"SBRT and BT should be the preferred treatment modalities for intermediate-risk prostate cancer," Dr. Albert Chang of the University of California, Los Angeles told Reuters Health by email. Yet, despite similar survival outcomes and the convenience and cost-effectiveness of SBRT and BT over DE-EBRT, he said, this study demonstrates that use of DE-EBRT "still dominates over SBRT and BT. Although the use of SBRT is increasing, BT utilization has significantly declined over the past decade."
"The American Brachytherapy Society has launched a 'Brachytherapy Call to Arms' initiative to train 300 radiation oncologists to become competent in BT over the next 10 years," he noted. "To further increase the utilization of BT, re-evaluation of reimbursement is warranted. Reimbursement for work time effort is significantly undervalued for BT in comparison to (DE-EBRT). Consideration of these factors is essential for cost-effective treatment, with the implementation of the Radiation Oncology Alternative Payment Model on the horizon."
As reported in JAMA Network Open, the team studied data on more than 30,000 patients (median age at diagnosis, 69; 84% white) with National Comprehensive Cancer Network intermediate risk prostate cancer (Gleason score of 6-7, clinical stage T1-T2, and prostate-specific antigen <20 ng/mL) diagnosed between 2004-2014.
Overall, 81.1% had favorable intermediate risk, and 18.9% had unfavorable intermediate risk; 41.8% received BT, 56.1% received DE-EBRT, and 2.1% received SBRT. Median follow-up was 6.7 years.
As Dr. Chang noted, from 2004 to 2014, use of SBRT increased steadily (0.03%to 10.6%), as did use of DE-EBRT (48.3% to 62.0%), while BT use declined from 48.3% to 27.4%.
In the favorable intermediate-risk cohort, no significant difference in overall survival (OS) was seen in comparisons of BT versus SBRT (HR, 0.804; 10-year OS, 67.02% vs. 64.2%) or SBRT versus DE-EBRT (HR, 1.096; 10-year OS, 64.2% vs. 70.9%).
However, men receiving BT had a small but statistically significant improvement in OS compared with those receiving DE-EBRT (HR, 0.881; 10-year OS, 69.8% vs. 66.1%).
Similarly, in the unfavorable intermediate-risk cohort, no OS differences were seen between BT and SBRT (HR, 0.749; 10-year OS, 64.9% vs. 63.2%) or SBRT and DE-EBRT (HR, 1.36; 10-year OS, 63.2% vs. 66.6%).
Again, men receiving BT showed a small but statistically significant improvement in OS versus those receiving DE-EBRT (HR, 0.818; 10-year OS, 61.2% vs. 58.7%).
Dr. Robert Wollman, medical director of radiation oncology at Providence Saint John's Health Center in Santa Monica, California, commented in an email to Reuters Health, "All these modalities, when performed by experienced clinicians on the correct patients, will provide very nearly the same outcomes. This is proven far more persuasively by other research, because database studies have many inherent biases in patient selection, as acknowledged by the authors."
"The caveat is selecting patients for the 'right' modality - i.e., pairing the right treatment to the right patient based on their underlying health conditions, urinary or bowel quality of life prior to treatment and or lifestyle," he said.
"For example, a man with a lot of urinary frequency from benign prostate disease may have greatly worsened urinary problems for a few months if we choose SBRT or BRT over EBRT," he noted. "On the other hand, a man with cardiac or pulmonary problems that might make anesthesia risky should be guided towards SBRT or EBRT over BRT."
By Marilynn Larkin
SOURCE: https://bit.ly/3nuUSnp JAMA Network Open, online September 24, 2020.
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