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Date: 	8/2/00 12:54PM
Subject: 	August 2000 Internet Radiation Oncology Journal Club =
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August 2000 Internet Radiation Oncology Journal Club (IROJC)=20

-------------------------------------------------------=20
Posting of references for review and discussion=20
-------------------------------------------------------=20

The 63rd collection of references suggested for attention and=20
discussion by the IROJC's Board of Editors:=20

Sarah Donaldson, M.D.=20
Editor, Pediatric Radiation Oncology=20

Robert Foote, M.D.=20
Editor, Head and Neck / Skin Radiation Oncology=20

Abram Recht, M.D.=20
Editor, Breast Radiation Oncology=20

Rich Hoppe, M.D.=20
Editor, Reticuloendothelial System Radiation Oncology=20

Dan Petereit, M.D.=20
Editor, Gynecological Radiation Oncology=20

Andrew Turrisi, M.D.=20
Editor, Lung and Mediastinum Radiation Oncology=20

Joel Tepper, M.D.=20
Editor, Gastrointestinal and Soft Tissue Sarcoma Radiation Oncology=20

Mack Roach, M.D.=20
Editor, Genitourinary Radiation Oncology=20

Glenn Bauman, M.D. Ph.D.=20
Editor, Central Nervous System Radiation Oncology=20

Rod Withers, M.D., D.Sc.=20
Editor, Radiobiology=20

James Hayman, M.D.=20
Editor, Health Services Research=20

George Chen, Ph.D.=20
Editor, Radiation Biophysics=20

-----------------------------------------------------=20

You're encouraged to critically review this set of references and=20
respond by posting your comments to the IROJC readership at=20
radoncjc@net.bio.net. Comments should be in compliance with IROJC=20
commentary rules (see below).=20

In the month that follows this posting of references, submitted=20
comments will be delivered to the e-mail boxes of the IROJC=20
readership.=20

------------------------------------------------------------=20

ARCHIVED IROJC material is available at=20
http://www.bio.net/hypermail/radoncjc/=20

------------------------------------------------------------=20

Commentary Rules:=20

(1) Please cite the subject category in the header of your e-mail=20
message, e.g., Subject: CNS 8/00.=20

(2) Address the readership at large - not the Editor who suggested=20
the reference. The Editor is under no obligation to respond to=20
questions posed by the IROJC readership.=20

(3) The Editor's selection is not necessarily an endorsement of the=20
authors' conclusions. In fact, articles may be selected for=20
criticism.=20

(4) Comments posted to the Internet are public. Professional wording=20
is prudent.=20

(5) Comment only on journal articles that you have read recently, and=20
please keep comments specific.=20

(6) In order to minimize confusion, limit comments to the current=20
month's list of references.=20

(7) Please sign all comments and questions to the IROJC. By identifying=20
yourself, you promote a more collegial and friendly environment!=20

(8) Address to the Moderator (goldsmithb@radiological.com) private=20
questions and comments which are not intended for IROJC posting=20
and public reading.=20

******************=20
Peds: Donaldson 8/00=20

AU: Haas-Kogan DA; Fisch BM; Wara WM; Swift PS; Farmer DL; Harrison
MR; Albanese C; Weinberg V; Matthay KK.
TI: Intraoperative radiation therapy for high-risk pediatric neuroblastoma.=

SO: Int J Radiat Oncol Biol Phys 2000 Jul 1;47(4):985-92

Abstract:
Purpose: To evaluate the efficacy of intraoperative radiation therapy
(IORT) in the treatment of high-risk pediatric neuroblastoma. Methods
and Materials: Between 1986 and 1998, 23 children received IORT for
pediatric neuroblastoma. Electron beam energies ranged from 4 MeV to
16 MeV and median dose was 10 Gy (7-16 Gy). Results: Twenty-one of 23
patients were classified as high-risk. A gross total resection (GTR) was
achieved in 18 patients, of whom 6 experienced disease recurrence, 2 of
which included a locoregional relapse as a component of failure. Fourteen
of 18 patients receiving IORT after a GTR are disease-free survivors. A
second subset of 5 patients had a subtotal resection (STR), with gross
residual disease remaining after surgery. All 5 patients recurred locally,
and all died of their disease. IORT was extremely well-tolerated in our
cohort. Surgical resection and IORT resulted in the narrowing of the
abdominal aorta and an atrophic kidney in 1 patient. Conclusions: For
high-risk neuroblastoma patients, IORT as the only radiotherapy to the
primary, produced excellent local control after a GTR. However, IORT as
the sole radiotherapy to the primary was inadequate for patients with
extensive adenopathy or a STR. In this setting, we are exploring the use
of IORT as a boost in conjunction with external beam radiation therapy.

