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Niazi T, Nabid A, Malagon T, Bettahar R, Vincent L, Martin AG, Jolicoeur M, Yassa M, Barkati M, Igidbashian L, Bahoric B, Archambault R, Villeneuve H, Tsui JMG, Mohiuddin M. Hypofractionated, Dose Escalation Radiation Therapy for High-Risk Prostate Cancer: The Safety Analysis of the Prostate Cancer Study-5, a Groupe de Radio-Oncologie Génito-Urinaire de Quebec Led Phase 3 Trial. Int J Radiat Oncol Biol Phys 2024; 118:52-62. [PMID: 37224928 DOI: 10.1016/j.ijrobp.2023.05.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 04/27/2023] [Accepted: 05/08/2023] [Indexed: 05/26/2023]
Abstract
PURPOSE The low α\β ratio of 1.2 to 2 for prostate cancer (PCa) suggests high radiation-fraction sensitivity and predicts a therapeutic advantage of hypofractionated (HF) radiation therapy (RT). To date, no phase 3 randomized clinical trial has compared moderately HF RT with standard fractionation (SF) exclusively in high-risk PCa patients. We are reporting the safety of moderate HF RT in high-risk PCa in an initially noninferiority-designed phase 3 clinical trial. METHODS AND MATERIALS From February 2012 to March 2015, 329 high-risk PCa patients were randomized to receive either SF or HF RT. All patients received neoadjuvant, concurrent, and long-term adjuvant androgen deprivation therapy. Standard fractionation RT consisted of 76 Gy in 2 Gy per fraction to the prostate, where 46 Gy was delivered to the pelvic lymph nodes. Hypofractionated RT included concomitant dose escalation of 68 Gy in 2.72 Gy per fraction to the prostate and 45 Gy in 1.8 Gy per fraction to the pelvic lymph nodes. The coprimary endpoints were acute and delayed toxicity at 6 and 24 months, respectively. The trial was originally designed as a noninferiority with a 5% absolute margin. Given the lower-than-expected toxicities in both arms, the noninferiority analysis was completely dropped. RESULTS Of the 329 patients, 164 were randomized to the HF and 165 to the SF arms. In total, there were more grade 1 or worse acute gastrointestinal (GI) events in the HF arm, 102 versus 83 events in the HF and SF arm, respectively (P = .016). This did not remain significant at 8 weeks of follow-up. There were no differences in grade 1 or worse acute GU events in the 2 arms, 105 versus 99 events in the HF and SF arm, respectively (P = .3). At 24 months, 12 patients in the SF arm and 15 patients in the HF arm had grade 2 or worse delayed GI-related adverse events (hazard ratio, 1.32; 95% CI, 0.62-2.83; P = .482). There were 11 patients in the SF arm and 3 patients in the HF arm with grade 2 or higher delayed genitourinary (GU) toxicities (hazard ratio, 0.26; 95% CI, 0.07-0.94; P = .037). There were 3 grade 3 GI and one grade 3 GU delayed toxicities in the HF arm and 3 grade 3 GU and no grade 3 GI toxicities in the SF arm. No grade 4-toxicities were reported. CONCLUSIONS This is the first study of moderate HF dose-escalated RT in exclusively high-risk patients with prostate cancer treated with long-term androgen deprivation therapy and pelvic RT. Although our data were not analyzed as a noninferiority, our results demonstrate that moderately HF RT is well-tolerated, similar to SF RT at 2 years, and could be considered an alternative to SF RT.
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Affiliation(s)
- Tamim Niazi
- Department of Oncology, Division of Radiation Onclogy, Hôpital Maisonneuve-Rosemont, Montreal, Quebec, Canada.
| | - Abdenour Nabid
- Department of Oncology, Division of Radiation Onclogy, Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Talia Malagon
- Department of Oncology, McGill University, Montreal, Quebec, Canada
| | - Redouane Bettahar
- Division of Radiation Onclogy, Centre Hospitalier Régional de Rimouski-Centre de Cancer, Rimouski, Quebec, Canada
| | - Linda Vincent
- Division of Radiation Onclogy, Pavillon Ste-Marie Centre Hospitalier Régional de Trois-Rivières, Trois-Rivières, Quebec, Canada
| | - Andre-Guy Martin
- Department of Oncology, Division of Radiation Onclogy, Centre Hospitalier Universitaire de Québec-L'Hôtel-Dieu de Québec, Quebec City, Quebec, Canada
| | - Marjory Jolicoeur
- Department of Oncology, Division of Radiation Onclogy, Hôpital Charles LeMoyne, Greenfield Park, Quebec, Canada
| | - Michael Yassa
- Department of Oncology, Division of Radiation Onclogy, Hôpital Maisonneuve-Rosemont, Montreal, Quebec, Canada
| | - Maroie Barkati
- Department of Oncology, Division of Radiation Onclogy, Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada
| | - Levon Igidbashian
- Division of Radiation Onclogy, Hôpital Cité-de-la-Santé, Laval, Quebec, Canada
| | - Boris Bahoric
- Department of Oncology, Division of Radiation Onclogy, Jewish General Hospital, McGill University, Quebec, Canada
| | - Robert Archambault
- Department of Oncology, Division of Radiation Onclogy, Hôpital Gatineau, Gatineau, Quebec, Canada
| | - Hugo Villeneuve
- Department of Oncology, Division of Radiation Onclogy, Hôpital de Chicoutimi, Chicoutimi, Quebec, Canada
| | - James Man Git Tsui
- Department of Oncology, Division of Radiation Onclogy, McGill University Health Centre, Montreal, Quebec, Canada
| | - Mohammed Mohiuddin
- Department of Oncology, Division of Radiation Onclogy, Saint John Regional Hospital (MM), Saint John, New Brunswick, Canada
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Qureshy SA, Diven MA, Ma X, Marciscano AE, Hu JC, McClure TD, Barbieri C, Nagar H. Differential Use of Radiotherapy Fractionation Regimens in Prostate Cancer. JAMA Netw Open 2023; 6:e2337165. [PMID: 37815829 PMCID: PMC10565603 DOI: 10.1001/jamanetworkopen.2023.37165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 08/29/2023] [Indexed: 10/11/2023] Open
Abstract
Importance Technical advances in treatment of prostate cancer and a better understanding of prostate cancer biology have allowed for hypofractionated treatment courses using a higher dose per fraction. Use of ultrahypofractionated stereotactic body radiotherapy (SBRT) has also been characterized. Objective To characterize US national trends of different RT fractionation schemes across risk groups of prostate cancer. Design, Setting, and Participants This retrospective cohort study used data collected by the National Cancer Database (NCDB) to characterize the fractionation regimens used for 302 035 patients diagnosed as having prostate cancer from January 1, 2004, to December 31, 2020, who underwent definitive RT. The analysis was performed between February 1 and April 30, 2023. Exposure Stereotactic body RT or ultrahypofractionation, defined as 5 or fewer fractions of external beam RT (EBRT), moderate hypofractionation, defined as 20 to 28 fractions of EBRT, or conventional fractionation, defined as all remaining EBRT fractionation schemes. Main Outcomes and Measures Temporal trends and clinical and sociodemographic factors associated with SBRT, moderate hypofractionation, and conventional fractionation use. Results A total of 302 035 men receiving EBRT for localized prostate cancer between 2004 and 2020 were identified (40.1% aged 60-69 years). Black patients comprised 17.6% of this cohort; White patients, 77.9%; and other races and ethnicities, 4.5%. Patients with low-risk disease comprised 17.5% of the cohort; favorable intermediate-risk disease, 23.5%; unfavorable intermediate-risk disease, 23.9%; and high-risk disease, 35.1%. Treatment consisted of conventional fractionation for 81.2%, moderate hypofractionation for 12.9%, and SBRT for 6.0%. The rate of increase over time in patients receiving SBRT compared with conventional fractionation was higher (adjusted odds ratio [AOR] for 2005 vs 2004, 3.18 [95% CI, 2.04-4.94; P < .001]; AOR for 2020 vs 2004, 264.69 [95% CI, 179.33-390.68; P < .001]) than the rate of increase in patients receiving moderate hypofractionation compared with conventional fractionation (AOR for 2005 vs 2004, 1.05 [95% CI, 0.98-1.12; P = .19]; AOR for 2020 vs 2004, 4.41 [95% CI, 4.15-4.69; P < .001]). Compared with White patients, Black patients were less likely to receive SBRT compared with conventional fractionation or moderate hypofractionation (AOR for conventional fractionation, 0.84 [95% CI, 0.80-0.89; P < .001]; AOR for moderate hypofractionation, 0.77 [95% CI, 0.72-0.81; P < .001]). Compared with 2019, patients treated with all fractionation regimens declined in 2020 by 24.4%. Conclusions and Relevance In this hospital-based cohort study of patients with prostate cancer treated with definitive EBRT, use of moderate hypofractionation and SBRT regimens for definitive prostate cancer treatment has increased from 2004 to 2020. Despite this increasing trend, findings suggest potential health care disparities for Black patients receiving EBRT for localized prostate cancer. The number of patients treated with EBRT in the year 2020 decreased, coinciding with official onset of the COVID-19 pandemic in March 2020.
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Affiliation(s)
- Sarah A. Qureshy
- currently a medical student at Weill Cornell Medicine, New York, New York
| | - Marshall A. Diven
- New York Presbyterian-Brooklyn Methodist Hospital, Brooklyn, New York
| | - Xiaoyue Ma
- Department of Population Health Sciences, Division of Biostatistics, Weill Cornell Medicine, New York, New York
| | - Ariel E. Marciscano
- Department of Radiation Oncology, Weill Cornell Medicine/NewYork-Presbyterian, New York, New York
| | - Jim C. Hu
- New York Presbyterian/Weill Cornell Medical Center, New York, New York
| | - Tim D. McClure
- Department of Urology, Weill Cornell Medicine, New York, New York
| | | | - Himanshu Nagar
- Department of Radiation Oncology, Weill Cornell Medicine/NewYork-Presbyterian, New York, New York
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Takayesu JSK, Heckman P, Short E, Hurley P, Narayana V, McLaughlin PW. Quality rectal hydrogel placement allows for gel-enabled dose-escalated EBRT (GEDE-EBRT) without rectal interference in prostate cancer. Med Dosim 2023; 48:286-292. [PMID: 37666707 DOI: 10.1016/j.meddos.2023.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 06/29/2023] [Accepted: 07/31/2023] [Indexed: 09/06/2023]
Abstract
Multiple trials have shown that dose-escalation of radiation for prostate cancer provides a biochemical progression-free survival benefit (bPFS); however, rectal constraints are often limiting. In this dosimetric study, we hypothesized that a well-placed rectal hydrogel (RH) would permit improved dose-escalation and target coverage. We selected patients with good-quality RH and created plans with and without RH, prescribing 70 Gy in 28 fractions to the prostate and proximal seminal vesicles (PSV), and a peripheral zone (PZ) boost to 84 Gy, 98 Gy, or 112 Gy. We then compared plans with and without RH, prescribing a 112 Gy boost to 1 to 2 cm simulated dominant intraprostatic lesions (DIL). In the 18 plans created with a PZ boost, the PTV_boost D95% was higher in RH plans compared to non-RH plans (median 98.5 Gy vs 75.53 Gy, p < 0.01). The PSV planning target volume (PTV_PSV) D95% was also marginally higher with RH (71.87 Gy vs 71.04 Gy, p < 0.01). All rectal metrics were improved with RH. For the 32 plans created for simulated DILs treated to 112 Gy, the PTV_boost coverage (median D95% 112.48 Gy vs 102.63 Gy, p < 0.01) and rectal metrics were improved with RH. Four non-RH plans with at least a 4 mm rectal-PTV_boost gap achieved D95% > 98% of the prescription dose for the PTV_boost. Our study showed that placement of a high-quality RH allowed for GEDE-EBRT up to 112 Gy in 28 fractions (EQD2 160 Gy with α/β = 2.5). This concept should be tested prospectively, particularly to assess for increases in nonrectal toxicities.
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Affiliation(s)
- Jamie S K Takayesu
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, USA.
| | - Paul Heckman
- Department of Radiation Oncology, Assarian Cancer Center, Ascension Providence Hospital, Novi, MI, USA
| | - Eric Short
- Department of Radiation Oncology, Assarian Cancer Center, Ascension Providence Hospital, Novi, MI, USA
| | - Patrick Hurley
- Department of Urology, Ascension Providence Hospital, Novi, MI, USA
| | - Vrinda Narayana
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, USA
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Yap SZL, Armstrong S, Aherne N, Shakespeare TP. PSMA-PET-guided dose-escalated volumetric arc therapy for newly diagnosed lymph node-positive prostate cancer: 5 Year outcomes following the FROGG and EviQ node-positive guidelines. J Med Imaging Radiat Oncol 2023. [PMID: 37186452 DOI: 10.1111/1754-9485.13534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 04/01/2023] [Indexed: 05/17/2023]
Abstract
INTRODUCTION The Royal Australian and New Zealand College of Radiologists (RANZCR) Faculty of Radiation Oncology Genitourinary Group (FROGG) guidelines and online EviQ protocols incorporate prostate-specific membrane antigen (PSMA) positron emission tomography (PET)-guided dose-escalated intensity-modulated radiation therapy (DE-IMRT) for newly diagnosed lymph node (LN) positive prostate cancer. We evaluated late toxicity and efficacy outcomes following the FROGG and EviQ approach. METHODS Patients with LN-positive-only metastases on PSMA-PET imaging were offered curative therapy with 3 months neoadjuvant androgen deprivation therapy (ADT) followed by DE-IMRT and 3 years adjuvant ADT. IMRT was delivered via volumetric arc therapy (VMAT). We aimed to deliver 81 Gy in 45 fractions (Fx) to the prostate and PET-positive LNs, and 60 Gy in 45 Fx to elective pelvic nodes, contoured using the PIVOTAL guidelines. RESULTS Forty-five patients were included. The median number of PET-positive nodes boosted was 2 (range 1-6) and median boost volume 1.16 cc (range 0.15-4.14). Seventeen (38%) patients had PET-positive nodes outside of PIVOTAL contouring guidelines. With 60 months median follow-up, disease-free, metastasis-free, prostate cancer-specific and overall survival were 88.1%, 95.3%, 100% and 91.5%. There were no in-field nodal failures. Late grade 1, 2 and 3 gastrointestinal toxicities occurred in 4%, 2% and 0% of patients, and genitourinary toxicity in 18%, 18% and 4%. Lower limb grade 2 lymphoedema occurred in three patients (7%). CONCLUSION Outcomes following FROGG guidelines and EviQ are promising, with high long-term disease control and low toxicity. Contouring guidelines require modification due to the high rate of PET-positive nodes demonstrated beyond recommended coverage.
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Affiliation(s)
- Shaun Zheng Liang Yap
- Department of Radiation Oncology, Mid-North Coast Cancer Institute, Coffs Harbour Health Campus, Coffs Harbour, New South Wales, Australia
| | - Shreya Armstrong
- Department of Radiation Oncology, North Coast Cancer Institute, Lismore Base Hospital, Lismore, New South Wales, Australia
| | - Noel Aherne
- Department of Radiation Oncology, Mid-North Coast Cancer Institute, Coffs Harbour Health Campus, Coffs Harbour, New South Wales, Australia
| | - Thomas Philip Shakespeare
- Department of Radiation Oncology, Mid-North Coast Cancer Institute, Coffs Harbour Health Campus, Coffs Harbour, New South Wales, Australia
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Akay SU, Çetin İA, Bekiroğlu GN. Dosimetric analysis of patients receiving radiotherapy with VMAT technique in localized prostate cancer and its correlation with side effects. J Cancer Res Ther 2023; 19:801-807. [PMID: 37470614 DOI: 10.4103/jcrt.jcrt_1621_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Aim The aim was to study the relationship between dosimetric data of localized prostate cancer patients who have been treated with curative radiotherapy (RT) and gastrointestinal (GIS), genitourinary (GUS), anal and sexual side effects, and whether there was a difference between dosimetric data and clinical findings between risk groups. Methods Eighty-seven patients who received curative radiotherapy for localized prostate cancer between 2014 and 2019 were included in the study. Dosimetrically; whether there was a relationship between V30, V40, V50, V60, V65, V70, V75 for rectum and bladder; D90 for the penile bulb, V72, V74, V76 for the bulbomembranous urethra, V30, V45, V53, Dmax for the anus, and V45 (cc) for the intestine data and the side effects were analyzed. It was evaluated whether there was a relationship between testosterone values and sexual side effects. The Kolmogorov-Smirnov test, one-way analysis of variance (ANOVA) (F-test), and paired-sample t-test were used as statistical methods. For statistical significance, P < 0.05 was accepted. Results : The mean age of the patients was 69 (50-86), the mean Prostat specific antigen (PSA) (ng/dL) before RT was 25.1 (0.9-339), the median RT dose was 76 Gy (74-78 Gy), and the mean follow-up period was 38.2 months. PTVmax, PTVmean, PTVmin, bladder V40, bladder V50, rectum V30, rectum V40, rectum V50, and intestinal V45 (cc) were determined as dosimetric data showing differences between risk groups. A statistically significant relationship was found between rectum V30 (P = 0.017), V60 (P = 0.019), V65 (P = 0.008), V70 (P = 0.007), and V75 (P = 0.034) and chronic GIS side effects. G2 GIS side effects were observed in four patients (4.6%) in the entire patient group during the acute period. A statistically significant relationship was found between the patients receiving hormonotherapy (P = 0.021) and testosterone values at the last control (P ≤ 0.001) and chronic sexual side effects. Conclusion Attention should be paid to the rectum V30, V60, V65, V70, and V75 values to minimize the long-term GIS side effects in patients who have undergone RT. Testosterone level and ADT status affect chronic sexual toxicity.
