Nicholas B. Vogelzang, MD, moderator of the press briefing where these findings were presented, agreed that the first study supports intensity-modulated radiotherapy (IMRT) as the current standard of care. With costs of health care increasing exponentially, it is important to establish the comparative benefits of newer, more costly therapies, he said.

“There is no clear evidence that proton-beam therapy is better than IMRT, and given its cost and bowel effects, we must continue to study these modalities,” Dr. Vogelzang stated.

Regarding the second study, Dr. Vogelzang said, “This begs the question as to why brachytherapy—the least toxic and most cost-effective of the three techniques—is less used. At its inception, the target population consisted of low-risk patients, which is a limited population. With experience, doctors are becoming more comfortable expanding its use to more patients. The lower cost is impressive.”

Dr. Vogelzang is Chair and Medical Director of the Developmental Therapeutics Committee of US Oncology, Las Vegas.

Cautionary Flag

Leonard Gomella, MD, Urology Chair and Associate Director of Clinical Affairs at the Kimmel Cancer Center at Jefferson, Philadelphia, said that people often think that the newer and more expensive therapy will be better. “This large dataset shows us that what we consider a safer, better way to deliver radiation to the prostate [ie, proton-beam therapy] is not actually the case,” he commented.

“Improvements in targeting techniques have improved the side-effect profile of IMRT dramatically over the past 10 years,” he stated.

“Proton-beam therapy is the most expensive treatment available for localized prostate cancer. We have to step back and realize that although protons are of benefit in certain areas of medicine—for example, children with CNS tumors—when we expand it to the most common tumor in men, the presumed toxicity benefits are not there based on this study. The study will put up a cautionary flag in the field of radiotherapy, as some rush out to open these very expensive technology centers.”

Regarding the second study, Dr. Gomella pointed out that many people who choose certain treatments for prostate cancer make their choice based on perceived side-effect profile. This study shows that minimally invasive procedures such as prostatectomy and brachytherapy may have a better side-effect profile than external-beam radiation therapy.

“External-beam radiation therapy may not be as good as presumed in avoiding side effects of so-called more invasive treatments,” he commented.

Dr. Gomella maintained that treatment selection has to be individualized. He did think that cost should be included in the discussion, as well as comorbidities, symptoms, and patient preferences. ■

Disclosure: Dr. Gomella is Urology Chair for RTOG. Dr. Vogelzang reported no potential conflicts of interest.