want to use the most tailored, pinpointed radiation to treat the prostate tumor effectively while minimizing side effects. This can depend on the tumors size and stage as well as other patient characteristics and even a patients individual preferences.
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Who Should Consider External Beam Radiation Therapy
In most cases, external beam radiation therapy is used for men with localized prostate cancer . The intent of EBRT in this case is to kill the tumor while sparing as much healthy tissue as possible. Sometimes it is used in more advanced cases. For example, it can be used along with hormone therapy, or used to relieve pain from bone metastases.
What To Expect After Radiation Therapy For Prostate Cancer
Patients who receive radiation therapy for prostate cancer may experience a wide range of short-term and long-term side effects. And side effects may vary widely from patient to patient depending on a variety of factors, including the extent of the disease and the patients overall health. For instance, some patients may need a urinary catheter to help empty the bladder. Other patients may experience sexual side effects.
At CTCA, our trained supportive care providers work closely with you and your doctors to determine how best to address radiation therapy side effects. Services may include:
- Pelvic floor therapy
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Greater Accuracy Through Mri Diagnosis
An effective radiation treatment course for prostate cancer begins with a highly precise diagnosis to find and study any prostate cancer lesions. Our team at the University of Michigan have designed advanced diagnostic tests using magnetic resonance imaging equipment that offer exact locations for potentially malignant or cancerous tissue. The MRI also helps physicians differentiate the prostate cancer from the surrounding healthy tissue for more accurate radiotherapy.
With precise lesion locations, a biopsy is performed and then sent to our expert pathology team to study the molecular make-up of the tissue sample. The radiation oncologist will work with other providers to design the most effective radiation treatment course. Not only with the MRI be used to ensure that all of the cancer is treated, it will also be used to avoid critical structures involved in erectile function, as well as bowel and bladder function.
Stereotactic Body Radiation Therapy Or Stereotactic Ablative Radiotherapy
This type of therapy is used to deliver high doses of radiation to a precise area in the prostate using specialized techniques not achievable by standard conventional radiation therapy. This allows the total dose of radiation to be given in a shorter amount of time, usually 4 -5 treatments over 1 2 weeks rather than the several weeks used for other types of external radiation therapy.
The radiation beam needs to be extremely accurate in order to limit the side effects on healthy tissue. During treatment, the body immobilization used is often more restrictive than with IMRT due to the high doses of radiation. Fiducials, or internal prostate markers, are often used in this type of treatment.
Cyberknife and Truebeam are two types of LINACs used for SBRT treatment of prostate cancer.
Prostate Radiation Only Slightly Increases The Risk Of Developing Another Cancer Stanford Researchers Find
Receiving radiation for prostate cancer increases the risk of other cancers very slightly, Stanford Medicine researchers find, allowing providers to better inform patients weighing treatment options.
Stanford Medicine researchers find that the risk of secondary cancer from prostate cancer radiation treatment is rare. Photo by Chinnapong
It has been known for decades that radiation therapy can treat cancer but can also raise the risk of developing another type of cancer years later. Now Stanford Medicine researchers have found that, for prostate cancer, the increased risk is negligible.
This study quantifies the risks associated with radiation therapy and shows that the risks arent equal between radiation and surgery. The findings can help providers better inform their patients about the relative risks of treatment options, while addressing any concerns about radiation exposure.
In a study of about 145,000 men with prostate cancer, the team found that the rate of developing a later cancer is 0.5% higher for those who received radiation treatment than for those who did not. Among men who received radiation, 3% developed another cancer, while among those who were treated without radiation, 2.5% developed another cancer.
The Side Effects Of Radiation Therapy For Prostate Cancer
There are a few side effects of radiation therapy for prostate cancer, like diarrhea and passing urine regularly.
These side effects often occur after one or two weeks of starting RT. The symptoms can worsen during treatment and after the treatment ends. But you can feel relief after two weeks of treatment.
The side effects that occur in one person may not come in another person. They can vary from person to person. The possible side effects of radiation therapy for prostate cancer are as follows:
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Are There Any New Developments In Treating My Disease
Doctors often successfully treat prostate cancer. Sometimes, however, the disease returns . An FDA-approved radiotracer for PET/CT called AxuminÂ® helps detect and locate cancer that recurs following radiation therapy or surgery.