Editor's comments:=20
Neuroblastoma is a radiosensitive childhood cancer.
Haas-Kogan and collegues have advanced the field with this novel approach =
of combining IORT with chemotherapy and resection for those children with =
high risk tumors. This technique allows use of an additional effective =
treatment modality, and nicely defines the role of IORT for those children =
with a small tumor burden. The next challange will be to combine IORT with =
external beam for those in whom pre-operative chemotherapy does not =
facilitate a complete resection.

******************=20
Head/Neck/Skin: Foote 8/00=20

AU: Skladowski K; Maciejewski B; Golen M; Pilecki B; Przeorek W;
Tarnawski R.
TI: Randomized clinical trial on 7-day-continuous accelerated irradiation
(CAIR) of head and neck cancer - report on 3-year tumour control and
normal tissue toxicity.
SO: Radiother Oncol 2000 May;55(2):101-10

Abstract:
PURPOSE: To evaluate tumour and normal tissues 3-year response to
7-day-a-week continuous accelerated irradiation (CAIR) compared to a
conventional treatment (5 days per week) in a randomized trial.
MATERIALS AND METHODS: One hundred patients with squamous
cell carcinoma of the head and neck in stage T(2-4)N(0-1)M(0) were
entered into the trial between December 1, 1993 and June 30, 1996. Dose
per fraction of 2.0 Gy (to the end of 1994), and 1.8 Gy (since January 1,
1995) was the same in both arms and delivered once a day at regular 24-h
intervals to total dose in the range of 66-72 Gy (depending on tumour
stage). The only difference was overall treatment time being 5 weeks in
the CAIR and 7 weeks in control arm. RESULTS: Actuarial 3-year local
tumour control was 82% in the CAIR and 37% in the control group
(P<0.0001) with reduction in local recurrence rate of 83%. Actuarial
3-year overall survival was 78 and 32% (P<0.0001), respectively.
Confluent mucositis was significantly more severe and lasted longer in the
CAIR than in control arm. After 2.0 Gy fractions five of 23 patients (22%)
in the CAIR developed early necroses over a period of 2-4 months of
follow-up which can be considered as a consequential to severe protracted
acute mucosal reactions (CLE). For this reason dose per fraction was
lowered to 1. 8 Gy and the CLE was not observed again until now. Thus
the overall rate of CLE decreased to 10%. CONCLUSIONS: The gain in
tumour control is likely the effect of shortening of overall treatment =
time
by 14 days and regular continuous dose delivery during the whole course
of radiation therapy including weekends. A 7-day schedule produces more
severe acute mucosal reactions lasting longer than in conventional
fractionation, however tolerable by patients. Relatively high rate (22%) =
of
CLE in the 7-day arm observed during the first year of the study was
eliminated by decreasing dose per fraction from 2.0 Gy to 1.8 Gy.

******************=20
GYN: Petereit 8/00=20

AU: Rose PG; Lappas PT.
TI: Analysis of the cost effectiveness of concurrent cisplatin-based
chemoradiation in cervical cancer: implications from five randomized =
trials.
SO: Gynecol Oncol 2000 Jul;78(1):3-6

Abstract:=20
PURPOSE: Five recent phase III trials provide strong evidence that a
new alternative therapy, cisplatin-based chemoradiation, is more effective
than standard therapy using radiation alone in the treatment of advanced
cervical cancer. We conducted a pharmacoeconomic analysis to determine
whether the alternative cisplatin-based chemoradiation is cost effective =
as
compared with standard therapy using radiation alone. METHODS: Using
an economic model, we applied costs to resource utilization data derived
from the cisplatin-based chemoradiation arms of these five randomized
trials. We examined the cisplatin-based chemoradiation benefits in terms
of increased median survival time. Incremental costs were divided by
difference in survival to determine the cost per patient benefited.
Incremental cost per year of life gained (IC/YLG) was calculated based on
both published and estimated survival figures. RESULTS: Cost per year
of life gained for cisplatin-based chemoradiation regimens varied from
$2384 to $28,770 based on published survival and from $308 to $3712
based on estimated survival. Variations in regimen cost were largely
dependent on treatment setting. Administration costs per patient for
cisplatin and fluorouracil in the inpatient setting were $8839 compared
with $3590 in the outpatient setting. CONCLUSION: The increased
median survival cost per year of life gained with cisplatin-based
chemoradiation (inpatient and outpatient settings) adds a substantial
benefit at an acceptable cost compared with radiation therapy alone.
Copyright 2000 Academic Press.

and

AU: Elit L, Gafni A, Levine MN.
TI: Better treatments that cost more: the dilemma.
SO: Gynecol Oncol. 2000 Jul;78(1):1-2.