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Affiliation(s)
- Sitki U Akay
- Marmara University Radiation Oncology Department, Marmara University, İstanbul, Turkey
| | - İlknur A Çetin
- Marmara University Radiation Oncology Department, Marmara University, İstanbul, Turkey
| | - Gülnaz N Bekiroğlu
- Marmara University Biostatistics Department, Marmara University, İstanbul, Turkey
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Cellini F, Tagliaferri L, Frascino V, Alitto AR, Fionda B, Boldrini L, Romano A, Casà C, Catucci F, Mattiucci GC, Valentini V. Radiation therapy for prostate cancer: What's the best in 2021. Urologia 2022; 89:5-15. [PMID: 34496707 DOI: 10.1177/03915603211042335] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Radiotherapy is highly involved in the management of prostate cancer. Its features and potential applications experienced a radical evolution over last decades, as they are associated to the continuous evolution of available technology and current oncological innovations. Some application of radiotherapy like brachytherapy have been recently enriched by innovative features and multidisciplinary dedications. In this report we aim to put some questions regarding the following issues regarding multiple aspects of modern application of radiation oncology: the current application of radiation oncology; the modern role of stereotactic body radiotherapy (SBRT) for both the management of primary lesions and for lymph-nodal recurrence; the management of the oligometastatic presentations; the role of brachytherapy; the aid played by the application of the organ at risk spacer (spacer OAR), fiducial markers, electromagnetic tracking systems and on-line Magnetic Resonance guided radiotherapy (MRgRT), and the role of the new opportunity represented by radiomic analysis.
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Affiliation(s)
- Francesco Cellini
- UOC di Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
- Istituto di Radiologia, Università Cattolica del Sacro Cuore, Roma, Italia
| | - Luca Tagliaferri
- UOC di Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
| | - Vincenzo Frascino
- UOC di Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
| | - Anna Rita Alitto
- UOC di Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
| | - Bruno Fionda
- UOC di Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
| | - Luca Boldrini
- UOC di Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
| | - Angela Romano
- UOC di Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
| | - Calogero Casà
- UOC di Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
| | | | - Gian Carlo Mattiucci
- Istituto di Radiologia, Università Cattolica del Sacro Cuore, Roma, Italia
- Radiation Oncology, Mater Olbia Hospital, Olbia, Italy
| | - Vincenzo Valentini
- UOC di Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
- Istituto di Radiologia, Università Cattolica del Sacro Cuore, Roma, Italia
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Calais J, Zhu S, Hirmas N, Eiber M, Hadaschik B, Stuschke M, Herrmann K, Czernin J, Kishan AU, Nickols NG, Elashoff D, Fendler WP. Phase 3 multicenter randomized trial of PSMA PET/CT prior to definitive radiation therapy for unfavorable intermediate-risk or high-risk prostate cancer [PSMA dRT]: study protocol. BMC Cancer 2021; 21:512. [PMID: 33962579 PMCID: PMC8103642 DOI: 10.1186/s12885-021-08026-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 03/12/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Definitive radiation therapy (dRT) is an effective initial treatment of intermediate-risk (IR) and high-risk (HR) prostate cancer (PCa). PSMA PET/CT is superior to standard of care imaging (CT, MRI, bone scan) for detecting regional and distant metastatic PCa. PSMA PET/CT thus has the potential to guide patient selection and the planning for dRT and improve patient outcomes. METHODS This is a multicenter randomized phase 3 trial (NCT04457245). We will randomize 312 patients to proceed with standard dRT (control Arm, n = 150), or undergo a PSMA PET/CT scan at the study site (both 18F-DCFPyL and 68Ga-PSMA-11 can be used) prior to dRT planning (intervention arm, n = 162). dRT will be performed at the treating radiation oncologist facility. In the control arm, dRT will be performed as routinely planned. In the intervention arm, the treating radiation oncologist can incorporate PSMA PET/CT findings into the RT planning. Androgen deprivation therapy (ADT) is administered per discretion of the treating radiation oncologist and may be modified as a result of the PSMA PET/CT results. We assume that approximately 8% of subjects randomized to the PSMA PET arm will be found to have M1 disease and thus will be more appropriate candidates for long-term systemic or multimodal therapy, rather than curative intent dRT. PET M1 patients will thus not be included in the primary endpoint analysis. The primary endpoint is the success rate of patients with unfavorable IR and HR PCa after standard dRT versus PSMA PET-based dRT. Secondary Endpoints (whole cohort) include progression free survival (PFS), metastasis-free survival after initiation of RT, overall survival (OS), % of change in initial treatment intent and Safety. DISCUSSION This is the first randomized phase 3 prospective trial designed to determine whether PSMA PET/CT molecular imaging can improve outcomes in patients with PCa who receive dRT. In this trial the incorporation of PSMA PET/CT may improve the success rate of curative intent radiotherapy in two ways: to optimize patient selection as a biomarker and to personalizes the radiotherapy plan. CLINICAL TRIAL REGISTRATION UCLA IND#147591 ○ Submission: 02.27.2020 ○ Safe-to-proceed letter issued by FDA: 04.01.2020 UCLA IRB #20-000378 ClinicalTrials.gov Identifier NCT04457245 . Date of Registry: 07.07.2020. Essen EudraCT 2020-003526-23.
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Affiliation(s)
- Jeremie Calais
- Ahmanson Translational Theranostics Division, Department of Molecular & Medical Pharmacology, David Geffen School of Medicine, University of California, Peter Norton Medical Building, 200 Medical Plaza, Suite B-114-51, Los Angeles, CA 90095-7370 USA
- Jonsson Comprehensive Cancer Center, University of California Los Angeles, Los Angeles, CA USA
- Institute of Urologic Oncology, University of California Los Angeles, Los Angeles, CA USA
| | - Shaojun Zhu
- Ahmanson Translational Theranostics Division, Department of Molecular & Medical Pharmacology, David Geffen School of Medicine, University of California, Peter Norton Medical Building, 200 Medical Plaza, Suite B-114-51, Los Angeles, CA 90095-7370 USA
| | - Nader Hirmas
- Department of Nuclear Medicine, University of Duisburg-Essen and German Cancer Consortium (DKTK)-University Hospital Essen, Hufelandstraße 55, 45131 Essen, Germany
| | - Matthias Eiber
- Department of Nuclear Medicine, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Boris Hadaschik
- Department of Urology, University of Duisburg-Essen and German Cancer Consortium (DKTK)-University Hospital Essen, Essen, Germany
| | - Martin Stuschke
- Department of Radiotherapy, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Ken Herrmann
- Department of Nuclear Medicine, University of Duisburg-Essen and German Cancer Consortium (DKTK)-University Hospital Essen, Hufelandstraße 55, 45131 Essen, Germany
| | - Johannes Czernin
- Ahmanson Translational Theranostics Division, Department of Molecular & Medical Pharmacology, David Geffen School of Medicine, University of California, Peter Norton Medical Building, 200 Medical Plaza, Suite B-114-51, Los Angeles, CA 90095-7370 USA
- Jonsson Comprehensive Cancer Center, University of California Los Angeles, Los Angeles, CA USA
- Institute of Urologic Oncology, University of California Los Angeles, Los Angeles, CA USA
| | - Amar U. Kishan
- Jonsson Comprehensive Cancer Center, University of California Los Angeles, Los Angeles, CA USA
- Institute of Urologic Oncology, University of California Los Angeles, Los Angeles, CA USA
- Department of Radiation Oncology, David Geffen School of Medicine, University of California, Los Angeles, USA
| | - Nicholas G. Nickols
- Jonsson Comprehensive Cancer Center, University of California Los Angeles, Los Angeles, CA USA
- Department of Radiation Oncology, David Geffen School of Medicine, University of California, Los Angeles, USA
- Department of Radiation Oncology, VA Greater Los Angeles Healthcare System, Los Angeles, California USA
- Department of Urology, David Geffen School of Medicine, University of California, Los Angeles, USA
| | - David Elashoff
- Institute of Urologic Oncology, University of California Los Angeles, Los Angeles, CA USA
- Department of Medicine Statistics Core (DOMStat), UCLA CTSI Biostatistics and Computational Biology, University of California, Los Angeles, USA
| | - Wolfgang P. Fendler
- Department of Nuclear Medicine, University of Duisburg-Essen and German Cancer Consortium (DKTK)-University Hospital Essen, Hufelandstraße 55, 45131 Essen, Germany
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Xiao YT, Zhao X, Chang Y, Lu X, Wang Y, Zhang H, Ren S. Assessing the safety and feasibility of neoadjuvant hormone and radiation therapy followed by robot-assisted radical prostatectomy for treating locally advanced prostate cancer: protocol for an open-label, dose-escalation, single-centre, phase I clinical trial. BMJ Open 2020; 10:e038678. [PMID: 33148738 PMCID: PMC7640530 DOI: 10.1136/bmjopen-2020-038678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Patients with locally advanced prostate cancer are at high risk of recurrence after definitive treatment. There are emerging data that radical prostatectomy can delay the progression of castration resistance and potentially prolong survival. Neoadjuvant radiation therapy improves local control and has shown survival benefit with favourable toxicity profiles in several other malignancies. We have designed this trial to investigate whether this combination, which theoretically maximises local control, is a safe and feasible approach for treating locally advanced prostate cancer. METHODS AND ANALYSIS This study is a phase I, open-label study to investigate the safety and feasibility of neoadjuvant hormone and radiation therapy followed by robot-assisted radical prostatectomy by a traditional 3+3 dose-escalation design with four planned radiation dose levels (39.6 Gy/22F, 45 Gy/25F, 50.4 Gy/28F and 54 Gy/30F). Locally advanced prostate cancer patients with positive pelvic and/or retroperitoneal lymph nodes will be recruited. The primary objective is to determine the adverse events and maximal tolerable dose (MTD) of neoadjuvant radiotherapy. Toxicity will be assessed using the National Cancer Institute Common Toxicity Criteria V.5.0. ETHICS AND DISSEMINATION This protocol was approved by the Institutional Review Board of Shanghai Changhai Hospital (ref. CHEC2019-070 and CHEC2019-082). The study will be performed in compliance with applicable local legislation and in accordance with the ethical principles developed by the World Medical Association in the Declaration of Helsinki 2013. Study results will be disseminated through conferences and peer-reviewed scientific journals. TRIAL REGISTRATION NUMBERS ChiCTR1900022716; ChiCTR1900022754.
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Affiliation(s)
- Yu-Tian Xiao
- Department of Urology, Shanghai Changhai Hospital, Shanghai, China
| | - Xianzhi Zhao
- Department of Radiation Oncology, Shanghai Changhai Hospital, Shanghai, China
| | - Yifan Chang
- Department of Urology, Shanghai Changhai Hospital, Shanghai, China
| | - Xiaojun Lu
- Department of Urology, Shanghai Changhai Hospital, Shanghai, China
| | - Ye Wang
- Department of Urology, Shanghai Changhai Hospital, Shanghai, China
| | - Huojun Zhang
- Department of Radiation Oncology, Shanghai Changhai Hospital, Shanghai, China
| | - Shancheng Ren
- Department of Urology, Shanghai Changhai Hospital, Shanghai, China
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9
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Thompson AB, Hamstra DA. Rectal Spacer Usage with Proton Radiation Therapy for Prostate Cancer. Int J Radiat Oncol Biol Phys 2020; 108:644-648. [DOI: 10.1016/j.ijrobp.2020.05.034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 05/11/2020] [Accepted: 05/18/2020] [Indexed: 01/03/2023]
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10
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Outaggarts Z, Wegener D, Berger B, Zips D, Paulsen F, Bleif M, Thorwarth D, Alber M, Dohm O, Müller AC. Target miss using PTV-based IMRT compared to robust optimization via coverage probability concept in prostate cancer. Acta Oncol 2020; 59:911-917. [PMID: 32436467 DOI: 10.1080/0284186x.2020.1760349] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Purpose: Cure- and toxicity rates of prostate IGRT can both be affected by ill-chosen planning target volume (PTV) margins. For dose-escalated prostate radiotherapy, we studied the potential for organ at risk (OAR) sparing and compensation of prostate motion with robust plan optimization using the coverage probability (CovP) concept compared to conventional PTV-based IMRT.Material and methods: We evaluated plan quality of CovP-plans for 27 intermediate risk prostate cancer patients treated in a prospective study (78 Gy/39 fractions). Clinical target volume (CTV) and OARs were contoured on three separate CTs to capture movement and deformation. To define the internal target volume (ITV), the union of CTV1-3 was encompassed by an isotropic margin of 7 mm for the planning process. CovP-dose distribution is optimized considering weight factors for IMRT constraints derived from probabilities of systematic organ displacement in the three CTs. CovP-dose volume histograms (DVHs) were compared with additionally calculated conventional PTV-based IMRT plans. PTV-based IMRT was planned on one-single CT with an isotropically expanded CTV to generate the PTV (i.e., CTV1 + 7mm) and was evaluated on the two other CTs.Results: The CovP-concept showed higher robustness in target volume coverage. Target miss was frequently observed with PTV-based IMRT, resulting in cold spots until 70 Gy with the CovP-concept. The target dose at 74 Gy was comparable, while further the dose-escalation (75-78 Gy) was improved with PTV-based IMRT. However, dose-escalation with PTV-based IMRT was associated with increased OAR-doses, especially in high-dose areas.Conclusions: Probabilistic dose-escalated IMRT was feasible in this prospective study. Comparison of the CovP-concept with PTV-based IMRT revealed superiority with regard to target-coverage and sparing of OARs. The CovP-concept implements a robust plan optimization strategy for organ deformation and motions and could, therefore, serve as a less demanding compromise on the way to adaptive IGRT avoiding daily time-consuming re-planning. SUMMARYWe evaluated the robustness of coverage probability (CovP)-based IMRT plans within a prospective study for prostate cancer radiotherapy. The treatment plans were compared with newly calculated conventional PTV-based IMRT plans. We were able to show that CovP led to a clearly more robust target coverage by avoiding hot spots at OARs compared to conventional PTV-based IMRT. In addition, negative consequences of an inflated PTV can be ameliorated by a more relaxed CovP-based dose prescription.
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Affiliation(s)
- Zoulikha Outaggarts
- Department of Radiation Oncology, University Hospital Tübingen, Tübingen, Germany
| | - Daniel Wegener
- Department of Radiation Oncology, University Hospital Tübingen, Tübingen, Germany
| | - Bernhard Berger
- Clinic for Radiation Oncology, Oberschwaben Hospital Group, Ravensburg, Germany
| | - Daniel Zips
- Department of Radiation Oncology, University Hospital Tübingen, Tübingen, Germany
| | - Frank Paulsen
- Department of Radiation Oncology, University Hospital Tübingen, Tübingen, Germany
| | - Martin Bleif
- Clinic for Radiology and Radiation Oncology, ALB FILS Clinics Hospital on the Eichert, Goppingen, Germany
| | - Daniela Thorwarth
- Department of Radiation Oncology, Section Medical Physics, University Hospital Tübingen, Tübingen, Germany
| | - Markus Alber
- Clinic for Radiation Oncology, University Hospital Heidelberg, Heidelberg, Germany
| | - Oliver Dohm
- Department of Radiation Oncology, Section Medical Physics, University Hospital Tübingen, Tübingen, Germany
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11
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López-Torrecilla J, Pastor-Peidro J, Vicedo-González A, González-Sanchis D, Hernandez-Machancoses A, Almendros-Blanco P, García-Miragall E, Gordo-Partearroyo JC, García-Hernández T, Brualla-González L, Granero-Cabañero D, Rosello-Ferrando J. Patterns of treatment failure in patients with prostate cancer treated with 76-80 Gy radiotherapy to the prostate and seminal vesicles ± hormonotherapy. Clin Transl Oncol 2020; 23:481-490. [PMID: 32621208 DOI: 10.1007/s12094-020-02437-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 06/19/2020] [Indexed: 01/13/2023]
Abstract
PURPOSE To assess the pattern of treatment failure in patients with prostate cancer (PCa) treated with radiotherapy (76-80 Gy) ± hormone therapy (HT). We also evaluated the influence of treatment failure on survival outcomes. METHODS Retrospective study of patients with PCa (n = 302) treated with radiotherapy (RT) ± HT at our centre between November 1999 and July 2007. The mean patient age was 70.2 years (range 51-87). Distribution by NCCN risk group was low (n = 80, 26.5%), intermediate (n = 86, 28.5%), high (n = 77, 25.5%), and very high (n = 49, 16.2%). Most patients (n = 273, 90.4%) received IMRT at a dose of 76-80 Gy. HT was administered in 237 patients (78.5%), in most cases (n = 167, 55.3%) for < 7 months RESULTS: Survival rates at 10 years were: overall survival (OS), 64.3%; biochemical disease-free survival, 83.9%; disease-free survival, 92.5%; and metastasis-free survival (MFS), 94.3%. Biochemical failure (BF) was observed in 55 cases (18.2%), 32 of whom subsequently developed clinical recurrence: metastasis (n = 17, 5.6%), local failure (n = 11, 3.6%), and regional failure (n = 4, 1.3%). The cause of death (n = 159) was intercurrent disease in 115 cases (72.3%), second cancer in 27 (17.0%), and PCa in 17 (10.7%). Biochemical failure-free survival ≤ 24 months was significantly associated with worse OS and MFS (p = 0.0001). Late genitourinary and gastrointestinal toxicity grade ≥ 3 (RTOG) was observed in 18 (6.0%) and 7 (2.3%) patients, respectively. CONCLUSIONS The main type of treatment failure after 76-80 Gy of radiotherapy ± HT is local or metastatic. In all cases, biochemical failure occurred prior to treatment failure. BF within 24 months of treatment completion was significantly associated with worse OS and MFS.
