Department of Radiation Oncology, St Francis Hospital, Hartford, Connecticut.
Department of Population Quantitative Health Science, Case Western Reserve University, Cleveland, Ohio.
JAMA Oncol. 2023 Dec 1;9(12):1696-1701. doi: 10.1001/jamaoncol.2023.4267.
Randomized clinical trials have demonstrated the noninferiority of shorter radiotherapy (RT) courses (termed hypofractionation) compared with longer RT courses in patients with localized prostate cancer. Although shorter courses are associated with cost-effectiveness, convenience, and expanded RT access, their adoption remains variable.
To identify the current practice patterns of external beam RT for prostate cancer in the US.
DESIGN, SETTING, AND PARTICIPANTS: This cohort study obtained data from the National Cancer Database, which collects hospital registry data from more than 1500 accredited US facilities on approximately 72% of US patients with cancer. Patients were included in the sample if they had localized prostate adenocarcinoma that was diagnosed between 2004 and 2020 and underwent external beam RT with curative intent. Analyses were conducted between February and March 2023.
Radiotherapy schedules, which were categorized as ultrahypofractionation (≤7 fractions), moderate hypofractionation (20-30 fractions), and conventional fractionation (31-50 fractions).
Longitudinal pattern in RT fractionation schedule was the primary outcome. Multivariable logistic regression was performed to evaluate the variables associated with shorter RT courses. Covariables included age, National Comprehensive Cancer Network risk group, rurality, race, facility location, facility type, median income, insurance type or status, and Charlson-Deyo Comorbidity Index.
A total of 313 062 patients with localized prostate cancer (mean [SD] age, 68.8 [7.7] years) were included in the analysis. There was a temporal pattern of decline in the proportion of patients who received conventional fractionation, from 76.0% in 2004 to 36.6% in 2020 (P for trend <.001). From 2004 to 2020, use of moderate hypofractionation increased from 22.0% to 45.0% (P for trend <.001), and use of ultrahypofractionation increased from 2.0% to 18.3% (P for trend <.001). By 2020, the most common RT schedule was ultrahypofractionation for patients in the low-risk group and moderate hypofractionation for patients in the intermediate-risk group. On multivariable analysis, treatment at a community cancer program (compared with academic or research program; odds ratio [OR], 0.54 [95% CI, 0.52-0.56]; P < .001), Medicaid insurance (compared with Medicare; OR, 1.49 [95% CI, 1.41-1.57]; P < .001), Black race (compared with White race; OR, 0.90 [95% CI, 0.87-0.92]; P < .001), and higher median income (compared with lower median income; OR, 1.28 [95% CI, 1.25-1.31]; P < .001) were associated with receipt of shorter courses of RT.
Results of this cohort study showed an increase in the use of shorter courses of RT for prostate cancer from 2004 to 2020; a number of social determinants of health appeared to be associated with reduced adoption of shorter treatment courses. Realignment of reimbursement models may be necessary to enable broader adoption of ultrahypofractionation to support technology acquisition costs.
随机临床试验已经证明，与较长的放射治疗（RT）疗程相比，局部前列腺癌患者接受较短的 RT 疗程（称为短程放疗）具有非劣效性。虽然较短的疗程与成本效益、便利性和扩大 RT 治疗机会相关，但它们的采用仍然存在差异。
确定美国外部束 RT 治疗前列腺癌的当前实践模式。
设计、设置和参与者：本队列研究从国家癌症数据库（National Cancer Database）获取数据，该数据库从美国 1500 多家认证机构收集约 72%的美国癌症患者的医院登记数据。如果患者患有局部前列腺腺癌，并且在 2004 年至 2020 年期间被诊断出，并接受了根治性外部束 RT 治疗，则将其纳入样本。分析于 2023 年 2 月至 3 月之间进行。
放疗方案，分为超短程放疗（≤7 次）、中短程放疗（20-30 次）和常规放疗（31-50 次）。
RT 分割方案的纵向模式是主要结果。多变量逻辑回归用于评估与较短 RT 疗程相关的变量。协变量包括年龄、国家综合癌症网络风险组、农村/城市程度、种族、设施位置、设施类型、中位数收入、保险类型或状况以及 Charlson-Deyo 合并症指数。
共纳入 313062 例局部前列腺癌患者（平均[标准差]年龄，68.8[7.7]岁）进行分析。接受常规分割治疗的患者比例呈下降趋势，从 2004 年的 76.0%下降到 2020 年的 36.6%（趋势 P<0.001）。从 2004 年到 2020 年，中程放疗的使用率从 22.0%增加到 45.0%（趋势 P<0.001），超短程放疗的使用率从 2.0%增加到 18.3%（趋势 P<0.001）。到 2020 年，低风险组患者最常见的 RT 方案是超短程放疗，中风险组患者最常见的 RT 方案是中程放疗。多变量分析显示，在社区癌症项目（与学术或研究项目相比；比值比[OR]，0.54[95%置信区间，0.52-0.56]；P<0.001）、医疗补助保险（与医疗保险相比；OR，1.49[95%置信区间，1.41-1.57]；P<0.001）、黑人种族（与白人种族相比；OR，0.90[95%置信区间，0.87-0.92]；P<0.001）和较高的中位数收入（与较低的中位数收入相比；OR，1.28[95%置信区间，1.25-1.31]；P<0.001）与接受较短的 RT 疗程相关。
本队列研究结果显示，2004 年至 2020 年间，接受较短 RT 疗程治疗前列腺癌的比例有所增加；一些健康的社会决定因素似乎与较短治疗疗程的采用减少有关。为了支持技术收购成本，可能需要重新调整报销模式，以更广泛地采用超短程放疗。
