Showing posts with label QOL. Show all posts
Showing posts with label QOL. Show all posts

Monday, December 5, 2016

SBRT vs. moderate hypofractionation: same or better quality of life

We have seen in several randomized clinical trials of external beam treatment of primary prostate cancer that moderately hypofractionated IMRT (HypoIMRT) treatment (accomplished in 12-26 treatments or fractions) is no worse than conventionally fractionated IMRT treatment (in 40-44 fractions).  We recently saw in a randomized clinical trial from Scandinavia that SBRT (in 5 fractions) is no worse than conventional IMRT (see this link) in long-term quality-of-life outcomes, even though they used inferior technology. The missing piece of the puzzle is to answer the question of whether SBRT is any worse than HypoIMRT.

We don’t yet have a definitive answer (which would require a randomized clinical trial), but an analysis of pooled data from 5 different clinical trials, suggests that SBRT is no worse and may be better than HypoIMRT in its urinary, rectal, and sexual outcomes. Johnson et al. pooled SBRT data from clinical trials among 534 men at 3 institutions (UCLA, Georgetown, and 21st Century Oncology) and HypoIMRT data from clinical trials among 378 men at Fox Chase Cancer Center and the University of Wisconsin. All patients were treated between 2002 and 2013 at those top institutions, with state-of-the-art equipment in the context of carefully controlled clinical trials. Because of this, all outcomes are probably better than those achieved in everyday community practice. The only significant difference in patient characteristics was that SBRT patients were about 5 years older (69 vs. 64 years of age for HypoIMRT). We expect older men to have more natural deterioration in urinary and sexual function.

The following table shows the percent of men receiving each treatment who suffered from at least the minimally detectable difference in patient-reported scores on validated quality-of-life questionnaires with respect to urinary, rectal, and sexual function. Numbers in bold typeface represent a statistically significant difference.

Odds Ratio (adjusted)

The data support the following conclusions:
  • Urinary and rectal problems at 2 years were experienced by fewer of the men who had SBRT.
  • Urinary and rectal problems improved after 2 years compared to 1 year post-treatment. For SBRT, they approached baseline values.
  • Sexual issues did not improve at 2 years.
  • While we expected the SBRT patients to experience greater deterioration owing to their age, the opposite occurred.
(update: 4/11/2020) Kwan et al. reported on 78 patients randomized to SBRT (36.25 Gy in 5 weekly treatments) or moderate hypofractionation (70 Gy in 28 treatments). After at least 6 months of follow-up:
  • there were no statistically significant differences in grade 2+ or grade 3 toxicities
  • there were no minimally important differences in patient-reported quality of life on incontinence, irritative/obstructive urinary issues or bowel issues.

Why were the SBRT outcomes better?

SBRT is not just a high-dose-per-fraction version of IMRT, although it is that too. When the linear accelerator is delivering only 2 Gy per fraction, missing the beam target by a little bit is not likely to make much difference – it will average out in the long run. Because a geographic “miss” of the beam target has much greater consequence for SBRT, where the dose per fraction can be 8 Gy, much more care is taken to achieve pinpoint accuracy. This includes such steps as:
  • Fiducials/transponders aligned within each treatment and not just between treatments.
  • Fast linear accelerators that minimize the time during which the prostate can move.
  • No treatment if the bowel is distended or the bladder is not full.
  • Tighter margins: as low as 0 mm on the rectal side and 2 mm on the front side. This compares to margins of 0.5-1 cm for IMRT.
  • Narrower dose constraints for organs at risk, including the bladder, rectum, urethra, femurs and penile bulb.
  • More care taken to find a plan that optimizes prostate dose relative to organs at risk.

It is entirely possible that IMRT outcomes might be equivalent to SBRT outcomes if the same factors were incorporated into IMRT planning and delivery. But fractionation probably has an effect as well. To understand why, we must look at the radiobiology of prostate cancer. Prostate cancer has been found to respond remarkably well to fewer yet higher doses of radiation. This is reflected in a characteristic called the “alpha/beta ratio (α/β).” The α/β of prostate cancer is very low, at about 1.5. It is lower, in fact, than that of surrounding healthy tissues. Many of those healthy tissues have an early response, which is responsible for acute toxicity, typically within 3 months of treatment (α/β = 10.0). Rectal mucosal tissue is an example. This means that a hypofractionated dosing schedule will kill relatively more cancer cells, while preserving more of the cells in the nearby organs.

