Evaluation of hypofractionated radiation therapy use and patient-reported outcomes in men with nonmetastatic prostate cancer in Australia and New Zealand

Key Points Question What factors are associated with use of hypofractionated vs conventional radiation therapy for prostate cancer, and is there a difference in patient-reported outcomes (PROs) at a population level? Findings In this cohort study of data from 6368 men with nonmetastatic prostate cancer, use of hypofractionation increased from 2.1% to 52.7% from the first half of 2016 to the second half of 2019 with no differences in PROs between those receiving hypofractionated radiation therapy and conventional radiation therapy. Substantial variation in use was found between jurisdictions, institutions, individual clinicians, and patient cohorts. Meaning Findings of this cohort study support the continued implementation of hypofractionated radiation therapy into routine practice and provide stakeholders with information that may be useful in targeting implementation strategies.
Importance Randomized clinical trials in prostate cancer have reported noninferior outcomes for hypofractionated radiation therapy (HRT) compared with conventional RT (CRT); however, uptake of HRT across jurisdictions is variable. Objective To evaluate the use of HRT vs CRT in men with nonmetastatic prostate cancer and compare patient-reported outcomes (PROs) at a population level. Design, Setting, and Participants Registry-based cohort study from the Australian and New Zealand Prostate Cancer Outcomes Registry (PCOR-ANZ). Participants were men with nonmetastatic prostate cancer treated with primary RT (excluding brachytherapy) from January 2016 to December 2019. Data were analyzed in March 2021. Exposures HRT defined as 2.5 to 3.3 Gy and CRT defined as 1.7 to 2.3 Gy per fraction. Main Outcomes and Measures Temporal trends and institutional, clinicopathological, and sociodemographic factors associated with use of HRT were analyzed. PROs were assessed 12 months following RT using the Expanded Prostate Cancer Index Composite (EPIC)–26 Short Form questionnaire. Differences in PROs were analyzed by adjusting for age and National Comprehensive Cancer Network risk category. Results Of 8305 men identified as receiving primary RT, 6368 met the inclusion criteria for CRT (n = 4482) and HRT (n = 1886). The median age was 73.1 years (IQR, 68.2-77.3 years), 2.6% (168) had low risk, 45.7% (2911) had intermediate risk, 44.5% (2836) had high-/very high–risk, and 7.1% (453) had regional nodal disease. Use of HRT increased from 2.1% (9 of 435) in the first half of 2016 to 52.7% (539 of 1023) in the second half of 2019, with lower uptake in the high-/very high–risk (1.9% [4 of 215] to 42.4% [181 of 427]) compared with the intermediate-risk group (2.2% [4 of 185] to 67.6% [325 of 481]) (odds ratio, 0.26; 95% CI, 0.15-0.45). Substantial variability in the use of HRT for intermediate-risk disease remained at the institutional level (median 53.3%; range, 0%-100%) and clinician level (median 57.9%; range, 0%-100%) in the last 2 years of the study period. There were no clinically significant differences across EPIC-26 urinary and bowel functional domains or bother scores. Conclusions and Relevance In this cohort study, use of HRT for prostate cancer increased substantially from 2016. This population-level data demonstrated clinically equivalent PROs and supports the continued implementation of HRT into routine practice. The wide variation in practice observed at the jurisdictional, institutional, and clinician level provides stakeholders with information that may be useful in targeting implementation strategies and benchmarking services.
This cohort study analyzes factors associated with the use of hypofractionated radiation therapy during the period from 2016 to 2019 and evaluates real-world patient-reported outcomes data for men with nonmetastatic prostate cancer receiving hypofractionated radiation therapy and conventional radiation therapy.