Use Of Short-course Radiotherapy Research Articles

Implementation Strategies to Promote Short-Course Radiation for Bone Metastases

For patients with nonspine bone metastases, short-course radiotherapy (RT) can reduce patient burden without sacrificing clinical benefit. However, there is great variation in uptake of short-course RT across practice settings. To evaluate whether a set of 3 implementation strategies facilitates increased adoption of a consensus recommendation to treat nonspine bone metastases with short-course RT (ie, ≤5 fractions). This prospective, stepped-wedge, cluster randomized quality improvement study was conducted at 3 community-based cancer centers within an existing academic-community partnership. Rollout was initiated in 3-month increments between October 2021 and May 2022. Participants included treating physicians and patients receiving RT for nonspine bone metastases. Data analysis was performed from October 2022 to May 2023. Three implementation strategies-(1) dissemination of published consensus guidelines, (2) personalized audit-and-feedback reports, and (3) an email-based electronic consultation platform (eConsult)-were rolled out to physicians. The primary outcome was adherence to the consensus recommendation of short-course RT for nonspine bone metastases. Mixed-effects logistic regression at the bone metastasis level was used to model associations between the exposure of physicians to the set of strategies (preimplementation vs postimplementation) and short-course RT, while accounting for patient and physician characteristics and calendar time, with a random effect for physician. Physician surveys were administered before implementation and after implementation to assess feasibility, acceptability, and appropriateness of each strategy. Forty-five physicians treated 714 patients (median [IQR] age at treatment start, 67 [59-75] years; 343 women [48%]) with 838 unique nonspine bone metastases during the study period. Implementing the set of strategies was not associated with use of short-course RT (odds ratio, 0.78; 95% CI, 0.45-1.34; P = .40), with unadjusted adherence rates of 53% (444 lesions) preimplementation vs 56% (469 lesions) postimplementation; however, the adjusted odds of adherence increased with calendar time (odds ratio, 1.68; 95% CI, 1.20-2.36; P = .003). All 3 implementation strategies were perceived as being feasible, acceptable, and appropriate; only the perception of audit-and-feedback appropriateness changed before vs after implementation (19 of 29 physicians [66%] vs 27 of 30 physicians [90%]; P = .03, Fisher exact test), with 20 physicians (67%) preferring reports quarterly. In this quality improvement study, a multicomponent set of implementation strategies was not associated with increased use of short-course RT within an academic-community partnership. However, practice improved with time, perhaps owing to secular trends or physician awareness of the study. Audit-and-feedback was more appropriate than anticipated. Findings support the need to investigate optimal approaches for promoting evidence-based radiation practice across settings.

Pathologic Outcomes of Short-Course and Long-Course Radiotherapy for Locally Advanced Rectal Cancers Treated With Total Neoadjuvant Therapy.

Total neoadjuvant therapy (TNT) for patients with locally advanced rectal cancer (LARC) is now the standard of care. Randomized trials suggest the use of short-course radiotherapy (SCRT) and long-course radiotherapy (LCRT) are oncologically equivalent. To describe pathologic outcomes after surgical resections of patients receiving SCRT versus LCRT as part of TNT for LARC. All patients with LARC treated at a single tertiary hospital who underwent proctectomy after completing TNT were included. Patients were excluded if adequate details of TNT were not available in the electronic medical record. A total of 53 patients with LARC were included. Thirty-nine patients (73.5%) received LCRT and 14 (26.4%) received SCRT. Forty-nine patients (92.5%) were clinical stage III (cN1-2) prior to treatment. The average lymph node yield after proctectomy was 20.9 for SCRT and 17.0 for LCRT (P = .075). Of the 49 patients with clinically positive nodes before treatment, 76.9% of those who received SCRT and 72.2% of those who received LCRT achieved pN0 disease after TNT. Additionally, there were no significant differences in rates of pathologic complete response between patients who received SCRT and LCRT, 7.1% and 12.8%, respectively (P = .565). Pathologic outcomes of patients with LARC treated with SCRT or LCRT, as part of TNT, may be similar. Further prospective trials are needed to assess long-term clinical outcomes and to determine best treatment protocols.