Conventional imaging, such as MRI or ultrasound, cannot locate recurring prostate cancer when it is small. PET/CT with AxuminÂ® can detect recurring cancer when PSA levels are low and when the cancer is small.
Identifying the exact location and extent of the disease at an early stage is vital. It allows doctors to specifically target the cancer and limit exposure to healthy tissues.
Prostate-specific membrane antigen is a protein that helps develop prostate cancer. A PSMA scan uses PET imaging and a radiotracer to locate recurrent cancer. Doctors are studying Lutetium-177 PSMA therapy in clinical trials for use in treating prostate cancer. Neither of these procedures has FDA approval yet.
Having Radiotherapy For Prostate Cancer
You have external beam radiotherapy as an outpatient in the radiotherapy department. Radiotherapy is given using a machine that is like a big x-ray machine. This is called a linear accelerator .
You usually have it as a series of short, daily treatments. The treatments are given from Monday to Friday, with a rest at the weekend. Radiotherapy is not painful, but you will need to lie still while you have it.
You may have radiotherapy over either:
- 4 weeks the dose you get for each treatment session is higher.
- 7 weeks the total overall dose of radiation is higher.
Both ways are effective, and the side effects are the same. You usually have radiotherapy over 4 weeks as it is a shorter treatment.
If you have a type of radiotherapy called stereotactic ablative radiotherapy you have it over a much shorter time.
Your doctor or nurse will explain how long your course of radiotherapy will take. It is safe for you to be with other people during external radiotherapy, including children.
There are different techniques used to treat prostate cancer more effectively. They treat the cancer while protecting healthy tissue and reducing side effects.
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Proton Beam Radiati On Therapy
Proton beam radiation therapy capitalizes on a unique physical property of high energy protons generated from a cyclotron. The accelerated charged particles travel through tissue until reaching a depth determined by their energy. Once they reach that depth, the remainder of the radiation dose is deposited in a sharp Bragg peak with no dose going beyond that point. When multiple proton beams are used, a very sharp and tight radiation dose distribution is created. This modality is especially attractive when tumors are in close proximity to sensitive organs. PCa is one of the more common indications in which proton therapy is utilized.
At Washington University in St. Louis we are collaborating with investigators from Massachusetts General Hospital and the Harvard Medical School conducting a randomized clinical trial of IG-IMRT versus proton beam radiation in men with low and intermediate risk PCa. The PARTIQoL trial is seeking to measure and compare relative the impact of the two modalities on patient quality of life after treatment. Figure 1 provides a comparison of these two treatment modalities.
Axial CT slice showing conformality of intensity modulated radiation therapy. Radio-opaque markers are apparent in the anterior aspect of the prostate gland. Axial CT slice showing conformality of proton beam radiation therapy in the same patient as panel a. More sparing of the anterior-lateral rectal wall and less dose to peripheral tissues is apparent.
What Are The Side Effects Of External Beam Radiation Therapy
As with most prostate cancer treatments, external beam radiation therapy can also cause side effects. The severity can depend on the type of radiation, dose size, length of treatment and area of treatments. These frequently include:
- Skin irritation
- Erectile dysfunction
- Secondary malignancy
If you are considering prostate cancer treatment with a form of EBRT, talk with your radiation oncologist to discuss options, potential side effects, and how those side effects will be managed.
Recently, the FDA approved the use of Space OAR, a hydrogel product for men choosing radiation therapy that can reduce the radiation received by the rectum during treatment. This can help decrease the chances of developing rectal complications such as the inability to control your bowels. The hydrogel is injected between the prostate and rectum where the gel solidifies and creates a space before radiation begins. To learn more about this product, visit the manufacturers site here.
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Prostate Cancer: Radiation Therapy
Radiation can be given from a machine outside the body and directed at the prostate . Or a surgeon can place radioactive materials into the tumor . These radioactive materials can be temporary or permanent.