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Affiliation(s)
- J López-Torrecilla
- Department of Radiation Oncology, ERESA, Hospital General Universitario de Valencia, Av. Tres Cruces, 2, 46014, Valencia, Spain.
| | - J Pastor-Peidro
- Department of Radiation Oncology, ERESA, Hospital General Universitario de Valencia, Av. Tres Cruces, 2, 46014, Valencia, Spain
| | - A Vicedo-González
- Medical Physics Department, ERESA, Hospital General Universitario de Valencia, Av. Tres Cruces, 2, 46014, Valencia, Spain
| | - D González-Sanchis
- Department of Radiation Oncology, ERESA, Hospital General Universitario de Valencia, Av. Tres Cruces, 2, 46014, Valencia, Spain
| | - A Hernandez-Machancoses
- Department of Radiation Oncology, ERESA, Hospital General Universitario de Valencia, Av. Tres Cruces, 2, 46014, Valencia, Spain
| | - P Almendros-Blanco
- Department of Radiation Oncology, ERESA, Hospital General Universitario de Valencia, Av. Tres Cruces, 2, 46014, Valencia, Spain
| | - E García-Miragall
- Department of Radiation Oncology, ERESA, Hospital General Universitario de Valencia, Av. Tres Cruces, 2, 46014, Valencia, Spain
| | - J C Gordo-Partearroyo
- Department of Radiation Oncology, ERESA, Hospital General Universitario de Valencia, Av. Tres Cruces, 2, 46014, Valencia, Spain
| | - T García-Hernández
- Department of Radiation Oncology, ERESA, Hospital General Universitario de Valencia, Av. Tres Cruces, 2, 46014, Valencia, Spain.,Medical Physics Department, ERESA, Hospital General Universitario de Valencia, Av. Tres Cruces, 2, 46014, Valencia, Spain
| | - L Brualla-González
- Medical Physics Department, ERESA, Hospital General Universitario de Valencia, Av. Tres Cruces, 2, 46014, Valencia, Spain
| | - D Granero-Cabañero
- Medical Physics Department, ERESA, Hospital General Universitario de Valencia, Av. Tres Cruces, 2, 46014, Valencia, Spain
| | - J Rosello-Ferrando
- Medical Physics Department, ERESA, Hospital General Universitario de Valencia, Av. Tres Cruces, 2, 46014, Valencia, Spain
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12
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Murray JR, Tree AC, Alexander EJ, Sohaib A, Hazell S, Thomas K, Gunapala R, Parker CC, Huddart RA, Gao A, Truelove L, McNair HA, Blasiak-Wal I, deSouza NM, Dearnaley D. Standard and Hypofractionated Dose Escalation to Intraprostatic Tumor Nodules in Localized Prostate Cancer: Efficacy and Toxicity in the DELINEATE Trial. Int J Radiat Oncol Biol Phys 2020; 106:715-724. [PMID: 31812718 DOI: 10.1016/j.ijrobp.2019.11.402] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Revised: 11/11/2019] [Accepted: 11/25/2019] [Indexed: 12/16/2022]
Abstract
PURPOSE To report a planned analysis of the efficacy and toxicity of dose escalation to the intraprostatic dominant nodule identified on multiparametric magnetic resonance imaging using standard and hypofractionated external beam radiation therapy. METHODS AND MATERIALS DELINEATE is a single centre prospective phase 2 multicohort study including standard (cohort A: 74 Gy in 37 fractions) and moderately hypofractionated (cohort B: 60 Gy in 20 fractions) prostate image guided intensity modulated radiation therapy in patients with National Comprehensive Cancer Network intermediate- and high-risk disease. Patients received an integrated boost of 82 Gy (cohort A) and 67 Gy (cohort B) to lesions visible on multiparametric magnetic resonance imaging. Fifty-five patients were treated in cohort A, and 158 patients were treated in cohort B; the first 50 sequentially treated patients in cohort B were included in this planned analysis. The primary endpoint was late Radiation Therapy Oncology Group rectal toxicity at 1 year. Secondary endpoints included acute and late toxicity measured with clinician- and patient-reported outcomes at other time points and biochemical relapse-free survival for cohort A. Median follow-up was 74.5 months for cohort A and 52.0 months for cohort B. RESULTS In cohorts A and B, 27% and 40% of patients, respectively, were classified as having National Comprehensive Cancer Network high-risk disease. The cumulative 1-year incidence of Radiation Therapy Oncology Group grade 2 or worse rectal and urinary toxicity was 3.6% and 0% in cohort A and 8% and 10% in cohort B, respectively. There was no reported late grade 3 rectal toxicity in either cohort. Within cohort A, 4 of 55 (7%) patients had biochemical relapse. CONCLUSIONS Delivery of a simultaneous integrated boost to intraprostatic dominant nodules is feasible in prostate radiation therapy using standard and moderately hypofractionated regimens, with rectal and genitourinary toxicity comparable to contemporary series without an intraprostatic boost.
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Affiliation(s)
- Julia R Murray
- The Royal Marsden NHS Foundation Trust, London, United Kingdom; The Institute of Cancer Research, London, United Kingdom.
| | - Alison C Tree
- The Royal Marsden NHS Foundation Trust, London, United Kingdom; The Institute of Cancer Research, London, United Kingdom
| | | | - Aslam Sohaib
- The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Steve Hazell
- The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Karen Thomas
- The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Ranga Gunapala
- The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Chris C Parker
- The Royal Marsden NHS Foundation Trust, London, United Kingdom; The Institute of Cancer Research, London, United Kingdom
| | - Robert A Huddart
- The Royal Marsden NHS Foundation Trust, London, United Kingdom; The Institute of Cancer Research, London, United Kingdom
| | - Annie Gao
- The Royal Marsden NHS Foundation Trust, London, United Kingdom; The Institute of Cancer Research, London, United Kingdom
| | - Lesley Truelove
- The Royal Marsden NHS Foundation Trust, London, United Kingdom; The Institute of Cancer Research, London, United Kingdom
| | - Helen A McNair
- The Royal Marsden NHS Foundation Trust, London, United Kingdom; The Institute of Cancer Research, London, United Kingdom
| | - Irena Blasiak-Wal
- The Royal Marsden NHS Foundation Trust, London, United Kingdom; The Institute of Cancer Research, London, United Kingdom
| | - Nandita M deSouza
- The Royal Marsden NHS Foundation Trust, London, United Kingdom; The Institute of Cancer Research, London, United Kingdom
| | - David Dearnaley
- The Royal Marsden NHS Foundation Trust, London, United Kingdom; The Institute of Cancer Research, London, United Kingdom
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Mahase SS, D'Angelo D, Kang J, Hu JC, Barbieri CE, Nagar H. Trends in the Use of Stereotactic Body Radiotherapy for Treatment of Prostate Cancer in the United States. JAMA Netw Open 2020; 3:e1920471. [PMID: 32022878 DOI: 10.1001/jamanetworkopen.2019.20471] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
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.
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Affiliation(s)
- Sean S Mahase
- Department of Radiation Oncology, Weill Cornell Medicine, New York, New York
| | - Debra D'Angelo
- Division of Biostatistics and Epidemiology, Department of Healthcare Policy and Research, Weill Cornell Medicine, New York, New York
| | - Josephine Kang
- Department of Radiation Oncology, Weill Cornell Medicine, New York, New York
| | - Jim C Hu
- Department of Urology, Weill Cornell Medicine, New York, New York
| | | | - Himanshu Nagar
- Department of Radiation Oncology, Weill Cornell Medicine, New York, New York
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14
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Alexidis P, Dragoumis D, Karatzoglou S, Drevelegas K, Tzitzikas I, Hatzimouratidis K, Chrisogonidis I, Giannakidis D, Koulouris C, Katsaounis A, Michalopoulos N, Huang H, Li Q, Aidoini Z, Fyntanidou V, Amaniti A, Hohenforst-Schmidt W, Maragouli E, Petanidis S, Zarogoulidis P, Sapalidis K, Kosmidis C, Romanidis K, Oinkonomou P, Vagionas A, Nikolaos-Katsios I, Ioannidis A, Boniou K, Kesisoglou I. The role of hypofractionated radiotherapy for the definitive treatment of localized prostate cancer: early results of a randomized trial. J Cancer 2019; 10:6217-6224. [PMID: 31772654 PMCID: PMC6856757 DOI: 10.7150/jca.35510] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2019] [Accepted: 08/25/2019] [Indexed: 02/07/2023] Open
Abstract
Background: Prostate cancer is considered to have a special biology which could affect the radiation therapy result based on the selected fractionation scheme. We present the preliminary results of a randomized trial comparing conventionally and hypofractionated radiation therapy for prostate cancer. Methods: Patients included in the study had localized prostate cancer (cT1c-T3bN0M0) and were randomly assigned to mild hypofractionated (72 Gy in 32 fractions, arm1) or conventionally fractionated (74 Gy in 37 fractions, arm2) radiation therapy treatment with Volumetric Arc Therapy technique. The treatment was delivered only to the prostate with or without the seminal vesicles according to physician's discretion and hormone therapy was optional according to the disease stage and comorbidities. Here we present the preliminary results of acute toxicity from the gastrointestinal (GI) and genitourinary (GU) system. Results: Between 2015 and 2016, 139 patients were enrolled. 67 patients were treated with conventional fractionation and 72 were treated with hypofractionation. Grade≥ 2 toxicity from GU and GI was observed in 23 and 21 patients (31,9% vs 31,3%, p=0,79) and 15 and 12 (20,8% vs 17,9%, p=0,6) for arm1 and arm2 respectively. No statistically significant differences were observed between arms in the incidence of early toxicity. There was no correlation observed between patient characteristics and toxicity from either GU or GI. Conclusions: Hypofractionated radiotherapy appears to be equally tolerated compared to conventional fractionation in the early setting. Longer follow up is needed to assess the late toxicity profile of the patients and any potential differences between the control and experimental arm.
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Affiliation(s)
- Petros Alexidis
- Department of Radiation Oncology, Interbalkan European Medical Center; Thessaloniki, Greece
| | - Dimitris Dragoumis
- Neurosurgical Department, ``G. Papanikolaou`` General Hospital, Thessaloniki, Greece
| | - Sotirios Karatzoglou
- Neurosurgical Department, ``G. Papanikolaou`` General Hospital, Thessaloniki, Greece
| | | | - Ioannis Tzitzikas
- Department of Radiation Oncology, AHEPA University Hospital of Thessaloniki, Faculty of Medicine, School of Health Sciences, Aristotle University of Thessaloniki, Greece
| | - Konstantinos Hatzimouratidis
- Department of Urology, Papageorgiou hospital of Thessaloniki, Faculty of Medicine, School of Health Sciences, Aristotle University of Thessaloniki, Greece
| | - Ioannis Chrisogonidis
- 3rd Department of Surgery, AHEPA University Hospital, Aristotle University of Thessaloniki, Medical School, Thessaloniki, Greece
| | - Dimitris Giannakidis
- 3rd Department of Surgery, AHEPA University Hospital, Aristotle University of Thessaloniki, Medical School, Thessaloniki, Greece
| | - Charilaos Koulouris
- 3rd Department of Surgery, AHEPA University Hospital, Aristotle University of Thessaloniki, Medical School, Thessaloniki, Greece
| | - Athanasios Katsaounis
- 3rd Department of Surgery, AHEPA University Hospital, Aristotle University of Thessaloniki, Medical School, Thessaloniki, Greece
| | - Nikolaos Michalopoulos
- 3rd Department of Surgery, AHEPA University Hospital, Aristotle University of Thessaloniki, Medical School, Thessaloniki, Greece
| | - Haidong Huang
- The Diagnostic and Therapeutic Center of Respiratory Diseases, Shanghai East Hospital, Tongji University, Shanghai, China
| | - Qiang Li
- The Diagnostic and Therapeutic Center of Respiratory Diseases, Shanghai East Hospital, Tongji University, Shanghai, China
| | - Zoi Aidoini
- 3rd Department of Surgery, AHEPA University Hospital, Aristotle University of Thessaloniki, Medical School, Thessaloniki, Greece
| | - Varbara Fyntanidou
- Anesthisiology Department, AHEPA University Hospital, Aristotle University of Thessaloniki, Medical School; Thessaloniki, Greece
| | - Aikaterini Amaniti
- Anesthisiology Department, AHEPA University Hospital, Aristotle University of Thessaloniki, Medical School; Thessaloniki, Greece
| | - Wolfgang Hohenforst-Schmidt
- Sana Clinic Group Franken, Department of Cardiology/Pulmonology/Intensive Care/Nephrology, "Hof" Clinics, University of Erlangen, Hof, Germany
| | - Elena Maragouli
- Oncology Department, University of Thessali, Larissa, Greece
| | - Savvas Petanidis
- Department of Pulmonology, I.M. Sechenov First Moscow State Medical University; Moscow, 119992, Russian Federation
| | - Paul Zarogoulidis
- 3rd Department of Surgery, AHEPA University Hospital, Aristotle University of Thessaloniki, Medical School, Thessaloniki, Greece
| | - Konstantinos Sapalidis
- 3rd Department of Surgery, AHEPA University Hospital, Aristotle University of Thessaloniki, Medical School, Thessaloniki, Greece
| | - Christoforos Kosmidis
- 3rd Department of Surgery, AHEPA University Hospital, Aristotle University of Thessaloniki, Medical School, Thessaloniki, Greece
| | - Konstantinos Romanidis
- Second Department of Surgery, University Hospital of Alexandroupolis, Medical School, Democritus University of Thrace, 68100 Alexandroupolis, Greece
| | - Panagoula Oinkonomou
- Second Department of Surgery, University Hospital of Alexandroupolis, Medical School, Democritus University of Thrace, 68100 Alexandroupolis, Greece
| | | | - Iason Nikolaos-Katsios
- 3rd Department of Surgery, AHEPA University Hospital, Aristotle University of Thessaloniki, Medical School, Thessaloniki, Greece
| | - Aris Ioannidis
- 3rd Department of Surgery, AHEPA University Hospital, Aristotle University of Thessaloniki, Medical School, Thessaloniki, Greece
| | - Konstantina Boniou
- Radiology Department, ``Theageneio`` Cancer Hospital, Thessaloniki, Greece
| | - Isaak Kesisoglou
- 3rd Department of Surgery, AHEPA University Hospital, Aristotle University of Thessaloniki, Medical School, Thessaloniki, Greece
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Impact of Radiation Therapy Dose Escalation on Prostate Cancer Outcomes and Toxicities. Am J Clin Oncol 2019; 41:409-415. [PMID: 27014930 DOI: 10.1097/coc.0000000000000285] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVES Freedom from biochemical failure (FFBF) is a common primary outcome of randomized-controlled trials of prostate cancer (PCa). We aimed to determine how increasing the PCa biologically equivalent dose (BED) of external radiation therapy (RT) is correlated with FFBF and overall patient outcomes: overall survival (OS), distant metastasis (DM), and cancer-specific mortality (CSM); as well as genitourinary (GU), and gastrointestinal toxicities. MATERIALS AND METHODS We performed a meta-analysis of 6884 PCa patients from 12 randomized-controlled trials of external beam RT. Mixed effects regression models were used to estimate weighted linear relationships between BED and observed percentages of 5- and 10-year outcomes. For toxicities, a subset analysis of using 3-dimensional conformal RT (3D-CRT) versus intensity-modulated RT (IMRT) was performed. RESULTS Increasing BED correlated with improved FFBF: 10-year absolute improvement of 9.6% and 7.2% for low-risk and intermediate-risk patients, respectively (P<0.05); but not with improvement of OS, DM, or CSM at either time point. BED escalation was not correlated with increased acute toxicities; it was correlated with increased late gastrointestinal toxicities in patients treated with 3D-CRT (1.5% increase over BED range, P<0.01). IMRT patients had significantly fewer late toxicities, despite being treated at higher BED. CONCLUSIONS RT BED escalation has resulted in significantly improved PCa FFBF at up to 10 years; but not with improvement in OS, DM, or CSM. Thus, FFBF is a poor surrogate of overall patient outcomes for trials of RT. Late toxicities were less frequent with IMRT than with 3D-CRT, even at higher BED.
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16
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Matta R, Chapple CR, Fisch M, Heidenreich A, Herschorn S, Kodama RT, Koontz BF, Murphy DG, Nguyen PL, Nam RK. Pelvic Complications After Prostate Cancer Radiation Therapy and Their Management: An International Collaborative Narrative Review. Eur Urol 2018; 75:464-476. [PMID: 30573316 DOI: 10.1016/j.eururo.2018.12.003] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Accepted: 12/04/2018] [Indexed: 02/06/2023]
Abstract
CONTEXT Radiotherapy used for treating localized prostate cancer is effective at prolonging cancer-specific and overall survival. Still, acute and late pelvic toxicities are a concern, with gastrointestinal (GI) and genitourinary (GU) sequelae being most common as well as other pelvic complications. OBJECTIVE To present a critical review of the literature regarding the incidence and risk factors of pelvic toxicity following primary radiotherapy for prostate cancer and to provide a narrative review regarding its management. EVIDENCE ACQUISITION A collaborative narrative review of the literature from 2010 to present was conducted. EVIDENCE SYNTHESIS Regardless of the modality used, the incidence of acute high-grade pelvic toxicity is low following conventionally fractionated external beam radiotherapy (EBRT). After moderate hypofractionation, the crude cumulative incidences for late grade 3 or higher (G3+) GI and GU complications are as high as 6% and 7%, respectively. After extreme hypofractionation, the 5-yr incidences of G2+ GU and GI toxicities are 3-9% and 0-4%, respectively. Following brachytherapy monotherapy, crude rates of late G3+ GU toxicity range from 6% to 8%, while late GI toxicity is rare. With combination therapy (EBRT and brachytherapy), the cumulative incidence of late GU toxicity is high, between 18% and 31%; however, the prevalence is lower at 4-14%. Whole pelvic radiotherapy remains a controversial treatment option as there is increased G3+ GI toxicity compared with prostate-only treatment, with no overall survival benefit. Proton beam therapy appears to have similar toxicity to photon therapies currently in use. With respect to specific complications, urinary obstruction and urethral stricture are the most common severe urinary toxicities. Rectal and urinary bleeding can be recurrent long-term toxicities. The risk of hip fracture is also increased following prostate radiotherapy. The literature is mixed on the risk of in-field secondary pelvic malignancies following prostate radiotherapy. Urinary and GI fistulas are rare complications. Management of these toxicities may require invasive treatment and reconstructive surgery for refractory and severe symptoms. CONCLUSIONS There has been progress in the delivery of radiotherapy, enabling the administration of higher doses with minimal tradeoff in terms of slightly increased or equal toxicity. There is a need to focus future improvements in radiotherapy on sparing critical structures to reduce GU and GI morbidities. While complications such as fistulae, bone toxicity, and secondary malignancy are rare, there is a need for higher-quality studies assessing these outcomes and their management. PATIENT SUMMARY In this report, we review the literature regarding pelvic complications following modern primary prostate cancer radiotherapy and their management. Modern radiotherapy technologies have enabled the administration of higher doses with minimal increases in toxicity. Overall, high-grade long-term toxicity following prostate radiotherapy is uncommon. Management of late high-grade pelvic toxicities can be challenging, with patients often requiring invasive therapies for refractory cases.