Editor's comments:=20
In light of the recently published five randomized trials demonstrating =
the
superiority of chemo-radiotherapy versus radiotherapy alone for cervical
cancer, Rose and colleagues set out to ascertain the economic impact of =
this approach in regards to incremental cost per year of life gained =
(IC/YLG).
According to ethicists and health care economists, incremental costs per
year of life in the range of $40,000 to $70,000 are acceptable in order to
justify the implementation of a new procedure. =20

To no surprise inpatient chemo-radiotherapy administration was much more
costly than outpatient administration.  For cisplatin-based regimens the
cost per year of life gained varied from about $2,400 to $29,000.
Continuation of chemotherapy beyond the radiation as given in the =
Intergroup Trial reported by Peters et al. was much more costly.

An excellent editorial was written by Elit et al. in this same issue.  =
They
discuss some of the limitations of the study and suggest that a preferable
measure of outcome would have been the use of quality-adjusted life years
(QALYs) since this would have assessed all relevant costs and consequences =
of  the new intervention.

To put these costs into perspective, the authors also compared the
incremental costs of chemo-radiotherapy to other accepted medical
interventions.  For example, the incremental cost per year of life gained =
is
$4,500 for colorectal screening in patients over the age of 40, $55,000 =
for
dialysis, $82,000 for annual cervical screening in woman over the age of =
40,
$110,000 for annual mammography in woman between the ages of 55-64, =
$130,000 for a bone marrow transplant for breast cancer, and $220,000 for =
multivessel coronary artery bypass surgery.

Interestingly, a sixth randomized cervical trial (NCIC study) was recently
presented by Pearcey et. al for stages IB-IIB cervical CA in which
chemo-radiotherapy (weekly cisplatin @ 40 mg/m2) did not confer a survival
benefit.  The five-year survival was 59% for the chemo-RT arm and 56% for
the RT alone arm (P=3D0.43). =20

As managed care continues to influence clinical practice patterns, we most
likely will see more of these studies.

******************=20
GI / Soft Tissue Sarcoma: Tepper 8/00=20
No Reference Selected

******************=20
CNS: Bauman 8/00=20

AU: Harsh GR; Deisboeck TS; Louis DN; Hilton J; Colvin M; Silver JS;
Qureshi NH; Kracher J; Finkelstein D; Chiocca EA; Hochberg FH.
TI: Thymidine kinase activation of ganciclovir in recurrent malignant
gliomas: a gene-marking and neuropathological study.
SO: J Neurosurg 2000 May;92(5):804-11.

Abstract:=20
OBJECT: The gene therapy paradigm of intratumoral activation of
ganciclovir (GCV) following transduction of tumor cells by retroviral
vectors bearing the thymidine kinase (tk) gene has produced dramatic
remissions of malignant gliomas in animal models. In human trials,
although the technique has been deemed safe, little antitumor effect
has been demonstrated. To evaluate the basis of this inefficacy in
human gliomas, the authors conducted a gene-marking trial involving
neuropathological and biochemical studies of treated tumor
specimens. METHODS: Five patients with malignant recurrent
gliomas underwent stereotactic biopsy sampling and intratumoral
implantation procedures with three aliquots of 10(6) vector-producing
cells (VPCs) in columns. After 5 days, the tumor was resected and the
tumor bed reimplanted with VPCs, and a course of GCV was given.
Patients received clinical and radiological follow up for 6 months.
Tumor specimens were analyzed neuropathologically and for tk gene
expression by anti-TK immunohistochemistry and TK enzymatic
activity. Four patients tolerated the treatment well but experienced
tumor progression. The other developed an abscess after the second
operation and died. Increased TK enzymatic activity was
demonstrated in the one tumor specimen analyzed.
Immunohistochemical evidence of tk gene expression was limited to
VPCs. Transduction of tumor cells was not seen. Viable tumor cells
were seen near VPCs containing TK. The lymphocytic immune
response was mild. CONCLUSIONS: Except for the risk of infection
inherent in reoperation, this tk-GCV paradigm was both feasible and
safe. Pathological studies indicated that limited dissemination of
VPCs and vector from the infusion site and failure to transduce tumor
cells with the tk gene are major barriers to efficacy.

