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

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.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).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.(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.