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Affiliation(s)
- Rano Matta
- Division of Urology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada; Institute for Health Policy, Management & Evaluation, University of Toronto, Toronto, Ontario, Canada
| | | | - Margit Fisch
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Axel Heidenreich
- Department of Urology, Uro-Oncology, Robot-Assisted and Reconstructive Surgery, University of Cologne, Cologne, Germany
| | - Sender Herschorn
- Division of Urology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Ronald T Kodama
- Division of Urology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Bridget F Koontz
- Department of Radiation Oncology, Duke Prostate and Urologic Cancers Center, Duke University Medical Center, Durham, NC, USA
| | - Declan G Murphy
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Australia; Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia
| | - Paul L Nguyen
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Robert K Nam
- Division of Urology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada; Institute for Health Policy, Management & Evaluation, University of Toronto, Toronto, Ontario, Canada.
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17
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Xiao C, Moughan J, Movsas B, Konski AA, Hanks GE, Cox JD, Roach M, Zeitzer KL, Lawton CA, Peters CA, Rosenthal SA, Hsu ICJ, Horwitz EM, Mishra MV, Michalski JM, Parliament MB, D'Souza DP, Pugh SL, Bruner DW. Risk factors for late bowel and bladder toxicities in NRG Oncology prostate cancer trials of high-risk patients: A meta-analysis of physician-rated toxicities. Adv Radiat Oncol 2018; 3:405-411. [PMID: 30202809 PMCID: PMC6128023 DOI: 10.1016/j.adro.2018.04.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Accepted: 04/29/2018] [Indexed: 01/03/2023] Open
Abstract
Purpose A meta-analysis of sociodemographic variables and their association with late (>180 days from start of radiation therapy[RT]) bowel, bladder, and clustered bowel and bladder toxicities was conducted in patients with high-risk (clinical stages T2c-T4b or Gleason score 8-10 or prostate-specific antigen level >20) prostate cancer. Methods and materials Three NRG trials (RTOG 9202, RTOG 9413, and RTOG 9406) that accrued from 1992 to 2000 were used. Late toxicities were measured with the Radiation Therapy Oncology Group Late Radiation Morbidity Scale. After controlling for study, age, Karnofsky Performance Status, and year of accrual, sociodemographic variables were added to the model for each outcome variable of interest in a stepwise fashion using the Fine-Gray regression models with an entry criterion of 0.05. Results A total of 2432 patients were analyzed of whom most were Caucasian (76%), had a KPS score of 90 to 100 (92%), and received whole-pelvic RT+HT (67%). Of these patients, 13 % and 16% experienced late grade ≥2 bowel and bladder toxicities, respectively, and 2% and 3% experienced late grade ≥3 bowel and bladder toxicities, respectively. Late grade ≥2 clustered bowel and bladder toxicities were seen in approximately 1% of patients and late grade ≥3 clustered toxicities were seen in 2 patients (<1%). The multivariate analysis showed that patients who received prostate-only RT+HT had a lower risk of experiencing grade ≥2 bowel toxicities than those who received whole-pelvic RT+long-term (LT) HT (hazard ratio: 0.36; 95% confidence interval, 0.18-0.73; P = .0046 and hazard ratio: 0.43; 95% confidence interval, 0.23-0.80; P = .008, respectively). Patients who received whole-pelvic RT had similar chances of having grade ≥2 bowel or bladder toxicities no matter whether they received LT or short-term HT. Conclusions Patients with high-risk prostate cancer who receive whole-pelvic RT+LT HT are more likely to have a grade ≥2 bowel toxicity than those who receive prostate-only RT. LT bowel and bladder toxicities were infrequent. Future studies will need to confirm these findings utilizing current radiation technology and patient-reported outcomes.
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Affiliation(s)
| | - Jennifer Moughan
- NRG Oncology Statistics and Data Management Center, Philadelphia, Pennsylvania
| | | | | | | | | | - Mack Roach
- UCSF Medical Center-Mount Zion, San Francisco, California
| | - Kenneth L Zeitzer
- Albert Einstein Medical Center (current) and Thomas Jefferson University Hospital (accruals), Philadelphia, Pennsylvania
| | - Colleen A Lawton
- Froedtert and the Medical College of Wisconsin and the VAMC, Milwaukee, Wisconsin
| | | | - Seth A Rosenthal
- Sutter Cancer Center (current) and Radiological Associates of Sacramento (accruals), Sacramento, California
| | - I-Chow Joe Hsu
- UCSF Medical Center-Mount Zion, San Francisco, California
| | | | - Mark V Mishra
- University of Maryland Medical Systems, Baltimore, Maryland
| | | | | | | | - Stephanie L Pugh
- NRG Oncology Statistics and Data Management Center, Philadelphia, Pennsylvania
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18
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Leiker AJ, Desai NB, Folkert MR. Rectal radiation dose-reduction techniques in prostate cancer: a focus on the rectal spacer. Future Oncol 2018; 14:2773-2788. [PMID: 29939069 DOI: 10.2217/fon-2018-0286] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Prostate cancer is the most common cancer in men. External beam radiotherapy by a variety of methods is a standard treatment option with excellent disease control. However, acute and late rectal side effects remain a limiting concern in intensification of therapy in higher-risk patients and in efforts to reduce treatment burden in others. A number of techniques have emerged that allow for high-radiation dose delivery to the prostate with reduced risk of rectal toxicity, including image-guided intensity-modulated radiation therapy, endorectal balloons and various forms of rectal spacers. Image-guided radiation therapy, either intensity-modulated radiation therapy or stereotactic ablative radiation therapy, in conjunction with a rectal spacer, is an efficacious means to reduce acute and long-term rectal toxicity.
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Affiliation(s)
- Andrew J Leiker
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, 2280 Inwood Road, Dallas, TX 75390-9303, USA
| | - Neil B Desai
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, 2280 Inwood Road, Dallas, TX 75390-9303, USA
| | - Michael R Folkert
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, 2280 Inwood Road, Dallas, TX 75390-9303, USA
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19
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Duvergé L, Castelli J, Lizée T, de Crevoisier R, Azria D. [Doses to organs at risk for conformational and stereotactic radiotherapy: Bladder]. Cancer Radiother 2017; 21:597-603. [PMID: 28882511 DOI: 10.1016/j.canrad.2017.07.038] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Accepted: 07/13/2017] [Indexed: 11/16/2022]
Abstract
Bladder dose constraints in case of conformational radiotherapy/intensity-modulated radiotherapy and stereotactic radiotherapy are reported from the literature, in particular from the French radiotherapy society RECORAD recommendations, according to the treated pelvic tumor sites. The dose-volume effect on urinary toxicity is not clearly demonstrated, making difficult to establish absolute dose constraints for the bladder. In case of high-dose prostate cancer radiotherapy, the bladder dose constraints are: V60Gy<50% and maximum dose<80Gy for standard fractionation and V60Gy<5%, V48Gy<25% and V41Gy<50% for moderate hypofractionation (20 fractions of 3Gy). In case of prostate stereotactic radiotherapy (five fractions of 7.25Gy), the most frequent dose constraints in the literature are V37Gy<10cm3 and V18Gy<40%. In case of conformational radiotherapy of cervix cancer, postoperative endometrium, anal canal and rectum, the recommendations are V40Gy<40% and D2% lower than the prescribed dose.
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Affiliation(s)
- L Duvergé
- Département de radiothérapie, centre Eugène-Marquis, avenue de la Bataille-Flandres-Dunkerque, 35000 Rennes, France.
| | - J Castelli
- Département de radiothérapie, centre Eugène-Marquis, avenue de la Bataille-Flandres-Dunkerque, 35000 Rennes, France
| | - T Lizée
- Département de radiothérapie, institut de cancérologie de l'Ouest, site Paul-Papin, 2, rue Moll, 49100 Angers, France
| | - R de Crevoisier
- Département de radiothérapie, centre Eugène-Marquis, avenue de la Bataille-Flandres-Dunkerque, 35000 Rennes, France
| | - D Azria
- Département de cancérologie radiothérapie, CRLC Val-d'Aurelle-Paul-Lamarque, 208, rue des Apothicaires, 34000 Montpellier, France
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20
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Makishima H, Ishikawa H, Tanaka K, Mori Y, Mizumoto M, Ohnishi K, Aihara T, Fukumitsu N, Okumura T, Sakurai H. A retrospective study of late adverse events in proton beam therapy for prostate cancer. Mol Clin Oncol 2017; 7:547-552. [PMID: 29046789 PMCID: PMC5639311 DOI: 10.3892/mco.2017.1372] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Accepted: 08/03/2017] [Indexed: 11/24/2022] Open
Abstract
The efficacy and safety of proton beam therapy (PBT) were retrospectively evaluated in 111 consecutive patients with prostate cancer who underwent definitive PBT between 2008 and 2012. Following exclusion of 18 patients due to treatment suspension, loss to follow-up, and histology, the analysis included 93 patients with a median age of 68 years (range, 49–81 years). A total of 7, 32 and 54 prostate cancer patients were classified as low-, intermediate- and high-risk, respectively, as follows: High-risk, T≥3a or prostate-specific antigen (PSA) ≥20 ng/ml or Gleason Score ≥8; low-risk, T ≤2b and PSA≤10 ng/ml and Gleason Score=6; intermediate-risk, all other combinations. The median initial prostate-specific antigen (PSA) level was 9.75 ng/ml (range, 1.4–100 ng/ml) and the median Gleason score was 7 (range, 6–10). Patients with low-risk disease received 74 GyE (relative biological effectiveness=1.1) in 37 fractions, and those at intermediate or higher risk received 78 GyE in 39 fractions. Complete androgen blockade (CAB) therapy was performed from 6 months prior to PBT for patients with intermediate- or high-risk disease. CAB was continued during PBT and then terminated at the end of PBT for intermediate-risk patients. Patients at high risk continued CAB for 3 years. No combination therapy was used for low-risk patients. All the patients were followed up for >2 years after PBT, and all but one were PSA failure-free. The Common Terminology Criteria for Adverse Events v.4.0 was used to evaluate late adverse events. One patient developed grade 3 non-infectious cystitis and hematuria. Grade 2 urinary frequency was observed in 1 patient, and grade 2 rectal bleeding occurred in 4 patients. Of the 4 patients with grade 2 rectal bleeding, 2 received anticoagulant therapy, but none had diabetes mellitus or another high-risk comorbidity. The median time to occurrence of an adverse event of grade ≥2 was 14 months (range, 3–41 months). Therefore, the present retrospective study revealed that PBT at 78 GyE/39 Fr was well-tolerated and achieved good tumor control in patients with prostate cancer.
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Affiliation(s)
- Hirokazu Makishima
- Department of Radiation Oncology and Proton Medical Research Center, University of Tsukuba, Tsukuba, Ibaraki 305-8576, Japan
| | - Hitoshi Ishikawa
- Department of Radiation Oncology and Proton Medical Research Center, University of Tsukuba, Tsukuba, Ibaraki 305-8576, Japan
| | - Keiichi Tanaka
- Department of Radiation Oncology and Proton Medical Research Center, University of Tsukuba, Tsukuba, Ibaraki 305-8576, Japan
| | - Yutaro Mori
- Department of Radiation Oncology and Proton Medical Research Center, University of Tsukuba, Tsukuba, Ibaraki 305-8576, Japan
| | - Masashi Mizumoto
- Department of Radiation Oncology and Proton Medical Research Center, University of Tsukuba, Tsukuba, Ibaraki 305-8576, Japan
| | - Kayoko Ohnishi
- Department of Radiation Oncology and Proton Medical Research Center, University of Tsukuba, Tsukuba, Ibaraki 305-8576, Japan
| | - Teruhito Aihara
- Department of Radiation Oncology and Proton Medical Research Center, University of Tsukuba, Tsukuba, Ibaraki 305-8576, Japan
| | - Nobuyoshi Fukumitsu
- Department of Radiation Oncology and Proton Medical Research Center, University of Tsukuba, Tsukuba, Ibaraki 305-8576, Japan
| | - Toshiyuki Okumura
- Department of Radiation Oncology and Proton Medical Research Center, University of Tsukuba, Tsukuba, Ibaraki 305-8576, Japan
| | - Hideyuki Sakurai
- Department of Radiation Oncology and Proton Medical Research Center, University of Tsukuba, Tsukuba, Ibaraki 305-8576, Japan
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21
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Kao J, Zucker A, Timmins J, Taramangalam S, Pettit J, Woodall AJ, Loizides E, Wong AT. Effect of modern, high-quality prostate intensity-modulated radiation therapy on outcome: Evidence from a community radiation oncology program. Mol Clin Oncol 2017; 7:252-258. [PMID: 28781797 DOI: 10.3892/mco.2017.1290] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Accepted: 05/03/2017] [Indexed: 11/06/2022] Open
Abstract
Radiation technique for prostate cancer has continuously evolved over the past several decades. The aim of the present study was to describe the effects of implementing modern prostate intensity-modulated radiation therapy (M-IMRT) on dosimetry and outcome. Between January 2010 and April 2012, 48 consecutive patients were treated with conventional prostate IMRT (C-IMRT) to a dose of 81 Gy. Between May 2012 and April 2015, 50 consecutive patients were treated with M-IMRT to the entire prostate to a dose of 75.6-79.2 Gy, while using prostate magnetic resonance imaging fusion, dose-volume constraints prioritizing normal tissue avoidance above planning target volume coverage, and boosting any dominant intraprostatic masses to 79.2-81 Gy. Rectal Dmax, V75, V60, V65 and V50, bladder Dmax, V75, V70 and V65, and acute and late toxicities were compared between the C-IMRT and M-IMRT groups. The median follow-up for the C-IMRT and M-IMRT groups was 61 vs. 26 months, respectively (P<0.001). M-IMRT resulted in a significant reduction in median rectal Dmax, rectal V75, rectal V70, rectal V65, bladder Dmax, bladder V75, bladder V70 and bladder V65 (P<0.01 for all). There was no significant difference in rectal V50. The 2-year rate of late grade ≥2 rectal bleeding was 13% with C-IMRT vs. 3% with M-IMRT (P=0.03). The 2-year rate of late grade ≥2 genitourinary toxicity was 11% for C-IMRT vs. 5% for M-IMRT (P=0.21). There were no significant differences in acute toxicity, biochemical control or overall survival. Therefore, compared with C-IMRT, M-IMRT was associated with reduced rectal toxicity without compromising disease control.
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Affiliation(s)
- Johnny Kao
- Department of Radiation Oncology, Good Samaritan Hospital Medical Center, West Islip, NY 11795, USA
| | - Amanda Zucker
- Department of Radiation Oncology, Good Samaritan Hospital Medical Center, West Islip, NY 11795, USA
| | - Jonathan Timmins
- Department of Radiation Oncology, Good Samaritan Hospital Medical Center, West Islip, NY 11795, USA
| | - Shankar Taramangalam
- Department of Radiation Oncology, Good Samaritan Hospital Medical Center, West Islip, NY 11795, USA
| | - Jeffrey Pettit
- Department of Radiation Oncology, Good Samaritan Hospital Medical Center, West Islip, NY 11795, USA
| | - Aaron J Woodall
- Division of Urology, Good Samaritan Hospital Medical Center, West Islip, NY 11795, USA
| | - Edward Loizides
- Division of Urology, Good Samaritan Hospital Medical Center, West Islip, NY 11795, USA
| | - Andrew T Wong
- Department of Radiation Oncology, Good Samaritan Hospital Medical Center, West Islip, NY 11795, USA
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22
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The Missing Pieces in Reporting of Randomized Controlled Trials of External Beam Radiation Therapy Dose Escalation for Prostate Cancer. Am J Clin Oncol 2017; 39:321-6. [PMID: 27322694 DOI: 10.1097/coc.0000000000000313] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Randomized controlled trials (RCTs) are the most rigorous way of determining whether a cause-effect relation exists between treatment and outcome and for assessing the cost-effectiveness of a treatment. For many patients, cancer is a chronic illness; RCTs evaluating treatments for indolent cancers must evolve to facilitate medical decision-making, as "concrete" patient outcomes (eg, survival) will likely be excellent independent of the intervention, and detecting a difference between trial arms may be impossible. In this commentary, we articulate 9 recommendations that we hope future clinical trialists and funding agencies (including those under the National Cancer Institute) will take into consideration when planning RCTs to help guide subsequent interpretation of results and clinical decision making, based on RCTs of external beam radiation therapy dose escalation for the most common indolent cancer in men, that is, prostate cancer. We recommend routinely reporting: (1) race; (2) medical comorbidities; (3) psychiatric comorbidities; (4) insurance status; (5) education; (6) marital status; (7) income; (8) sexual orientation; and (9) facility-related characteristics (eg, number of centers involved, type of facilities, yearly hospital volumes). We discuss how these factors independently affect patient outcomes and toxicities; future clinicians and governing organizations should consider this information to plan RCTs accordingly (to maximize patient accrual and total n), select appropriate endpoints (eg, toxicity, quality of life, sexual function), actively monitor RCTs, and report results so as to identify the optimal treatment among subpopulations.
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23
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Jolnerovski M, Salleron J, Beckendorf V, Peiffert D, Baumann AS, Bernier V, Huger S, Marchesi V, Chira C. Intensity-modulated radiation therapy from 70Gy to 80Gy in prostate cancer: six- year outcomes and predictors of late toxicity. Radiat Oncol 2017. [PMID: 28622770 PMCID: PMC5473104 DOI: 10.1186/s13014-017-0839-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Objective To report grade ≥2 overall late rectal and urinary toxicities in patients (pts) with prostate cancer treated by intensity-modulated radiotherapy (IMRT) at 3 dose-levels. Identify predictors of radiation toxicity and report biochemical progression free survival (bPFS). Methods A total of 277 pts were treated with 70Gy (10.8%), 74Gy (63.9%) and 80 Gy (25.3%) using IMRT without pelvic irradiation were analyzed. Short or long-course androgen deprivation therapy (ADT) was allowed in 46.1% of pts. The toxicity was described using the Common Terminology Criteria for Adverse Events (CTCAE) v4.0 scale. Cox regression models addressed demographics, disease and dosimetry characteristics as potential predictors of late grade ≥2 toxicity after adjusting for other modifying factors. Results The median follow-up was 77 months (range 15; 150). There was no grade ≥4 toxicity. The 5-year cumulative rate of grade ≥2 late rectal and urinary toxicities was 6.3% (95% CI = 3.8%; 10.3%) and 25.3% (95% CI = 19.8%; 31.8%) respectively. In multivariate analysis, only the dose (80Gy vs 74 and 70Gy) was found to increase the risk of rectal toxicity (HR = 2.96 [1.07; 8.20]). For pts receiving 74 Gy, International Prostate Symptom Score (IPSS) at baseline ≥8 (HR = 2.40 [1.08; 5.35]) and dose ≥73Gy delivered in more than 2% of bladder (D2%) were found to be predictors of bladder toxicity (HR = 3.29 [1.36; 7.98]). The 5–year biochemical relapse free survival was 81.0% [74.5%; 86.0%] in the entire population, 97.5% [83.5%; 99.6%] in the low risk group, 84.9% [76.7%; 90.3%] in the intermediate risk group and 66.4% [51.8%; 77.4%] in the high-risk group. D’Amico low (HR = 0.09 [0.01; 0.69]) and intermediate risk groups (HR = 0.50 [0.28; 0.88]) as well as PSA nadir ≥0.2 ng/ml (HR = 1.79 [1.01; 3.21]) were predictive of biochemical relapse. Conclusions The rate of late rectal toxicity increased with higher doses, while Dmax ≥74Gy, D2% ≥ 73Gy for bladder wall and baseline IPSS ≥8 increased late urinary toxicity.