Editor's comments:=20
A well done clinicopathologic study examining the efficacy of gene
therapy in a small series of patients. The discussion is a good review of =
the TK gene therapy paradigm for malignant glioma.

******************=20
Breast: Recht 8/00=20

AU: Froud PJ; Mates D; Jackson JS; Phillips N; Andersen S; Jackson SM;
Bryce CJ; Olivotto IA.
TI: Effect of time interval between breast-conserving surgery and =
radiation
therapy on ipsilateral breast recurrence.
SO: Int J Radiat Oncol Biol Phys 2000 Jan 15;46(2):363-72

Abstract:=20
PURPOSE: To examine the effect of the time interval (interval) between
breast-conserving surgery (BCS) and the start of radiation therapy (RT)
on the subsequent risk of ipsilateral breast cancer recurrence (IBR).
METHODS AND MATERIALS: We reviewed interval and a number of
prognostic and treatment factors among 1,962 women treated with BCS
and RT for invasive breast cancer diagnosed between January 1, 1989
and December 31, 1993 in British Columbia, Canada. Subjects were
female, less than 90 years old at diagnosis, not treated with
chemotherapy, not stage T4 or M1, and had survived more than 30 days
from diagnosis. The cumulative incidence of IBR was estimated in four
interval groups: 0-5, 6-8, 9-12, and 13+ weeks. Only 23 women had an
interval of greater than 20 weeks between BCS and start of RT. To
assess whether an imbalance of prognostic and treatment factors could be
obscuring real differences between the interval groups, Cox proportional
hazards regression analyses were conducted. RESULTS: Median
follow-up was 71 months. The crude incidence of IBR for the entire
sample was 3.9%. The cumulative incidence of IBR in the 6-8, 9-12, and
13+ week groups was not statistically significantly different from the
cumulative incidence of IBR in the 0-5 week group. Multivariate analyses
demonstrated that patients not using tamoxifen p =3D 0.027) and those with
grade 3 histology (p =3D 0.003) were more likely to recur in the breast.
Interval between BCS and RT was not a statistically significant predictor
of breast recurrence when entered into a model incorporating tamoxifen
use and tumor grade (0-5 vs. 6-8 weeks, p =3D 0.872; 0-5 vs. 9-12 weeks, p =
=3D
0.665; 0-5 vs. 13+ weeks, p =3D 0.573). CONCLUSIONS: We found no
univariate or multivariate difference in ipsilateral breast cancer
recurrence between intervals of 0 to 20 weeks from breast conserving
surgery to start of radiation therapy, in a population-based, low risk =
group
of women not receiving adjuvant chemotherapy, after controlling for other
factors important in predicting ipsilateral breast cancer recurrence.

Editor's comments:
This very important, extremely well-analyzed series contains a wealth=20
of data on many aspects of breast-conserving therapy. Besides the=20
issue of the surgery-radiotherapy interval (SRI) and its impact on=20
local control, the authors' findings on the role of systemic therapy=20
and different fractionation schemes is of great interest. The low=20
risk of local failure in all subgroups is note-worthy. However, as=20
the authors note, there were few patients who began radiotherapy more=20
than 20 weeks after breast surgery. Therefore, this study cannot=20
provide reassurance regarding the risk of local failure in patients=20
treated with prolonged chemotherapy programs prior to starting RT. At=20
present, I prefer to treat such patients with a "sandwich" approach=20
(e.g., 4 cycles of AC, then RT, then 4 cycles of taxol). More data on=20
this subject may be available in the coming years from retrospective=20
studies and randomized trials (including ones recently conducted in=20
Europe).

