Authors' objectives: This report aims to identify and summarise evidence that addresses the following question: What is the clinical and cost effectiveness of extreme hypofractionated radiotherapy (EHFRT) to treat localised prostate cancer compared to standard care?

Authors' results and conclusions: We identified two randomised controlled trials evaluating the clinical effectiveness of EHFRT compared to either conventionally fractionated or moderately hypofractionated radiotherapy in 39 or 20 fractions or conventional fractionated radiotherapy in 39 fractions. These trials reported acute or longer-term toxicity outcomes, as well as overall, failure-free, and distant-free survival, and quality of life outcomes. For both randomised controlled trials, there were no statistically significant differences in most toxicity outcomes between the EHFRT group and the control group at any point after treatment, except for an increase in urinary toxicity in the EHFRT group compared to the control group at one-year follow-up. Similarly, there was no significant difference in the overall, failure-free, and distant free survival at five years between the treatment groups. At the six-year follow-up, there was no difference in the incidence of clinically relevant deterioration between the groups for overall urinary, bowel, sexual and global health. The three Canadian cost-utility analyses included in the health economic evidence review were assessed as partially applicable with serious limitations. The studies each found EHFRT to be the optimal strategy. One original cost-utility analysis found that EHFRT was more expensive and less effective than conventionally fractionated radiotherapy in people with localised prostate cancer. The model results were sensitive to changes in slot times for fraction delivery. EHFRT was cost effective compared with conventional fractionation without fiducial markers, if EHFRT was delivered in slot lengths of 15 minutes for all seven fractions of EHFRT, or if EHFRT was delivered as five fractions, with slot lengths of 20 minutes each. When EHFRT was compared with conventional fractionation with fiducial markers, the results were more favourable towards EHFRT. EHFRT was cost effective when seven fractions were delivered in slot lengths of 20 minutes, or five fractions were delivered in slot lengths of 30 minutes. At a threshold of £20,000 per QALY gained, there was a 31% probability that EHFRT is cost effective.

Authors' recommendations: The evidence supports the routine adoption of extreme hypofractionated radiotherapy (EHFRT) to treat localised prostate cancer. EHFRT is associated with equivalent short- and medium-term cancer recurrence and survival outcomes compared with standard care (moderately or conventionally fractionated radiotherapy). EHFRT reduces the number of visits required for treatment and is associated with a low incidence of adverse events. EHFRT is likely to be cost effective when compared with standard care. Compared with moderately hypofractionated radiotherapy guided by fiducial markers, EHFRT (seven fractions) using fiducial markers is likely to be cost effective if it is delivered in treatment slots of 20 minutes or shorter. If EHFRT is delivered in five fractions, it is likely to be cost effective at all slot lengths up to 30 minutes.

Authors' methods: The Evidence Appraisal Report is based on a literature search (strategy available on request) for published clinical and economic evidence on the health technology of interest. It is not a full systematic review but aims to identify the best available evidence on the health technology of interest. Researchers critically evaluate and synthesise this evidence. We include the following clinical evidence in order of priority: systematic reviews; randomised trials; non-randomised trials. We only include evidence for “lower priority” evidence where outcomes are not reported by a “higher priority” source. We also search for economic evaluations or original research that can form the basis of an assessment of costs/cost comparison.

Project Status: Completed

Year Published: 2022

URL for published report: https://healthtechnology.wales/reports-guidance/extreme-hypofractionated-radiotherapy-ehfrt/

English language abstract: An English language summary is available

Publication Type: Rapid Review

Country: Wales, United Kingdom

Organisation Name: Health Technology Wales

Contact Address: c/o Digital Health Care Wales, 21 Cowbridge Road East Cardiff CF11 9AD

Contact Name: Susan Myles, PhD

Contact Email: healthtechnology@wales.nhs.uk

Copyright: Health Technology Wales