Economics of radiotherapy and radiotherapy boost for high grade invasive breast cancer

Prof Philip Poortmans - University Medical Center, Nijmegen, The Netherlands

Philip, you’re President of ESTRO, you’re based in Nijmegen. Tell me about the rest of what you do, very briefly.

Yes, Philip Poortmans, I’m a radiation oncologist, Head of the Department of the Radboud University Medical Centre in Nijmegen now for a little bit over a year.

You’re into radiation oncology, of course, but there’s a shortage of capacity globally and especially in certain countries. What are the consequences of this and what are your thoughts about the announcement that there could be a big benefit from correcting that shortage?

Indeed, in fact we are very happy with this new, just released, paper. The effect of the shortage in infrastructure and in manpower results in a lot of avoidable deaths due to cancer. If we bring the current capacity in radiation therapy up to the evidence based required levels we can spare a lot of lives and the sparing of a lot of lives will also have a lot of economical benefits.

How impressed are you with the data that there are economical benefits, though?

I am very impressed, especially if you know that the return on investment is nearly five. If you invest today one euro you will get five euros back in twenty years.

What’s the main practical thing that needs to be done to implement what presumably you’re hoping for to correct that shortage of capacity?

At first we really need to invest money, not only in machines but at the same time and to at least the same level in the training of personnel to work with the machines.

Now, in the treatment of women with primary breast cancer, early breast cancer, you have discovered in a very big study that there are striking differences in approaches. What is it you have found and what needs to be done?

There are a lot of differences in approaches and one of them is the use of breast conserving therapy and another is the use of systemic therapy, adjuvant systemic therapy.

What things might be going wrong at the moment?

Wrong, it depends on the national guidelines and the interpretation of the results of trials. Most trials include women up to 70 years of age so can you use them when you have a patient of 80 years? We suppose we do but we know that the effects of systemic therapy decrease with age.

What are the big deficiencies you’d like to see changed?

We need to have outcome based data. We don’t need new clinical trials in those patients, we need to see what really happens in daily practice. We treat today a patient, what’s the outcome in five years, in ten years, in fifteen years? This we need to prospectively register, analyse and present.

Do you see the possibility of having clearer guidelines for treating older patients with systemic, for instance hormonal, therapies?

Absolutely, but again based on real data, not on prospective clinical trials because we will have the results only for a future generation. We have the data if we collect and properly analyse them subsequently.

Again, the EORTC boost no-boost study has given us some very important data on the efficacy of radiation therapy and some prognostic and predictive factors have emerged. It seems, however, there’s some real action can be taken coming out of this. How would you summarise that action?

Yes, very simply said, giving a boost in the framework of breast conserving therapy reduces the risk for recurrences and reduces the subsequent mastectomy rate. However, if we do it for all our patients we give it to a lot of patients with little or no benefit and we increase side effects. Therefore we have to focus on the high risk patients. What is a high risk? It is mainly determined by a young age, high grade of the tumour, DCIS component linked to the tumour and, of course, the surgical excision rate.

Now the young age and the high grade have been known for a little while but the DCIS involvement, that’s a little bit new, isn’t it?

It is based on the 17.2 years follow-up of this famous trial. The reason that it was not accepted is that the ending on the trial the results were different. This has to do with quality of pathology, standardising of pathology. In the boost no-boost trial we did for all patients, of course, the local pathology but for an important subgroup we also went to central pathology review and we learned a lot out of that.

So what are your guidelines now for treating patients who have one or more of these risk factors?

We give a boost for patients with risk factors, even one risk factor in our opinion is sufficient.

And if they have all three risk factors how much benefit can they get?

The benefit will be for the highest risk group the risk of local recurrences might be reduced by three-quarters and even a little bit more, as shown in a small subgroup of the participants through the trial.

So what are the messages coming out of some of these different developments in radiation oncology and also with the treatment of older breast cancer patients? What would you say to doctors around the world?

I would say first of all invest in radiation oncology services, infrastructure, personnel. You get a splendid return on investment, not only in money but also in quality of life, in life spared. Secondly, we need to collect our data, not only in clinical trials but from all the patients we treat on a daily basis, the so-called famous big data. And we need to analyse them continuously so that we can every day update our anticipations on the result when we have a new patient in front of us. Risk factors, prognostic factors, like in the boost no-boost trial, form an essential part of that.

Philip, thank you very much.