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Hypofractionation has shown to be beneficial in the management of a wide range of cancers1,2 including other advantages such as cost savings3.  Trials over the last decade4,5,6 have demonstrated the advantages of hypofractionation compared with a standard radiotherapy regimen3.

Covid-19 significantly impacted the way in which cancer patients7 are managed  and even though the use of hypofractionation is well established in some cancer types; the application thereof during the pandemic has been widely expanded to minimise treatment time8.  Even though the treatment outcomes have been well defined, there is limited evidence to suggest changes in patient care.  Some oncology centres advocated for a reduced contact time between patient and staff9.

Hypofractionation in an ageing population is particularly advantageous in allowing people to receive treatment in a shorter time demonstrating treatment outcomes similar to younger age groups10 however; greater consideration should be given to performance status and comorbidities associated with these treatment outcomes11. Fractionation schedules which allow delivery in less fractions, can be highly effective with limited treatment-related toxicity. Studies have shown that the late consequences of radiotherapy in these patient groups are seldom an issue even with larger fraction s12. However more recent studies suggest that a reduction in treatment time should not be the only reason for selecting this approach.  Moderate hypofractionation should therefore be considered for those patient who are younger and who might experience long terms effects13. More studies are now investigating the tolerability of ultra-hypofractionated radiotherapy in an attempt to improve the therapeutic gain, suggesting that these approaches are well-tolerated and showed no statistical difference in toxicity14.

Hypofractionation in radiotherapy may be a good alternative to conventional fractionation however patience care remains paramount in the management of all toxicities related the radiotherapy delivery.  There is no evidence to suggest the patient care of these patients have changed, however the tolerability and outcomes of this method of delivery requires constant review. Patient care needs to consider the site of treatment, age of the patient, performance status, and tolerability.  A model of shared decision making in managing care is advocated with greater emphasis on self-care.    


References:

1)    Haviland et al (2013) The UK Standardisation of Breast Radiotherapy (START) trials of radiotherapy hypofractionation for treatment of early breast cancer: 10-year follow-up results of two randomised controlled trials. Lancet Oncol  14: 1086–94
2)    Bledsoe et al (2017) Hypofractionated Radiotherapy for Patients with Early-Stage Glottic Cancer: Patterns of Care and Survival.  JNCI J Natl Cancer Inst 109(10)
3)    Yaremko et al (2021) Cost Minimization Analysis of Hypofractionated Radiotherapy. Current Oncology. 28(1) 716-725
4)    Yee et al.  (2018) Radiation-induced skin toxicity in breast cancer patients: a systematic review of randomized trials. Clin Breast Cancer 2018 18: e825–40
5)    Mulliez et al (2013) Hypofractionated whole breast irradiation for patients with large breasts: a randomized trial comparing prone and supine positions. Radiother Oncol 108: 203–8
6)    Valle et al (2017) Hypofractionated whole breast radiotherapy in breast conservation for early-stage breast cancer: a systematic review and meta-analysis of randomized trials. Breast Cancer Res Treat 162:409–17
7)    Jereczek-Fossa et al (2020) COVID-19 outbreak and cancer radiotherapy disruption in Italy: Survey endorsed by the Italian Association of Radiotherapy and Clinical Oncology (AIRO).  Radiotherapy and Oncology 149: 89–93
8)    Agrawal et al (2021) Role of altered fractionation in radiation therapy with or without chemotherapy in management of carcinoma cervix: Time to revisit in the current COVID-19 pandemic. Clinical Cancer Investigation Journal. 10(2) 53-59
9)    Wu et al (2020) Radiation Therapy Care During a Major Outbreak of COVID-19 in Wuhan. Advances in Radiation Oncology  5, 531-533
10)    Mucha-Małecka et al (2021) Prognostic factors in elderly patients with T1 glottic cancer treated with radiotherapy. Scientific Reports. 11(1) 1-14
11)    Colloca et al (2020) Management of The Elderly Cancer Patients Complexity. Ageing and Disease. 3: 649-657
12)    Veness M.  (2018) Hypofractionated radiotherapy in older patients with non‐melanoma skin cancer: Less is better. Australasian Journal of Dermatology. 59(2) 124-127
13)    Krug et al (2021) Moderate hypofractionation remains the standard of care for whole-breast radiotherapy in breast cancer: Considerations regarding FAST and FAST-Forward.  Strahlentherapie und Onkologie 197; 269–280
14)    Dinçer et al (2021) The efficacy and tolerability of ultra-hypofractionated radiotherapy in low-intermediate risk prostate cancer patients: single center experience. Aging Male 24(1)50