How Many Randomized Trials Does It Take to Make You Do the Right Thing?

Kate Hitchcock, MD, PhD


March 29, 2022

There are shops out there still performing only long-course radiotherapy for rectal cancer. One has to suspect that in talking to patients they are not bringing up the short-course option, or at least not in any way that fairly explains the extensive data supporting its use.

At this stage in the evidence, this is presumably the fault of antiquated rules for compensation to radiation oncology clinics. Payers have had to be reluctantly dragged out of the era of light boxes and grease pencils. IMRT is still a dirty word in Insurance Land. But here they are shooting themselves in the foot by paying us to give longer, more expensive treatment by compensating us less for shorter care.

In case you don't treat GI cancers, the summary of our current understanding is that short-course radiotherapy, delivered over 5 days, results in equal rates of local control with clinically comparable toxicities when compared with the traditional radiotherapy given with sensitizing chemotherapy over 28 fractions.

Short-course RT is substantially less expensive for patients paying out of pocket. It requires far fewer clinic visits, a huge quality-of-life factor in a population of patients that includes many trying to continue working at jobs far from the cancer center. In the middle of the pandemic, fewer visits is/was always better for patient safety. Giving short-course followed immediately by neoadjuvant chemotherapy speeds exposure to multiagent systemic therapy, resulting in lower rates of distant metastasis in multiple trials. Finally, the 1-week plan results in a higher probability of completing prescribed treatment.

The advantages of long-course are... well, I'm hard-pressed to think of a single one. Except that it remunerates better. In other words, it's better for the doctor.

How can I assert that these things are true? Swedish Rectal Cancer Trial, Polish I, TROG 01.04, Stockholm III, RAPIDO, STELLAR, PRODIGE-42, to name just a few.

For those who feel that more evidence is needed, I have to ask: Do you think we should still be performing radical mastectomy on every woman with breast cancer, too?

Initially there was an argument that we achieve greater rates of pathologic complete response following long-course radiotherapy, but studies like RAPIDO, in which neoadjuvant chemotherapy is given between RT and surgery, show us impressive CR rates, better even than with long-course, implying that the difference is more time, not more fractions of radiation.

Yes, we could still be doing shared decision-making on this topic, but if your patient chooses long-course, given the above, you probably are not fairly presenting the options. Just like informed consent, real shared choices can only be made in the context of honest and complete information.

How are you talking to your patients about radiotherapy for rectal cancer? Please join the discussion in the comments.

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About Dr Kate Hitchcock
Kate Hitchcock, MD, PhD, is a radiation oncologist, biomedical engineer, and retired aircraft carrier driver who grew up as a Wyoming cowgirl. When she is not at the hospital, you can find her with Carolyn, Mary, Tyler, Nick, Marlee, and Colby the barking dog, enjoying the natural splendor of the great state of Florida. She thinks you should visit sometime and try to solve the puzzle of why the natives have so carefully shunted all of the tourists toward the House of Mouse. Connect with her on Twitter: @hitchcock_kate


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