The impact of oncological package implementation on the treatment of rectal cancer in years 2013–2019 in Poland – multicenter study

<b><br>Introduction:</b> In 2015, in Poland, the oncological package (OP) was established. This law constituted a fast track of oncological diagnosis and treatment and obligatory multidisciplinary team meetings (MDT).</br> <b><br>Aim:</b> The aim of this study was to analyze the impact of OP on rectal cancer treatment.</br> <b><br>Methods:</b> The study was a multicenter, retrospective analysis of data collected from five centers. It included clinical data of patients operated on due to rectal cancer between 2013 and 2019. For most analyses, patients were categorized into three groups: 2013–2014 – before OP (A), 2015–2016 – early development of OP (B), 2017–2019 – further OP functioning (C).</br> <b><br>Results:</b> A total of 1418 patients were included. In all time intervals, the majority of operations performed were anterior resections. There was a significantly lower local tumor stage (T) observed in subsequent time intervals, while there were no significant differences for N and M. In period C, the median of resected nodes was significantly higher than in previous periods. Four of the centers showed an increasing tendency in the use of preoperative radiotherapy. The study indicated a significant increase in the use of short-course radiotherapy (SCRT) and a decrease in the number of patients who did not receive any form of preoperative therapy in subsequent periods. In the group that should receive radiotherapy (T3/4 or N+ and M0), the use of SCRT was also significantly increasing.</br> <b><br>Conclusions:</b> In the whole cohort, there was a significant increase in the use of preoperative radiotherapy and a decrease in the T stage, changing with the development of OP. Nevertheless, this relation is indirect and more data should be gathered for further conclusions.</br>

Short-course radiotherapy for rectal cancer: real-world evidence in Argentina.

Short-course radiotherapy (SCRT) of 25 Gy in five daily fractions is a recommended strategy in the neoadjuvant setting for resectable locally advanced rectal cancer (LARC), as well as in cases of metastatic disease for local control. There is scarce information regarding the use of SCRT for patients who have received nonoperative management. To describe the characteristics of patients who received treatment with SCRT for LARC and metastatic rectal cancer, toxicity, and the approach after radiation treatment. This is a retrospective analysis of all patients who underwent SCRT for rectal cancer at the Alexander Fleming Institute from March 2014 to June 2022. In total, 44 patients were treated with SCRT. The majority were male (29, 66%), with a median age of 59 years (interquartile range 46-73). Most patients had stage IV disease (26, 59.1%), followed by LARC (18, 40.9%). Most lesions were located in the middle rectum (30, 68%). The majority of LARC patients underwent SCRT followed by consolidation chemotherapy (ChT) (16/18, 89%), while most patients with metastatic disease underwent SCRT followed by consolidation ChT (14/26, 53.8%). A clinical complete response (cCR) was documented in 8/44, 18.2% of patients. Most patients with LARC and cCR were managed by a watch and wait approach (5/18, 27.7%). Local recurrence was observed in LARC cases (2/18, 11.1%). Patients who underwent SCRT following consolidation ChT were more likely to have adverse events (AEs) than those undergoing induction ChT following SCRT (11/30, 36.7% versus 3/12, 25%, p = 0.02). In a subgroup of patients diagnosed with LARC and treated with SCRT followed by ChT, surgical treatment could be omitted after they achieved a cCR. Local recurrence was similar to that reported in a previous study. SCRT is a reasonable option for local disease control in stage IV disease, yielding low toxicity rates. Therefore, decisions must be made by a multidisciplinary team. Prospective studies are necessary to reach further conclusions.

Trends in Use of and Medicare Spending on Short-Course Radiotherapy for Lymphomas From 2015 to 2019

This cross-sectional study uses Centers for Medicare & Medicaid Services payment data to examine use of short-course radiotherapy from 2015 to 2019 among Medicare beneficiaries with indolent lymphoma.

