Does IMRT work best when altered fractionation is used? a radiation oncologist we met with today said that with IMRT altered fractionation is unnecessary, which struck me as questionable. He also said altered fractionation is not useful in treating tongue lesions.

Here is a whitepaper from Adam S. Garden, MD
Associate Professor of Radiation Oncology, Department of Radiation Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, Texas that discusses this very item.

http://www.cancernetwork.com/head-and-neck-cancer/article/10165/96653

Kevin

Keep in mind that this article is from 2001, and much has been done since, and many studies are underway.

One of the schools of thought is that IMRT, as applied in many institutions, with boost therapy, is effectively incorporating the concepts that underlie hyperfractionation regimes, as it maximizes radiation delivery to targeted tissues, and minimizes delivery to normal, non-target tissues, reducing toxicity and maximizing efficacy. Studies are underway to confirm this.

The situation is complicated by the fact that other advancements have come into play at the same time, such as simultaneous chemotherapy and the monoclonal therapies, such as Erbitux. Lots of studies underway designed to see how each advance plays into the overall picture.

From what I understand, unless the radiation plans (points of irradiation) are changed, hyperfractionation does not change the target volumes irradiated (or relative radiation distribution healthy vs normal tissue).
What is different is how tissue reacts to dose per fraction and total dose (which in this case may be slightly higher).

In normal IMRT you get irradiated once a day if hyperfractionation is used this goes to 2 time a day which is probably a practical limit, unless you want to camp at the facility. This is effect means that the IMRT can only to 50% of the patients, which you might be able to do if there is sufficient capacity and this may become more possible as more IMRT come on line.
Following this though:
Since you are using essentially twice the machine and personnel time does that mean that hyperfractionation is twice as expensive? ( doubt that they carge by the photon).

M

Thanks, What I am tryng to figure out is, is it worth 3-4 hours of driving per day to go to the clinic further away with hyperfractionation?

Marma,

My husband had hyperfractionated rads. In laymen's terms, his RO suggested that in his studies, it gave us a little better chance at 5 year survival..10 to 20%. Since Bill decided to take as aggressive a stance with his treatment as possible, he opted for it. We live within 10 miles of the treatment facility so driving was not as much of a problem but I will say that twice a day was still hard.

If you opt for this, could you not set up a temporary living situation while undergoing treatment. I definitely know that toward the end of treatment, it will be very rough on your FIL as well as his caregivers because along with all the driving you will be faced with feedings and fluids and meds and a very sick patient. It can be done, but it will be very tough.

Deb

This technique was heavily favored PRIOR to IMRT radiation. I had it 10 years ago, and it was cutting edge at that time. IMRT changed many things. I hope that GARY will chime in here since this is his area of expertise, but my understanding is that fractionated radiation is less of a benefit in IMRT than it used to be in the past. I have an good source for an informed opinion from MDACC, but I will not be able to call them until Monday. However there are papers since this 2001 that look at SMART techniques which appear to have benefit. Simultaneous modulated accelerated radiation therapy, may indeed be the next incarnation of IMRT therapy where fractionation shows value and becomes the standard.

Thanks Brian and all you experts for chiming in on this...I was very hesitant to say anything with my lack of expertise or knowledge on this. Bill's RO did not push the hyperfractionated treatment..he gave it as an option and explained that one of his colleagues told him never to do "that" to someone. The RO also explained that he would not follow the course unless Bill had a PEG tube. He was cautious to give us all the facts...at least the ones that he thought we could understand.

I feel like we made a fairly informed decision and Bill did very well with his treatments so we are glad we opted and hope in the long run, it was worth it. So far, so good.

Re the cost...I don't know what a normal radiation treatment plan costs having never gone thru it. I will say that we (the insurance co.) were charged for each treatment...in other words billed for 2 treatments each day X $1566(that is just for the rads/no doctor charges) so over $3000 for each day of treatment. I am an insurance freak so I check these things..actual total payments (just for the radiation) from both insurance(in network agreed upon charges) and us personally was about $75,000 .
Deb

they are giving me twice a day radiation on fridays

As other have posted earlier in this thread this modality is aimed at reducing toxicity and maximizing efficiency of the radiation. In the days before IMRT I can only say that it was a difficult regime, but I am still here today, and perhaps this choice my docs made, was the determining factor. But I can remember that in the second half of the treatments - when the sessions were doubled up - that it was physically demanding. (Thank God for morphine) IMRT would reduce some of that. I would not let geography dictate choices. I will do my best to get you some kind of science based answer of value on Monday if I can reach the doctor. At the end of the day though, you have to consider no one that has published on this has mentioned reasons NOT to do it, such as toxicity, or other long term issues.