Factors associated with the omission of androgen deprivation therapy in radiation-managed high-risk prostate cancer

Enhancing Androgen Deprivation Therapy (ADT) integration in prostate cancer: Insights for Stereotactic Body Radiotherapy (SBRT) and brachytherapy modalities

The utilization of Androgen Deprivation Therapy (ADT) in conjunction with Stereotactic Body Radiotherapy (SBRT) and Brachytherapy (BT) boost in prostate cancer treatment is a subject of ongoing debate and evolving clinical practice. While contemporary trends lean towards underutilizing ADT with these modalities, existing evidence suggests that its omission may lead to potentially inferior oncologic outcomes. Recommendations for ADT use should be patient-centric, considering individual risk profiles and comorbidities, with a focus on achieving optimal oncologic outcomes while minimizing potential side effects. Ongoing clinical trials, such as PACE-C, SPA, SHIP 0804, and SHIP 36B, are anticipated to provide valuable insights into the optimal use and duration of ADT in both SBRT and BT settings. Until new evidence emerges, it is recommended to initiate ADT for unfavorable intermediate-risk and high-risk prostate cancer patients undergoing radiotherapy, with a minimum duration of 6 months for unfavorable intermediate-risk patients and at least 12 months for those with high-risk characteristics. The decision to incorporate ADT into these radiation therapy modalities should be individualized, acknowledging the unique needs of each patient and emphasizing a tailored approach to achieve the best possible oncologic outcomes.

Real-world utilisation of brachytherapy boost and patient-reported functional outcomes in men who had external beam radiation therapy for prostate cancer in Australia

Background and purpose

We aimed to evaluate utilisation of brachytherapy (BT) boost in men who had external beam radiation therapy (EBRT) for prostate cancer, and to compare patient-reported functional outcomes (PRO) following each approach in a population-based setting in Australia.

Materials and methods

This is a population-based cohort of men with localised prostate cancer enrolled in the Victorian Prostate Cancer Outcomes Registry, who had EBRT between 2015 and 2020. Primary outcomes were proportion who had BT-boost, and PRO (assessed using the EPIC-26 questionnaires) 12 months post-treatment. Multivariable logistic regressions were used to evaluate factors associated with BT-boost, and linear regressions were used to estimate differences in EPIC-26 domain scores between EBRT alone and EBRT + BT.

Results

Of the 1,626 men in the study, 88 (5.4 %) had BT-boost. Factors independently associated with BT-boost were younger age, higher socioeconomic status, and treatment in public institutions. 1,555 men completed EPIC-26 questionnaires. No statistically or clinically significant differences in EPIC-26 urinary, sexual and bowel functional domain scores were observed between men who had EBRT + BT vs EBRT alone, with adjusted mean differences in urinary incontinence, urinary irritative/ obstruction, sexual, and bowel domain of 1.28 (95 %CI = -3.23 to 5.79), -2.87 (95 %CI = -6.46 to 0.73), 0.49 (95 %CI = -4.78 to 5.76), and 2.89 (95 %CI = -0.83 to 6.61) respectively.

Conclusion

1-in-20 men who had EBRT for prostate cancer had BT-boost. This is the first time that PRO following EBRT+/-BT is reported at a population-based level in Australia, with no evidence to suggest worse PRO with addition of BT-boost 12 months post-treatment.

Suboptimal use of hormonal therapy among German men with localized high-risk prostate Cancer during 2005 to 2015: analysis of registry data

BACKGROUND

This study assesses the use of hormonal therapy to treat high-risk localized prostate cancer (HRLPCa) cases diagnosed between 2005 and 2015.

METHODS

All N0-XM0 with ≥T3a, or PCa cases with poorly differentiated feature (equivalent to Gleason score ≥ 8), diagnosed between 2005 and 2015 were extracted from German population-based cancer registries. Cases treated by surgery or chemotherapy were excluded. Description of hormonal therapy use by HRLPCa cases' profile was presented. Relative risk (RR) was computed with a log-link function to identify factors associated with hormonal therapy use among radiotherapy-treated HRLPCa cases.

