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The Endorectal Balloon Reduces Late Rectal Mucosal Changes after Prostate Three-dimensional Conformal Radiotherapy: Update of 5 Years Repeated Endoscopy
I. J. Radiation Oncology d Biology d Physics
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Volume 78, Number 3, Supplement, 2010
7.25. We estimated the costs of each regimen per patient using 2010 Medicare reimbursement, for both hospital-based and freestanding facilities. We assumed free-standing facilities accounted for 30% of patient volume. Results: In our SEER data set, 8,487 patients were treated with EBRT. Extrapolating to the U.S. population, approximately 43,000 prostate cancer patients would be treated annually with EBRT. The Medicare costs for single patient EBRT course for hospital and free-standing facilities were 44 fxs $27,059 and $36,909; 38 fxs $23,977 and $32,548; 26 fxs $17,514 and $23,563; 20 fxs $14,432 and $19,202; 12 fxs $10,124 and $13,212; 5 fxs (SBRT codes) $20,865 and $12,420, respectively. Nationally, prostate EBRT therapy would cost $1.30 billion; $1.15 billion; $837 million; $687 million; $478 million; and $793 million respectively. Assuming a current average baseline utilization of 40 fxs per treatment course ($1.16 billion), hypofractionation could allow for overall cost savings of 30% with 26 fxs, 43% with 20 fxs, 60% with 12 fxs, and 34% with 5 fxs (SBRT). Conclusions: Provided that the ongoing clinical trials and the maturation of long-term data reveal at least comparable tumor control and side effects profile, hypofractionated/SBRT regimens may allow for better therapeutic ratio, improved patient convenience, and significant cost savings. Our estimates may provide an incentive to fund additional trials that investigate the feasibility and effectiveness of hypofractionated/SBRT regimens in the treatment of prostate cancer. Author Disclosure: P. Mroz, None; J.M. Martin, None; T.A. DiPetrillo, None; D.E. Wazer, None; T. Dvorak, None.
2310
The Endorectal Balloon Reduces Late Rectal Mucosal Changes after Prostate Three-dimensional Conformal Radiotherapy: Update of 5 Years Repeated Endoscopy
E. van Lin, G. McColl, R. Smeenk, D. de Jong, J. Kaanders Radboud University Nijmegen Medical Centre, Nijmegen 6500 HB, Netherlands Purpose/Objective(s): To investigate prospectively late anorectal toxicity and rectal wall (Rwall) mucosal changes after prostate cancer radiotherapy with or without an endorectal balloon (ERB). Material/Methods: 24 patients with ERB and 24 without ERB (No-ERB) were treated with three-dimensional conformal radiotherapy (3D-CRT), four field ‘‘box’’ to a dose of 67.5 Gy. For spatial dose distribution evaluation, Rwall dose surface maps were constructed. To assess late mucosal damage up to 16 cm cranial from the anal verge, the Rwall was divided into 16 mucosal areas (1). After 3 months, 6 months, 1 year, 2, 3, and 5 years a rectosigmoidoscopy was performed and each mucosal area was scored on telangiectasia, congestion, ulceration, stricture and necrosis. Results: The ERB significantly altered the spatial dose distribution by reducing the Rwall volume exposed to doses . 40 Gy and increasing the Rwall surface exposed to doses\40 Gy. After 5 years, in the No-ERB group, 5 patients (20%) presented with rectal bleeding, compared to one patient in the ERB group. In the No-ERB group, 10 patients had grade 1 late rectal toxicity (urgency, frequency, slight rectal discharge), while 2 patients scored grade 2 rectal toxicity (frequency needing medication). In the ERBgroup, 2 patients experienced grade 1 rectal toxicity, and one patient scored grade 2 (leakage needing bandages). 213 scopies and 3408 mucosal areas were analyzed. Telangiectases were most frequently seen. At 1, 2, 3, and 5 year’s endoscopy, less high-grade confluent telangiectasia was observed in the ERB. Over the years the absolute percentage of damaged mucosal areas reduced in both groups; for the No-ERB-group from 19.8% (1 year) to 9.0% (5 years) and for the ERB group from 11.6% to 5.9%. In the ERB-group, at the lateral and posterior parts of the Rwall, exposed to intermediate and low doses, the high grade telangiectasia practically resolved from 18.1% to 3.2% after 5 years. In the No-ERB group this improvement was less, from 37.8% to 17.4% after 5 years. Conclusions: After 5 years of follow-up, in this small-sized prospective study, patients treated with ERB reported less rectal toxicity. This may be explained by the ERB, reducing the Rwall volume exposed to doses . 40 Gy. In the ERB-group, less severe Rwall mucosal damage was observed. In both groups, after 5 years, improvement of mucosal changes was seen, but more pronounced in the ERB-group at the lateral and posterior parts of the Rwall. 1. van Lin et al. IJROBP 2007;67:799-811. Author Disclosure: E. van Lin, None; G. McColl, None; R. Smeenk, None; D. de Jong, None; J. Kaanders, None.