How Do I Prepare For Prostate Radiation
Before undergoing prostate radiation treatment, you should get a prostate ultrasound. This will help your doctor determine the right position for your needles. After you have had the ultrasound, a doctor will insert small needles called fiducial markers into your prostate. These needles are made of soft nylon and contain radioactive iridium-192. They give off radiation in low doses for several weeks. Once the treatment is complete, your doctor will remove the catheters.
If you have had a previous radiation treatment, you should be prepared for your next appointment. During your treatment, you will be asked to remove any jewelry or valuables. In some cases, you may have to undergo a CT scan to make sure the treatment is working. Before your treatment, your doctor will give you instructions about how to prepare for this procedure.
Radiation therapy is an effective way to treat prostate cancer. It works by killing cancer cells by destroying them. There are several different types of radiation therapy for prostate cancer, including external beam radiation and brachytherapy. In either case, the treatment is relatively painless and is delivered by an experienced radiation oncologist. Your doctor will use computerized tomography to plan the treatment, which will allow your doctor to provide the right dose to your prostate.
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What Are The Different Types Of External Beam Radiation Therapy
Many of the techniques noted below use technology to direct the treatment to target the cancer. Each type of external beam radiation starts with a CT scan to map your body and custom tailor the radiation to your specific anatomy. Special computers are then used to plan radiation treatment to deliver an adequate dose to the prostate while sparing nearby organs, such as the rectum and bladder, as much as possible.
Best Prostate Cancer Radiation
Nearly all men with prostate cancer who opt for external beam radiation get a treatment called intensity-modulated radiation therapy or IMRT. IMRT has almost entirely replaced another type of radiation treatment called 3D conformational therapy — even though it’s much more expensive, with little head-to-head evidence showing it works better.
And there’s an even newer and even more expensive prostate cancer treatment: proton beam therapy. More and more medical centers are spending hundreds of millions of dollars to build new proton beam therapy centers.
Which treatment really offers a man the best chance of a prostate cancer cure with the fewest side effects? IMRT, according to Ronald C. Chen, MD, MPH, and colleagues at the University of North Carolina at Chapel Hill.
“For prostate cancer in this country, we have completely adopted IMRT,” Chen tells WebMD. “I don’t see anybody going back to 3D therapy. And thankfully, our study does show it is better in terms of cancer control and reducing long-term side effects. So IMRT is here to stay.”
The study analyzed data from 6,666 men treated with IMRT, 6,310 men treated with 3D conformational therapy, and 684 men treated with proton beam therapy.
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If I Choose Surgery Will Radiation Treatment Still Be Required
Your surgery may be incomplete or show a more advanced cancer. If the surgeon has inadvertently cut through tumor, you have what is called a positive margin. Having a positive margin or disease that breaks through the capsule of the prostate gland or invades the seminal vesicles are reasons to meet with a radiation oncologist soon after you recover from surgery. Additional radiation therapy within three to six months may prevent the cancer from coming back. Discuss this option with your treatment team.
Economic Analysis Of Various Radiotherapy Treatment Delivery Methods
Treatment techniques have evolved over the course of many years as a result of the technologic advancement. Improvements in treatment planning software as well as linear accelerators have allowed treatment techniques to transition from 2-dimensional treatment plans and techniques to 3-dimenesional treatment plans and then to IMRT. The increased work necessary for physicians, dosimetrists, and physicists needed to design and perform quality assurance resulted in increased reimbursement, both on the professional and technical sides. The development and implementation of IMRT was made possible by the further improvements in treatment planning software and linear accelerators, with the advent of multi-leaf collimators. IMRT treatment techniques, as reported elsewhere in this issue, made it possible to escalate the delivered radiotherapy dose while reducing both acute and late toxicity. The increased in delivered radiotherapy dose resulted in higher biochemical disease-free survival . IMRT was rapidly adopted as the standard of care in the treatment of prostate cancer because of these results without randomized clinical trials comparing IMRT to 3D conformal radiotherapy . Reimbursements for IMRT, however, were considerable higher when compared to 3DCRT dramatically increasing the overall cost of care for prostate cancer. Economic analyses using decision models were performed to provide evidence of cost-effectiveness of IMRT compared to 3DCRT.
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