Practical considerations for prostate hypofractionation in the developing world

External beam radiotherapy is an effective curative treatment option for localized prostate cancer, the most common cancer in men worldwide. However, conventionally fractionated courses of curative external beam radiotherapy are usually 8–9 weeks long, resulting in a substantial burden to patients and the health-care system. This problem is exacerbated in low-income and middle-income countries where health-care resources might be scarce and patient funds limited. Trials have shown a clinical equipoise between hypofractionated schedules of radiotherapy and conventionally fractionated treatments, with the advantage of drastically shortening treatment durations with the use of hypofractionation. The hypofractionated schedules are supported by modern consensus guidelines for implementation in clinical practice. Furthermore, several economic evaluations have shown improved cost effectiveness of hypofractionated therapy compared with conventional schedules. However, these techniques demand complex infrastructure and advanced personnel training. Thus, a number of practical considerations must be borne in mind when implementing hypofractionation in low-income and middle-income countries, but the potential gain in the treatment of this patient population is substantial.
Conventionally fractionated external beam radiotherapy is an effective treatment for localized prostate cancer, but long treatment programmes result in a substantial burden to patients and the health-care system, which is particularly problematic in low-income and middle-income countries (LMICs) where health-care resources might be scarce and patient funds limited. Here, the authors discuss the outcomes and benefits of hypofractionation — in terms of both oncology and economics — and how it could be used to improve prostate cancer care in LMICs.
Key points The global burden of prostate cancer is increasing and prostate cancer is becoming a major source of health-care burden in low-income and middle-income countries (LMICs).Radiotherapy is an essential treatment modality in the management of prostate cancer. However, radiotherapy resources are lacking in LMICs, resulting in excess morbidity and mortality.Hypofractionated radiotherapy schedules offer an opportunity to maintain excellent treatment outcomes while shortening curative radiotherapy courses. This approach expands the treatment capacity and could improve crucial access in communities with limited radiotherapy resources.Initial investments are required for technological upgrades, such as intensity-modulated radiotherapy and image-guided radiotherapy, as well as in specialized training in order to optimally provide hypofractionated treatment. Discussion amongst government agencies and device manufacturers is essential to lower these costs.Personnel training and access to external consultation are critical resources for developing radiotherapy centres. Information and communication technologies enable remote guidance between developing and developed radiotherapy centres.In the long term, hypofractionation programmes result in long-term cost savings and simultaneously expand patient access to a curative modality in the management of prostate cancer.