Scott Webb (Host): Carle's Radiation Oncology Radiation Therapy Program is a regional leader in hypofractionated radiotherapy in East Central Illinois. And joining me today to tell us what that means and how cancer patients benefit from this radiotherapy, is Dr. Sinisa Stanic. He's a Radiation Oncologist with Carle. And this is Expert Insights with the Carle Foundation Hospital. I'm Scott Webb.

Doctor, it's so great to have your time today. We're going to talk about the hypofractionation and what that means both for you, for patients in terms of outcomes and so on. But before we get there, tell listeners a little bit about yourself and what you do for Carle.

Sinisa Stanic, MD (Guest): I'm a Radiation Oncologist by training. I have been at Carle for the past 10 years and as a radiation oncologist, I am primarily involved in the management of many solid malignancies. My focus is mostly on the chest and pelvis, meaning, lung, breast cancer, and in the pelvis, uh prostate and gynecological cancers.

Host: Yeah. So a lot of experience of course. And you and I were just kind of kicking things around a little bit before we got rolling here today. And so I have a sense of what hypofractionation is, basically shorter radiotherapy courses. But I want to have you talk more about it. Tell listeners what does that mean, what is it, what types of cancers are being treated and so on.

Dr. Stanic: So hypofractionation is one of the latest advancements that we see in oncology that is significantly reshaping the field. So, traditionally, if we look in the 1970s, 80s and 90s, radiation therapy was delivered over a long period of time, five days a week, anywhere between five and nine weeks, if we look at the common malignancies such as breast cancer and prostate cancer. And this creates many challenges. This includes many visits. So prostate cancer patients would need to go for eight and a half weeks, almost nine weeks of radiation, Monday thru Friday. Breast cancer patients for six weeks.

And the clinical trials tested to see if shorter courses of radiation therapy are as good as long courses of radiation therapy. So instead of delivering your radiation therapy with small daily dose over a protracted period of time, the same outcome can be achieved if patients receive slightly higher daily dose over a shorter period of time. So that new approach when we squeeze the whole course instead of six weeks, three to four weeks, is called hypofractionation, meaning slightly higher daily dose, and fewer treatments for the patients.

This approach is now routinely utilized in the United States for patients with breast cancer and also for patients with prostate cancer.

Host: Yeah, it sounds really amazing, as you say, the old days, 70s, 80s, 90s, and obviously, the hypo fractionation is shorter, less treatments. Maybe you can just go through that. When we think about less treatments, what does that mean ultimately for patients, for the medical system, maybe for insurance companies, and so on.

Dr. Stanic: Excellent question. That means benefit for both, number one, patients and also for the medical system. So having fewer treatments does not mean having more side effects, even though the daily dose is higher. So to give you one example, breast radiation therapy prior to hyperfractionization, was typically six to six and a half weeks.

Now the same thing can be done over a period of only three to four weeks. So this means for breast cancer patients, fewer daily appointments. And that can result in patients experiencing less fatigue. And eventually this also lowers economic burden to the society as hypofractionated treatments are cheaper for the healthcare system than the traditional, what we call conventionally fractionated radiation therapies. The same applies to prostate cancer. So prostate cancer, radiation therapy has been traditionally eight to nine weeks. And now with hypofractionation, the same outcome can be achieved in only five and a half weeks as an example. If we now look at the national guidelines in the United States by National Comprehensive Cancer Network that we often call NCCN; NCCN says that hypofractionation is the preferred approach for radiation therapy for prostate cancer, any type, any stage. So this is indeed the latest advancement that we have, that Carle offers in the community that benefits the patients, number one, and also the medical system.

Host: Yeah. And not only does it sound like Carle is the regional leader in hypofractionated radiotherapy, especially in east Central Illinois, but it sounds like it's becoming really the standard of care, gold standard, if you will, across the US, which is really amazing. Maybe you could talk more about the outcomes, right?

So we know the benefits ultimately during the course of treatment, but what about the outcomes for patients?

Dr. Stanic: The outcomes are excellent following Hypofractionated Radiation Therapy. Those patients do not experience more side effects. And data for breast cancer show that patients even have fewer acute side effects during radiation therapy delivery. And when we look at the cure rate is equally good, meaning hypofractionated radiation therapy is not inferior to conventionally fractionated radiation therapy. And when we look at the large clinical trials, the outcomes are essentially equivalent in both cure rate and also toxicities.

Host: Yeah. And you mentioned trials there, and we don't want to go maybe too far into the weeds here. But at least briefly, maybe you can discuss the evidence. So from these trials, the evidence to support this newer and really sort of mind blowing approach.

Dr. Stanic: Evidence is exceptionally strong. When we talk about breast cancer and we look at the Canadian trial and we look at the trials from the United Kingdom, we're talking about close to 5,000 patients analyzed on prospective randomized clinical trials. And if we look at the trial that was done in Canada, the patients were divided between long course of radiation therapy and a short course of radiation therapy.

Those patients were followed for substantial period of time, 10 years. And hypofractionated whole breast radiation was not inferior to the standard radiation treatment in patients who receive breast conservation surgery for invasive breast cancer with clear margins and negative auxiliary lymph nodes.

When we look at the data for prostate cancer, we have a similar situation. Exceptionally strong evidence the hypofractionated radiation therapy provides excellent outcomes. As an example is the RTOG trial that was published in 2016 by Dr. Lee. And in this clinical trial, the patients were randomized between the long course and short course. And the efficacy of short course over five and a half weeks was not inferior to long course of radiation therapy.

Host: Yeah, I'm just taking all this in and so glad to have your expertise today. I think as we wrap up, Doctor, just want to have you talk about how long you've been doing it at Carle and how it helps Carle to be this regional leader in this type of radiotherapy and why you really want patients to know what you're doing there and how they can reach out and the benefits and so on.

Dr. Stanic: So Carle is absolutely original leader in hypofractionation. When hypofractionation for breast cancer became widely adopted in 2015, Carle was one of the first to implement hypofractionated radiation therapy for breast cancer. In 2018, when American Society of Clinical Oncology published a statement article saying that hypofractionization should become a new standard for prostate cancer management, Carle was again, one of the first to adopt that approach and to offer these to our patients in the community. And Carle covers pretty large geographic area, if we look in terms of geographic location, where our patients come from. And for many patients who need to drive easily 50, 60 miles each way on a daily basis, telling them, listen, instead of eight and a half weeks of radiation, your radiation is going to be five and a half weeks. Or telling a busy mom instead of six weeks, your radiation is going to be only three weeks for your breast cancer is absolutely huge, and I can see many times on faces of my patients, significant relief when we talk about, and I mention the traditional approach and I see a concern on their face. And then when I mention, well, this all can be done with the newer approach, which is absolutely the standard of care, and you see a smile on patient's face. So this is indeed very well accepted by our patients in uh, oncology clinics.

Host: Yeah, it's amazing and I'm sure the smiles on faces both before when you tell them, you know, it's only going to be five, five and a half versus the old school way of doing things and all the other benefits. Really amazing to learn more today from you Doctor and to have your expertise. So thanks so much. You stay well.

Dr. Stanic: Thank you for having me.

Host: For more information and to get connected with one of our providers, please visit carle.org. And that wraps up this episode of Expert Insights with the Carle Foundation Hospital. I'm Scott Webb. Stay well.