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Affiliation(s)
- Maria Jolnerovski
- Departments of Radiation Oncology and Medical Physics, Institut de Cancérologie de Lorraine, 6 Avenue de Bourgogne - CS 30519, 54519, Vandoeuvre-lès-Nancy Cedex, France
| | - Julia Salleron
- Department of Biostatistics, Institut de Cancérologie de Lorraine, 6 Avenue de Bourgogne, 54519, Vandoeuvre-lès-Nancy, France
| | - Véronique Beckendorf
- Departments of Radiation Oncology and Medical Physics, Institut de Cancérologie de Lorraine, 6 Avenue de Bourgogne - CS 30519, 54519, Vandoeuvre-lès-Nancy Cedex, France
| | - Didier Peiffert
- Departments of Radiation Oncology and Medical Physics, Institut de Cancérologie de Lorraine, 6 Avenue de Bourgogne - CS 30519, 54519, Vandoeuvre-lès-Nancy Cedex, France
| | - Anne-Sophie Baumann
- Departments of Radiation Oncology and Medical Physics, Institut de Cancérologie de Lorraine, 6 Avenue de Bourgogne - CS 30519, 54519, Vandoeuvre-lès-Nancy Cedex, France
| | - Valérie Bernier
- Departments of Radiation Oncology and Medical Physics, Institut de Cancérologie de Lorraine, 6 Avenue de Bourgogne - CS 30519, 54519, Vandoeuvre-lès-Nancy Cedex, France
| | - Sandrine Huger
- Departments of Radiation Oncology and Medical Physics, Institut de Cancérologie de Lorraine, 6 Avenue de Bourgogne - CS 30519, 54519, Vandoeuvre-lès-Nancy Cedex, France
| | - Vincent Marchesi
- Departments of Radiation Oncology and Medical Physics, Institut de Cancérologie de Lorraine, 6 Avenue de Bourgogne - CS 30519, 54519, Vandoeuvre-lès-Nancy Cedex, France
| | - Ciprian Chira
- Departments of Radiation Oncology and Medical Physics, Institut de Cancérologie de Lorraine, 6 Avenue de Bourgogne - CS 30519, 54519, Vandoeuvre-lès-Nancy Cedex, France.
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24
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Casares-Magaz O, Moiseenko V, Hopper A, Pettersson NJ, Thor M, Knopp R, Deasy JO, Muren LP, Einck J. Associations between volume changes and spatial dose metrics for the urinary bladder during local versus pelvic irradiation for prostate cancer. Acta Oncol 2017; 56:884-890. [PMID: 28401808 DOI: 10.1080/0284186x.2017.1312014] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Inter-fractional variation in urinary bladder volumes during the course of radiotherapy (RT) for prostate cancer causes deviations between planned and delivered doses. This study compared planned versus daily cone-beam CT (CBCT)-based spatial bladder dose distributions, for prostate cancer patients receiving local prostate treatment (local treatment) versus prostate including pelvic lymph node irradiation (pelvic treatment). MATERIAL AND METHODS Twenty-seven patients (N = 15 local treatment; N = 12 pelvic treatment) were treated using daily image-guided RT (1.8 Gy@43-45 fx), adhering to a full bladder/empty rectum protocol. For each patient, 9-10 CBCTs were registered to the planning CT, using the clinically applied translations. The urinary bladder was manually segmented on each CBCT, 3 mm inner shells were generated, and semi and quadrant sectors were created using axial/coronal cuts. Planned and delivered DVH metrics were compared across patients and between the two groups of treatment (t-test, p < .05; Holm-Bonferroni correction). Associations between bladder volume variations and the dose-volume histograms (DVH) of the bladder and its sectors were evaluated (Spearman's rank correlation coefficient, rs). RESULTS Bladder volumes varied considerably during RT (coefficient of variation: 16-58%). The population-averaged planned and delivered DVH metrics were not significantly different at any dose level. Larger treatment bladder volumes resulted in increased absolute volume of the posterior/inferior bladder sector receiving intermediate-high doses, in both groups. The superior bladder sector received less dose with larger bladder volumes for local treatments (rs ± SD: -0.47 ± 0.32), but larger doses for pelvic treatments (rs ± SD: 0.74 ± 0.24). CONCLUSIONS Substantial bladder volume changes during the treatment course occurred even though patients were treated under a full bladder/daily image-guided protocol. Larger bladder volumes resulted in less bladder wall spared at the posterior-inferior sector, regardless the treatment received. Contrary, larger bladder volumes meant larger delivered doses to the superior bladder sector for pelvic RT but smaller doses for local treatments.
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Affiliation(s)
| | - Vitali Moiseenko
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA, USA
| | - Austin Hopper
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA, USA
| | - Niclas Johan Pettersson
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA, USA
| | - Maria Thor
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York City, NY, USA
| | - Rick Knopp
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA, USA
| | - Joseph O. Deasy
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York City, NY, USA
| | - Ludvig Paul Muren
- Department of Medical Physics, Aarhus University Hospital, Aarhus, Denmark
| | - John Einck
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA, USA
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Zaorsky NG, Showalter TN, Ezzell GA, Nguyen PL, Assimos DG, D'Amico AV, Gottschalk AR, Gustafson GS, Keole SR, Liauw SL, Lloyd S, McLaughlin PW, Movsas B, Prestidge BR, Taira AV, Vapiwala N, Davis BJ. ACR Appropriateness Criteria ® external beam radiation therapy treatment planning for clinically localized prostate cancer, part I of II. Adv Radiat Oncol 2016; 2:62-84. [PMID: 28740916 PMCID: PMC5514238 DOI: 10.1016/j.adro.2016.10.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Accepted: 10/12/2016] [Indexed: 12/24/2022] Open
Affiliation(s)
| | | | | | - Gary A Ezzell
- Mayo Clinic, Phoenix, Arizona (research author, contributing)
| | - Paul L Nguyen
- Dana-Farber Cancer Institute/Brigham and Women's Hospital, Boston, Massachusetts (panel vice-chair)
| | - Dean G Assimos
- University of Alabama School of Medicine, Birmingham, Alabama (American Urological Association)
| | - Anthony V D'Amico
- Dana-Farber Cancer Institute/Brigham and Women's Hospital, Boston, Massachusetts (American Society of Clinical Oncology)
| | | | | | | | | | - Shane Lloyd
- Huntsman Cancer Hospital, Salt Lake City, Utah
| | | | | | | | - Al V Taira
- Mills Peninsula Hospital, San Mateo, California
| | - Neha Vapiwala
- University of Pennsylvania, Philadelphia, Pennsylvania
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Zaorsky NG, Shaikh T, Murphy CT, Hallman MA, Hayes SB, Sobczak ML, Horwitz EM. Comparison of outcomes and toxicities among radiation therapy treatment options for prostate cancer. Cancer Treat Rev 2016; 48:50-60. [PMID: 27347670 DOI: 10.1016/j.ctrv.2016.06.006] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2016] [Revised: 06/07/2016] [Accepted: 06/08/2016] [Indexed: 01/13/2023]
Abstract
We review radiation therapy (RT) options available for prostate cancer, including external beam (EBRT; with conventional fractionation, hypofractionation, stereotactic body RT [SBRT]) and brachytherapy (BT), with an emphasis on the outcomes, toxicities, and contraindications for therapies. PICOS/PRISMA methods were used to identify published English-language comparative studies on PubMed (from 1980 to 2015) that included men treated on prospective studies with a primary endpoint of patient outcomes, with ⩾70 patients, and ⩾5year median follow up. Twenty-six studies met inclusion criteria; of these, 16 used EBRT, and 10 used BT. Long-term freedom from biochemical failure (FFBF) rates were roughly equivalent between conventional and hypofractionated RT with intensity modulation (evidence level 1B), with 10-year FFBF rates of 45-90%, 40-60%, and 20-50% (for low-, intermediate-, and high-risk groups, respectively). SBRT had promising rates of BF, with shorter follow-up (5-year FFBF of >90% for low-risk patients). Similarly, BT (5-year FFBF for low-, intermediate-, and high-risk patients have generally been >85%, 69-97%, 63-80%, respectively) and BT+EBRT were appropriate in select patients (evidence level 1B). Differences in overall survival, distant metastasis, and cancer specific mortality (5-year rates: 82-97%, 1-14%, 0-8%, respectively) have not been detected in randomized trials of dose escalation or in studies comparing RT modalities. Studies did not use patient-reported outcomes, through Grade 3-4 toxicities were rare (<5%) among all modalities. There was limited evidence available to compare proton therapy to other modalities. The treatment decision for a man is usually based on his risk group, ability to tolerate the procedure, convenience for the patient, and the anticipated impact on quality of life. To further personalize therapy, future trials should report (1) race; (2) medical comorbidities; (3) psychiatric comorbidities; (4) insurance status; (5) education status; (6) marital status; (7) income; (8) sexual orientation; and (9) facility-related characteristics.
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Affiliation(s)
- Nicholas G Zaorsky
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA.
| | - Talha Shaikh
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Colin T Murphy
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Mark A Hallman
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Shelly B Hayes
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Mark L Sobczak
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Eric M Horwitz
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
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Shakespeare TP, Wilcox SW, Aherne NJ. Can we avoid high levels of dose escalation for high-risk prostate cancer in the setting of androgen deprivation? Onco Targets Ther 2016; 9:2819-24. [PMID: 27274277 PMCID: PMC4869660 DOI: 10.2147/ott.s105174] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Aim Both dose-escalated external beam radiotherapy (DE-EBRT) and androgen deprivation therapy (ADT) improve outcomes in patients with high-risk prostate cancer. However, there is little evidence specifically evaluating DE-EBRT for patients with high-risk prostate cancer receiving ADT, particularly for EBRT doses >74 Gy. We aimed to determine whether DE-EBRT >74 Gy improves outcomes for patients with high-risk prostate cancer receiving long-term ADT. Patients and methods Patients with high-risk prostate cancer were treated on an institutional protocol prescribing 3–6 months neoadjuvant ADT and DE-EBRT, followed by 2 years of adjuvant ADT. Between 2006 and 2012, EBRT doses were escalated from 74 Gy to 76 Gy and then to 78 Gy. We interrogated our electronic medical record to identify these patients and analyzed our results by comparing dose levels. Results In all, 479 patients were treated with a 68-month median follow-up. The 5-year biochemical disease-free survivals for the 74 Gy, 76 Gy, and 78 Gy groups were 87.8%, 86.9%, and 91.6%, respectively. The metastasis-free survivals were 95.5%, 94.5%, and 93.9%, respectively, and the prostate cancer-specific survivals were 100%, 94.4%, and 98.1%, respectively. Dose escalation had no impact on any outcome in either univariate or multivariate analysis. Conclusion There was no benefit of DE-EBRT >74 Gy in our cohort of high-risk prostate patients treated with long-term ADT. As dose escalation has higher risks of radiotherapy-induced toxicity, it may be feasible to omit dose escalation beyond 74 Gy in this group of patients. Randomized studies evaluating dose escalation for high-risk patients receiving ADT should be considered.
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Affiliation(s)
- Thomas P Shakespeare
- Department of Radiation Oncology, North Coast Cancer Institute, University of New South Wales, Coffs Harbour, NSW, Australia; Rural Clinical School, Faculty of Medicine, University of New South Wales, Coffs Harbour, NSW, Australia
| | - Shea W Wilcox
- Department of Radiation Oncology, North Coast Cancer Institute, University of New South Wales, Coffs Harbour, NSW, Australia
| | - Noel J Aherne
- Department of Radiation Oncology, North Coast Cancer Institute, University of New South Wales, Coffs Harbour, NSW, Australia; Rural Clinical School, Faculty of Medicine, University of New South Wales, Coffs Harbour, NSW, Australia
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Lee WR, Dignam JJ, Amin MB, Bruner DW, Low D, Swanson GP, Shah AB, D'Souza DP, Michalski JM, Dayes IS, Seaward SA, Hall WA, Nguyen PL, Pisansky TM, Faria SL, Chen Y, Koontz BF, Paulus R, Sandler HM. Randomized Phase III Noninferiority Study Comparing Two Radiotherapy Fractionation Schedules in Patients With Low-Risk Prostate Cancer. J Clin Oncol 2016; 34:2325-32. [PMID: 27044935 DOI: 10.1200/jco.2016.67.0448] [Citation(s) in RCA: 428] [Impact Index Per Article: 53.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Conventional radiotherapy (C-RT) treatment schedules for patients with prostate cancer typically require 40 to 45 treatments that take place from > 8 to 9 weeks. Preclinical and clinical research suggest that hypofractionation-fewer treatments but at a higher dose per treatment-may produce similar outcomes. This trial was designed to assess whether the efficacy of a hypofractionated radiotherapy (H-RT) treatment schedule is no worse than a C-RT schedule in men with low-risk prostate cancer. PATIENTS AND METHODS A total of 1,115 men with low-risk prostate cancer were randomly assigned 1:1 to C-RT (73.8 Gy in 41 fractions over 8.2 weeks) or to H-RT (70 Gy in 28 fractions over 5.6 weeks). This trial was designed to establish (with 90% power and an α of .05) that treatment with H-RT results in 5-year disease-free survival (DFS) that is not worse than C-RT by more than 7.65% (H-RT/C-RT hazard ratio [HR] < 1.52). RESULTS A total of 1,092 men were protocol eligible and had follow-up information; 542 patients were assigned to C-RT and 550 to H-RT. Median follow-up was 5.8 years. Baseline characteristics were not different according to treatment assignment. The estimated 5-year DFS was 85.3% (95% CI, 81.9 to 88.1) in the C-RT arm and 86.3% (95% CI, 83.1 to 89.0) in the H-RT arm. The DFS HR was 0.85 (95% CI, 0.64 to 1.14), and the predefined noninferiority criterion that required that DFS outcomes be consistent with HR < 1.52 was met (P < .001). Late grade 2 and 3 GI and genitourinary adverse events were increased (HR, 1.31 to 1.59) in patients who were treated with H-RT. CONCLUSION In men with low-risk prostate cancer, the efficacy of 70 Gy in 28 fractions over 5.6 weeks is not inferior to 73.8 Gy in 41 fractions over 8.2 weeks, although an increase in late GI/genitourinary adverse events was observed in patients treated with H-RT.
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Affiliation(s)
- W Robert Lee
- W. Robert Lee and Bridget F. Koontz, Duke University Medical Center, Durham, NC; James J. Dignam, University of Chicago, Chicago, IL; Mahul B. Amin and Howard M. Sandler, Cedars-Sinai Medical Center; Daniel Low, University of California, Los Angeles, Los Angeles; Samantha A. Seaward, Kaiser Permanente Northern California, Santa Clara, CA; Deborah W. Bruner, Emory University, Atlanta, GA; Gregory P. Swanson, Baylor Scott & White Healthcare Temple Clinic, Temple, TX; Amit B. Shah, York Cancer Center, York; James J. Dignam and Rebecca Paulus, NRG Oncology Statistics and Data Management Center, Philadelphia, PA; David P. D'Souza, London Regional Cancer Program, London, Ontario; Ian S. Dayes, McMaster University, Hamilton, Ontario; Sergio L. Faria, McGill University Health Center, Montreal, Quebec, Canada; Jeff M. Michalski, Washington University School of Medicine, St Louis, MO; William A. Hall, Medical College of Wisconsin, Milwaukee, WI; Paul L. Nguyen, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Boston, MA; Thomas M. Pisansky, Mayo Clinic, Rochester, MN; and Yuhchyau Chen, University of Rochester, Rochester, NY.