PO-1258 Pragmatic and effective use of short course radiotherapy for stage IV rectal cancer

PO-1258 Pragmatic and effective use of short course radiotherapy for stage IV rectal cancer

P-265 Neoadjuvant radiotherapy for locally advanced rectal cancer during the first wave of COVID19 pandemic: Guy’s cancer cohort experience

The Covid-19 pandemic is a healthcare emergency with a significant impact on cancer services provision. In March 2020, our institution adopted the ESMO expert consensus guidelines for radiotherapy management of rectal cancer during the pandemic. Here we present short-term oncological outcomes of this approach compared to the same period in 2018. Patients who underwent neoadjuvant (chemo) radiotherapy for rectal cancer between 1st March 2020 and 31 May 2020 were identified from a research ethics committee (REC)-approved research database for cancer patients (Guy’s Cancer Cohort). Patient demographics and treatment characteristics were extracted and compared with a control cohort treated in the same period in 2018. The definition of local response was based on identification of downstaging on re-staging Magnetic Resonance Imaging (MRI) post neoadjuvant treatment (mrT3c/d-4 to mrT0-2 and mrT2 to mrT0-1) and classified in a binary format (response vs no response). In addition, in patients who underwent total mesorectal excision (TME), neoadjuvant rectal (NAR) score was calculated, as described previously, and classified into low (<8), intermediate (>=8<=16) and high (>16). The frequency of MRI and pathological response was compared using non-parametric Fisher exact test. Thirty patients were treated in the three-month period in 2020 as compared with 21 in 2018 (43% increase). No statistically significant differences were observed in baseline tumour characteristics. The use of neoadjuvant short-course radiotherapy (SCRT) treatment increased significantly from 19% of cases in 2018 to 50% during the pandemic, which was reflected in reduced radiotherapy-related hospital footfall (median 15 appointments in 2020 vs 25 appointments in 2018). While the use of concomitant fluoropyrimidines was lower (47 vs 71%), the use of induction chemotherapy was higher (30 vs 19%) in 2020 compared to 2018, which may reflect more prevalent use of total neoadjuvant treatment. There was no difference in the proportion of MRI responders between cohorts (52% in 2020 vs 38% in 2018). In patients who underwent TME, there was no difference in the proportion of R1 resection (0 in 2020 vs 9% in 2018), median NAR scores (8 (1-30) in 2020 v 15 (range 4-50) in 2018) or NAR score categories (22% good responders, 64% intermediate and 14% non-responders during Covid-19 vs 9% good responders, 55% intermediate and 36% non-responders in 2018). Changes in radiotherapy treatment of rectal cancer during Covid-19 pandemic, including more frequent use of SCRT (often in combination with neoadjuvant chemotherapy), did not seem to have negatively impacted short-term oncological outcomes, as measured by MRI downstaging rates and NAR scores following TME. The effect of the pandemic on medium and long-term oncological outcomes is still awaited.

A Prospective Observational Study Comparing Long-Course Conventional Neoadjuvant Chemoradiotherapy with Short-Course Radiotherapy Followed by Consolidation Chemotherapy with Delayed Surgery in Locally Advanced Rectal Cancer.

Background Polish and Australian randomized studies compared short-course radiotherapy (RT) with immediate surgery and long-course chemoradiotherapy (CRT) with delayed surgery. In these studies, similar long-term survival and local control have been reported for both these approaches, but pathological complete response (pCR) is not better with short-course RT. Moreover, studies have shown better tumor downstaging with delayed surgery. In this context, the use of short-course RT with delayed surgery may have some advantages and needs to be tested in clinical trials. Patients and Methods This was a two-arm, prospective, observational study, in which preoperative short-course RT followed by two cycles of chemotherapy was compared with the conventional neoadjuvant CRT in locally advanced rectal cancer. The primary end points were the rate of complete response and toxicity profile. The secondary end points were the rate of R0 resection, overall survival, and progression-free survival. The data obtained from the two arms were analyzed using Pearson’s chi-square test to determine the statistical significance between the two treatment arms. Results The pCR rate was 6.7% in the study arm and 0 in the control arm ( p = 0.343). The RO resection rates were 92.8 and 92.3% in the study and control arms, respectively. The rates of grade 3and 4 acute toxicity in the study and control arms were 14.2 and 61.5%, respectively ( p = 0.011). The rates of grade 3 and 4 late toxicity in the study and control arms were 21.4 and 15.3%, respectively ( p = 0.686). Conclusions The pCR rates and the late toxicities in both arms are comparable. The major advantages of the 5 × 5 Gy regimen with chemotherapy in a neoadjuvant setting are a significant reduction in acute toxicities and better patient compliance along with similar efficacy as that of the standard regimen.

