In this issue of ONCOLOGY, Aneja and colleagues explore the beneficial aspects of the use of hypofractionated radiotherapy in the treatment of adenocarcinoma of the prostate. The authors make the case for use of hypofractionated radiotherapy by reviewing the literature and demonstrating that hypofractionated radiotherapy has been shown to be at least equivalent to a more fractionated course of radiotherapy in the treatment of low- and intermediate-risk adenocarcinoma of the prostate. The authors acknowledge the relatively small numbers of patients treated with either a more conventional or extreme course of hypofractionated radiotherapy—and the limited follow-up—in the studies of hypofractionation, compared with the more mature results of studies of more conventionally fractionated schedules.
One of the main points argued by Aneja et al is that the advantages offered by hypofractionated regimens are of particular importance in a financially conservative health care system. Some may not agree that the current health care system is fiscally conservative, given the projected rise in the percentage of the gross domestic product (GDP) that health care expenditures are forecasted to account for. Health care expenditures are expected to increase from 17.9% of GDP in 2009 to over 19% of GDP in 2019. The percentage may increase still further as the population ages and new treatments are developed to treat chronic diseases such as heart disease and diabetes. This figure will also undoubtedly grow still larger as newer targeted agents are used to treat metastatic cancer, with the result that some cancers will be turned into chronic diseases.
The authors make the point that hypofractionated radiotherapy will be more cost-effective because of the reduced cost of the smaller number of daily fractions. If it is assumed that Medicare reimbursement is used, and if reimbursement for just the technical component of the treatment is considered, a 35% reduction in cost would be realized with the use of a hypofractionated radiotherapy regimen consisting of 26 fractions, compared to a treatment regimen consisting of 40 fractions. This would theoretically result in a loss of revenue to the hospital or cancer center of $293,966 a year if one patient a week was treated with a 26-treatment course of hypofractionated radiotherapy. A potentially greater reduction in cost would be realized if a 5-fraction course of stereotactic body radiotherapy (SBRT) were used instead of the 40-fraction treatment course. A recent Canadian study found an average patient out-of-pocket savings of Can$1,900 if a 5-fraction course of radiotherapy was utilized instead of a 39-fraction course. The loss would obviously be greater if more patients were treated with less than a standard course of therapy.
Revenue from radiation oncology departments has traditionally been used to fund the less revenue-generating departments or areas of hospitals and cancer centers that are nonetheless vital to oncology programs. The loss in revenue from the use of hypofractionated radiotherapy could cause hospitals to re-evaluate these less profitable programs, resulting in a potential reduction in service and quality of care. In addition, the use of more hypofractionated treatment regimens, regardless of treatment site, could affect a hospital’s decision to replace aging radiotherapy equipment. A hospital’s need to trim expenses to compensate for the reduction in revenue associated with increased use of hypofractionation could also result in a decision to cut staff, especially radiation therapy staff (given that there would be fewer patients to treat), below levels needed for safe operation and treatment delivery.
On the other hand, the use of hypofractionated treatment regimens could have a positive impact. The new health care legislation currently being considered by the Supreme Court may result in payments being based on “episodes of disease.” An accountable care organization (ACO) would receive a payment to provide care for patients with a specific disease and would then distribute the payment among the participating parties. In other words, the ACO would receive $X to take care of a certain population of patients and would need to determine the most effective treatments that would keep the costs of care within the projected budget. An ACO could benefit if a 35% reduction in cost were achieved through the use of a conventionally hypofractionated regimen. An even greater savings might result from the use of an extreme hypofractionated course of treatment, although this savings would need to be measured against the increased cost of the equipment. Thus, from an episode-of-care perspective, hypofractionated treatment regimens would provide the most cost-effective method of treating some cancers.
The authors also present convincing evidence that hypofractionated radiotherapy will be more convenient for patients and their families because of the reduction in the number of daily radiotherapy fractions. Less time spent traveling to and from daily treatments would reduce the out-of-pocket expenses for patients and could also result in increases in productivity at work. This would help to further improve the cost-effectiveness of hypofractionated radiotherapy in a cost-effectiveness analysis performed from a societal perspective. However, the authors did not mention the most convenient radiotherapy treatment of prostate cancer, brachytherapy. Brachytherapy has a long history of being an effective and well-tolerated treatment for adenocarcinoma of the prostate. Brachytherapy can be performed with only a minimal number of visits and can be both the most convenient and least expensive therapy of all.
Aneja et al have articulated a convincing argument for the use of hypofractionated radiotherapy regimens in the treatment of prostate cancer. Longer follow-up of efficacy and toxicity is needed to confirm equal endpoints compared with more conventional fractionation regimens. However, hypofractionated radiotherapy could be a solution for newly formed ACOs, should the recent health care legislation be upheld by the Supreme Court.
Financial Disclosure:The author has no significant financial interest or other relationship with the manufacturers of any products or providers of any service mentioned in this article.