JAMA paper on IMRT vs. proton beam for localized prostate cancer

We’ve written numerous times on this site about the costly proliferation of newer forms of radiation therapy – intensity-modulated radiation therapy (IMRT) and proton beam therapy.

A paper in this week’s Journal of the American Medical Association compares the two for localized prostate cancer.  The authors’ conclusion:

Among patients with nonmetastatic prostate cancer, use of IMRT vs conformal radiation therapy increased substantially from 2000 to 2008. Compared with conformal radiation therapy, IMRT was associated with fewer diagnoses of gastrointestinal morbidity, hip fractures, and additional cancer therapy but more erectile dysfunction. Proton therapy was associated with more gastrointestinal morbidity than IMRT. This population-based study suggests that IMRT may be associated with improved disease control without compromising morbidity compared with conformal radiation therapy, although proton therapy does not appear to provide additional benefit.

Reuters reported, “Pricier therapy no better for early prostate cancer.”  Excerpt:

Researchers said that proton beam facilities can cost $100 million or more to build. A round of proton beam radiation treatment costs insurers up to $100,000 per patient, while IMRT is billed at about $50,000.

“Here we have more expensive therapy that is not proven to give a better outcome,” said Dr. Eric Klein, a prostate cancer researcher at the Cleveland Clinic, who didn’t take part in the new study.

Researchers agreed that policymakers, including those that decide how much Medicare will pay for various treatments, should reevaluate the evidence for cancer outcomes — including whether proton beam therapy is worth its hefty price tag.

“There’s a trend in this country of adopting newer, costly, promising treatments, without very much evidence to prove they’re better,” Chen told Reuters Health.

“What our data provides the patients is evidence that IMRT is a good prostate cancer treatment,” he said. Until more rigorous studies are available, “That’s the type of radiation that they should seek.”

WATCHFUL WAITING?

Another perfectly good option for men with early prostate cancer is not to get treatment at all, but to wait and see whether the cancer grows or doesn’t cause any harm, researchers said.

“Many men with early disease, especially men who are older, likely don’t need treatment,” said Dr. W. Robert Lee, a radiation oncologist at the Duke University School of Medicine in Durham who wasn’t involved in the new study.

“Active surveillance really plays a very important role,” he told Reuters Health.

(Dr. Matthew Cooperberg, a urologist from the University of California, San Francisco) told Reuters Health that if men find their doctor pushing one treatment option, especially if it’s a high-tech radiation option, they should seek outside opinions and think about their priorities — in terms of what side effects they can put up with and the chance of needing more serious treatment.

“Prostate cancer is very much a disease of options,” Lee said.

A statement issued by a chain of centers using proton beam therapy calls the study’s conclusion “controversial” and says it is “firmly contradicted by a number of well-regarded peer-reviewed studies that found protons reduce – not increase – gastrointestinal side effects.”

Stay tuned for one or two other prostate cancer treatment blog posts this week.