Travel costs and ecologic imprint associated with different fractionation schedules in prostate cancer radiotherapy

Abstract

Purpose

Improving the sustainability and cost-effectiveness of healthcare systems has become increasingly relevant in times of climate change, energy transition, an aging population and skyrocketing social costs. The selection of an adequate fractionation schedule is of fundamental importance in the field of Radiation Oncology. We evaluated three internationally established fractionation schedules for definitive prostate cancer radiation therapy (RT) with respect to their ecological and health-economic impacts.

Methods

We analyzed the data of 109 patients with prostate cancer, who underwent outpatient radiation therapy at Jena University Hospital in 2022. After determination of travel distances between their homes and the treatment facility, carbon dioxide (CO₂)-emissions and taxi costs were calculated for normofractionated RT (39 fractions, A), moderately hypofractionated RT (20 fractions, B) and ultrahypofractionated RT (5 fractions, C).

Results

Travel distances of 1616 km (A), 848 km (B) and 242 km (C) were calculated with corresponding costs ranging from 638 € (C) to 4255 € (A). According to the 2024 German physician’s fee schedule, 9,604 € would be invoiced for medical treatment and transportation in (A), with transportation costs accounting for 44% of total treatment costs in normofractionated RT. The travel distance, CO₂-emissions and transportation costs could be reduced by up to 85% by hypofractionation.

Conclusion

(Ultra-)hypofractionated radiation therapy for prostate cancer has great potential to lower healthcare costs and reduce environmental pollution. Given that and the non-inferiority of oncological outcome and toxicity, hypofractionation should appear beneficial from patient’s and healthcare provider’s point of view. Current reimbursement structures seem to be inappropriate regarding increased personnel and technical efforts required for highly precise dose application and might hinder comprehensive establishment of ultrahypofraktionated RT in Germany.

Keywords

Prostate cancer - transport costs - ecological imprint - hypofractionation - healthcare system - radiotherapy

Introduction

In times of climate change, energy transition, an aging population and skyrocketing social costs, approaches to improve the sustainability and cost-effectiveness of healthcare systems are increasingly in the focus of discussion. With regard to our work as practicing radiation oncologists, the major potential to contribute to the topic may lie in providing carbon-efficient and cost-effective treatment options, particularly for numerically significant oncologic diseases like prostate cancer (PC). PC is one of the most prevalent malignancies. In Germany, around 66,000 new cases are diagnosed annually [1], making PC the most common neoplasm in men nationwide. For localized disease, radiotherapy (RT) and radical prostatectomy (rPE) are the backbones of curative treatment [2] [3]. Of note, RT and rPE differ substantially not only with respect to possible side effects but also with respect to their ecologic imprint and economic characteristics. Thereof, one major aspect is treatment duration. Whereas rPE is routinely performed in a single intervention and patients are usually discharged from the hospital within a week[1], the traditional RT regimen for localized PC (39×2 Gy=78 Gy) requires a total treatment time of almost 8 weeks. It is therefore not surprising that this approach scores poorly in terms of acceptance among patients as well as in terms of ecological and health economic aspects.

However, advances in radiation therapy techniques, such as intensity-modulated radiation therapy (IMRT) and image-guided radiation therapy (IGRT), have allowed for more precise tumor targeting while sparing nearby organs. Moderately hypofractionated schedules, with slightly higher single fraction doses (SFDs) of about 3 Gy and a reduced total dose of about 60 Gy [4] [5] [6] [7], have consequently gained popularity. With an overall treatment time of almost the half, those regimens provide oncological outcomes and toxicity profiles similar to those of the traditional radiotherapeutic approaches [7]. The non-inferiority of moderate hypofractionation (MH) has been demonstrated in several randomised, multicentre, phase 3 trials [4] [6]. It is obvious that MH also represents significant progress in terms of ecological and health-economic benefits. Hence, MH has meanwhile been recommended by various societies for radiation therapy as new standard of care [3] [8]. In contrast, the German S3-guideline treatment recommendations still recommend the use of MH only with reservations [2].