******************=20
RES: Hoppe 8/00=20

AU: O'Brien P, Roos D, Pratt G, Liew K, Barton M, Poulsen M, Olver I,
Trotter G.
TI: Phase II multicenter study of brief single-agent methotrexate followed =
by
irradiation in primary CNS lymphoma.
SO: J Clin Oncol. 2000 Feb;18(3):519-26.
URL: http://www.jco.org/cgi/content/abstract/18/3/519
PDF: http://www.jco.org/cgi/content/full/18/3/519

Abstract:
PURPOSE: To assess, in a multi-institutional setting, the impact on
relapse, survival, and toxicity of adding two cycles of intravenous
methotrexate to cranial irradiation for immunocompetent patients with
primary CNS lymphoma. PATIENTS AND METHODS: Forty-six
patients with a median age of 58 years and Eastern Cooperative Oncology
Group performance status 0 to 3 were entered onto this phase II study.
The protocol consisted of methotrexate 1 g/m(2) on days 1 and 8 followed
by cranial irradiation on day 15. A whole-brain dose of 45 Gy was followed
by a boost of 5.4 Gy. Intrathecal chemotherapy and spinal irradiation
were given only to patients for whom cytologic examination of CSF was
positive for CNS lymphoma. The median follow-up time was 36 months,
with a minimum potential follow-up of 12 months. RESULTS: Median
survival was 33 months, with 2-year probability of survival 62% +/- 15%
(95% confidence interval). Twenty patients have relapsed. The
predominant site of relapse was the brain. Neither performance status nor
age was found to influence survival. Six patients developed a dementing
illness at a median of 16 months after treatment, and three of these died
as a consequence. CONCLUSION: A brief course of intravenous
methotrexate before cranial irradiation is associated with 2-year and
median survival rates superior to those reported for radiotherapy alone
and similar to more intensive combined-modality regimens. Neurotoxicity
remains an important competing risk for these patients.

Editor's comments:
This report from the Trans-Tasman Radiation Oncology Group underlines the =
frustrations of dealing with primary CNS lymphoma.  A group of 46 patents =
was treated with IV MTX x 2, followed by whole brain RT (45 Gy) and a 5.4 =
Gy boost.  The 2-year survival was reasonable, 62%, and the median =
survival was 33 months.  Local failure was a problem despite the radiation =
doses employed.  In addition, among patients who survived, neurotoxicity =
(dementia) was a significant risk.  Innovative new management programs are =
required for this lymphoma, which has a distinctly unfavorable prognosis.

******************=20
Lung/Mediastinum: Turrisi 8/00=20
No Reference Selected

******************=20
GU: Roach 8/00=20
No Reference Selected

******************=20
Radiobiology: Withers 8/00=20

AU: Martin M; Lefaix J; Delanian S.
TI: TGF-beta1 and radiation fibrosis: a master switch and a specific
therapeutic target?
SO: Int J Radiat Oncol Biol Phys 2000 May 1;47(2):277-90

Abstract:
Radiation fibrosis is a frequent sequel of therapeutic or accidental
radiation overexposure in normal human tissues. One of the main
fundamental problems yet unsolved in fibrotic tissues is the origin of the
chronic activation of myofibroblasts within these tissues. It has been
postulated that this chronic activation results from a continuous
production of activating factors. In this context, fibrosis could be =
defined
as a wound where continuous signals for tissue repair are emitted.
Cytokines and growth factors probably play a central role in this process.
Among them, transforming growth factor-beta1 (TGF-beta1) is considered
as a master switch for the fibrotic program. This review discusses recent
evidence on the critical role played by TGF-beta in the initiation,
development, and persistence of radiation fibrosis. It summarizes the
results concerning this factor after irradiation of various tissues and =
cells,
with an emphasis on superficial fibrosis, including skin and subcutaneous
tissues. Finally, recent data concerning the treatment of established
fibrotic disorders of various etiology are presented, as well as the =
possible
mechanisms involved in fibrosis regression, which show that the TGF-beta
pathway may constitute a specific target for antifibrotic agents.

Editor's comments:
This is an excellent, up to the minute review of radiation fibrosis.  The
principal author and her colleagues span the spectrum from basic biology =
to
clinical radiation oncology and present here a compelling overall
hypothesis with exciting clinical implications.  The cellular responses,
and the cytokines which drive them, may be more amenable to modification
than has been appreciated in the traditional view of fibrosis as
progressive and irreversible.  Much of the review will be tough-sledding
for many clinicians, but you should persist because emerging clinical
relevance is made clear.

