Re: Proton vs intensity-modulated radiotherapy for prostate cancer: patterns of care and early toxicity.
Re: Proton vs intensity-modulated radiotherapy for prostate cancer: patterns of care and early toxicity.
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回复：前列腺癌的质子与调强放射治疗：护理模式和早期毒性。
DOI：
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发表时间：
2013
期刊：
影响因子：
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通讯作者：
R. Foote
中科院分区：
文献类型：
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作者：
S. Schild;S. Keole;R. Foote
在过去的十年中，调强放射治疗（IMRT）已成为治疗前列腺癌的标准放射治疗形式，占所有放射治疗的80%以上（1）。即使调强放射治疗已被广泛采用，其他放射治疗方式也已进入市场，最著名的是质子放射治疗（PRT）。尽管PRT早于IMRT，但近年来PRT的传播迅速增加。部分原因是其高资本成本，据报道，医疗保险以1.4至2.5倍的比例补偿PRT调强放疗（2-4），尽管有许多未探讨的问题。
首先，缺乏关于国家使用模式和PRT在医疗保险受益人中的真实成本的数据。目前，在美国只有9个PRT中心在运行（5），这种相对较低的处理能力限制了成本。然而，其他八个中心正在开发中（5），沿着更小、更便宜的质子机器（6），可以想象，这将为在全国范围内更广泛地采用PRT打开大门。
其次，临床和经济审查研究所一致认为，目前对比较临床有效性的了解“不足”（7，8）。由于前列腺癌治疗的癌症治愈率和生存率的差异通常需要多年才能变得明显，因此有人建议前列腺癌治疗的初步研究应该集中在治疗相关的毒性上（8）。PRT的支持者认为，质子的物理性质可能会减少与前列腺放疗相关的最常见的副作用-胃肠道和泌尿生殖毒性（9）。研究PRT的单组前瞻性试验的早期结果即将到来，表明早期随访的辐射诱导毒性水平较低（10，11）。然而，IMRT本身有大量文献描述了前列腺癌治疗的优异疗效和低毒性（12）。因此，目前尚不清楚PRT是否提供了超过IMRT的统计学显著获益。先前使用监测、流行病学和最终结果-医疗保险数据库调查医疗保险受益人PRT的研究是单机构研究（13，14），因此，不是全国性的。这些研究（13，14）指出，与PRT相比，接受IMRT的患者胃肠道毒性在统计学上显著降低。PRT与IMRT的全面比较需要对整个国家最近几年的可用情况进行检查。
随着越来越多的PRT中心投入运营，患者、供应商和政策制定者了解PRT的成本和国家模式以及与IMRT相比的治疗相关毒性的发生率将至关重要。因此，我们使用了一个全国性的前列腺癌医疗保险受益人样本来调查PRT的模式和成本，以及与调强放疗相比，PRT相关的早期治疗相关毒性。
Over the past decade, intensity modulated radiotherapy (IMRT) has become the standard form of radiotherapy for the treatment of prostate cancer, accounting for more than 80% of all radiotherapy (1). Even as IMRT has been widely adopted, other radiotherapy modalities have come to market, most notably proton radiotherapy (PRT). Although PRT predates IMRT, dissemination of PRT has been increasing rapidly in recent years. In part because of its high capital cost, Medicare is reported to reimburse PRT at a rate 1.4 to 2.5 times that of IMRT (2–4), despite many unexplored questions.
First, there is a lack of data regarding national patterns of use and the true cost of PRT among Medicare beneficiaries. Currently, there are only nine PRT centers in operation in the United States (5), and this relatively low treatment capacity limits costs. However, eight other centers are in development (5), along with smaller and more affordable proton machines (6), conceivably opening the door to more widespread adoption of PRT across the country.
Second, the Institute for Clinical and Economic Review concluded unanimously that the state of current knowledge of comparative clinical effectiveness was “insufficient” (7,8). Because differences in cancer cure rates and survival from prostate cancer treatment often take many years to become evident, it has been suggested that initial study of prostate cancer treatments should focus on treatment-related toxicity (8). Proponents of PRT argue that the physical properties of protons may decrease the most common side effects associated with prostate radiotherapy—gastrointestinal and genitourinary toxicity (9). Early outcomes from single-arm, prospective trials investigating PRT are forthcoming, indicating low levels of radiation-induced toxicity with early follow-up (10,11). However, IMRT itself has a robust literature describing excellent efficacy and low toxicity in the treatment of prostate cancer (12). Therefore, it is unclear that PRT offers a statistically significant benefit beyond IMRT. Prior studies investigating PRT in Medicare beneficiaries using the Surveillance, Epidemiology, and End Results–Medicare database have been single-institution studies (13,14) and, therefore, are not of the whole country. These studies (13,14) noted a statistically significant reduction of gastrointestinal toxicity for patients undergoing IMRT compared with PRT. A comprehensive comparison of PRT with IMRT requires examination of the entire country for the most recent years available.
As more PRT centers become operational, it will be crucial for patients, providers, and policy makers to understand the cost and national pattern of adoption of PRT and the incidence of treatment-related toxicity compared with IMRT. Therefore, we used a national sample of Medicare beneficiaries with prostate cancer to investigate the patterns and cost of PRT delivery, as well as the early treatment-related toxicity associated with PRT compared with IMRT.