Since prostate cancer cells are considered to have an unusually low α/β-ratio, it has been assumed that even higher single doses might be beneficial from a radiobiological point of view [9]. Meanwhile, using predominantly advanced and highly precise linear accelerators, SFDs of>>4 Gy were safely administered. This, so-called “ultrahypofractionated”, treatment regimen allows for an overall treatment time of only one to two weeks. Recently, the results of two large, randomized phase III trials [10] [11] [12] paved the way for the acceptance of ultrahypofractionated (UHF) RT as a safe and effective treatment option for localized, low and intermediate risk PC. Given the current data, UHF and MH are proven to be non-inferior regarding oncological outcome and toxicity [3] [8] [13]. Of note, UHF places high demands on the technical equipment, accuracy and expertise of medical service providers [10] [11] [14] [15] [16]. If these requirements can be met, ultrahyporactionated RT may also be recommended as routine treatment beyond clinical trials [3] [13] [14].

The aim of this work was to demonstrate the significant impact of fractionation on transportation costs and carbon dioxide (CO₂)-emissions in outpatient radiation therapy. As prostate cancer is one of the most common entities treated by RT, we focused on definitive prostate cancer treatment in the federal state of Thuringia, Germany, for this exemplary calculation.

Material & Methods

We analyzed the data of 109 patients with prostate cancer, who underwent outpatient RT at Jena University Hospital between January and December 2022. The distances between their homes and our facility and corresponding travel times were derived from Google Maps via R statistics mapsapi package (version 4.3.2, R Core Team), using the patients’ registered addresses.

The average C0₂ emissions of a mid-size car were derived from Statista ‘Market Insights’ [17], based on registration numbers of the Federal Office for Motor Traffic (Kraftfahrzeugbundesamt). Patients were assumed to be insured with a German statutory health insurance (SHI).

In Germany, taxi costs for outpatient radiotherapy treatment are largely covered by SHIs. Hence, transportation costs were calculated taking a local contract for the provision of patient transportation as a basis. The contracting parties included a large health insurance company and taxi companies [18].

Three different fractionation regimens were analysed ([Fig. 1]): A normofractionated (NF) schedule with 39 fractions, which still reflects the standard of care in Germany, a moderately hypofractionated (MH) schedule with 20 fractions [4] and an ultrahypofractionated (UHF) schedule with only 5 fractions [3] [14]. An additional visit for planning computed tomography (CT) was assumed for all three scenarios.

Fig. 1 Overview of the three different fractionation schedules for radiotherapy of localized prostate cancer. TAD – total adsorbed dose, SFD – single fraction dose.

Epidemiologic data were obtained from the Federal Office of Statistics [19] and from the Office for Statistics of the Federal State of Thuringia [20]. Analyses were performed using SPSS Statistics 29 (IBM, Armonk / NY, USA) and Excel 2016 (Microsoft, Redmond / WA, USA), artwork was created with Keynote 13.2 (Apple, Cupertino / CA, USA).

Results

Distances and travel times from patients’ homes to our facility

We included 109 prostate patients in this cohort with a median age of 72 years ([Table 1]). Of note, nearly 81% of these patients were older than 65 years. The median distance between patients’ homes and our facility (d _{access one-way} ) was 20.2 km. Of note, distances ranged from 0.75 km to 93.92 km with a trend towards shorter distances (75% quartile: 48.13 km). The estimated travel (t _{access one-way} ) times ranged from less than three minutes to 65 minutes (median: 23 minutes). [Table 2] and [Fig. 2a, b] depict the characteristics of this cohort in detail.

Fig. 2 Travel distances (a ) and estimated travel times (b ) for 109 prostate cancer patients treated with outpatient radiation therapy at Jena University Hospital in 2022.

Table 1 Age-distribution [years] of the underlying cohort of patients with prostate cancer and numbers of patients being over 65 years old.

	Age [years]
Median	72
Minimum	49
Maximum	89
Standard Deviation	7.49
Interquartile range (IQR) (25%–75%)	66–77
Age>65	88 patients (80.7%)

Table 2 Travel distances and estimated travel times for 109 prostate cancer patients treated with outpatient radiation therapy at Jena University Hospital in 2022.