| | - James J Dignam
- W. Robert Lee and Bridget F. Koontz, Duke University Medical Center, Durham, NC; James J. Dignam, University of Chicago, Chicago, IL; Mahul B. Amin and Howard M. Sandler, Cedars-Sinai Medical Center; Daniel Low, University of California, Los Angeles, Los Angeles; Samantha A. Seaward, Kaiser Permanente Northern California, Santa Clara, CA; Deborah W. Bruner, Emory University, Atlanta, GA; Gregory P. Swanson, Baylor Scott & White Healthcare Temple Clinic, Temple, TX; Amit B. Shah, York Cancer Center, York; James J. Dignam and Rebecca Paulus, NRG Oncology Statistics and Data Management Center, Philadelphia, PA; David P. D'Souza, London Regional Cancer Program, London, Ontario; Ian S. Dayes, McMaster University, Hamilton, Ontario; Sergio L. Faria, McGill University Health Center, Montreal, Quebec, Canada; Jeff M. Michalski, Washington University School of Medicine, St Louis, MO; William A. Hall, Medical College of Wisconsin, Milwaukee, WI; Paul L. Nguyen, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Boston, MA; Thomas M. Pisansky, Mayo Clinic, Rochester, MN; and Yuhchyau Chen, University of Rochester, Rochester, NY
| | - Mahul B Amin
- W. Robert Lee and Bridget F. Koontz, Duke University Medical Center, Durham, NC; James J. Dignam, University of Chicago, Chicago, IL; Mahul B. Amin and Howard M. Sandler, Cedars-Sinai Medical Center; Daniel Low, University of California, Los Angeles, Los Angeles; Samantha A. Seaward, Kaiser Permanente Northern California, Santa Clara, CA; Deborah W. Bruner, Emory University, Atlanta, GA; Gregory P. Swanson, Baylor Scott & White Healthcare Temple Clinic, Temple, TX; Amit B. Shah, York Cancer Center, York; James J. Dignam and Rebecca Paulus, NRG Oncology Statistics and Data Management Center, Philadelphia, PA; David P. D'Souza, London Regional Cancer Program, London, Ontario; Ian S. Dayes, McMaster University, Hamilton, Ontario; Sergio L. Faria, McGill University Health Center, Montreal, Quebec, Canada; Jeff M. Michalski, Washington University School of Medicine, St Louis, MO; William A. Hall, Medical College of Wisconsin, Milwaukee, WI; Paul L. Nguyen, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Boston, MA; Thomas M. Pisansky, Mayo Clinic, Rochester, MN; and Yuhchyau Chen, University of Rochester, Rochester, NY
| | - Deborah W Bruner
- W. Robert Lee and Bridget F. Koontz, Duke University Medical Center, Durham, NC; James J. Dignam, University of Chicago, Chicago, IL; Mahul B. Amin and Howard M. Sandler, Cedars-Sinai Medical Center; Daniel Low, University of California, Los Angeles, Los Angeles; Samantha A. Seaward, Kaiser Permanente Northern California, Santa Clara, CA; Deborah W. Bruner, Emory University, Atlanta, GA; Gregory P. Swanson, Baylor Scott & White Healthcare Temple Clinic, Temple, TX; Amit B. Shah, York Cancer Center, York; James J. Dignam and Rebecca Paulus, NRG Oncology Statistics and Data Management Center, Philadelphia, PA; David P. D'Souza, London Regional Cancer Program, London, Ontario; Ian S. Dayes, McMaster University, Hamilton, Ontario; Sergio L. Faria, McGill University Health Center, Montreal, Quebec, Canada; Jeff M. Michalski, Washington University School of Medicine, St Louis, MO; William A. Hall, Medical College of Wisconsin, Milwaukee, WI; Paul L. Nguyen, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Boston, MA; Thomas M. Pisansky, Mayo Clinic, Rochester, MN; and Yuhchyau Chen, University of Rochester, Rochester, NY
| | - Daniel Low
- W. Robert Lee and Bridget F. Koontz, Duke University Medical Center, Durham, NC; James J. Dignam, University of Chicago, Chicago, IL; Mahul B. Amin and Howard M. Sandler, Cedars-Sinai Medical Center; Daniel Low, University of California, Los Angeles, Los Angeles; Samantha A. Seaward, Kaiser Permanente Northern California, Santa Clara, CA; Deborah W. Bruner, Emory University, Atlanta, GA; Gregory P. Swanson, Baylor Scott & White Healthcare Temple Clinic, Temple, TX; Amit B. Shah, York Cancer Center, York; James J. Dignam and Rebecca Paulus, NRG Oncology Statistics and Data Management Center, Philadelphia, PA; David P. D'Souza, London Regional Cancer Program, London, Ontario; Ian S. Dayes, McMaster University, Hamilton, Ontario; Sergio L. Faria, McGill University Health Center, Montreal, Quebec, Canada; Jeff M. Michalski, Washington University School of Medicine, St Louis, MO; William A. Hall, Medical College of Wisconsin, Milwaukee, WI; Paul L. Nguyen, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Boston, MA; Thomas M. Pisansky, Mayo Clinic, Rochester, MN; and Yuhchyau Chen, University of Rochester, Rochester, NY
| | - Gregory P Swanson
- W. Robert Lee and Bridget F. Koontz, Duke University Medical Center, Durham, NC; James J. Dignam, University of Chicago, Chicago, IL; Mahul B. Amin and Howard M. Sandler, Cedars-Sinai Medical Center; Daniel Low, University of California, Los Angeles, Los Angeles; Samantha A. Seaward, Kaiser Permanente Northern California, Santa Clara, CA; Deborah W. Bruner, Emory University, Atlanta, GA; Gregory P. Swanson, Baylor Scott & White Healthcare Temple Clinic, Temple, TX; Amit B. Shah, York Cancer Center, York; James J. Dignam and Rebecca Paulus, NRG Oncology Statistics and Data Management Center, Philadelphia, PA; David P. D'Souza, London Regional Cancer Program, London, Ontario; Ian S. Dayes, McMaster University, Hamilton, Ontario; Sergio L. Faria, McGill University Health Center, Montreal, Quebec, Canada; Jeff M. Michalski, Washington University School of Medicine, St Louis, MO; William A. Hall, Medical College of Wisconsin, Milwaukee, WI; Paul L. Nguyen, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Boston, MA; Thomas M. Pisansky, Mayo Clinic, Rochester, MN; and Yuhchyau Chen, University of Rochester, Rochester, NY
| | - Amit B Shah
- W. Robert Lee and Bridget F. Koontz, Duke University Medical Center, Durham, NC; James J. Dignam, University of Chicago, Chicago, IL; Mahul B. Amin and Howard M. Sandler, Cedars-Sinai Medical Center; Daniel Low, University of California, Los Angeles, Los Angeles; Samantha A. Seaward, Kaiser Permanente Northern California, Santa Clara, CA; Deborah W. Bruner, Emory University, Atlanta, GA; Gregory P. Swanson, Baylor Scott & White Healthcare Temple Clinic, Temple, TX; Amit B. Shah, York Cancer Center, York; James J. Dignam and Rebecca Paulus, NRG Oncology Statistics and Data Management Center, Philadelphia, PA; David P. D'Souza, London Regional Cancer Program, London, Ontario; Ian S. Dayes, McMaster University, Hamilton, Ontario; Sergio L. Faria, McGill University Health Center, Montreal, Quebec, Canada; Jeff M. Michalski, Washington University School of Medicine, St Louis, MO; William A. Hall, Medical College of Wisconsin, Milwaukee, WI; Paul L. Nguyen, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Boston, MA; Thomas M. Pisansky, Mayo Clinic, Rochester, MN; and Yuhchyau Chen, University of Rochester, Rochester, NY
| | - David P D'Souza
- W. Robert Lee and Bridget F. Koontz, Duke University Medical Center, Durham, NC; James J. Dignam, University of Chicago, Chicago, IL; Mahul B. Amin and Howard M. Sandler, Cedars-Sinai Medical Center; Daniel Low, University of California, Los Angeles, Los Angeles; Samantha A. Seaward, Kaiser Permanente Northern California, Santa Clara, CA; Deborah W. Bruner, Emory University, Atlanta, GA; Gregory P. Swanson, Baylor Scott & White Healthcare Temple Clinic, Temple, TX; Amit B. Shah, York Cancer Center, York; James J. Dignam and Rebecca Paulus, NRG Oncology Statistics and Data Management Center, Philadelphia, PA; David P. D'Souza, London Regional Cancer Program, London, Ontario; Ian S. Dayes, McMaster University, Hamilton, Ontario; Sergio L. Faria, McGill University Health Center, Montreal, Quebec, Canada; Jeff M. Michalski, Washington University School of Medicine, St Louis, MO; William A. Hall, Medical College of Wisconsin, Milwaukee, WI; Paul L. Nguyen, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Boston, MA; Thomas M. Pisansky, Mayo Clinic, Rochester, MN; and Yuhchyau Chen, University of Rochester, Rochester, NY
| | - Jeff M Michalski
- W. Robert Lee and Bridget F. Koontz, Duke University Medical Center, Durham, NC; James J. Dignam, University of Chicago, Chicago, IL; Mahul B. Amin and Howard M. Sandler, Cedars-Sinai Medical Center; Daniel Low, University of California, Los Angeles, Los Angeles; Samantha A. Seaward, Kaiser Permanente Northern California, Santa Clara, CA; Deborah W. Bruner, Emory University, Atlanta, GA; Gregory P. Swanson, Baylor Scott & White Healthcare Temple Clinic, Temple, TX; Amit B. Shah, York Cancer Center, York; James J. Dignam and Rebecca Paulus, NRG Oncology Statistics and Data Management Center, Philadelphia, PA; David P. D'Souza, London Regional Cancer Program, London, Ontario; Ian S. Dayes, McMaster University, Hamilton, Ontario; Sergio L. Faria, McGill University Health Center, Montreal, Quebec, Canada; Jeff M. Michalski, Washington University School of Medicine, St Louis, MO; William A. Hall, Medical College of Wisconsin, Milwaukee, WI; Paul L. Nguyen, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Boston, MA; Thomas M. Pisansky, Mayo Clinic, Rochester, MN; and Yuhchyau Chen, University of Rochester, Rochester, NY
| | - Ian S Dayes
- W. Robert Lee and Bridget F. Koontz, Duke University Medical Center, Durham, NC; James J. Dignam, University of Chicago, Chicago, IL; Mahul B. Amin and Howard M. Sandler, Cedars-Sinai Medical Center; Daniel Low, University of California, Los Angeles, Los Angeles; Samantha A. Seaward, Kaiser Permanente Northern California, Santa Clara, CA; Deborah W. Bruner, Emory University, Atlanta, GA; Gregory P. Swanson, Baylor Scott & White Healthcare Temple Clinic, Temple, TX; Amit B. Shah, York Cancer Center, York; James J. Dignam and Rebecca Paulus, NRG Oncology Statistics and Data Management Center, Philadelphia, PA; David P. D'Souza, London Regional Cancer Program, London, Ontario; Ian S. Dayes, McMaster University, Hamilton, Ontario; Sergio L. Faria, McGill University Health Center, Montreal, Quebec, Canada; Jeff M. Michalski, Washington University School of Medicine, St Louis, MO; William A. Hall, Medical College of Wisconsin, Milwaukee, WI; Paul L. Nguyen, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Boston, MA; Thomas M. Pisansky, Mayo Clinic, Rochester, MN; and Yuhchyau Chen, University of Rochester, Rochester, NY
| | - Samantha A Seaward
- W. Robert Lee and Bridget F. Koontz, Duke University Medical Center, Durham, NC; James J. Dignam, University of Chicago, Chicago, IL; Mahul B. Amin and Howard M. Sandler, Cedars-Sinai Medical Center; Daniel Low, University of California, Los Angeles, Los Angeles; Samantha A. Seaward, Kaiser Permanente Northern California, Santa Clara, CA; Deborah W. Bruner, Emory University, Atlanta, GA; Gregory P. Swanson, Baylor Scott & White Healthcare Temple Clinic, Temple, TX; Amit B. Shah, York Cancer Center, York; James J. Dignam and Rebecca Paulus, NRG Oncology Statistics and Data Management Center, Philadelphia, PA; David P. D'Souza, London Regional Cancer Program, London, Ontario; Ian S. Dayes, McMaster University, Hamilton, Ontario; Sergio L. Faria, McGill University Health Center, Montreal, Quebec, Canada; Jeff M. Michalski, Washington University School of Medicine, St Louis, MO; William A. Hall, Medical College of Wisconsin, Milwaukee, WI; Paul L. Nguyen, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Boston, MA; Thomas M. Pisansky, Mayo Clinic, Rochester, MN; and Yuhchyau Chen, University of Rochester, Rochester, NY
| | - William A Hall
- W. Robert Lee and Bridget F. Koontz, Duke University Medical Center, Durham, NC; James J. Dignam, University of Chicago, Chicago, IL; Mahul B. Amin and Howard M. Sandler, Cedars-Sinai Medical Center; Daniel Low, University of California, Los Angeles, Los Angeles; Samantha A. Seaward, Kaiser Permanente Northern California, Santa Clara, CA; Deborah W. Bruner, Emory University, Atlanta, GA; Gregory P. Swanson, Baylor Scott & White Healthcare Temple Clinic, Temple, TX; Amit B. Shah, York Cancer Center, York; James J. Dignam and Rebecca Paulus, NRG Oncology Statistics and Data Management Center, Philadelphia, PA; David P. D'Souza, London Regional Cancer Program, London, Ontario; Ian S. Dayes, McMaster University, Hamilton, Ontario; Sergio L. Faria, McGill University Health Center, Montreal, Quebec, Canada; Jeff M. Michalski, Washington University School of Medicine, St Louis, MO; William A. Hall, Medical College of Wisconsin, Milwaukee, WI; Paul L. Nguyen, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Boston, MA; Thomas M. Pisansky, Mayo Clinic, Rochester, MN; and Yuhchyau Chen, University of Rochester, Rochester, NY
| | - Paul L Nguyen
- W. Robert Lee and Bridget F. Koontz, Duke University Medical Center, Durham, NC; James J. Dignam, University of Chicago, Chicago, IL; Mahul B. Amin and Howard M. Sandler, Cedars-Sinai Medical Center; Daniel Low, University of California, Los Angeles, Los Angeles; Samantha A. Seaward, Kaiser Permanente Northern California, Santa Clara, CA; Deborah W. Bruner, Emory University, Atlanta, GA; Gregory P. Swanson, Baylor Scott & White Healthcare Temple Clinic, Temple, TX; Amit B. Shah, York Cancer Center, York; James J. Dignam and Rebecca Paulus, NRG Oncology Statistics and Data Management Center, Philadelphia, PA; David P. D'Souza, London Regional Cancer Program, London, Ontario; Ian S. Dayes, McMaster University, Hamilton, Ontario; Sergio L. Faria, McGill University Health Center, Montreal, Quebec, Canada; Jeff M. Michalski, Washington University School of Medicine, St Louis, MO; William A. Hall, Medical College of Wisconsin, Milwaukee, WI; Paul L. Nguyen, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Boston, MA; Thomas M. Pisansky, Mayo Clinic, Rochester, MN; and Yuhchyau Chen, University of Rochester, Rochester, NY
| | - Thomas M Pisansky
- W. Robert Lee and Bridget F. Koontz, Duke University Medical Center, Durham, NC; James J. Dignam, University of Chicago, Chicago, IL; Mahul B. Amin and Howard M. Sandler, Cedars-Sinai Medical Center; Daniel Low, University of California, Los Angeles, Los Angeles; Samantha A. Seaward, Kaiser Permanente Northern California, Santa Clara, CA; Deborah W. Bruner, Emory University, Atlanta, GA; Gregory P. Swanson, Baylor Scott & White Healthcare Temple Clinic, Temple, TX; Amit B. Shah, York Cancer Center, York; James J. Dignam and Rebecca Paulus, NRG Oncology Statistics and Data Management Center, Philadelphia, PA; David P. D'Souza, London Regional Cancer Program, London, Ontario; Ian S. Dayes, McMaster University, Hamilton, Ontario; Sergio L. Faria, McGill University Health Center, Montreal, Quebec, Canada; Jeff M. Michalski, Washington University School of Medicine, St Louis, MO; William A. Hall, Medical College of Wisconsin, Milwaukee, WI; Paul L. Nguyen, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Boston, MA; Thomas M. Pisansky, Mayo Clinic, Rochester, MN; and Yuhchyau Chen, University of Rochester, Rochester, NY
| | - Sergio L Faria
- W. Robert Lee and Bridget F. Koontz, Duke University Medical Center, Durham, NC; James J. Dignam, University of Chicago, Chicago, IL; Mahul B. Amin and Howard M. Sandler, Cedars-Sinai Medical Center; Daniel Low, University of California, Los Angeles, Los Angeles; Samantha A. Seaward, Kaiser Permanente Northern California, Santa Clara, CA; Deborah W. Bruner, Emory University, Atlanta, GA; Gregory P. Swanson, Baylor Scott & White Healthcare Temple Clinic, Temple, TX; Amit B. Shah, York Cancer Center, York; James J. Dignam and Rebecca Paulus, NRG Oncology Statistics and Data Management Center, Philadelphia, PA; David P. D'Souza, London Regional Cancer Program, London, Ontario; Ian S. Dayes, McMaster University, Hamilton, Ontario; Sergio L. Faria, McGill University Health Center, Montreal, Quebec, Canada; Jeff M. Michalski, Washington University School of Medicine, St Louis, MO; William A. Hall, Medical College of Wisconsin, Milwaukee, WI; Paul L. Nguyen, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Boston, MA; Thomas M. Pisansky, Mayo Clinic, Rochester, MN; and Yuhchyau Chen, University of Rochester, Rochester, NY
| | - Yuhchyau Chen
- W. Robert Lee and Bridget F. Koontz, Duke University Medical Center, Durham, NC; James J. Dignam, University of Chicago, Chicago, IL; Mahul B. Amin and Howard M. Sandler, Cedars-Sinai Medical Center; Daniel Low, University of California, Los Angeles, Los Angeles; Samantha A. Seaward, Kaiser Permanente Northern California, Santa Clara, CA; Deborah W. Bruner, Emory University, Atlanta, GA; Gregory P. Swanson, Baylor Scott & White Healthcare Temple Clinic, Temple, TX; Amit B. Shah, York Cancer Center, York; James J. Dignam and Rebecca Paulus, NRG Oncology Statistics and Data Management Center, Philadelphia, PA; David P. D'Souza, London Regional Cancer Program, London, Ontario; Ian S. Dayes, McMaster University, Hamilton, Ontario; Sergio L. Faria, McGill University Health Center, Montreal, Quebec, Canada; Jeff M. Michalski, Washington University School of Medicine, St Louis, MO; William A. Hall, Medical College of Wisconsin, Milwaukee, WI; Paul L. Nguyen, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Boston, MA; Thomas M. Pisansky, Mayo Clinic, Rochester, MN; and Yuhchyau Chen, University of Rochester, Rochester, NY
| | - Bridget F Koontz
- W. Robert Lee and Bridget F. Koontz, Duke University Medical Center, Durham, NC; James J. Dignam, University of Chicago, Chicago, IL; Mahul B. Amin and Howard M. Sandler, Cedars-Sinai Medical Center; Daniel Low, University of California, Los Angeles, Los Angeles; Samantha A. Seaward, Kaiser Permanente Northern California, Santa Clara, CA; Deborah W. Bruner, Emory University, Atlanta, GA; Gregory P. Swanson, Baylor Scott & White Healthcare Temple Clinic, Temple, TX; Amit B. Shah, York Cancer Center, York; James J. Dignam and Rebecca Paulus, NRG Oncology Statistics and Data Management Center, Philadelphia, PA; David P. D'Souza, London Regional Cancer Program, London, Ontario; Ian S. Dayes, McMaster University, Hamilton, Ontario; Sergio L. Faria, McGill University Health Center, Montreal, Quebec, Canada; Jeff M. Michalski, Washington University School of Medicine, St Louis, MO; William A. Hall, Medical College of Wisconsin, Milwaukee, WI; Paul L. Nguyen, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Boston, MA; Thomas M. Pisansky, Mayo Clinic, Rochester, MN; and Yuhchyau Chen, University of Rochester, Rochester, NY
| | - Rebecca Paulus
- W. Robert Lee and Bridget F. Koontz, Duke University Medical Center, Durham, NC; James J. Dignam, University of Chicago, Chicago, IL; Mahul B. Amin and Howard M. Sandler, Cedars-Sinai Medical Center; Daniel Low, University of California, Los Angeles, Los Angeles; Samantha A. Seaward, Kaiser Permanente Northern California, Santa Clara, CA; Deborah W. Bruner, Emory University, Atlanta, GA; Gregory P. Swanson, Baylor Scott & White Healthcare Temple Clinic, Temple, TX; Amit B. Shah, York Cancer Center, York; James J. Dignam and Rebecca Paulus, NRG Oncology Statistics and Data Management Center, Philadelphia, PA; David P. D'Souza, London Regional Cancer Program, London, Ontario; Ian S. Dayes, McMaster University, Hamilton, Ontario; Sergio L. Faria, McGill University Health Center, Montreal, Quebec, Canada; Jeff M. Michalski, Washington University School of Medicine, St Louis, MO; William A. Hall, Medical College of Wisconsin, Milwaukee, WI; Paul L. Nguyen, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Boston, MA; Thomas M. Pisansky, Mayo Clinic, Rochester, MN; and Yuhchyau Chen, University of Rochester, Rochester, NY
| | - Howard M Sandler
- W. Robert Lee and Bridget F. Koontz, Duke University Medical Center, Durham, NC; James J. Dignam, University of Chicago, Chicago, IL; Mahul B. Amin and Howard M. Sandler, Cedars-Sinai Medical Center; Daniel Low, University of California, Los Angeles, Los Angeles; Samantha A. Seaward, Kaiser Permanente Northern California, Santa Clara, CA; Deborah W. Bruner, Emory University, Atlanta, GA; Gregory P. Swanson, Baylor Scott & White Healthcare Temple Clinic, Temple, TX; Amit B. Shah, York Cancer Center, York; James J. Dignam and Rebecca Paulus, NRG Oncology Statistics and Data Management Center, Philadelphia, PA; David P. D'Souza, London Regional Cancer Program, London, Ontario; Ian S. Dayes, McMaster University, Hamilton, Ontario; Sergio L. Faria, McGill University Health Center, Montreal, Quebec, Canada; Jeff M. Michalski, Washington University School of Medicine, St Louis, MO; William A. Hall, Medical College of Wisconsin, Milwaukee, WI; Paul L. Nguyen, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Boston, MA; Thomas M. Pisansky, Mayo Clinic, Rochester, MN; and Yuhchyau Chen, University of Rochester, Rochester, NY
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Kumabe A, Fukuhara N, Utsunomiya T, Kawase T, Iwata K, Okada Y, Sutani S, Ohashi T, Oya M, Shigematsu N. Three-dimensional conformal arc radiotherapy using a C-arm linear accelerator with a computed tomography on-rail system for prostate cancer: clinical outcomes. Radiat Oncol 2015; 10:208. [PMID: 26458948 PMCID: PMC4603912 DOI: 10.1186/s13014-015-0515-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Accepted: 10/02/2015] [Indexed: 11/26/2022] Open
Abstract
Background We report the feasibility and treatment outcomes of image-guided three-dimensional conformal arc radiotherapy (3D-CART) using a C-arm linear accelerator with a computed tomography (CT) on-rail system for localized prostate cancer. Methods and materials Between 2006 and 2011, 282 consecutive patients with localized prostate cancer were treated with in-room CT-guided 3D-CART. Biochemical failure was defined as a rise of at least 2.0 ng/ml beyond the nadir prostate-specific antigen level. Toxicity was scored according to the National Cancer Institute Common Terminology Criteria for Adverse Events, version 4.0. Results A total of 261 patients were analyzed retrospectively (median follow-up: 61.6 months). The median prescribed 3D-CART dose was 82 Gy (2 Gy/fraction, dose range: 78–86 Gy), and 193 of the patients additionally received hormonal therapy. The 5-year overall survival rate was 93.9 %. Among low-, intermediate-, and high-risk patients, 5-year rates of freedom from biochemical failure were 100, 91.5 and 90.3 %, respectively. Rates of grade 2–3 late gastrointestinal and genitourinary toxicities were 2.3 and 11.4 %, respectively. No patient experienced late grade 4 or higher toxicity. Conclusions In-room CT-guided 3D-CART was feasible and effective for localized prostate cancer. Treatment outcomes were comparable to those previously reported for intensity-modulated radiotherapy.
