Aubrie Rice

RST 3574
Annotated Bibliography

Prostate Cancer Treatment Comparisons

Aubrie Rice
rice.528@buckeyemail.osu.edu
The Ohio State University

Aubrie Rice
RST 3574
Annotated Bibliography
Prostate Cancer Treatment Comparisons
Intensity-modulated radiation therapy, proton therapy, or conformal radiation
therapy and morbidity and disease control in localized prostate cancer.
The type of research conducted in this article would be considered an
ecological study.4 The authors used data collected from the SEER-Medicare
database. This data included information about surveillance, epidemiology
and end results of sixteen population-based cancer registries.1 A comparison
of IMRT versus conformal radiation therapy showed a decreased risk of
gastrointestinal morbidities and hip fractures for IMRT patients but an
increase in the presence of late erectile dysfunction.1 The strength of this
type of study is that it collects data on a large number of individuals instead
of just a small group. Although it does have this strength, this type of
research isnt at the top of the chain when it comes to research studies and it
does have some limitations.4 These limitations may affect the reliability and
validity of the article as well. Though this study gathered information from a
large amount of individuals through the SEER-Medicare database, it did not
collect information that would control for confounding variables. For
example, the SEER-Medicare database only has information on 97% of US
patients ages 65 and older.1 Ages younger than this are not represented.
Therefore, erectile dysfunction, which was seen to have a higher incidence in
patients treated with IMRT versus conformal, could have been due to other
factors such as increased age but this factor was not accounted for. Since the
data does include information of the majority of patients diagnosed with
2

Aubrie Rice
RST 3574
Annotated Bibliography
prostate cancer ages 65 and older, I do believe such research is valid when
considering only this specific age range. Although this study had a limited
age range in its population, it did exhibit a few favorable research methods.
First, it demonstrated several important control variables. The SEER registry
was able to distinguish several patient demographic variables such as age at
diagnosis and race.1 Having such control variables makes this a stronger
research study and therefore more reliable.
This study is extremely relevant to my clinical practice. As we know,
getting insurance to cover certain treatments is a big factor in planning both
for the doctor and for the patient. More complicated plans like IMRT might
not be covered if it is not proven to be more beneficial as for cure rates and
side effects, and possible toxicities due to radiating normal tissue. Aetna
insurance company states that IMRT is only considered medically necessary
where critical structures cannot be adequately protected with standard 3dimensional (3D) conformal radiotherapy.5 This studys results demonstrate
that critical structures are in fact better protected with IMRT due to patients
lessened risk of hip fractures and gastrointestinal morbidities. 1 I personally
would not be responsible for making changes in my clinical practice due to
the results of this article. This is a definite interest to doctors though when it
comes to making decisions on the type of treatment they want to use for
their patients.
Preliminary toxicity analysis of 3-dimensional conformal radiation therapy
versus intensity modulated radiation therapy on the high-dose arm of the
Radiation Therapy Oncology Group 0126 prostate cancer trial
3

Aubrie Rice
RST 3574
Annotated Bibliography
In this article, toxicity outcomes for 3D conformal and Intensity
Modulated Radiation Therapy (IMRT) patients were compared. The study
found that patients treated with 3D conformal radiation therapy encountered
a 15.1% rate of grade 2 or worse acute gastrointestinal and/or genitourinary
toxicity2, while IMRT patients had a 9.7% rate.2 Intensity modulated
radiation therapy (IMRT) was also found in this study to have less GI toxicity
as well when comparing to 3D conformal.2 The type of research conducted in
this article was phase III of a randomized clinical trial. This phase is a largescale trial that is conducted in order to measure clinical applicability.6 This
type of study is seen as the gold standard design6 when it comes to
research studies. It involves randomization of its subjects into groups, which
controls for confounding variables and this type of study can also show cause
and effect.6 All of these aspects would be considered strengths. The study
had an acceptable number of participants in order to see valid results,
consisting of 1,532 patients total.2 One thing that the study pointed out that
could have made for a confounding variable would be that patients treated
at US institutions were more likely to receive an IMRT treatment. As the study
states, this finding may explain the racial imbalance and the preponderance
of T1 stage in the IMRT group because US patients may have been more
likely to be diagnosed by PSA screening.2 This should be something that is
considered but I do not think it takes away from the reliability of the
research.

