On 2014 Jun 16, S Sundar commented:

Medical paternalism in prostate radiotherapy.

Authors: Dr S.Sundar & colleagues (E.F, G.W, R.T)

The MRC RT01 randomised trial has shown no overall survival benefit for escalated doses of radiation in prostate cancer( 1). This complete lack of overall survival benefit for higher doses of radiation is a consistent finding across many well designed randomised trials (2). It is a fundamental radiobiological fact that radiation toxicity is directly proportional to total dose of radiation administered. So, not surprisingly, escalated doses of radiation has been associated with higher toxicity across the randomised trials (2).

In spite of the lack of overall survival benefit coupled with higher radiation toxicity, escalated doses of radiation have inexplicably become the international standard of care. Various guidelines including National Institute for Health and Care Excellence (NICE) guideline (CG 175) recommend escalated doses of radiation with the NICE guideline making a specific recommendation of at least 74 Grays of radiation.

If escalated radiation dose is treated in the same way as a pharmacological drug, it certainly would not have been accepted as a universal standard of care due to higher toxicity and lack of overall survival benefit. Medical paternalism seems rife in prostate radiotherapy. A patient preference study from Netherlands has demonstrated that prostate patients prefer lower toxicity and are happy to trade off efficacy for better quality of life. However,more importantly, physicians were poor in predicting this patient preference(3)(4).

Radiation oncologists need to shed medical paternalism and engage patients. They should explain the pros and cons of escalated doses of radiation, may be with the us of decision aids, and help patients make an informed choice. Radiation oncologists need to demonstrate evidence based medicine particularly when there is an ongoing debate about appropriate use of prostate radiotherapy in urologist owned radiation facilities (5).

References: 1 Dearnaley DP, Jovic G, Syndikus I, et al. Escalated-dose versus control-dose conformal radiotherapy for prostate cancer: long-term results from the MRC RT01 randomised controlled trial. Lancet Oncol 2014. doi:10.1016/S1470-2045(14)70040-3.

2 Viani GA, Stefano EJ, Afonso SL. Higher-than-conventional radiation doses in localized prostate cancer treatment: a meta-analysis of randomized, controlled trials. Int J Radiat Oncol Biol Phys 2009; 74: 1405–18.

3 Van Tol-Geerdink JJ, Stalmeier PFM, van Lin ENJT, et al. Do patients with localized prostate cancer treatment really want more aggressive treatment? J Clin Oncol Off J Am Soc Clin Oncol 2006; 24: 4581–6.

4 Stalmeier PFM, van Tol-Geerdink JJ, van Lin ENJT, et al. Doctors’ and patients’ preferences for participation and treatment in curative prostate cancer radiotherapy. J Clin Oncol Off J Am Soc Clin Oncol 2007; 25: 3096–100.

5 Mitchell JM. Urologists’ use of intensity-modulated radiation therapy for prostate cancer. N Engl J Med 2013; 369: 1629–37.

On 2014 Jun 16, S Sundar commented:

Medical paternalism in prostate radiotherapy.

Authors: Dr S.Sundar & colleagues (E.F, G.W, R.T)

The MRC RT01 randomised trial has shown no overall survival benefit for escalated doses of radiation in prostate cancer( 1). This complete lack of overall survival benefit for higher doses of radiation is a consistent finding across many well designed randomised trials (2). It is a fundamental radiobiological fact that radiation toxicity is directly proportional to total dose of radiation administered. So, not surprisingly, escalated doses of radiation has been associated with higher toxicity across the randomised trials (2).

In spite of the lack of overall survival benefit coupled with higher radiation toxicity, escalated doses of radiation have inexplicably become the international standard of care. Various guidelines including National Institute for Health and Care Excellence (NICE) guideline (CG 175) recommend escalated doses of radiation with the NICE guideline making a specific recommendation of at least 74 Grays of radiation.

If escalated radiation dose is treated in the same way as a pharmacological drug, it certainly would not have been accepted as a universal standard of care due to higher toxicity and lack of overall survival benefit. Medical paternalism seems rife in prostate radiotherapy. A patient preference study from Netherlands has demonstrated that prostate patients prefer lower toxicity and are happy to trade off efficacy for better quality of life. However,more importantly, physicians were poor in predicting this patient preference(3)(4).

Radiation oncologists need to shed medical paternalism and engage patients. They should explain the pros and cons of escalated doses of radiation, may be with the us of decision aids, and help patients make an informed choice. Radiation oncologists need to demonstrate evidence based medicine particularly when there is an ongoing debate about appropriate use of prostate radiotherapy in urologist owned radiation facilities (5).

References: 1 Dearnaley DP, Jovic G, Syndikus I, et al. Escalated-dose versus control-dose conformal radiotherapy for prostate cancer: long-term results from the MRC RT01 randomised controlled trial. Lancet Oncol 2014. doi:10.1016/S1470-2045(14)70040-3.

2 Viani GA, Stefano EJ, Afonso SL. Higher-than-conventional radiation doses in localized prostate cancer treatment: a meta-analysis of randomized, controlled trials. Int J Radiat Oncol Biol Phys 2009; 74: 1405–18.

3 Van Tol-Geerdink JJ, Stalmeier PFM, van Lin ENJT, et al. Do patients with localized prostate cancer treatment really want more aggressive treatment? J Clin Oncol Off J Am Soc Clin Oncol 2006; 24: 4581–6.

4 Stalmeier PFM, van Tol-Geerdink JJ, van Lin ENJT, et al. Doctors’ and patients’ preferences for participation and treatment in curative prostate cancer radiotherapy. J Clin Oncol Off J Am Soc Clin Oncol 2007; 25: 3096–100.

5 Mitchell JM. Urologists’ use of intensity-modulated radiation therapy for prostate cancer. N Engl J Med 2013; 369: 1629–37.