The British Medical Journal - Hypofractionation: Don't Lose Sight of the Patient
I was recently commissioned to write a piece for the British Medical Journal on a move towards hypofractionation radiation treatment, from a patient perspective. It was a departure from my normal writing style. Less humour, more radiation.
Some interesting thoughts on protecting the environment as we treat patients, and what should the patient keep in mind if offered this type of higher intensity treatment with a shorter overall treatment time.
Sustainable practice: don’t lose sight of the patient experience
By Sheilagh Foley - patient author, Ireland
As a cancer survivor, who has experienced radiation therapy, I was interested to learn about hypofractionation as an alternative to traditional radiation.
In hypofractionation the total dose of radiation is divided into fewer parts and delivered over a shorter time frame than traditional radiation treatment. It reduces the number of visits a patient will have to make to the hospital. For this and other reasons, it offers a co-benefit of reducing the carbon footprint from radiotherapy treatment, while also optimising the hospital experience for cancer patients.
Shorter treatment windows have many advantages, most notably the sheer convenience they provide the patient, allowing them to start down the hopeful path of recovery sooner. A cancer patient's main focus tends to be staying alive, but if treatments that are equally effective also have benefits such as reduced transportation costs and lower greenhouse gas emissions, that is a bonus.
Nonetheless, when new treatments or approaches are rolled out, it is crucial to consider how they affect every stage of a patient’s journey, including the post-treatment impact. It is important to allow space for patients to ask questions and communicate concerns.
As someone who experienced both chemotherapy and radiation therapy, I felt the chemo was far more debilitating than the radiation. I had to be driven to my chemo appointments, whereas I was able to walk a mile to my radiation appointments. For those living further away, the public facility where I received my treatment also offered onsite accommodation for patients and their families.
Although CO2 emissions from patient transport were less of a concern during my own radiation treatment, there are many ways that changes aimed at improving the patient experience can also contribute to offsetting the carbon footprint left by radiotherapy. Oncology departments, and hospital services more broadly, should work with government, hospital administrators, and patient organisations to enhance public and pooled transport options, increase engagement with telehealth and smart tech, and improve patient support services and education so that personal and environmental sustainability is promoted from many angles.
Any moves to a more sustainable practice should involve shared decision making and ample patient-friendly information and communication. Sustainability partners need to work with patients and healthcare providers on how to take steps to decarbonise medical care without compromising patient safety or satisfaction.
I had Hodgkins Lymphoma and received wide field mantle radiation topped off with a radiation boost. I suffered considerable late effects from the radiation, including another cancer and heart failure. It is my understanding that wide blasts of radiation to normal cells are no longer administered, and targeted precision radiation is the much safer approach used these days.
Despite improvements in radiation techniques, I remain wary about approaches that increase the fractional dosage of radiation, even if the total dose is the same.
Has thought been given to the long term effects from intensive radiation therapy? They can take years to manifest.
Side effects, in general, are an ongoing concern for active cancer patients undergoing treatment. Symptoms like fatigue can be very difficult to manage. It is of great importance that clinicians give patients the opportunity to raise questions about how new treatments and technology could affect their symptoms. In this case, could these symptoms become more pronounced during a hypofractionation regimen versus traditional therapy?
When I finished chemo and moved on to radiation therapy, I was assured that the radiation would be “easier” with less side effects. This was true in some ways, but the symptoms I experienced from radiation were by no means “easy” to cope with. I turned out to be somewhat sensitive to the radiation and endured episodes of unexpected hematemesis (vomiting blood). If I was asked about commencing a hypofractionation regimen today, I would want to know: Could hypofractionation trigger even more severe side effects in the sensitive patient?
I am open to the idea of hypofractionation radiation, and I understand the benefits for the environment. However, when considering this approach as a patient, I personally would want more scientific reassurance that I was not taking on any extra risk, especially in terms of the late-effect toxicity of larger dosages.
It is comforting to know there is some evidence that the hypofractionation approach is considered non-inferior, yet it’s unclear to me if that consideration takes into account late effects. There may be studies supporting the longer-term safety of hypofractionation, but these data are not necessarily readily available or accessible for patients, and it’s unclear whether it encompasses all cancers. How does the data relate to the individual? This should form the basis of an open and honest conversation between oncologists and patients.
While sustainability is important, these efforts must take care not to lose sight of patient safety and experience.
Afterall, the impact of radiation treatment is long term, and any changes to protocols today could affect the patient decades down the line. Seeing the results of patients who have undergone hypofractionation radiotherapy treatment 20 years on would give me more confidence in this eco-friendly approach. In the meantime, clinicians should be aware that new approaches may raise questions and be open to discussing these.
We all want a greener future, but we must make sure we are all able to enjoy it.
I have read and understood the BMJ policy on declaration of interests and declare the following interests: none.
Provenance and peer review: Commissioned, not externally peer reviewed.
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