Backing Off From Brachytherapy? Deciphering the Decline

Kate Johnson

May 05, 2015

BARCELONA, Spain — The declining use of brachytherapy was a much-discussed enigma among radiation oncologists and other experts who attended this year's European Society for Radiotherapy and Oncology (ESTRO) 3rd Forum here.

In the face of ample evidence about the benefits and sometimes even dramatic advantages of brachytherapy in the treatment of various cancers, the conversations of researchers and discussants alike drifted repeatedly to the puzzle of brachytherapy's underuse ― at least in some places.

"Brachytherapy use in the United States is declining," Sahaja Acharya, MD, a resident physician in the Radiation Oncology Department of Washington University, in St. Louis, Missouri, told Medscape Medical News.

And yet her study, presented at the meeting and reported by Medscape Medical News, showed that in women with inoperable early- stage endometrial cancer, 3-year overall survival is significantly longer among those whose treatment includes brachytherapy compared with those who receive external beam radiotherapy (EBRT) alone (67% vs 40%; hazard ratio, 0.67; P = .003).

Potential reasons for the decline in brachytherapy use "may include an increased use of external beam techniques such as IMRT [intensity-modulated radiation therapy] and a decrease in brachytherapy training nationally," she said after presenting her results, taken from the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) database.

Indeed, "brachytherapy utilization appears low in this population that is potentially curable with this technique," agreed Sushil Beriwal, MD, associate professor of radiation oncology at the University of Pittsburgh School of Medicine, in Pennsylvania, who was not involved in the study.

In the case of endometrial cancer, the unique advantage of brachytherapy over EBRT is that "it enables delivery of a high local dose to the uterine cavity," he explained. "It is difficult to replicate this dose delivery through external beam radiation without putting nearby organs at risk," he explained.

But Dr Beriwal and his colleagues recently published a National Cancer Data Base analysis showing a similar US decline in brachytherapy use for other gynecologic cancers, including cervical ( Int J Radiat Oncol Biol Phys. 2014;90:1083-90) and vaginal ( Pract Radiat Oncol. 2015;5:56-61).

"We identified a concerning decline in the utilization of brachytherapy boost for those with vaginal and cervical cancer and a corresponding increase in IMRT," he said. "This translated into increased mortality risk, which is of significant concern."

Although studies and reviews have been published documenting the decline of brachytherapy use in the United States, it remains unclear how much the treatment is being used elsewhere around the world.

"I am afraid that brachytherapy is also in decline or not readily available in parts of Europe as well ― but we have only gut feelings and no data," Jacob Lindegaard, MD, from Aarhus University Hospital, in Denmark, and chair of the Brachytherapy Committee for ESTRO and the Groupe Européen de Curiethérapie, told Medscape Medical News.

But according to David Wazer, MD, from Tufts University School of Medicine, Boston, Massachusetts, who published a recent review entitled Brachytherapy: Where Has It Gone? ( J Clin Oncol. 2015;33:980-2), the decline remains confined to the United States.

"In Canada and Europe, where health systems place an emphasis on value-based payment, brachytherapy remains a robust component of contemporary cancer care," he told Medscape Medical News.

"The primary reason for its diminished utilization in the US is due to unfavorable economics," he explained. "Over the past dozen years, brachytherapy has experienced severe and progressive declines in reimbursement, which has resulted in the growth of alternative treatment modalities that are more costly and, in some cases, less efficacious."

Indeed, Canadian interest in prostate brachytherapy appears "robust," in light of one study reported at the ESTRO meeting.

The ASCENDE-RT (Androgen Suppression Combined With Elective Nodal and Dose Escalated Radiation Therapy) trial included almost 400 intermediate- or high-risk prostate cancer patients recruited by 39 radiation oncologists at six Canadian cancer centers, reported researcher James Morris, MD, from the Vancouver Cancer Centre, British Columbia Cancer Agency (BCCA), in Canada.

The study found that the addition of brachytherapy to EBRT doubled the rate of progression-free survival at 9 years compared with EBRT alone.

As a result, "prostate brachytherapy has now become the standard of care for all patients with high-risk prostate cancer at the BCCA," added coinvestigator Sree Rodda, MD.

But south of the border, in another analysis of the US National Cancer Database, entitled The Rise and Fall of Prostate Brachytherapy ( Cancer. 2014;120:2114-21), researchers have shown that prostate brachytherapy is not the standard of care in the United States.

"Multiple other studies looking at cost-effectiveness of treatment options for prostate cancer have found brachytherapy to be the most cost-effective," said lead investigator Jeffrey Martin, MD, from the Fox Chase Cancer Center, in Philadelphia, Pennsylvania. "Despite this, our study found that brachytherapy utilization in the US decreased from 16.9% of cases in 2002 down to just 8.2% in 2010," he told Medscape Medical News.

Mirroring the picture for other cancers, Dr Martin's study showed that US prostate cancer patients are more often treated with external beam radiation or surgery.

"Our study period corresponds with the introduction of robotic prostatectomy and IMRT, which may be leading providers and patients to favor these treatment options," he said.

 
Brachytherapy is reimbursed less than other treatments in the US.
 

"I suspect the main reason is that brachytherapy is reimbursed less than other treatments in the US," added one Canadian brachytherapy expert, who asked to remain anonymous.

But, reimbursement issues aside, even European clinicians may be attracted away from brachytherapy and toward more recent technology, said Dr Lindegaard.

"There is the trend to have the most modern technique, and maybe brachytherapy is looked at as old-fashioned and awkward," he said. "You really have to touch the patient, feel the tumor, and get blood on your hands ― it's not like new external beam techniques, where you don't have to touch the patient."

Yet, brachytherapy has a much longer history in Europe, which is still considered the birthplace of the approach, according to Nam Nguyen, MD, professor and chair of radiation oncology at Howard University, in Washington, DC, and president of the International Geriatric Radiotherapy Group.

"I am not so sure that brachytherapy is in decline in Europe, because the Europeans have a long tradition of performing brachytherapy, and they have centers of excellence in France and Austria, for example," he told Medscape Medical News.

"The French are the experts in brachytherapy because they have a lot of patients and because of their pioneering work ― Dr Pierquin was world renowned, for example. I had to go to France after my residency program to acquire more experience in brachytherapy."

The US decline in brachytherapy "puts at risk the necessary skills to maintain its appropriate role for future cancer care in the US," noted Dr Wazer. "The safe and effective application of brachytherapy is highly dependent upon the training and depth of ongoing experience of the radiation oncologist," he said.

 
It is time to bring brachytherapy back. Dr David Wazer
 

"It is the responsibility of all oncologists to educate our patients, insurers, and policy makers about the critical value of brachytherapy," he wrote in his review. "Brachytherapy not only works, it is an irreplaceable component of contemporary cancer care. It is time to bring brachytherapy back."

Yet, even in Europe, "we're against hard odds," said Dr Lindegaard. "There's politics, lobbying reimbursement policies, and other interests. When we work in groups and cooperate together, we can generate data showing the benefits of brachytherapy, and you cannot argue with that."

None of the physicians interviewed have disclosed any relevant financial relationships.

European Society for Radiotherapy and Oncology (ESTRO) 3rd Forum.

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