2311
Trends in Treatment with Intensity Modulated (IMRT) vs. 3D Conformal (CRT) Radiotherapy for Non-metastatic Prostate Cancer
D. Yeboa1, R. Sunderland2, K. Liao3, K. Armstrong3, J. Bekelman2 1
University of Pennsylvania, Philadelphia, PA, 2Department of Radiation Oncology, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA, 3Division of General Internal Medicine, University of Pennsylvania, Philadelphia, PA Purpose/Objective(s): Intensity-modulated radiotherapy (IMRT) and 3D conformal radiotherapy (CRT) for prostate cancer treatment have received substantial national attention. We describe temporal trends and determinants of IMRT treatment for prostate cancer in the linked Surveillance, Epidemiology, and End Results (SEER)-Medicare database. Materials/Methods: Using data from the SEER-Medicare program, we identified 20,622 men 65 years and older diagnosed from January 1, 2001 to December 31, 2005 with non-metastatic prostate cancer who received IMRT or CRT as definitive treatment. Delivery of IMRT was identified based on the presence of Healthcare Common Procedure Coding System (HCPCS) codes 77418 and G1074. Delivery of CRT was identified based on the presence of code 77295 (conformal simulation) or a combination of 77290 (complex simulation) and 76370 (computed tomography guidance for placement of radiotherapy portals). We performed multivariable logistic regression to examine the relationship between IMRT treatment and patient (age at diagnosis, race, ethnicity, marital status), clinical (T stage, Gleason sum, history of TURP or androgen suppression, comorbidity), and demographic (diagnosis year, SEER registry, area population, area median income) characteristics. Results: The proportion of patients with non-metastatic prostate cancer undergoing external beam radiation who received IMRT increased from 9% in 2001 to 83% in 2005. In 2005, rates of IMRT treatment varied by SEER registry, ranging from 58% in Kentucky to 98% in Hawaii. In multivariable logistic regression, IMRT treatment was positively associated with residing in higher
S342
Volume 78, Number 3, Supplement, 2010
7.25. We estimated the costs of each regimen per patient using 2010 Medicare reimbursement, for both hospital-based and freestanding facilities. We assumed free-standing facilities accounted for 30% of patient volume. Results: In our SEER data set, 8,487 patients were treated with EBRT. Extrapolating to the U.S. population, approximately 43,000 prostate cancer patients would be treated annually with EBRT. The Medicare costs for single patient EBRT course for hospital and free-standing facilities were 44 fxs $27,059 and $36,909; 38 fxs $23,977 and $32,548; 26 fxs $17,514 and $23,563; 20 fxs $14,432 and $19,202; 12 fxs $10,124 and $13,212; 5 fxs (SBRT codes) $20,865 and $12,420, respectively. Nationally, prostate EBRT therapy would cost $1.30 billion; $1.15 billion; $837 million; $687 million; $478 million; and $793 million respectively. Assuming a current average baseline utilization of 40 fxs per treatment course ($1.16 billion), hypofractionation could allow for overall cost savings of 30% with 26 fxs, 43% with 20 fxs, 60% with 12 fxs, and 34% with 5 fxs (SBRT). Conclusions: Provided that the ongoing clinical trials and the maturation of long-term data reveal at least comparable tumor control and side effects profile, hypofractionated/SBRT regimens may allow for better therapeutic ratio, improved patient convenience, and significant cost savings. Our estimates may provide an incentive to fund additional trials that investigate the feasibility and effectiveness of hypofractionated/SBRT regimens in the treatment of prostate cancer. Author Disclosure: P. Mroz, None; J.M. Martin, None; T.A. DiPetrillo, None; D.E. Wazer, None; T. Dvorak, None.
