128 Chapter 8 radiation induced cardiac toxicity, it actually does not give any information on the cause of death or whether this is related to cardiac complication. As all mentioned endpoints have their limitations, another, more sensitive method of detecting differences between treatment groups has been proposed by Song ea. The individual patient wants to live, with a good quality of life and preferably without toxicity. In this method, patients within de different treatment arms are first compared on the most important outcome, when there is no difference, lower priority outcomes are evaluated in these patients [37]. This method will be more sensitive in finding differences between groups as it combines overall survival with QOL and toxicities as a (primary) endpoint. For further research, I expect both types of research are needed. Studies like used in the current thesis will generate hypotheses on possible mechanisms and doseeffect relationships of toxicities, resulting in which (sub)substructures are most relevant tin radiation-induced toxicity development. This can be used to guide optimizing radiation treatment plans. Whether this eventually results in relevant clinical advantages for patients, needs to be confirmed in either randomised trials or prospective validation cohorts (real life data). Within these “confirming” trials, data on overall survival as well as on QOL and toxicity should be collected. Using multiple endpoints to quantify treatment benefit, like proposed by Song ea. as mentioned before, probably have a higher sensitivity in detecting clinically relevant differences and can be used to evaluate new radiotherapy techniques and treatment plan optimalisation.
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