Expert Point of View: David Beyer, MD

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David Beyer, MD

These three studies help support radiation oncologists who have already adopted hypofractionation in selected cases. The standard of care will change slowly.

—David Beyer, MD

In an interview with The ASCO Post, incoming ASTRO President David Beyer, MD, provided his perspective on the use of hypofractionation in prostate cancer. Dr. Beyer is Medical Director of the Cancer Centers of Northern Arizona in Sedona.

“Fractionation has been an important topic over the past few years. It’s had been on our radar in breast, lung, and head and neck cancers, and the question is whether we can deliver radiation therapy more quickly without compromising efficacy or safety. The three studies asked the same question with different modifications and different endpoints to answer the question of how many weeks of a man’s life does he need to give up to get radiation,” Dr. Beyer explained. “Even with hypofractionation, he is still coming in for treatment for a number of days.”

Several investigators are looking at ways to cut down the associated costs and timing of radiation therapy, including techniques such as brachytherapy or stereotactic body radiation therapy.

More on the Three Studies

The study by Incrocci et al. was mounted to show that hypofractionation is better than conventional radiation therapy and that larger fractions given on fewer days will lead to better outcomes. “There are theoretical reasons why that might be the case. The unique biology of prostate cancer might be more amenable to bigger doses. However, the outcomes in this trial were equivalent,” Dr. Beyer noted.

The next study by Lee, Sandler, and colleagues proved noninferiority of hypofractionation vs conventional fractionation. Outcomes were similar with the two techniques.

“Two studies that ask the same questions using different statistical approaches end up in the same place: Is cancer control the same? They indicate that it is,” he continued.

The third study by Shaikh et al. asked a different but important question related to the patient’s perspective on outcomes, Dr. Beyer continued. “There are subtle differences in the regimens. The data from Shaikh et al. are fairly mature. There is no difference in patient-reported outcomes for hypofractionation vs conventional fractionation with intensity-modulated radiation therapy,” Dr. Beyer stated.

Moving Forward Cautiously

“These three studies explored the issue of whether we can start to give our treatments more quickly. I think the answer is probably yes. But when do we get to the point where that becomes standard of care? It is unclear how many studies need to be done to cross that threshold,” revealed Dr. Beyer. “These three studies all show equivalence, but other studies have shown greater toxicity, and some radiation oncologists are leery about adopting this as a new standard too quickly.”

Dr. Beyer continued: “In most practices, radiation oncologists are starting to consider hypofractionation in selected patients. It depends on the practice environment; I won’t make a wholesale shift in my patients. But for patients who have travel issues, I can look them in the eye and say, ‘You don’t have to give me 2 months of your life.’”

“People who support hypofractionation based on economics are probably pushing the envelope further. There are still more studies to consider, and an even shorter regimen of 5 fractions or brachytherapy may be an alternative,” he added.

Dr. Beyer concluded: “These three studies help support radiation oncologists who have already adopted hypofractionation in selected cases. The standard of care will change slowly. The main advantages of hypofractionation are fewer clinic visits and more time to enjoy your life. In areas where there are physician and technology shortages, hypofractionation could be safely adopted. The impetus is to find ways to be less wasteful.” ■

Disclosure: Dr. Beyer reported no potential conflicts of interest.


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