	Travel distance (one-way) daccess one-way [km]	Travel time (one-way) taccess one-way[[Minutes]
Median	20.20	23.10
Minimum	0.75	2.77
Maximum	93.92	65.00
Standard Deviation	24.56	17.10
Interquartile range (IQR) (25%–75%)	7.42–48.13	13.08–45.51

Transportation for RT causes relevant costs

Given the median daily travel distance and an outpatient treatment, requiring the patients to travel twice daily, a substantial cumulative travel distance occurs over the course of definitive RT. This distance increases proportionally with the number of fractions (Equation 1). The resulting travel distances for the three fractionation schedules are compared in [Table 3].

Table 3 Overall travel distances, CO₂-emissions and transportation costs according to the applied fractionation schedule (NF – normofractionation, MH – moderate hypofractionation, UHF – ultrahypofractionation). Calculations were performed with a median distance of 20.2 km between the patients’ homes and our facility. The number of transports was calculated from twice the number of fractions and two additional transports for one pre-treatment visit. Taxi drives were invoiced at 2.43 € per km plus a base price of 4.10 €. An average CO₂-emission of 84 g/km was assumed (data from [17]).

Number of fractions	39 (NF)	20 (MH)	5 (UHF)
Number of transports	80	42	12
Travel distances [km]	1616	848	242
CO 2 -emissions [kg]	136	71	20.
Transportation costs [€]	4255	2234	638

For illustration purposes, the resulting cumulative travel distance was matched with one-way distances between European popular capital cities and our treatment facility in the city of Jena, which is located in the middle of Germany ([Fig. 3]). The average distance that a patient of our department has to travel by taxi as part of NF corresponds with a journey from Jena to Barcelona (1616 km). A moderately hypofractionated schedule (20 fractions) would reduce this distance to 848 km, still equivalent with a one-way trip to Paris. In contrast, the travel distance required for an ultrahypofractionated schedule (5 fractions) corresponds with the distance between Jena and Berlin (242 km).

d_treatment = d_{access one-way}*2*^nfractions

Fig. 3 Destinations that are comparable to the three different fractionation schemes in terms of distance to be traveled (one-way) and corresponding CO₂-emissions.

Equation 1 Calculation of the total travel distance d _treatment during radiotherapy by multiplying the number of fractions n _fractions and twice the one-way distance between patient’s residence and the treatment facility d _{access one-way} .

As by German law, transportation costs for long-term treatments, such as chemotherapy or RT, may be reimbursed by German SHIs [21]. The pricing is based on local contracts and accounts for the travel distance and number of drives. Resulting costs are calculated as by the locally applicable regulation [18] in our department according to [Table 3]. Consequently, costs for transport are proportionally increasing with the number of RT fractions (Equation 1).

For comparison purposes, treatment costs for a NF RT of prostate cancer were calculated in Euro (€) according to the German physician’s fee schedule for ambulatory treatment (“Einheitlicher Bewertungsmaßstab”, EBM) and the 2024 conversion factor of 0.1193 € per point [22]. Assuming a routine treatment with 39 RT fractions, 5,349 € would be invoiced. Consequently, the total treatment costs for the insurances, consisting from treatment costs and transportation costs, were 9,604 € ([Table 4]). So, 44.3% of the total treatment costs for NF are resulting from transportation. In other words, transportation accounts for 79.5% of RT costs.

Table 4 Treatment costs for normofractionated radiotherapy (NF RT, 39 fractions) of prostate cancer according to the German physician’s fee schedule (“Einheitlicher Bewertungsmaßstab”, EBM) (data from [22]). According to the currently (2024) applicable conversion factor of 0.1193 € per point, a total charge of 5,349.25 € was calculated. Abbreviations: computed tomography (CT), Intensity-modulated radiotherapy (IMRT), linear accelerator (LINAC)

Procedure identifier according to EBM	Description	Points	Factor	Total
25211	Consultation / Physical examination	1’041	1	1,041
34360	Computed tomography (CT) for simulation	354	1	354
25342	Treatment planning	4’744	1	4’744
25343	Addition for IMRT treatment	1’245	1	1’245
25321	RT treatment, use of LINAC, per fraction	960	39	37’440
Total points				44’824
Charges	Conversion factor: 0.1193 € per 1 point			5’349.25