There are fewer types of tissue in the pelvic area that have a delayed response to radiation, and those tissues, like nerve cells, tend to be radio-resistant. This is why late-term toxicity is relatively low. Some of the late-term effects we do see are due to cumulative responses to radiation, like the buildup of scar tissue and other reactive responses in vasculature, along the urethra, and in the rectum. Late responding tissue has an α/β of about 3.5

We can compare the biologically effective dose (BED) of the various dosing schedules to see the effect that hypofractionation would theoretically have in killing cancer cells and preserving healthy tissue.

BED for cancer control
Relative BED for cancer control
BED for acute side effects
Relative BED for acute side effects
BED for late side effects
Relative BED for late side effects
80 Gy in 40 fractions
187 Gy
96 Gy
126 Gy
60 Gy in 20 fractions
180 Gy
78 Gy
111 Gy
40 Gy in 5 fractions
253 Gy
72 Gy
131 Gy

So the kind of fractionation used in SBRT theoretically has about 35% more effective cancer-killing power than conventional fractionation, while its ability to generate acute toxic side effects is reduced by 25%, and its late-term side effects would be similar.

Why isn’t everyone who elects to have primary treatment with external beam radiation treated with SBRT?

It’s one thing to make predictions based on theory, but it’s quite another to determine whether it works as well in clinical practice. So far, non-randomized trials like the ones examined in this study have shown excellent oncological and quality-of-life outcomes for SBRT with up to 9 years of follow-up. We await the oncological results of randomized trials comparing SBRT to IMRT. The oncological outcomes from the randomized Scandinavian trial are expected any time now. There are several others that are ongoing.

With SBRT, the patient enjoys the obvious benefits of appreciably lower cost and a more convenient therapy regimen. Medicare and most (but far from all) insurance companies now cover SBRT. There is considerable resistance from radiation oncologists in private practice who would get reduced revenues, and would have to learn the new techniques and gain adequate experience in using them.

Sunday, August 28, 2016

LDRBT, IMRT and SBRT Quality of Life

Some of the leading lights in radiation oncology have collaborated on a study by Evans et al. of patient-reported quality of life (QOL) following various primary radiation treatments for prostate cancer. They analyzed three monotherapies (all without hormone therapy): low dose rate brachytherapy (LDRBT), intensity-modulated radiation therapy (IMRT), and stereotactic body radiation therapy (SBRT). It did not include high dose rate brachytherapy or proton therapy.

Because this study was so far-reaching in its scope and its findings, it is worth taking a close, detailed look at it. I will break it into three parts. In the first part, we’ll look at the basis of the study – how the study was designed and carried out, and what does it purport to tell us. In Part 2, we will look at some of the more important findings of the study. And in Part 3, we will discuss the implications and caveats of its findings, and draw conclusions.


The purpose of the study was to evaluate three primary radiation therapies – LDRBT, IMRT and SBRT – with respect to the patient-perceived side effects of those treatments, and to do so in a standardized and consistent manner. While this was a prospective study, it was not a randomized comparison, which is the gold standard for doing that. However, it does provide the doctor and patient with more information on what they can reasonably expect, across those treatments, than we’ve ever had before.

Data was provided by several of the top institutions in the US:

Michigan (2 sites)
Mass General
Beth Israel Deaconess
MD Anderson
Cleveland Clinic
Washington University (St Louis)

21st Century (2 sites)

The number of patients in the two-year follow up:
  • ·        LDRBT: 243 patients
  • ·        IMRT: 140 patients
  • ·        SBRT: 272 patients

I don’t know how they selected which doctors and medical centers to include. In addition, the study was done with the assistance of the PROSTQA Study Consortium, a blue-ribbon panel of top researchers. They previously published much of this data on IMRT and LDRBT in 2008 (see this link). The SBRT data are new. Their results are a good indicator of outcomes from top practitioners at major treatment centers, and are not a good indicator of expected outcomes in community practice. I’m sure that many patients have favorite doctors whose work was not represented in this study, and they will argue that these results are not representative.

