Hypofractionation – no long-term effect on quality of life

Reducing the number of radiation treatments had no long-term differential effect on urinary, rectal or sexual quality of life, according to a study from Fox Chase Cancer Center that was recently presented at the ASTRO meeting.

These findings compliment their 2013 report of equivalent rates of cancer control from the two treatment schedules. Between 2002 and 2006, they randomly assigned 303 patients to either hypofractionation or conventional fractionation:

• ·      Hypofractionation: 70.2 Gy in 26 fractions (2.7 Gy per fraction)
• ·      Conventional fractionation: 76 Gy in 38 fractions (2.0 Gy per fraction)
• ·      High-risk patients received long-term adjuvant ADT; some intermediate risk patients received short-term ADT (there were no low risk patients).
• ·      Mean age was 67 years in both groups.
• ·      Patients evaluated their quality of life using the EPIC and IPSS questionnaires

The findings that were presented at ASTRO or included in a Medscape article about it were:

• ·      Urinary irritative symptoms declined by less than the amount considered to be minimally clinically detectable at both 3 years and 5 years, and were not different between the two groups.
• ·      Urinary continence symptoms declined by 7% at 3 years and by 9% at 5 years in the hypofractionated group. Compared to the conventionally fractionated group, it was significantly different at 3 years but not significantly different at 5 years. (The EPIC categories that are lumped together as “urinary incontinence” may not mean what most people mean by the term. It may include patient perception of any leaking or dribbling, as well as any pad use. The decline was large enough to be noticeable, but were not very large. The fact that they were not significantly different between the two groups at 5 years may speak to common age-related declines.)
• ·      Patients with poor baseline genitourinary function had worse quality of life outcomes with hypofractionated radiation than with conventionally fractionated radiation
• ·      Bowel symptoms declined by less than the amount considered to be minimally clinically detectable at both 3 years and 5 years, and were not different between the two groups.
• ·      Sexual function declined by a clinically detectable degree at both 3 years and 5 years, but was not different between the two groups.
• ·      Baseline function was an important predictor of long-term quality of life outcomes.

These findings echo the results just reported in the CHHiP trial in the UK. While caution is warranted among men with poor baseline urinary, rectal and sexual function, these two studies provide strong Level 1 evidence that hypofractionated radiation is not inferior to conventionally fractionated radiation. Most patients should be able to complete primary IMRT treatments in about 5 weeks rather than 8 weeks, and at considerably reduced cost.