2310
The Endorectal Balloon Reduces Late Rectal Mucosal Changes after Prostate Three-dimensional Conformal Radiotherapy: Update of 5 Years Repeated Endoscopy
E. van Lin, G. McColl, R. Smeenk, D. de Jong, J. Kaanders Radboud University Nijmegen Medical Centre, Nijmegen 6500 HB, Netherlands Purpose/Objective(s): To investigate prospectively late anorectal toxicity and rectal wall (Rwall) mucosal changes after prostate cancer radiotherapy with or without an endorectal balloon (ERB). Material/Methods: 24 patients with ERB and 24 without ERB (No-ERB) were treated with three-dimensional conformal radiotherapy (3D-CRT), four field ‘‘box’’ to a dose of 67.5 Gy. For spatial dose distribution evaluation, Rwall dose surface maps were constructed. To assess late mucosal damage up to 16 cm cranial from the anal verge, the Rwall was divided into 16 mucosal areas (1). After 3 months, 6 months, 1 year, 2, 3, and 5 years a rectosigmoidoscopy was performed and each mucosal area was scored on telangiectasia, congestion, ulceration, stricture and necrosis. Results: The ERB significantly altered the spatial dose distribution by reducing the Rwall volume exposed to doses . 40 Gy and increasing the Rwall surface exposed to doses\40 Gy. After 5 years, in the No-ERB group, 5 patients (20%) presented with rectal bleeding, compared to one patient in the ERB group. In the No-ERB group, 10 patients had grade 1 late rectal toxicity (urgency, frequency, slight rectal discharge), while 2 patients scored grade 2 rectal toxicity (frequency needing medication). In the ERBgroup, 2 patients experienced grade 1 rectal toxicity, and one patient scored grade 2 (leakage needing bandages). 213 scopies and 3408 mucosal areas were analyzed. Telangiectases were most frequently seen. At 1, 2, 3, and 5 year’s endoscopy, less high-grade confluent telangiectasia was observed in the ERB. Over the years the absolute percentage of damaged mucosal areas reduced in both groups; for the No-ERB-group from 19.8% (1 year) to 9.0% (5 years) and for the ERB group from 11.6% to 5.9%. In the ERB-group, at the lateral and posterior parts of the Rwall, exposed to intermediate and low doses, the high grade telangiectasia practically resolved from 18.1% to 3.2% after 5 years. In the No-ERB group this improvement was less, from 37.8% to 17.4% after 5 years. Conclusions: After 5 years of follow-up, in this small-sized prospective study, patients treated with ERB reported less rectal toxicity. This may be explained by the ERB, reducing the Rwall volume exposed to doses . 40 Gy. In the ERB-group, less severe Rwall mucosal damage was observed. In both groups, after 5 years, improvement of mucosal changes was seen, but more pronounced in the ERB-group at the lateral and posterior parts of the Rwall. 1. van Lin et al. IJROBP 2007;67:799-811. Author Disclosure: E. van Lin, None; G. McColl, None; R. Smeenk, None; D. de Jong, None; J. Kaanders, None.
2311
Trends in Treatment with Intensity Modulated (IMRT) vs. 3D Conformal (CRT) Radiotherapy for Non-metastatic Prostate Cancer
D. Yeboa1, R. Sunderland2, K. Liao3, K. Armstrong3, J. Bekelman2 1
University of Pennsylvania, Philadelphia, PA, 2Department of Radiation Oncology, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA, 3Division of General Internal Medicine, University of Pennsylvania, Philadelphia, PA Purpose/Objective(s): Intensity-modulated radiotherapy (IMRT) and 3D conformal radiotherapy (CRT) for prostate cancer treatment have received substantial national attention. We describe temporal trends and determinants of IMRT treatment for prostate cancer in the linked Surveillance, Epidemiology, and End Results (SEER)-Medicare database. Materials/Methods: Using data from the SEER-Medicare program, we identified 20,622 men 65 years and older diagnosed from January 1, 2001 to December 31, 2005 with non-metastatic prostate cancer who received IMRT or CRT as definitive treatment. Delivery of IMRT was identified based on the presence of Healthcare Common Procedure Coding System (HCPCS) codes 77418 and G1074. Delivery of CRT was identified based on the presence of code 77295 (conformal simulation) or a combination of 77290 (complex simulation) and 76370 (computed tomography guidance for placement of radiotherapy portals). We performed multivariable logistic regression to examine the relationship between IMRT treatment and patient (age at diagnosis, race, ethnicity, marital status), clinical (T stage, Gleason sum, history of TURP or androgen suppression, comorbidity), and demographic (diagnosis year, SEER registry, area population, area median income) characteristics. Results: The proportion of patients with non-metastatic prostate cancer undergoing external beam radiation who received IMRT increased from 9% in 2001 to 83% in 2005. In 2005, rates of IMRT treatment varied by SEER registry, ranging from 58% in Kentucky to 98% in Hawaii. In multivariable logistic regression, IMRT treatment was positively associated with residing in higher