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Systematic Review of the Relationship between Acute and Late Gastrointestinal Toxicity after Radiotherapy for Prostate Cancer. Prostate Cancer 2015; 2015:624736. [PMID: 26697225 PMCID: PMC4677238 DOI: 10.1155/2015/624736] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Accepted: 11/15/2015] [Indexed: 12/24/2022] Open
Abstract
A small but meaningful percentage of men who are treated with external beam radiation therapy for prostate cancer will develop late gastrointestinal toxicity. While numerous strategies to prevent gastrointestinal injury have been studied, clinical trials concentrating on late toxicity have been difficult to carry out. Identification of subjects at high risk for late gastrointestinal injury could allow toxicity prevention trials to be performed using reasonable sample sizes. Acute radiation therapy toxicity has been shown to predict late toxicity in several organ systems. Late toxicities may occur as a consequential effect of acute injury. In this systematic review of published reports, we found that late gastrointestinal toxicity following prostate radiotherapy seems to be statistically and potentially causally related to acute gastrointestinal morbidity as a consequential effect. We submit that acute gastrointestinal toxicity may be used to identify at-risk patients who may benefit from additional attention for medical interventions and close follow-up to prevent late toxicity. Acute gastrointestinal toxicity could also be explored as a surrogate endpoint for late effects in prospective trials.
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Kountouri M, Zilli T, Rouzaud M, Dubouloz A, Linero D, Escudé L, Jorcano S, Miralbell R. Moderate Hypofractionated Protracted Radiation Therapy and Dose Escalation for Prostate Cancer: Do Dose and Overall Treatment Time Matter? Int J Radiat Oncol Biol Phys 2015; 94:272-9. [PMID: 26853336 DOI: 10.1016/j.ijrobp.2015.10.055] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Revised: 10/19/2015] [Accepted: 10/26/2015] [Indexed: 10/22/2022]
Abstract
PURPOSE This was a retrospective study of 2 sequential dose escalation regimens of twice-weekly 4 Gy/fractions hypofractionated intensity modulated radiation therapy (IMRT): 56 Gy and 60 Gy delivered within a protracted overall treatment time (OTT) of 6.5 and 7 weeks, respectively. METHODS AND MATERIALS 163 prostate cancer patients with cT1c-T3a disease and nodal involvement risk ≤20% (Roach index) were treated twice weekly to the prostate ± seminal vesicles with 2 sequential dose-escalated IMRT schedules: 56 Gy (14 × 4 Gy, n=81) from 2003 to 2007 and 60 Gy (15 × 4 Gy, n=82) from 2006 to 2010. Patient repositioning was made with bone matching on portal images. Gastrointestinal (GI) and genitourinary (GU) toxicities were scored according to the Common Terminology Criteria for Adverse Events version 3.0 grading scale. RESULTS There were no significant differences regarding the acute GU and GI toxicities in the 2 dose groups. The median follow-up times were 80.2 months (range, 4.5-121 months) and 56.5 months (range, 1.4-91.2 months) for patients treated to 56 and 60 Gy, respectively. The 5-year grade ≥2 late GU toxicity-free survivals with 56 Gy and 60 Gy were 96 ± 2.3% and 78.2 ± 5.1% (P=.001), respectively. The 5-year grade ≥2 late GI toxicity-free survivals with 56 Gy and 60 Gy were 98.6 ± 1.3% and 85.1 ± 4.5% (P=.005), respectively. Patients treated with 56 Gy showed a 5-year biochemical progression-free survival (bPFS) of 80.8 ± 4.7%, worse than patients treated with 60 Gy (93.2 ± 3.9%, P=.007). A trend for a better 5-year distant metastasis-free survival was observed among patients treated in the high-dose group (95.3 ± 2.7% vs 100%, P=.073, respectively). On multivariate analysis, only the 60-Gy group predicted for a better bPFS (P=.016, hazard ratio = 4.58). CONCLUSIONS A single 4-Gy additional fraction in patients treated with a hypofractionated protracted IMRT schedule of 14 × 4 Gy resulted in a similar and minimal acute toxicity, in worse moderate to severe urinary and GI late effects, but a significantly better biochemical control.
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Affiliation(s)
- Melpomeni Kountouri
- Department of Radiation Oncology, Geneva University Hospital, Geneva, Switzerland
| | - Thomas Zilli
- Department of Radiation Oncology, Geneva University Hospital, Geneva, Switzerland
| | - Michel Rouzaud
- Department of Radiation Oncology, Geneva University Hospital, Geneva, Switzerland
| | - Angèle Dubouloz
- Department of Radiation Oncology, Geneva University Hospital, Geneva, Switzerland
| | - Dolors Linero
- Radiation Oncology, Teknon Oncologic Institute, Barcelona, Spain
| | - Lluís Escudé
- Radiation Oncology, Teknon Oncologic Institute, Barcelona, Spain
| | - Sandra Jorcano
- Radiation Oncology, Teknon Oncologic Institute, Barcelona, Spain
| | - Raymond Miralbell
- Department of Radiation Oncology, Geneva University Hospital, Geneva, Switzerland; Radiation Oncology, Teknon Oncologic Institute, Barcelona, Spain.
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Alonzi R. Functional Radiotherapy Targeting using Focused Dose Escalation. Clin Oncol (R Coll Radiol) 2015; 27:601-17. [PMID: 26456478 DOI: 10.1016/j.clon.2015.06.015] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2015] [Accepted: 06/17/2015] [Indexed: 12/12/2022]
Abstract
Various quantitative and semi-quantitative imaging biomarkers have been identified that may serve as valid surrogates for the risk of recurrence after radiotherapy. Tumour characteristics, such as hypoxia, vascularity, cellular proliferation and clonogen density, can be geographically mapped using biological imaging techniques. The potential gains in therapeutic ratio from the precision targeting of areas of intrinsic resistance makes focused dose escalation an exciting field of study. This overview will explore the issues surrounding biologically optimised radiotherapy, including its requirements, feasibility, technical considerations and potential applicability.
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Affiliation(s)
- R Alonzi
- Mount Vernon Cancer Centre, Northwood, UK.
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Alves GG, Kinoshita A, Oliveira HFD, Guimarães FS, Amaral LL, Baffa O. Accuracy of dose planning for prostate radiotherapy in the presence of metallic implants evaluated by electron spin resonance dosimetry. ACTA ACUST UNITED AC 2015; 48:644-9. [PMID: 26017344 PMCID: PMC4512104 DOI: 10.1590/1414-431x20154367] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2014] [Accepted: 02/05/2015] [Indexed: 11/22/2022]
Abstract
Radiotherapy is one of the main approaches to cure prostate cancer, and its success depends on the accuracy of dose planning. A complicating factor is the presence of a metallic prosthesis in the femur and pelvis, which is becoming more common in elderly populations. The goal of this work was to perform dose measurements to check the accuracy of radiotherapy treatment planning under these complicated conditions. To accomplish this, a scale phantom of an adult pelvic region was used with alanine dosimeters inserted in the prostate region. This phantom was irradiated according to the planned treatment under the following three conditions: with two metallic prostheses in the region of the femur head, with only one prosthesis, and without any prostheses. The combined relative standard uncertainty of dose measurement by electron spin resonance (ESR)/alanine was 5.05%, whereas the combined relative standard uncertainty of the applied dose was 3.35%, resulting in a combined relative standard uncertainty of the whole process of 6.06%. The ESR dosimetry indicated that there was no difference (P>0.05, ANOVA) in dosage between the planned dose and treatments. The results are in the range of the planned dose, within the combined relative uncertainty, demonstrating that the treatment-planning system compensates for the effects caused by the presence of femur and hip metal prostheses.
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Affiliation(s)
- G G Alves
- Departamento de Física, Faculdade de Filosofia, Ciências e Letras de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brasil
| | - A Kinoshita
- Departamento de Física, Faculdade de Filosofia, Ciências e Letras de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brasil
| | - H F de Oliveira
- Hospital das Clínicas, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brasil
| | - F S Guimarães
- Hospital das Clínicas, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brasil
| | - L L Amaral
- Hospital das Clínicas, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brasil
| | - O Baffa
- Departamento de Física, Faculdade de Filosofia, Ciências e Letras de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brasil
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Improved beam angle arrangement in intensity modulated proton therapy treatment planning for localized prostate cancer. Cancers (Basel) 2015; 7:574-84. [PMID: 25831258 PMCID: PMC4491671 DOI: 10.3390/cancers7020574] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2015] [Revised: 03/17/2015] [Accepted: 03/23/2015] [Indexed: 11/24/2022] Open
Abstract
Purpose: This study investigates potential gains of an improved beam angle arrangement compared to a conventional fixed gantry setup in intensity modulated proton therapy (IMPT) treatment for localized prostate cancer patients based on a proof of principle study. Materials and Methods: Three patients with localized prostate cancer retrospectively selected from our institution were studied. For each patient, IMPT plans were designed using two, three and four beam angles, respectively, obtained from a beam angle optimization algorithm. Those plans were then compared with ones using two lateral parallel-opposed beams according to the conventional planning protocol for localized prostate cancer adopted at our institution. Results: IMPT plans with two optimized angles achieved significant improvements in rectum sparing and moderate improvements in bladder sparing against those with two lateral angles. Plans with three optimized angles further improved rectum sparing significantly over those two-angle plans, whereas four-angle plans found no advantage over three-angle plans. A possible three-beam class solution for localized prostate patients was suggested and demonstrated with preserved dosimetric benefits because individually optimized three-angle solutions were found sharing a very similar pattern. Conclusions: This study has demonstrated the potential of using an improved beam angle arrangement to better exploit the theoretical dosimetric benefits of proton therapy and provided insights of selecting quality beam angles for localized prostate cancer treatment.
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Yahya N, Ebert MA, Bulsara M, Haworth A, Kearvell R, Foo K, Kennedy A, Richardson S, Krawiec M, Joseph DJ, Denham JW. Impact of treatment planning and delivery factors on gastrointestinal toxicity: an analysis of data from the RADAR prostate radiotherapy trial. Radiat Oncol 2014; 9:282. [PMID: 25498565 PMCID: PMC4271488 DOI: 10.1186/s13014-014-0282-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Accepted: 12/01/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To assess the impact of incremental modifications of treatment planning and delivery technique, as well as patient anatomical factors, on late gastrointestinal toxicity using data from the TROG 03.04 RADAR prostate radiotherapy trial. METHODS The RADAR trial accrued 813 external beam radiotherapy participants during 2003-2008 from 23 centres. Following review and archive to a query-able database, digital treatment plans and data describing treatment technique for 754 patients were available for analysis. Treatment demographics, together with anatomical features, were assessed using uni- and multivariate regression models against late gastrointestinal toxicity at 18-, 36- and 54-month follow-up. Regression analyses were reviewed in the context of dose-volume data for the rectum and anal canal. RESULTS A multivariate analysis at 36-month follow-up shows that patients planned using a more rigorous dose calculation algorithm (DCA) was associated with a lower risk of stool frequency (OR: 0.435, CI: 0.242-0.783, corrected p = 0.04). Patients using laxative as a method of bowel preparation had higher risk of having increased stool frequency compared to patients with no dietary intervention (OR: 3.639, CI: 1.502-8.818, corrected p = 0.04). Despite higher risks of toxicities, the anorectum, anal canal and rectum dose-volume histograms (DVH) indicate patients using laxative had unremarkably different planned dose distributions. Patients planned with a more rigorous DCA had lower median DVH values between EQD23 = 15 Gy and EQD23 = 35 Gy. Planning target volume (PTV), conformity index, rectal width and prescription dose were not significant when adjusted for false discovery rate. Number of beams, beam energy, treatment beam definition, positioning orientation, rectum-PTV separation, rectal length and mean cross sectional area did not affect the risk of toxicities. CONCLUSIONS The RADAR study dataset has allowed an assessment of technical modifications on gastrointestinal toxicity. A number of interesting associations were subsequently found and some factors, previously hypothesised to influence toxicity, did not demonstrate any significant impact. We recommend trial registries be encouraged to record technical modifications introduced during the trial in order for more powerful evidence to be gathered regarding the impact of the interventions.
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Affiliation(s)
- Noorazrul Yahya
- School of Physics, University of Western Australia, Crawley, Western Australia, Australia. .,School of Health Sciences, National University of Malaysia, Bangi, Malaysia.
| | - Martin A Ebert
- School of Physics, University of Western Australia, Crawley, Western Australia, Australia. .,Department of Radiation Oncology, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia.
| | - Max Bulsara
- Institute for Health Research, University of Notre Dame, Fremantle, Western Australia, Australia.
| | - Annette Haworth
- Department of Physical Sciences, Peter MacCallum Cancer Centre, Victoria, Australia. .,Sir Peter MacCallum Department of Oncology, University of Melbourne, Victoria, Australia.
| | - Rachel Kearvell
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia.
| | - Kerwyn Foo
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia.
| | - Angel Kennedy
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia.
| | - Sharon Richardson
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia.
| | - Michele Krawiec
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia.
| | - David J Joseph
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia. .,School of Surgery, University of Western Australia, Crawley, Western Australia, Australia.
| | - Jim W Denham
- School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia.
