Radiation after prostatectomy

An article last week in JAMA seems to indicate that IMRT is not any better than Conformal Radiotherapy. IMRT (Intensity modulated radiotherapy) is a sophisticated technique for delivering radiation in a more precise way to tumors. As computers have increased in power, their ability to focus the radiation has improved, and in prostate cancer this has allowed increasing dose to the gland while still sparing surrounding tissue like the bowel and bladder. The evidence that this increased dose produces higher cure rates is pretty convincing. However, after prostate surgery, there is no gland to aim the beam at. Hence, less precise (and cheaper) conformal radiation is adequate as shown in the JAMA article. The dose (which naturally includes bladder and bowel, in addition to the small amount of tissue where the prostate used to be) is limited by the tolerance of those organs.

This trend for more sophistication at higher cost seems to be an unstoppable trend in prostate cancer therapy. I have written elsewhere about the robotic revolution. If we are to get our costs under control, it is critical that increased costs be associated with meaningful improvements in outcomes. We have a long ways to go, so “let the buyer beware” remains a good axiom for third party payers like our tax dollars.