Carbon dioxide emissions

According to [Fig. 4], an average CO₂-emission of E _{base value} =84 g/km was used for the calculations [19]. Of note, the increasing number of eco-friendly engines in the underlying registry has already reduced the average CO₂ emissions per km by approximately 30%. We calculated the CO₂ emissions (E _treatment) for the three treatment schedules as summarized in [Table 3] according to Equation 2. The use of NF resulted in a massive overall CO₂-emission of 136 kg. In contrast, with an UHF schedule, the overall CO₂-emission could be reduced by 85% (20 kg).

E_treatment = E_{base value}*d_treatment

Fig. 4 Average carbon dioxide (CO₂) emissions) of mid-size cars (right axis, black line) and corresponding rates of engine types (left axis, bar chart). Of note, with an increasing use of eco-friendly engines, average CO₂-emissions have recently decreased. The data was obtained from the German tax register [17].

Equation 2 The total CO₂-emissions from treatment-related travel is calculated from the average CO₂-emission of a mid-size car per kilometer (E _{base value} ) and the total travel distance d _treatment .

Transportation costs

According to the local contract between the health insurance company and the taxi companies [20], the drives were invoiced at a rate of 2.43 € per km plus a basic rate of 4.10 €. Thus, the median one-way drive (20.2 km) was rated at 53.19 €. The corresponding overall transportation costs are depicted in [Table 3]. Choosing UHF instead of NF would result in a dramatic reduction in the median overall transportation costs from 4255 € to 638 € (−85%).

Discussion

Research addressing the sustainability and costs of new medical treatment approaches is still leading a shadowy existence. To the best of our knowledge, this is the first study assessing the effects of different fractionation schedules for prostate cancer radiotherapy on CO₂-emissions and transportation costs in Germany.

Although the majority of the Thuringian population lives in rural areas [20], the median travel distance from patients’ homes to our facility was only 20 km, reflecting the well-developed medical care in the small federal state of Thuringia, even in specialized fields such as radiation oncology. Nevertheless, as travel distances increase overall treatment costs proportionally (Equation 1), our results are strongly influenced from the local sociodemographic structure as well as the local health care structure (e. g. density of radiotherapy facilities). This local example is thus not simply generalizable. Of note, in other countries, distances to be covered for radiation therapy may be substantially greater [23] and the correlations illustrated above would become even more significant. Another point, outside of the scope of this manuscript, is the potential to decrease the duration of sick leave and consecutive salary compensation by shortening the overall treatment time. In the underlying cohort, this point would apply to approximately 20% of the patients.

Of course, the recognition that outpatient radiotherapy with fewer fractions is associated with lower CO₂-emissions and transport costs is obvious. Accordingly, the purpose of this study was not to prove this phenomenon, but to illustrate its local extent. An equivalence or non-inferiority, respectively, of moderate hypofractionation has been successfully demonstrated for more and more indications [24] and generally offers enormous potential for reducing travel costs and emissions. Nevertheless, ultrahypofractionated treatments are not considered current standard of care in many indications except for stereotactic treatments, such as e. g. locally ablative RT for metastasis [25] [26] [27]. To date, despite their conspicuous benefits for the environment and health insurance providers, hypofractionated and ultrahypofractionated RT schedules have not been used by default to treat prostate cancer in Germany. This may be due to medical concerns, but also due to economic reasons. From a medical point of view, excellent data on the oncological efficacy and tolerability of MH RT are now available [4] [6]. The value of UHF has also been impressively demonstrated, at least for certain the subgroups of low/intermediate and high risk, localized prostate cancer [10] [11] [12] [15] [16] [28]. Accordingly, both fractionation regimens have been firmly anchored in the American guidelines [3] [8]. The expert association ‘German Society of Radiation Oncology’ (DEGRO) now also recommends the use of both regimens outside of clinical trials [13]. Nevertheless, high technical standards are (rightly) demanded. Linear accelerators (LINAC) specialized in stereotactic radiation therapy are perfectly suitable for that purpose and have widely been used in the two clinical trials that paved the way for UHF [11] [12] [13]. Another encouraging approach is the, so-called, online-adaptive RT. With this new technique, daily changes in the anatomy, particularly the different filling states of the bladder and bowel, can be compensated for with adapted radiotherapy plans [29]. A major limitation of this exemplary calculation is, however, the hypothetical application of UHF RT to all patients in this cohort. Although trials were proving the application of UHF for both low/intermediate [11] [30] and high risk tumors [16] [31], there are frequent contraindications, such as e. g. bilateral hip prostheses or prior transurethral resection for benign prostatic hypertrophy, defined in the original study PACE-protocol [32]. Furthermore, data on applicability in old and frail patients is scarce. The Hypo-RT-trial, for example, excluded patients being over 75 years of age [16]. In our sample, however, a relevant fraction of patients would have been excluded for this reason (median age: 72 years). But, especially for these aged patients, long travel times might be associated with a relevant burden: In this simulation, one fourth of the patients would be expected to travel longer than 45 minutes, which seems stressful in the light of potential acute radiotoxicity, such as pollakiuria or diarrhea.

