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Original Investigation
December 26, 2019

Comparative Effectiveness of Proton vs Photon Therapy as Part of Concurrent Chemoradiotherapy for Locally Advanced Cancer

Author Affiliations
  • 1Department of Radiation Oncology, University of Pennsylvania, Philadelphia
  • 2Department of Radiation Oncology, Washington University in St Louis, St Louis, Missouri
  • 3Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
  • 4Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia
  • 5currently a medical student at Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
  • 6Division of Medical Oncology, University of Pennsylvania, Philadelphia
  • 7Abramson Cancer Center, University of Pennsylvania, Philadelphia
JAMA Oncol. 2020;6(2):237-246. doi:10.1001/jamaoncol.2019.4889
Key Points

Question  Can proton therapy reduce the risk of severe adverse events associated with unplanned hospitalizations compared with photon therapy for patients undergoing concurrent chemoradiotherapy?

Findings  In this comparative effectiveness study of 1483 adults with nonmetastatic cancer and treated with curative intent, proton therapy was associated with a two-thirds reduction in adverse events associated with unplanned hospitalizations, with no difference in disease-free or overall survival.

Meaning  These findings suggest that, in adults with locally advanced cancer, proton therapy with concurrent chemoradiotherapy may significantly reduce severe adverse events compared with photon therapy, with comparable oncologic outcomes.


Importance  Concurrent chemoradiotherapy is the standard-of-care curative treatment for many cancers but is associated with substantial morbidity. Concurrent chemoradiotherapy administered with proton therapy might reduce toxicity and achieve comparable cancer control outcomes compared with conventional photon radiotherapy by reducing the radiation dose to normal tissues.

Objective  To assess whether proton therapy in the setting of concurrent chemoradiotherapy is associated with fewer 90-day unplanned hospitalizations (Common Terminology Criteria for Adverse Events, version 4 [CTCAEv4], grade ≥3) or other adverse events and similar disease-free and overall survival compared with concurrent photon therapy and chemoradiotherapy.

Design, Setting, and Participants  This retrospective, nonrandomized comparative effectiveness study included 1483 adult patients with nonmetastatic, locally advanced cancer treated with concurrent chemoradiotherapy with curative intent from January 1, 2011, through December 31, 2016, at a large academic health system. Three hundred ninety-one patients received proton therapy and 1092, photon therapy. Data were analyzed from October 15, 2018, through February 1, 2019.

Interventions  Proton vs photon chemoradiotherapy.

Main Outcomes and Measures  The primary end point was 90-day adverse events associated with unplanned hospitalizations (CTCAEv4 grade ≥3). Secondary end points included Eastern Cooperative Oncology Group (ECOG) performance status decline during treatment, 90-day adverse events of at least CTCAEv4 grade 2 that limit instrumental activities of daily living, and disease-free and overall survival. Data on adverse events and survival were gathered prospectively. Modified Poisson regression models with inverse propensity score weighting were used to model adverse event outcomes, and Cox proportional hazards regression models with weighting were used for survival outcomes. Propensity scores were estimated using an ensemble machine-learning approach.

Results  Among the 1483 patients included in the analysis (935 men [63.0%]; median age, 62 [range, 18-93] years), those receiving proton therapy were significantly older (median age, 66 [range, 18-93] vs 61 [range, 19-91] years; P < .01), had less favorable Charlson-Deyo comorbidity scores (median, 3.0 vs 2.0; P < .01), and had lower integral radiation dose to tissues outside the target (mean [SD] volume, 14.1 [6.4] vs 19.1 [10.6] cGy/cc × 107; P < .01). Baseline grade ≥2 toxicity (22% vs 24%; P = .37) and ECOG performance status (mean [SD], 0.62 [0.74] vs 0.68 [0.80]; P = .16) were similar between the 2 cohorts. In propensity score weighted–analyses, proton chemoradiotherapy was associated with a significantly lower relative risk of 90-day adverse events of at least grade 3 (0.31; 95% CI, 0.15-0.66; P = .002), 90-day adverse events of at least grade 2 (0.78; 95% CI, 0.65-0.93; P = .006), and decline in performance status during treatment (0.51; 95% CI, 0.37-0.71; P < .001). There was no difference in disease-free or overall survival.

Conclusions and Relevance  In this analysis, proton chemoradiotherapy was associated with significantly reduced acute adverse events that caused unplanned hospitalizations, with similar disease-free and overall survival. Prospective trials are warranted to validate these results.

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