Because this was not set up as a randomized comparison of treatments, differences in patient selection may skew the results. Importantly, the LDRBT cohort is 5 years younger (65 years, median) than the other two groups (69 years, median). In all quality-of-life studies, younger patients do better. They are less likely to suffer deleterious effects of radiation, and they are more resilient in their recovery. Paralleling the difference in age at baseline, the baseline sexual QOL was best for LDRBT, and the baseline prostate symptom scores were best for LDRBT, followed by IMRT and SBRT.

The instruments they used to evaluate quality of life were EPIC-26 and SF-12. Patient-reported assessments have an advantage over physician-reported toxicity reports. The physician data depends on the patient to voluntarily tell the doctor about all adverse events, which is useful for highest grade events (3 or 4), but is less reliable for low grade events (1 or 2) that the patient might never bring to the doctor’s attention. Some men “tough it out,” some see their PCP instead (who may be more accessible), and some worry about even the most minor events. The survey instruments used here are standardized and validated, and guide the patient through a detailed assessment of the QOL issues that have been found to matter most. Patients filled them out at baseline, at 1-2 months, 6, 12, and 24 months. EPIC scores are based on scale of 0 (worst) to 100 (best). Although they also measured such qualities as general physical and mental status, and vitality/well-being, none of these were impacted by treatments.

IMRT and LDRBT patients were treated from 2003 to 2006; SBRT patients from 2007 to 2011. Contemporary best practice was observed as follows:

·        LDRBT: 144 Gy prescribed dose for I-125, US-guided, transperineal placement, I-125 or Pd-103 used, and 3-5 mm margins (more details here)
·        IMRT:76-79 Gy in 1.8-2.0 Gy increments, and 0.5-1.5 cm margins.
·        SBRT: 35-40 Gy in 5 fractions, fiducials or Calypso image guidance, and 3-5 mm margins.

There were two kinds of urinary problems that were measured: urinary incontinence (leakage, dribbling, control & pad use) and urinary irritation/obstruction (frequency, pain/burning, weak/incomplete). Bowel issues comprised urgency, frequency, leakage, bleeding and pain. The sexual domain comprised ability to have erections, their firmness, and frequency when needed; also, quality of orgasms and overall sexual function.

All of the study’s findings relate to how much patient evaluations changed compared to their baseline evaluations in the urinary, rectal and sexual quality of life domains. We expect that the radiation therapies that do the least damage will show the least deterioration in the patient perceptions in each domain.

Because the study was not randomized, and it did not attempt to match triplets of patients on their demographics and co-morbidities, we have the difficulty of comparing results in different kinds of patients. The analysis of patient characteristics across treatments revealed only one real glaring discrepancy – LDRBT patients were 5 years younger than the rest. The authors made some attempt to restore comparability by only looking at sexual scores among patients who were 60 years of age or older, but such analyses were limited in their published results. In my opinion, they ought to have computed age-adjusted scores in all domains. The failure to do so will compound the difficulties in interpreting results as they carry their tracking into the future when the aging of the study population has greater effects.


In this part we’ll look at the results of their analysis. The authors did a great job of compiling a vast amount of information. Even so, in some cases, I wish more of the information had been presented (I was able to see the full text). Perhaps they will reveal more of the details in future analyses of this rich database.

Change from Baseline

The following table shows the EPIC score change from baseline after two years among patients having each kind of therapy. The last column shows, for reference, the minimum amount of change that has been found to be clinically important for that set of symptoms.

Urinary- irritative/obstructive
Urinary - incontinence
* Change is statistically significant
†Among those with scores over 60 at baseline (to help compensate for age-related differences).

Sexual status was the domain that was most affected by all the treatments. For LDRBT, it had the greatest deterioration. Deterioration in urinary and bowel scores were statistically significant and clinically meaningful in patients who had LDRBT. IMRT also had its greatest impact on sexual status, and not much different from LDRBT. Other than sexual status, only IMRT bowel scores deteriorated meaningfully; urinary status returned to near baseline. SBRT had the smallest change in sexual status, albeit large enough to be meaningful. Bowel and urinary status returned to baseline.