RESULTS

A total of 5361 HRLPCa cases were analyzed. Only 27.6% (95% confidence interval [CI]: 26.4-28.8%) of the HRLPCa cases received hormonal therapy in combination with radiotherapy. The use of combined hormonal therapy and radiotherapy varied from 19.8% in Saxony to 47.8% in Schleswig-Holstein. Application of hormonal therapy was higher for the locally advanced cases compared to the poorly differentiated cases (relative risk [RR] = 1.28; 95%CI: 1.19, 1.37). Older patients showed a slightly increased use of hormonal therapy (RR for a 10-year age increase = 1.09; 95%CI: 1.02, 1.16). Compared to PCa cases from the most affluent residential areas, cases from the least affluent (RR = 0.71; 95%CI: 0.55, 0.92) and medium (RR = 0.75; 95%CI: 0.58, 0.96) areas had decreased use of hormonal therapy. The introduction of the German S3-guideline did not make a marked difference in the uptake of both hormonal therapy and radiotherapy (RR = 1.02; 95%CI: 0.95, 1.09).

CONCLUSION

This study found a low use of hormonal therapy among HRLPCa patients treated without surgery. The introduction of the German S3-guideline for prostate cancer treatment does not seem to have impacted hormonal therapy use.

Addition of Androgen-Deprivation Therapy or Brachytherapy Boost to External Beam Radiotherapy for Localized Prostate Cancer: A Network Meta-Analysis of Randomized Trials

PURPOSE

In men with localized prostate cancer, the addition of androgen-deprivation therapy (ADT) or a brachytherapy boost (BT) to external beam radiotherapy (EBRT) have been shown to improve various oncologic end points. Practice patterns indicate that those who receive BT are significantly less likely to receive ADT, and thus we sought to perform a network meta-analysis to compare the predicted outcomes of a randomized trial of EBRT plus ADT versus EBRT plus BT.

MATERIALS AND METHODS

A systematic review identified published randomized trials comparing EBRT with or without ADT, or EBRT (with or without ADT) with or without BT, that reported on overall survival (OS). Standard fixed-effects meta-analyses were performed for each comparison, and a meta-regression was conducted to adjust for use and duration of ADT. Network meta-analyses were performed to compare EBRT plus ADT versus EBRT plus BT. Bayesian analyses were also performed, and a rank was assigned to each treatment after Markov Chain Monte Carlo analyses to create a surface under the cumulative ranking curve.

RESULTS

Six trials compared EBRT with or without ADT (n = 4,663), and 3 compared EBRT with or without BT (n = 718). The addition of ADT to EBRT improved OS (hazard ratio [HR], 0.71 [95% CI, 0.62 to 0.81]), whereas the addition of BT did not significantly improve OS (HR, 1.03 [95% CI, 0.78 to 1.36]). In a network meta-analysis, EBRT plus ADT had improved OS compared with EBRT plus BT (HR, 0.68 [95% CI, 0.52 to 0.89]). Bayesian modeling demonstrated an 88% probability that EBRT plus ADT resulted in superior OS compared with EBRT plus BT.

CONCLUSION

Our findings suggest that current practice patterns of omitting ADT with EBRT plus BT may result in inferior OS compared with EBRT plus ADT in men with intermediate- and high-risk prostate cancer. ADT for these men should remain a critical component of treatment regardless of radiotherapy delivery method until randomized evidence demonstrates otherwise.

Trends in the Use of Stereotactic Body Radiotherapy for Treatment of Prostate Cancer in the United States

IMPORTANCE

Stereotactic body radiotherapy is a hypofractionated, cost-effective treatment option for localized prostate cancer.

OBJECTIVE

To characterize US national trends and the clinical and socioeconomic factors associated with the use of stereotactic body radiotherapy in prostate cancer.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study used data collected by the National Cancer Database to assess the clinical and socioeconomic factors among 106 926 men diagnosed as having prostate cancer from 2010 to 2015 who underwent definitive radiotherapy and the trends in the use of this therapy. The initial analysis was performed between January and February 2018, with final updates performed August 2019.

EXPOSURE

Stereotactic body radiotherapy, defined as 5 fractions of radiotherapy.

MAIN OUTCOMES AND MEASURES

Temporal trends and clinical and sociodemographic factors associated with stereotactic body radiotherapy use.