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Yamazaki H, Nakamura S, Nishimura T, Yoshida K, Yoshioka Y, Koizumi M, Ogawa K. Transitioning from conventional radiotherapy to intensity-modulated radiotherapy for localized prostate cancer: changing focus from rectal bleeding to detailed quality of life analysis. JOURNAL OF RADIATION RESEARCH 2014; 55:1033-1047. [PMID: 25204643 PMCID: PMC4229926 DOI: 10.1093/jrr/rru061] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/20/2014] [Revised: 05/27/2014] [Accepted: 06/09/2014] [Indexed: 06/02/2023]
Abstract
With the advent of modern radiation techniques, we have been able to deliver a higher prescribed radiotherapy dose for localized prostate cancer without severe adverse reactions. We reviewed and analyzed the change of toxicity profiles of external beam radiation therapy (EBRT) from the literature. Late rectal bleeding is the main adverse effect, and an incidence of >20% of Grade ≥2 adverse events was reported for 2D conventional radiotherapy of up to 70 Gy. 3D conformal radiation therapy (3D-CRT) was found to reduce the incidence to ∼10%. Furthermore, intensity-modulated radiation therapy (IMRT) reduced it further to a few percentage points. However, simultaneously, urological toxicities were enhanced by dose escalation using highly precise external radiotherapy. We should pay more attention to detailed quality of life (QOL) analysis, not only with respect to rectal bleeding but also other specific symptoms (such as urinary incontinence and impotence), for two reasons: (i) because of the increasing number of patients aged >80 years, and (ii) because of improved survival with elevated doses of radiotherapy and/or hormonal therapy; age is an important prognostic factor not only for prostate-specific antigen (PSA) control but also for adverse reactions. Those factors shift the main focus of treatment purpose from survival and avoidance of PSA failure to maintaining good QOL, particularly in older patients. In conclusion, the focus of toxicity analysis after radiotherapy for prostate cancer patients is changing from rectal bleeding to total elaborate quality of life assessment.
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Affiliation(s)
- Hideya Yamazaki
- Department of Radiology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajiicho Kawaramachi Hirokoji, Kamigyo-ku, Kyoto 602-8566, Japan
| | - Satoaki Nakamura
- Department of Radiology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajiicho Kawaramachi Hirokoji, Kamigyo-ku, Kyoto 602-8566, Japan
| | - Takuya Nishimura
- Department of Radiology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajiicho Kawaramachi Hirokoji, Kamigyo-ku, Kyoto 602-8566, Japan
| | - Ken Yoshida
- Department of Radiology, Osaka Medical College, 2-7 Daigaku-machi, Takatsuki-City, Osaka, 569-8686, Japan
| | - Yasuo Yoshioka
- Department of Radiation Oncology, Osaka University Graduate School of Medicine, Yamadaoka 2-2, Suita, 565-0871 Osaka, Japan
| | - Masahiko Koizumi
- Department of Radiation Oncology, Osaka University Graduate School of Medicine, Yamadaoka 2-2, Suita, 565-0871 Osaka, Japan
| | - Kazuhiko Ogawa
- Department of Radiation Oncology, Osaka University Graduate School of Medicine, Yamadaoka 2-2, Suita, 565-0871 Osaka, Japan
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Shioyama Y, Tsuji H, Suefuji H, Sinoto M, Matsunobu A, Toyama S, Nakamura K, Kudo S. Particle radiotherapy for prostate cancer. Int J Urol 2014; 22:33-9. [PMID: 25308767 DOI: 10.1111/iju.12640] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2014] [Accepted: 09/03/2014] [Indexed: 01/03/2023]
Abstract
Recent advances in external beam radiotherapy have allowed us to deliver higher doses to the tumors while decreasing doses to the surrounding tissues. Dose escalation using high-precision radiotherapy has improved the treatment outcomes of prostate cancer. Intensity-modulated radiation therapy has been widely used throughout the world as the most advanced form of photon radiotherapy. In contrast, particle radiotherapy has also been under development, and has been used as an effective and non-invasive radiation modality for prostate and other cancers. Among the particles used in such treatments, protons and carbon ions have the physical advantage that the dose can be focused on the tumor with only minimal exposure of the surrounding normal tissues. Furthermore, carbon ions also have radiobiological advantages that include higher killing effects on intrinsic radio-resistant tumors, hypoxic tumor cells and tumor cells in the G0 or S phase. However, the degree of clinical benefit derived from these theoretical advantages in the treatment of prostate cancer has not been adequately determined. The present article reviews the available literature on the use of particle radiotherapy for prostate cancer as well as the literature on the physical and radiobiological properties of this treatment, and discusses the role and the relative merits of particle radiotherapy compared with current photon-based radiotherapy, with a focus on proton beam therapy and carbon ion radiotherapy.
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Kil WJ, Mendenhall NP, Morris CG, Nichols RC, Henderson RH, Mendenhall WM, Bryant C, Williams C, Li Z, Hoppe BS. Patient-reported Hip Symptoms following Treatment with Proton Therapy for Prostate Cancer. Int J Part Ther 2014. [DOI: 10.14338/ijpt.13-00005.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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40
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Schlaff CD, Krauze A, Belard A, O'Connell JJ, Camphausen KA. Bringing the heavy: carbon ion therapy in the radiobiological and clinical context. Radiat Oncol 2014; 9:88. [PMID: 24679134 PMCID: PMC4002206 DOI: 10.1186/1748-717x-9-88] [Citation(s) in RCA: 92] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2013] [Accepted: 03/16/2014] [Indexed: 12/23/2022] Open
Abstract
Radiotherapy for the treatment of cancer is undergoing an evolution, shifting to the use of heavier ion species. For a plethora of malignancies, current radiotherapy using photons or protons yields marginal benefits in local control and survival. One hypothesis is that these malignancies have acquired, or are inherently radioresistant to low LET radiation. In the last decade, carbon ion radiotherapy facilities have slowly been constructed in Europe and Asia, demonstrating favorable results for many of the malignancies that do poorly with conventional radiotherapy. However, from a radiobiological perspective, much of how this modality works in overcoming radioresistance, and extending local control and survival are not yet fully understood. In this review, we will explain from a radiobiological perspective how carbon ion radiotherapy can overcome the classical and recently postulated contributors of radioresistance (α/β ratio, hypoxia, cell proliferation, the tumor microenvironment and metabolism, and cancer stem cells). Furthermore, we will make recommendations on the important factors to consider, such as anatomical location, in the future design and implementation of clinical trials. With the existing data available we believe that the expansion of carbon ion facilities into the United States is warranted.
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Affiliation(s)
| | | | | | | | - Kevin A Camphausen
- Radiation Oncology Branch, National Cancer Institute, 10 Center Drive Magnuson Clinical Center Room B3B100, Bethesda, MD 20892, USA.
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Mendenhall NP, Hoppe BS, Nichols RC, Mendenhall WM, Morris CG, Li Z, Su Z, Williams CR, Costa J, Henderson RH. Five-Year Outcomes from 3 Prospective Trials of Image-Guided Proton Therapy for Prostate Cancer. Int J Radiat Oncol Biol Phys 2014; 88:596-602. [DOI: 10.1016/j.ijrobp.2013.11.007] [Citation(s) in RCA: 83] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2013] [Revised: 10/30/2013] [Accepted: 11/04/2013] [Indexed: 12/31/2022]
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Incidence of complications other than urinary incontinence or erectile dysfunction after radical prostatectomy or radiotherapy for prostate cancer: a population-based cohort study. Lancet Oncol 2014; 15:223-31. [DOI: 10.1016/s1470-2045(13)70606-5] [Citation(s) in RCA: 163] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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43
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Dose escalation using ultra-high dose IMRT in intermediate risk prostate cancer without androgen deprivation therapy: preliminary results of toxicity and biochemical control. JOURNAL OF EXPERIMENTAL & CLINICAL CANCER RESEARCH : CR 2013; 32:103. [PMID: 24330467 PMCID: PMC3878738 DOI: 10.1186/1756-9966-32-103] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/23/2013] [Accepted: 12/03/2013] [Indexed: 11/30/2022]
Abstract
Background To investigate the feasibility of dose escalation (86 Gy at 2 Gy/fraction) with intensity modulated radiation therapy (IMRT) in intermediate-risk prostate cancer without androgen deprivation therapy. Methods Patients with histologically proven adenocarcinoma of the prostate, intermediate prognostic category, were enrolled in this study. Early and late toxicity were scored according to the Cancer Therapy Evaluation Program, Common Terminology Criteria for Adverse Events, Version 3.0. Treatment outcome was stated in terms of biochemical failure, biopsy result and clinical failure. Results 39 patients with a median follow-up of 71 months were analyzed. No patient experienced G3 or G4 acute gastrointestinal (GI) or genitourinary (GU) toxicity. G2 acute GI and GU toxicity were observed in 17 (44%) and 20 (51%) patients, respectively. Fourteen patients (36%) did not experience acute GI toxicity and 4 patients (10%) did not experience acute GU toxicity. G2 late GI bleeding occurred in 7 of 39 patients (18%). Both G3 and G4 late GI toxicity were seen only in one patient (2.5%). Two patients (5%) experienced G2 late GU toxicity, while G3 late GU toxicity occurred in 3 patients (8%). The 5-year actuarial freedom from biochemical failure (FFBF) was 87%. Thirty-four patients (87%) did not show biochemical relapse. Seventeen patients (44%) underwent biopsy two year after radiotherapy; of these only two were non-negative and both did not show evidence of biochemical disease. Conclusions IMRT treatment of patients with localized intermediate-risk prostate cancer at high dose levels without using androgen deprivation therapy (ADT) seems to give good disease control. Nevertheless, future trials should aim at further decreasing toxicity by exploiting image guidance techniques and by reducing the dose delivered at the interface between organs at risk and prostate.
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Lam ET, Glodé LM. Neoadjuvant and Adjuvant Hormonal and Chemotherapy for Prostate Cancer. Hematol Oncol Clin North Am 2013; 27:1189-204, viii. [DOI: 10.1016/j.hoc.2013.08.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Cautious Optimism for Extreme Dose Escalation in Prostate Cancer. Eur Urol 2013; 64:939-40. [DOI: 10.1016/j.eururo.2013.02.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2013] [Accepted: 02/20/2013] [Indexed: 11/22/2022]
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Yoshioka Y, Konishi K, Suzuki O, Nakai Y, Isohashi F, Seo Y, Otani Y, Koizumi M, Yoshida K, Yamazaki H, Nonomura N, Ogawa K. Monotherapeutic high-dose-rate brachytherapy for prostate cancer: a dose reduction trial. Radiother Oncol 2013; 110:114-9. [PMID: 24183062 DOI: 10.1016/j.radonc.2013.10.015] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2012] [Revised: 07/16/2013] [Accepted: 10/14/2013] [Indexed: 10/26/2022]
Abstract
PURPOSE To report preliminary results of our second regimen with 45.5 Gy/7 fractions aiming to reduce toxicity, compared with our first regimen with 54 Gy/9 fractions, using high-dose-rate (HDR) brachytherapy as monotherapy for prostate cancer. MATERIALS AND METHODS From 2005 through 2010, 63 patients with localized prostate cancer were treated with HDR brachytherapy alone in 45.5 Gy/7 fractions for 4 days. Thirty-four patients were considered as intermediate-risk and 29 as high-risk. Thirty-seven patients also received neoadjuvant and/or adjuvant hormonal therapy. Biologically effective dose assuming α/β=1.5 Gy (BED₁.₅) was reduced from 270 Gy to 243 Gy, and BED₃.₀ from 162 Gy to 144 Gy, compared to previous 54 Gy/9 fractions for 5 days. RESULTS Median follow-up time was 42 months (range 13-72). Grade 2 acute toxicities occurred in six (9.5%), late toxicities in five (7.9%) patients, and Grade 3 or higher in none. Grade 2 late gastrointestinal toxicity rate was 1.6%, compared with 7.1% for the 54 Gy regimen. Three-year PSA failure-free rates for intermediate- and high-risk patients were 96% and 90%, which were comparable to 93% and 85% for the 54 Gy regimen. CONCLUSIONS Compared to the 54 Gy/9 fractions regimen, dose-reduced regimen of 45.5 Gy/7 fractions using HDR brachytherapy as monotherapy preliminarily showed an equivalent or lower incidence rate for acute and late toxicities without compromising the excellent PSA failure-free rate. Further studies with more patients and longer follow-up are warranted.
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Affiliation(s)
- Yasuo Yoshioka
- Department of Radiation Oncology, Osaka University Graduate School of Medicine, Japan.
| | - Koji Konishi
- Department of Radiation Oncology, Osaka Medical Center for Cancer and Cardiovascular Diseases, Japan
| | - Osamu Suzuki
- Department of Radiation Oncology, Osaka University Graduate School of Medicine, Japan
| | - Yasutomo Nakai
- Department of Urology, Osaka University Graduate School of Medicine, Japan
| | - Fumiaki Isohashi
- Department of Radiation Oncology, Osaka University Graduate School of Medicine, Japan
| | - Yuji Seo
- Department of Radiation Oncology, Osaka University Graduate School of Medicine, Japan
| | - Yuki Otani
- Department of Radiation Oncology, Osaka University Graduate School of Medicine, Japan
| | - Masahiko Koizumi
- Department of Radiation Oncology, Osaka University Graduate School of Medicine, Japan
| | - Ken Yoshida
- Department of Radiology, Osaka Medical College, Japan
| | - Hideya Yamazaki
- Department of Radiology, Kyoto Prefectural University of Medicine, Japan
| | - Norio Nonomura
- Department of Urology, Osaka University Graduate School of Medicine, Japan
| | - Kazuhiko Ogawa
- Department of Radiation Oncology, Osaka University Graduate School of Medicine, Japan
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La Radioterapia Nel Trattamento Del Carcinoma Della Prostata: Indicazioni, Evoluzione Tecnologica e Approcci Integrati. Urologia 2013; 80:188-201. [DOI: 10.5301/ru.2013.11499] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/01/2013] [Indexed: 11/20/2022]
Abstract
Prostate cancer is a heterogeneous, indolent or sometimes aggressive tumor. Treatment options are various and without proved superiority. Radiotherapy (RT) plays a key role in the disease history. Technological evolution with Intensity Modulate Radiation Therapy (IMRT) and Image Guided Radiation Therapy (IGRT) allowed improvement, with significant results on local control and survival. Hypofractionation, Stereotactic Body RT (SBRT) and new brachytherapy approachs are still under investigation, with promising opportunities. Adjuvant vs salvage postoperative RT, hormone association, prophylactic pelvic irradiation are still under debate, but guidelines express overlapping indications. Multidisciplinary managements will be the future for care optimization, providing the best tool for holistic and informed patients' choice.
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Sasaki M, Ikushima H, Nakaguchi Y, Kishi T, Kimura M, Bandou R, Oita M. [A comparison of four commercial radiation treatment planning systems for prostate intensity modulated radiation therapy]. Nihon Hoshasen Gijutsu Gakkai Zasshi 2013; 69:761-772. [PMID: 23877154 DOI: 10.6009/jjrt.2013_jsrt_69.7.761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
At present, every manufacturer of intensity modulated radiation therapy (IMRT) equipment uses multi-leaf collimators (MLCs); however, each company's intensity modulation methods and dose calculation algorithms differ. This study used four typical radiation treatment planning systems (RTPSs) employed domestically for prostate IMRT plans to carry out 15 case studies by one planner based on the dose limits at this clinic. The results were used to compare the differences, if any, in RTPS treatment plans. With prostate IMRT plans, an overlap area exists between the PTV and the rectum. For this reason, while observing dose limits of 60-75 Gy (within the dose tolerated by the rectum), securing uniformity and concentration of dose is essential to create the most appropriate treatment plan for the PTV and other targets. Although each RTPS uses different planning methods, it was generally possible to observe this clinic's dose limits by adjusting the parameter values. When identical beam data is used, it is possible to create similar treatment plans.
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Ahmed AA, Egleston B, Alcantara P, Li L, Pollack A, Horwitz EM, Buyyounouski MK. A novel method for predicting late genitourinary toxicity after prostate radiation therapy and the need for age-based risk-adapted dose constraints. Int J Radiat Oncol Biol Phys 2013; 86:709-15. [PMID: 23664324 DOI: 10.1016/j.ijrobp.2013.03.020] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2012] [Revised: 03/12/2013] [Accepted: 03/18/2013] [Indexed: 11/18/2022]
Abstract
BACKGROUND There are no well-established normal tissue sparing dose-volume histogram (DVH) criteria that limit the risk of urinary toxicity from prostate radiation therapy (RT). The aim of this study was to determine which criteria predict late toxicity among various DVH parameters when contouring the entire solid bladder and its contents versus the bladder wall. The area under the histogram curve (AUHC) was also analyzed. METHODS AND MATERIALS From 1993 to 2000, 503 men with prostate cancer received 3-dimensional conformal RT (median follow-up time, 71 months). The whole bladder and the bladder wall were contoured in all patients. The primary endpoint was grade ≥2 genitourinary (GU) toxicity occurring ≥3 months after completion of RT. Cox regressions of time to grade ≥2 toxicity were estimated separately for the entire bladder and bladder wall. Concordance probability estimates (CPE) assessed model discriminative ability. Before training the models, an external random test group of 100 men was set aside for testing. Separate analyses were performed based on the mean age (≤ 68 vs >68 years). RESULTS Age, pretreatment urinary symptoms, mean dose (entire bladder and bladder wall), and AUHC (entire bladder and bladder wall) were significant (P<.05) in multivariable analysis. Overall, bladder wall CPE values were higher than solid bladder values. The AUHC for bladder wall provided the greatest discrimination for late bladder toxicity when compared with alternative DVH points, with CPE values of 0.68 for age ≤68 years and 0.81 for age >68 years. CONCLUSION The AUHC method based on bladder wall volumes was superior for predicting late GU toxicity. Age >68 years was associated with late grade ≥2 GU toxicity, which suggests that risk-adapted dose constraints based on age should be explored.
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Affiliation(s)
- Awad A Ahmed
- Temple University School of Medicine, Philadelphia, Pennsylvania, USA
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Horwich A, Hugosson J, de Reijke T, Wiegel T, Fizazi K, Kataja V, Parker C, Bellmunt J, Berthold D, Bill-Axelson A, Carlsson S, Daugaard G, De Meerleer G, de Reijke T, Dearnaley D, Fizazi K, Fonteyne V, Gillessen S, Heinrich D, Horwich A, Hugosson J, Kataja V, Kwiatkowski M, Nilsson S, Padhani A, Papandreou C, Parker C, Roobol M, Sella A, Valdagni R, Van der Kwast T, Verhagen P, Wiegel T. Prostate cancer: ESMO Consensus Conference Guidelines 2012. Ann Oncol 2013; 24:1141-62. [DOI: 10.1093/annonc/mds624] [Citation(s) in RCA: 114] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
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