******************=20
Health Services Research: Hayman 8/00=20

AU: Horwitz EM; Hanlon AL; Pinover WH; Hanks GE.
TI: The cost effectiveness of 3D conformal radiation therapy compared with
conventional techniques for patients with clinically localized prostate
cancer.
SO: Int J Radiat Oncol Biol Phys 1999 Dec 1;45(5):1219-25

Abstract:=20
BACKGROUND: We previously demonstrated the advantages of
three-dimensional conformal radiation therapy (3DCRT) in improved
rates of biochemical (bNED) control in certain subsets of patients with
clinically localized prostate cancer. However, in this era of cost
consciousness and limited resources, the cost effectiveness of 3DCRT
compared with conventional external beam irradiation (CRT) remains
unexamined. METHODS AND MATERIALS: Between October 1, 1987
and November 30, 1991, 193 patients with clinically localized prostate
cancer received definitive external beam irradiation at Fox Chase Cancer
Center. The 1998 Medicare fee schedule was used to determine
treatment charges and to provide a reference for a national comparison.
Complete charges for pretreatment work-up, treatment, and follow-up
were tabulated for each patient. The mean total charges (MTC) using the
Lin method of estimating medical costs was used to analyze and compare
costs between groups. A matched case/control analysis was performed to
further evaluate the effect of cost between techniques. The median
follow-up was 72 months (range 3-118). RESULTS: The overall 5-year
actuarial rate of bNED control was 41% and 53%, respectively, for the
CRT and 3DCRT patients (p =3D 0.03). The MTC for the CRT patients was
$10,544.53. For the 3DCRT patients, the MTC was $8,955.48. The
sample mean of the total costs from the observed deaths for the two
patient groups by follow-up interval ranged from $9,800.63 to $59,635.01
for the CRT patients to $17,259.00 to $24,250.38 for the 3DCRT patients.
No statistically significant difference in cost was observed between
groups using the matched case/control analysis. CONCLUSION: Initial
work-up and treatment costs were greater for patients treated with
3DCRT compared with patients treated with conventional techniques.
However, with longer follow-up, the mean total cost of treatment was not
statistically different between the two treatment groups. Because of
improved rates of bNED control for these patients and the increased
costs associated with the treatment of a greater fraction of patients with
recurrent disease following CRT, 3DCRT was cost effective for patients
with clinically localized prostate cancer.

Editor's comments:
It has been hypothesized that the use of 3DCRT for the treatment of =
clinically localized prostate cancer will improve outcomes both by =
increasing the likelihood of tumor control (through dose escalation) and =
by decreasing the likelihood of complications (by sparing normal tissue).  =
In this paper, the authors chose to examine the impact of 3DCRT on the =
cost of treating these patients.  Not surprisingly, these investigators =
found that the initial cost of treatment associated with the use of 3DCRT =
was greater than the cost associated with the use of conventional =
treatment (approximately $10,300 and $9,000, respectively, though they do =
not tell us if this difference was statistically significant).  However, =
more importantly, rather than just estimating the upfront treatment costs, =
these investigators then went on to examine the downstream costs incurred =
during the follow-up of these patients too.  As noted in the abstract, the =
mean total charges were lower for the 3DCRT patients (due to lower costs =
associated with the treatment of recurrent disease) but this difference =
was not statistically significant.  There are several limitations of this =
analysis.  Rather than examining the actual cost of treatment, the =
analysis was performed from the perspective of HFCA and Medicare reimbursem=
ent was used as a proxy for these costs.  In addition, it is not clear if =
the investigators were able to capture the costs for treatment of =
complications and progressive disease that occurred outside of their =
institution.  However, more importantly, I have some difficulty with the =
authors' conclusion that this study demonstrates that 3DCRT is "cost-effect=
ive" as compared to conventional treatment.  Instead, it is probably =
better characterized their findings as demonstrating that 3DCRT does not =
appear to be more expensive than conventional RT when examined over an =
intermediate time period (i.e., 8 years).  Their assertion that 3DCRT is =
"cost-effective" is based on the finding that bNED control at 5 years was =
greater in the 3DCRT patients than in the conventional RT patients.  =
However, as noted by the authors, biochemical failure is only a surrogate =
endpoint and it is not clear yet if 3DCRT will lead to an improvement in =
survival.  It is possible that biochemical failure, in and of itself, is =
associated with a decline in quality of life but, to the best of my =
knowledge, this has not been clearly quantified in a manner in which it =
could be incorporated into an economic analysis (i.e., decline in =
utility).  So, while the authors of this study should be commended for =
examining the downstream costs associated with two different methods for =
administering radiation, I don't think, based on this analysis, that we =
yet have the data needed to conclude that the use of 3DCRT is "cost-effecti=
ve" in this setting.=20

******************=20
Radiation Biophysics: Chen 8/00=20
No Reference Selected

******************=20

Brian J. Goldsmith, M.D.=20
Moderator, IROJC=20