MRI response rate after short-course radiotherapy on rectal cancer in the elderly comorbid patient: results from a retrospective cohort study

BackgroundThe aim of the present study was to evaluate MRI response rate and clinical outcome of short-course radiotherapy (SCRT) on rectal cancer as an alternative to chemoradiotherapy in patients where downstaging is indicated.MethodsA retrospective analysis was performed of a patient cohort with rectal carcinoma (cT1-4cN0-2 cM0–1) from a large teaching hospital receiving restaging MRI, deferred surgery or no surgery after SCRT between 2011 and 2017. Patients who received chemotherapy during the interval between SCRT and restaging MRI were excluded.The primary outcome measure was the magnetic resonance tumor regression grade (mrTRG) at restaging MRI after SCRT followed by a long interval. Secondary, pathological tumor stage, complete resection rate and 1-year overall survival were assessed.ResultsA total of 47 patients (M:F = 27:20, median age 80 (range 53–88) years), were included. In 33 patients MRI was performed for response assessment 10 weeks after SCRT. A moderate or good response (mrTRG≤3) was observed in 24 of 33 patients (73%). While most patients (85%; n = 28) showed cT3 or cT4 stage on baseline MRI, a ypT3 or ypT4 stage was found in only 20 patients (61%) after SCRT (p < 0.01). A complete radiologic response (mrTRG 1) was seen in 4 patients (12%). Clinical N+ stage was diagnosed in n = 23 (70%) before SCRT compared to n = 8 (30%) post-treatment (p = 0.03).After SCRT, 39 patients underwent deferred surgery (after a median of 14 weeks after start of SCRT) and a resection with complete margins was achieved in 35 (90%) patients. One-year overall survival after surgery was 82%. Complete pathological response was found in 2 patients (5%).ConclusionsThe use of SCRT followed by a long interval to restaging showed a moderate to good response in 73% and therefore can be considered as an alternative to chemoradiotherapy in elderly comorbid patients.

The Financial Impact of Fractionation Scheme and Treatment Planning Method for Rectal Cancer in the United States

BackgroundPreoperative long-course chemoradiotherapy (CRT) and short-course radiotherapy (SCR) for locally advanced rectal cancer (LARC) were found to have equivalent outcomes in 3 randomized trials. SCR has not been widely adopted in the United States (US). Three-dimensional (3D) treatment planning is standard, whereas intensity-modulated radiotherapy (IMRT) is controversial. In this study, we assessed the economic impact of fractionation scheme and planning method for payers in the US. Materials and MethodsWe performed a population-based analysis of the total cost of radiotherapy for LARC in the US annually. The national annual target population was calculated using the Surveillance, Epidemiology, and End Results database. Radiotherapy costs were based on billing codes and 2018 pricing by Medicare's Hospital Outpatient Prospective Payment System. ResultsWe estimate that 12,945 patients with LARC are treated with radiotherapy annually in the US. The cost of CRT with 3D or IMRT is US $15,882 and $23,745 per patient, respectively. With SCR, the cost with 3D or IMRT is $5,458 and $7,323 per patient, respectively. The use of SCR would lead to 53% to 77% annual savings of $106,168,871 to $232,105,727 compared with CRT. IMRT increases the total cost of treatment by 34% to 50%, and if adopted widely, would lead to an excess cost of $24,152,134 and $101,784,723 annually with SCR and CRT, respectively. ConclusionsSCR may have the potential to save approximately US $106 to t232 million annually in the US, likely without impacting outcomes. Lack of evidence showing benefit with costly IMRT should limit its use to clinical trials. It would be reasonable for public and private payers to consider which type of radiation is most suited to reimbursement.

The financial impact of fractionation scheme and treatment planning method for rectal cancer in the United States.

