Impact case study database

There are approximately 48,500 new prostate cancer cases in the UK annually and since the early 1990s incidence has increased by 41%. UK incidence rates for prostate cancer are expected to rise by 12% between 2014 and 2035 [A]. Therefore it is a growing healthcare burden, both in the UK and globally. 30% of patients diagnosed with prostate cancer have radiotherapy as part of their primary cancer treatment. Radiotherapy is the most commonly used curative form of therapy in the UK, and development of more effective radiotherapy techniques provides huge opportunities for clinical benefit by increasing survival rates and reducing treatment-related toxicities. This latter consideration is increasingly important as cancer patients survive longer and live with the long-term consequences of treatment.

International guidelines/recommendation and international uptake of the improved radiotherapy techniques. The commissioning policy in 2014 recommended a dose of 74Gy in 37 fractions which was based on the UK national phase 3 dose-escalation radiotherapy trial (Ref. 1) led by Professor Dearnaley [B]. In 2017 the results from the ICR-led CHHiP phase 3 trial (Ref. 2-7) led to the new recommendation by the NHS England Clinical Commissioning Policy that high dose intensity modulated hypofractionated radiotherapy is both safe and effective when delivered giving 60Gy in 20 fractions over a 4-week period for prostate cancer [C]. The guidance states that:

“Radiotherapy providers must submit their activity to the national Radiotherapy Dataset (RTDS) on a monthly basis. For reporting purposes, it is expected that 70% of prostate cancer patients requiring radical external beam radiotherapy should receive hypofractionated radiotherapy (i.e., ≤20 fractions of treatment).”

In addition this guidance mandated the use of IMRT and recommended that IGRT should be used to reduce side effects of high dose radiotherapy based on data from the CHHiP trial.

In the UK, the National Cancer Registration and Analysis Service (NCRAS) has recorded prostate cancer fractionation in the National Radiotherapy Dataset (RTDS). There has been an increase in the use of the 60Gy treatment in 20 fractions from 8% in 2012/13 rising to 49% in 2016/17, with a corresponding decrease in the previous standard treatment (74–78Gy in 37–39 fractions) from 77% to 26% [D]. Moreover, the National Prostate Cancer Audits reported that 91% rising to 96% of people in 2019 and 2020, respectively, receiving radical radiotherapy for intermediate-risk disease had the 60Gy treatment in 20 fractions in combination with androgen deprivation therapy [E, F]. These data show the increased uptake of this schedule across the UK following the publication of results of the CHHiP trial.

In addition, there have been international recommendations of the 60Gy treatment in 20 fractions protocol based on data from the CHHiP trial. The American Society for Radiation Oncology (ASTRO), American Society of Clinical Oncology (ASCO), and American Urological Association (AUA) Evidence-Based Guideline concluded that the accumulated data are sufficiently robust to justify routine use of 60Gy treatment in 20 fractions protocol in clinical practice. This guideline is endorsed by the Society of Urologic Oncology, the European Society for Radiotherapy & Oncology (ESTRO), and the Royal Australian and New Zealand College of Radiologists [G]. In 2019, the National Institute for Health and Care Excellence (NICE) reviewed the evidence as part of a larger update of their prostate cancer guideline and the committee agreed with the recommendations made by NHS England (see [C] ) that 60Gy in 20 fractions was the optimal dose for patients having radiotherapy for localized prostate cancer [H].

Patient benefit of the improved radiotherapy techniques. The CHHiP trial found that long-term side effects were similar in the hypofractionated groups compared with the conventional group. There were no significant differences in either the proportion or cumulative incidence of side effects 5 years after treatment using clinician-reported and patient-reported outcome measures (Ref. 4). However, the 60Gy treatment in 20 fractions approach has further benefits for patients as it leads to an average of 17 less hospital visits per patients, reducing time spent attending appointments and reducing patients’ travel costs. It is estimated that 238,906 hours per year are saved for all patients. The benefits of 60Gy treatment in 20 fractions was perhaps best highlighted by a prostate cancer patient himself, whose treatment was influenced by the CHHiP trial:

“I found the 20 sessions of radiotherapy sessions extremely manageable. It was so much better psychologically to ‘get it over and done with’, and in terms of less disruption to my daily life, to have the sessions condensed was great. […] I have been lucky in a way. I haven’t had any particularly serious side effects from the treatment, and now live a normal life. This is a huge step forward in the development of radiotherapy treatment, it will save the NHS money and cause less disruption for the patient. It would be great if things continue to develop in this way.” [I]

Cost saving for the NHS and global healthcare as a result of improved radiotherapy techniques. Full UK implementation of the CHHiP regimen (60Gy treatment in 20 fractions) in prostate cancer is estimated to reduce total treatment fractions and attendances by approximately 200,000 per year with an annual NHS cost saving of GBP28,000,000. The regimen saves 17 hospital trips and complex radiotherapy treatments for each patient, leading to a national reduction of more than 150,000 visits per year [D]. Prostate cancer radiotherapy accounts for 28% of the workload of radiotherapy departments and the use of hypofractionation is expected to release approximately 13% of capacity, resulting in shorter waiting times and greater availability of radiotherapy resource for other uses.

The cost of standard fractionation (45 or 39 fractions) in the US is USD26,782 and USD23,625 per patient, respectively. With 60Gy treatment in 20 fractions, the cost is reduced to USD13,402 per patient. Therefore the use of 60Gy treatment in 20 fractions may have the potential to save approximately USD360,000,000 in the US annually without impacting survival or tolerability [J].