RESULTS

In total, 106 926 patients diagnosed as having localized prostate cancer between 2010 and 2015 and receiving definitive radiotherapy were identified. White patients composed 77.3% of this cohort, whereas black patients composed 18.7%. Government-issued insurance was used by 61.2% of patients. More than 80% of patients had a Charlson-Deyo Comorbidity Index score of 0 (range, 0 to ≥3, with lower numbers indicating fewer comorbidities). In the study population, 25.7% had low-risk disease; 26.3%, favorable intermediate-risk disease; 23.3%, unfavorable intermediate-risk disease; and 24.7%, high-risk disease. The proportion of patients who underwent radiotherapy and received stereotactic body radiotherapy (a total of 5395 patients) increased from 3.1% in 2010 to 7.2% in 2015 (odds ratio, 0.36; 95% CI, 0.33-0.40; P < .001). Among the entire cohort, patients received a median dose of 36.25 Gy (range, 30.00-50.00 Gy). Androgen deprivation therapy use increased significantly as disease risk level increased among all patients receiving radiotherapy (9.5% with low risk to 76.6% with high risk; P = .02) and among those receiving stereotactic body radiotherapy (4.1% with low risk to 33.2% with high risk; P = .04) or not receiving stereotactic body radiotherapy (9.9% with low risk to 77.6% with high risk; P = .04). Patients treated at an academic center, living in an urban area, or possessing higher incomes and those who were healthier, white individuals, or were diagnosed as having lower-risk prostate cancer had higher odds of receiving stereotactic body radiotherapy.

CONCLUSIONS AND RELEVANCE

This study found that stereotactic body radiotherapy use in prostate cancer more than doubled from 2010 to 2015 but accounted for less than 10% of all patients undergoing radiotherapy. Androgen deprivation therapy use increased with disease risk among patients overall, regardless of receiving stereotactic body radiotherapy. Socioeconomic and clinical determinants of stereotactic body radiotherapy included risk category, Charlson-Deyo Comorbidity Index score, facility type and location, income, race/ethnicity, and year of diagnosis. These results are hypothesis generating; further studies evaluating potential disparities in stereotactic body radiotherapy use in localized prostate cancer are warranted.

Variations in patterns of concurrent androgen deprivation therapy use based on dose escalation with external beam radiotherapy vs. brachytherapy boost for prostate cancer

PURPOSE

Retrospective data suggest less benefit from androgen deprivation therapy (ADT) in the setting of dose-escalated definitive radiation for prostate cancer, especially when a combination of external beam radiotherapy (EBRT) and brachytherapy approaches are used. This study aimed to test the hypothesis that patients with prostate cancer with intermediate- or high-risk disease undergoing extreme dose escalation with a brachytherapy boost are less likely to receive ADT.

METHODS AND MATERIALS

Data from the National Cancer Database were extracted for men aged 40-90 years diagnosed with node-negative, non-metastatic prostate cancer from 2004 to 2015. Only patients with intermediate- or high-risk disease who were treated with definitive radiotherapy were included. The association and patterns of care between dose escalated radiotherapy and ADT receipt were assessed using multivariable logistic regression.

RESULTS

Patients with unfavorable intermediate- and high-risk prostate cancer were significantly less likely to receive ADT if they underwent dose escalation with a combination of EBRT and brachytherapy (odds ratio 0.67, p < 0.0001). Over time, this decrease in ADT utilization has widened for patients with unfavorable intermediate-risk disease. There was no difference in ADT utilization when comparing patients treated with non-dose-escalated EBRT to those treated with dose-escalated EBRT (without brachytherapy).

CONCLUSION

In this large national database, patients with unfavorable intermediate- and high-risk prostate cancer were significantly less likely to receive guideline-indicated ADT if they underwent extreme dose escalation with combined radiation modalities. As we await prospective data guiding the utility of ADT with dose escalated radiation, these findings suggest potential underutilization of ADT in patients at higher risk of advanced disease.

Application of a Prognostic Stratification System for High-risk Prostate Cancer to Patients Treated With Radiotherapy: Implications for Treatment Optimization

OBJECTIVES

We applied an established prognostic model to high-risk prostate cancer (HRPC) patients treated with radiotherapy (RT) and evaluated the influence of clinical and treatment variables on treatment outcomes.

METHODS

In total, 1075 HRPC patients undergoing definitive radiotherapy (RT) between 1995 and 2010 were retrospectively reviewed. Median follow-up was 62.3 months. Patients received either dose-escalated external beam radiotherapy (n=628, EBRT) or combined-modality radiotherapy (n=447, pelvic RT and low-dose rate brachytherapy boost, CMRT). 82.9% received androgen-deprivation therapy (ADT). A prognostic model stratified patients into predefined groups (good, intermediate, and poor). Kaplan-Meier methods and Cox proportional hazards regressions assessed biochemical failure (BF), distant metastasis (DM), prostate cancer-specific mortality (PCSM) and overall mortality (OM). C-indices analyzed predictive value.