Aubrie Rice
RST 3574
Annotated Bibliography
Again, like the study above, this study is very relevant to my clinical
practice due to insurance reasons as well as for the welfare of future
radiation patients. We know that insurance companies only cover IMRT
treatment over 3D conformal if they see it to be medically necessary due
to critical structures not being spared enough with 3D conformal. 5 This
becomes a concern for doctors in radiation oncology when it comes time to
plan treatments for these individuals. Studies such as these that prove IMRT
plans can reduce the risk of acute and late toxicities will help to show
insurance companies that IMRT is a better treatment for prostate patients.
We, as healthcare providers want to provide the best treatment for the
patient that is possible. If acute and late side effects can be reduced by
treating with IMRT rather than conformal, this is something that needs to be
greatly considered by both insurance companies (when deciding what can be
covered) and by doctors when deciding on the type of treatment to use.
Dose comparisons for conformal, IMRT and VMAT prostate plans
For this study, eight localized prostate and prostatectomy patients
were randomly selected. For each case, four treatment plans were made to
compare dose volume histograms between conformal, IMRT and one and two
arc VMAT plans.3 It was found in this study that critical structures were better
spared by the VMAT plans. For example, VMAT plans received less dose to
the rectum and femoral heads compared to IMRT and conformal plans. 3 The
type of research conducted in this article is a randomized clinical trial.
Though this study was not based on the outcomes or results of the actual
5

Aubrie Rice
RST 3574
Annotated Bibliography
treatment of patients, it did evaluate the various outcomes of four different
dosimetric plans from real and randomly selected patients.3 One criticism I
have of this study is the sample size. This study only involved eight total
randomly selected cases, which amounted to 32 treatment plans to compare.
I feel that with a larger number of cases, this studys results would have
been much more accurate and reliable.
This study is relevant to my clinical practice because it defines which
plans can better spare critical structures such as the femoral heads, bowel
and rectum, which are a concern when planning prostate treatments.
Reducing dose to these structures could mean fewer side effects for patients
and in turn create a better overall outcome for patients as well. We need to
spare such critical structures in order to avoid certain late effects of
radiation, which can cause serious issues for patients. Also, we want to
reduce dose to normal tissue in order to reduce the chance of second
malignancies due to radiation as well. All of these things are concerns that
make this study relevant to my clinical practice.
References
1. Sheets NC, Goldin GH, Meyer A, et al. Intensity-modulated radiation
therapy, proton therapy, or conformal radiation therapy and morbidity and
disease control in localized prostate cancer. Journal of the American Medical
Association. 2012; 307(15):1611-1620
2. Michalski JM, Yan Y, Watkins-Bruner D, et al. Preliminary toxicity analysis of
3-dimensional conformal radiation therapy versus intensity modulated
radiation therapy on the high-dose arm of the Radiation Therapy Oncology
Group 0126 prostate cancer trial. Int J Radiat Oncol. 2013; 87(5): 932-938.

Aubrie Rice
RST 3574
Annotated Bibliography
3. Sale C, Moloney P. Dose comparisons for conformal, IMRT and VMAT
prostate plans. J Med Imaging Radiat Oncol. 2011;55(6):611-621.
4. Taylor, C. Observational Study Designs. [PowerPoint]. Columbus, OH: OSU
School of Health and Rehabilitation Sciences; 2014.
5. Aetna. Policy Bulletin: Intensity Modulated Radiation Therapy. February 12,
2002. Available at:
http://www.aetna.com/cpb/medical/data/500_599/0590.html. Accessed April
19, 2015.
6. Taylor, C. Experimental Designs. [PowerPoint]. Columbus, OH: OSU School
of Health and Rehabilitation Sciences; 2014.