Minimal Clinically Detectable Change

The authors also looked at what% of patients suffered a minimal clinically detectable (MCD) change in each of those components of their quality of life over time. The typical pattern was a sharp increase at 1 or 2 months (acute effects). In all but sexual scores, that was followed by improvement. Predictably, urinary irritation/obstructive were most impacted, reaching about 90% at two months for LDRBT, and significantly better at all time points for IMRT and SBRT. The proportion who had MCD bowel symptoms and sexual symptoms was consistently more favorable for SBRT than for LDRBT or IMRT.

As a measure of the severity of symptoms, the authors looked at the % of patients who suffered an MCD increase of twofold or more over baseline after two years:

Urinary (all)
None of the above
All of the above

In general, large clinical deteriorations in QOL were about twice as frequent for LDRBT compared to SBRT, with IMRT falling in the middle.

Symptom Severity over Time

As another measure of symptom severity, the table below shows the% change versus baseline in the proportion who rated their symptoms as moderate to severe, at 1-2 months and at 2 years:


2 mos.
24 mos.
2 mos.
24 mos.
1 mo.
24 mos.
Urinary (all)
Erectile dysfunction†
† inability to have erections, among patients of all ages

Moderate to severe acute urinary and rectal side effects increased markedly for LDRBT and IMRT. For SBRT, they increased much less and returned to slightly better than baseline levels.

Keeping in mind that LDRBT patients were a median of 5 years younger than the other two groups, the increase in erectile dysfunction among LDRBT patients is troubling.  As we saw in a recent study, the deterioration occurs earlier than was previously thought. For SBRT, in contrast, there was only a +5% increase in erectile dysfunction severity at two months after treatment, but that increased to +11% by two years. Nevertheless, that was still lower than the other two therapies.


In this section, we will make an attempt to explain the findings of the study and draw whatever conclusions we can from them.

We have seen a very consistent pattern across all the measures of QOL and in all of the domains: LDRBT patients did worst, SBRT patients did best, and IMRT patients were in between. Why should that be? Let’s examine a few hypotheses:

Patient selection/non-random

This was not a randomized comparative trial, so it is possible that the LDRBT patients selected were, for some reason, more prone to the damaging effects of radiation. This argument is weakened by the fact that they were 5 years younger, and their urinal, rectal and erectile function at baseline were better than in the other two groups.

Better practitioners not represented

Some of the top LDRBT practitioners like Peter Grimm, Michael Zelefsky, Brian Moran, and Gregory Merrick, to name a few, were not represented here. One could also argue in the other direction that some of the most experienced SBRT practitioners, like Christopher King, Alan Katz, and Debra Freeman, were not represented here. Their results might have increased comparative favorability of the SBRT results still further. However, the results do seem to be comparable to those reported by Katz and the 8-institution consortium.

Time of treatment

IMRT and LDRBT results were based on best practice in 2003-2006, while SBRT was based on patients treated in 2007-2011. There were technological improvements in both modalities since then that might make their outcomes more comparable to SBRT. As radiation technology continues to evolve, it becomes problematic to choose among them based on past performance.

Hypofractionation spares healthy tissue

Hypofractionation (SBRT or HDRBT) – radiation applied in fewer treatments (or fractions) – has been found to kill cancer cells more efficiently than normal fractionation (IMRT) or continuous fractionation (LDRBT). Because prostate cancer is especially susceptible to hypofractionation (technically, we say it has a low alpha/beta ratio of about 1.5), and because healthy nearby early-responding tissues are less susceptible (they have a higher alpha/beta ratio of about 10), healthy tissues are better spared by it.

A convenient measure for comparing the dose seen by nearby healthy tissues is something called the biologically effective dose (BED). We can compute for each modality the maximum BED experienced by nearby early-responding tissues that are responsible for acute side effects. With SBRT (7.5 Gy X 5 fractions), the BED to those tissues is 30% less than the dose from IMRT (1.8 Gy X 44 fractions). For LDRBT (144 Gy I-125 Rx dose), the maximum BED to those tissues is 56% greater than the dose from IMRT. ). Making comparisons solely on BED is problematic because LDRBT radiation is extremely short range, so a lower proportion of the bladder and rectum surface may be exposed to that maximum dose.