6518 Background: Preoperative long-course chemoradiotherapy (CRT) and short-course radiotherapy (SCR) for locally advanced rectal cancer (LARC) were found to have equivalent outcomes in three randomized trials. SCR may have lower acute toxicity and the down-staging following CRT is more well-established. At present, SCR is frequently used in Europe but has not been widely adopted in the United States (US). It is standard to deliver radiotherapy by 3D planning, while the use of Intensity-modulated radiotherapy (IMRT) is controversial. In recent years there has been an increasing focus on understanding the cost and value of cancer care. In this study we aimed to assess the economic impact of fractionation scheme and treatment planning method for payers in the US. Methods: We performed a population-based analysis of the total cost of radiotherapy for LARC in the US annually. The national annual target population of patients was calculated using the Surveillance, Epidemiology, and End Results (SEER) database. Treatment costs for various fractionation schemes were based on billing codes and 2018 pricing by Medicare's Hospital Outpatient Prospective Payment System (OPPS). The cost of chemotherapy was based on the Payment Allowance Limits for Medicare Part B Drugs by Centers for Medicare and Medicaid Services (CMS). Results: We estimate that 12,945 patients with LARC are treated with radiotherapy annually in the US. The cost of CRT with 3-D or IMRT is US$ 15,881.76 and US$ 23,744.82 per patient, respectively. With 3-D SCR the cost is US$ 5,457 per patient. The use of SCR would lead to 64-77% annual savings of US$ 125,701,387 - US$ 236,727,934 in the US compared with 3-D and IMRT based CRT, respectively. IMRT based planning increases the total cost of CRT by 49% and if adopted widely would lead to an excess cost of US$ 101,787,312 annually. Conclusions: SCR may have the potential to save in the region of US$ 0.12-0.23 billion annually in the US, likely without impacting outcomes. Lack of evidence showing benefit with costly IMRT should limit its use to clinical trials. SCR may also lead to lower personal financial toxicity. It would be reasonable for public and private payers to consider which type of radiation is most suited to reimbursement.

Short-Course Radiation Therapy Versus Long-Course Chemoradiation in the Neoadjuvant Treatment of Locally Advanced Rectal Cancer: New Insights from Randomized Trials

Examine prospective evidence supporting preoperative short-course radiotherapy (SCRT) and long-course chemoradiotherapy (LCRT) for locally advanced rectal cancer and discuss recently published data that are helping to clarify the utility of SCRT. SCRT with early surgery results in lower pCR rates, lower severe acute toxicities, no difference in late toxicities, and no apparent difference in local control, DFS, and OS when compared with LCRT. When surgery is delayed after SCRT, cancer outcomes appear equivalent, including pCR rates. The addition of full-dose systemic therapy with SCRT prior to surgery is attractive to further downstage patients, particularly in patients at high risk of distant relapse. Increasing randomized evidence is accumulating to support the use of SCRT as an acceptable preoperative treatment approach for locally advanced rectal cancer. Increasing the interval from SCRT to surgery and/or adding systemic doses of chemotherapy may mitigate potential concerns related to SCRT. More mature data and future results of ongoing randomized trials will help clarify the oncologic equivalence and safety of SCRT followed by preoperative chemotherapy.

Low rates of local recurrence after surgical resection of rectal cancer suggest a selective policy for preoperative radiotherapy

Preoperative short-course radiotherapy (SCRT) is increasingly recommended to reduce local recurrence after surgery for rectal cancer. Its avoidance may be beneficial, however, if the risk of local recurrence is low. We report a single centre experience which suggests that selective rather than uniform use of SCRT may be the best approach. Analysis was carried out on a prospectively collected unselected series of 1606 patients with rectal cancer treated in one centre. Follow-up was 97% complete. SCRT was performed selectively and all patients had a mesorectal excision. Among 940 patients undergoing a potentially curative major resection the operative mortality was 4.6%, the permanent stoma rate 23% and the crude 5-year survival 61%. The local recurrence rate after curative anterior resection was 2.9% and 7.7% after abdominoperineal excision. The overall local recurrence rate after a potentially curative major resection was 4.0%. The routine use of preoperative radiotherapy for rectal cancer is probably not justified where local recurrence after curative rectal resection is uncommon.

Neoadjuvant Radiotherapy for Non-Fixed Rectal Cancer: The Logical Choice

The inaccuracy of our current pretreatment staging methods, the better efficacy and lower toxicity of neoadjuvant radiotherapy as compared with postoperative radiotherapy, and the additive effect of meticulous surgical technique and radiotherapy make the treatment of patients with non-fixed, uT3N0 rectal adenocarcinoma with neoadjuvant radiotherapy the logical choice. The use of short-course radiotherapy (2000 to 2500 cGy in 5 fractions) may be the best option for the majority of these patients.