RESULTS

The model was prognostic; C-indices for BF, DM, PCSM and OM were: 0.62, 0.64, 0.61, and 0.57. On multivariate analysis, CMRT and longer ADT (≥24 mo) were associated with improved BF, DM, and PCSM. Gleason score (GS) 9-10 was the strongest predictor of PCSM. C-indices for BF, DM, PCSM, and OM using a 4-compartment model incorporating GS 9-10 were: 0.62, 0.65, 0.68, and 0.56. In poor-prognosis patients (GS 8-10+additional risk factors), CMRT+LTADT (>12 mo) had 10-year PCSM (3.7%±3.6%), comparing favorably to 25.8%±9.2% with EBRT+LTADT.

CONCLUSIONS

The model applies to high-risk RT patients; GS 9-10 remains a powerful predictor of PCSM. Comparing similar prognosis patients, CMRT is associated with improved disease-specific outcomes relative to EBRT. In poor-prognosis patients, CMRT+LTADT yields superior 10-year PCSM, potentially improving RT treatment personalization for those with HRPC.

Localised prostate cancer in elderly men aged 80-89 years, findings from a population-based registry

OBJECTIVES

To investigate the rate of prostate cancer-specific mortality (PCSM) and disease characteristics in patients diagnosed with localised prostate cancer at age 80-89 years in comparison with men diagnosed at age 70-79 years.

PATIENTS AND METHODS

This is a retrospective study of data from the South Australian Prostate Cancer Clinical Outcomes Collaborative (SA-PCCOC). Included were men diagnosed between 2005 and 2014, aged ≥70 years with no evidence of metastatic disease at presentation. Propensity score matching and competing risk Fine and Grey regression were used to assess the chance of treatment (curative vs non-curative) and treatment effect on PCSM.

RESULTS

Of the 1 951 eligible patients, 1 428 (76%) were aged 70-79 years and 460 (24%) were aged 80-89 years at diagnosis, with a median (interquartile range) age of 74 (72-76) and 83 (81-85) years, respectively. The 80-89 years group had higher Gleason scores and Prostate Specific Antigen (PSA) values (all P < 0.001) in comparison with the younger group. The 80-89 years group were less likely to be treated with curative treatment (odds ratio 0.12, 95% confidence interval 0.09-0.16; P < 0.001). The proportion of deaths attributable to prostate cancer was similar in both groups: 73 of 263 deaths (28%) in the 80-89 years group vs 97 of 310 deaths (31%) in the 70-79 years group. The risk of PCSM in individuals treated with curative intent was reduced in both groups.

CONCLUSIONS

The proportion of prostate cancer deaths was similar in both groups. These findings support carefully selected individualised management of elderly patients diagnosed with localised prostate cancer.

Under-utilisation of high-dose-rate brachytherapy boost in men with intermediate-high risk prostate cancer treated with external beam radiotherapy

INTRODUCTION

The aim of this study was to evaluate the use of high-dose-rate brachytherapy (HDR-BT) boost with definitive external beam radiotherapy (EBRT) in prostate cancer (CaP) management.

METHODS

The study population comprised men with intermediate-high risk CaP captured in the population-based Prostate Cancer Outcome Registry Victoria (PCOR-Vic), treated with EBRT from January 2010 to December 2015. The primary outcome is the proportion of men who received HDR-BT boost. Multivariate logistic regressions were used to evaluate the effect of patient-, tumour- and treatment-factors on the likelihood of HDR-BT use. Medicare Benefit Schedule (MBS) data was accessed to evaluate the Australia-wide pattern of HDR-BT use.

RESULTS

One thousand eight hundred and six patients were included in this study - 886 (49%) intermediate-risk, and 920 (51%) high-risk CaP patients. Overall, only 124 (7%) patients had EBRT + HDR-BT - 47 (5%) intermediate-risk and 77 (8%) high-risk CaP patients (P = 0.01). There is higher proportion of patients who had HDR-BT in public institutions (7% public vs. 3% private, P = 0.005) and in metropolitan centres (9% metropolitan vs. 2% regional, P < 0.001). In multivariate analyses, older patients were less likely to have HDR-BT (OR = 0.92; 95% CI = 0.89-0.94, P < 0.001), while patients with high-risk CaP (OR = 1.8; 95% CI = 1.3-2.7; P = 0.002) treated in metropolitan centres (OR = 5.0; 95% CI = 2.6-9.8; P < 0.001) and public institutions (OR = 3.8; 95% CI = 1.5-9.4; P = 0.005) were more likely to have EBRT + HDR-BT. There was significant decline in numbers of HDR-BT performed throughout Australia, from 313 cases in 2010 to 125 cases in 2015.

CONCLUSION

High-dose-rate brachytherapy is under-utilised with EBRT in this contemporary population-based cohort of Victorian men with CaP. The decline in HDR-BT use was also observed nationally.