Dose constraints

Radiation oncologists set strict dose constraints for the bladder, urethra, rectum, and sometimes to the penile bulb, limiting the volume of those organs that receive potentially toxic doses. However, there is only so much that doses can be limited if they are to effectively kill the cancer in the prostate. I don’t know what dose constraints were set for the three modalities examined in this study. We can only assume that they used best practices.


The imaging of the pelvic organs both in planning and in the application of radiation makes a large difference in toxicity. This is where SBRT shines. SBRT commonly uses a fused image of a CT and MRI with fiducials or transponders in place for planning. This helps to precisely predetermine, down to less than a millimeter, where all the beams will be directed. These practices can be used with IMRT as well. However, with IMRT, the images are aligned only once per session, whereas with SBRT, the images are aligned continually throughout the session. We recently saw how disastrous SBRT could be without intra-fractional motion tracking. LDRBT seed placement is commonly accomplished under ultrasound image guidance, using computerized intra-operative planning. The ultrasound can help the doctor see where the needles are going, but it can’t see the seeds well. Even stranded seeds tend to move, the prostate is moved by each needle insertion, and the prostate swells throughout the procedure, so that it is impossible to know where their final position will be. An image is obtained about a month later, after the swelling subsides, to check for major discrepancies in seed positions and to give an after-the-fact reading of the doses absorbed by organs at risk.

Late term effects

This study tracked patients for two years, which is long enough for most of the late-term side effects to show up. However, some will inevitably show up even later. Some tissues, particularly some in the bowel, are “late responding” to radiation damage. Late responding tissues are relatively more sensitive to the concentrated radiation of SBRT (they have an alpha/beta ratio of 3-5), so it is possible that SBRT’s advantage will decrease with longer follow up.


Although one can quibble over methodological issues in comparing the modalities, SBRT certainly provides excellent quality of life to treated patients. SBRT also is the most convenient of the treatments, requiring only five short visits, no intrusive procedures (other than fiducial placement), and no anesthesia. LDRBT is the winner on cost of treatment, with a $17,000 median Medicare reimbursement, followed by SBRT ($22,000) and IMRT ($31,000). However, a full cost analysis should also include the costs of managing the side effects of treatment, which seem to be much lower for SBRT and higher for LDRBT. Based on the findings of this study, and approximately equivalent oncological control for the 3 modalities in favorable risk patients, it is hard to justify IMRT. Availability is an issue: IMRT is available everywhere, while there is less access to excellent practitioners of SBRT (usually as CyberKnife®) and LDRBT. Some insurance still will not cover SBRT, although that is less often a barrier now.

An oft-heard argument against SBRT is that there’s not enough long-term data. SBRT is the youngest of the three modalities, used against prostate cancer since 2003. The longest-running SBRT study, has 7 years of follow up on 515 patients. For comparison, robotic prostatectomy has been used since 2000, and has never been proven superior to open surgery in a randomized comparative trial. IMRT, likewise, has never been evaluated in a comparative randomized trial, and in its current form, using dose escalation and precision IGRT techniques, was only begun in the mid-1990s. The longest-running IMRT study, at Memorial Sloan Kettering, has 10 years of follow up on 170 patients. LDRBT has been used, in some form, for over a hundred years. However, in its modern form with dose escalation and intra-operative planning methods, there are no studies older than 15 years that have any decisional value. I have often bemoaned the problem of “irrelevance” in long-term clinical studies: by the time we get the results, technology and practice have changed so much that the results have become irrelevant in making decisions among the best available therapies.

While this study raises the hypothesis that SBRT may be superior to IMRT and LDRBT, it is prudent for the patient to keep them all in his consideration set at least until the results of randomized comparative trials become available. This study should influence patients and clinicians to give serious consideration to SBRT.

Later this year, we will have the early results from Sweden of a randomized clinical trial of SBRT versus IMRT in intermediate-risk patients. There are several more comparative trials that are scheduled for completion in the coming years. If they confirm the results of this study, it will be difficult to justify IMRT as first-line therapy. Unfortunately, as far as I know, there are none planned comparing SBRT and LDRBT. There are few institutions that offer both modalities (Memorial Sloan Kettering is an exception), so randomization would be problematic.