In addition to medical concerns, our actual reimbursement logic certainly represents another major obstacle in the introduction of (ultra-)hypofractionated RT for PC. In Germany, the reimbursement for RT is generally designed to be “per fraction”. Hence, high numbers of fractions at low doses are still incentivized, whereas the use of modern techniques, such as (ultra-)hypofractionated RT, is penalized. In view of the high costs of modern technology, this can quickly become a question of economic survival for a RT center. Hence, despite an obvious international paradigm shift towards fewer fractions and shorter overall treatment times, the majority of PC patients will probably still be deprived from access to the new treatment approaches in Germany. Currently, in addition to us treating physicians, the payers and self-governing bodies of the German healthcare system should create appropriate framework conditions as soon as possible. For instance, SHI could conclude corresponding selective contracts with the service providers in a first step. Furthermore, the German S3-guideline urgently needs to be revised, because it does not take into account the latest study results or the statement of the German Society of Radiation Oncology (Deutsche Gesellschaft für Radioonkologie, DEGRO) on (ultra-)hypofractionated radiation therapy [13]. Unfortunately, this guideline is often mistakenly ascribed a normative character, especially by non-physician decision-makers, who may hold back sensible and necessary decisions if they are out of date. Nevertheless, especially in the light of an overageing population and consequently rising costs for health insurances, optimizing treatment reimbursement structures is critical. Additional patients can be offered treatment without exceeding the insurances’ budget by reducing the number of treatment sessions.

We thus feel, that travel distances of equal length with a trip to Barcelona should be limited to occasional recreational purposes and, in the light of recent treatment schedules, not be generally demanded from our patients.

Ethics approval and consent to participate

The study was conducted in accordance with the Declaration of Helsinki, and approved by the institutional Ethics Committee of JENA UNIVERSITY HOSPITAL (2024-3279-Daten). Individual patient’s consent was waived due to the retrospective nature of this analysis.

Availability of data

The datasets used and analyzed during the current study are available from the corresponding author upon reasonable request.

Funding

This work was realized without external funding. G.W. receives support from the “Clinician Scientist”-program of the Interdisciplinary Center for Clinical Research, Jena University Hospital (grant-No.: CSP-11) outside of this work. The funding had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript; or in the decision to publish the results.

Author Contributions

Conceptualization, G.W. and M.G.; methodology, G.W., M.G., C.S., D.M.; software, S.W.; validation, K.P; formal analysis, G.W.; investigation, S.W., G.W. and M.G.; resources, S.W. and G.W.; data curation, G.W. and M.G.; writing—original draft preparation, G.W.; writing—review and editing, all authors.; visualization, G.W.; supervision, K.P.; project administration, G.W.; funding acquisition, n/a. All authors have read and agreed to the published version of the manuscript.

This article is part of the DNVF supplement “Health Care Research and Implementation”

Conflict of Interest

The authors declare that they have no conflict of interest.

^# These authors contributed equally.

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Publication History

Received: 23 July 2024

Accepted after revision: 13 December 2024

Article published online:
05 March 2025