1
|
Mohan R, Kneebone A, Eade T, Hsiao E, Emmett L, Brown C, Hunter J, Hruby G. Long-term outcomes of SBRT for PSMA PET detected oligometastatic prostate cancer. Radiat Oncol 2023; 18:127. [PMID: 37528487 PMCID: PMC10394924 DOI: 10.1186/s13014-023-02302-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Accepted: 06/19/2023] [Indexed: 08/03/2023] Open
Abstract
BACKGROUND Oligometastatic disease in prostate cancer (PCa) is a challenging clinical scenario encountered more frequently with the widespread adoption of PSMA-PET. SBRT aims to defer androgen deprivation and may deliver sustained biochemical failure (BF) free survival in selected patients. Little long-term data is currently available regarding the effectiveness of this approach. METHODS A retrospective single institution study of PSMA-PET directed SBRT without initial ADT for oligo-metachronous PCa. Median dose/fractionation was 24 Gy in 2# to bones and 30 Gy in 3# to lymph nodes. The primary endpoint was time to BF (PSA + 0.2 ug/L above nadir). Secondary endpoints included time to ADT for relapse (i.e. palliative ADT), BF defined as PSA nadir + 2 ug/L, toxicity, patterns of failure and survival. Patients were excluded if they received ADT with their SBRT, had short disease-free interval, or > 3 metastases on PSMA-PET. RESULTS 103 patients treated from November-2014 to December-2019 were analysed from our prospective database. Median follow-up was 5 years. 64 patients were treated for nodal only disease, 35 bone only and 4 mixed. 15% were free of any BF at 5 years with median time to BF of 1.1 years. 32% (33/103) of patients had further curative-intent radiation treatment following their first BF after SBRT, including subsequent SBRT. Eight patients underwent potentially curative treatment for their second or third relapse. Allowing for salvage treatment, 29/103 (28%) were biochemically disease free at last follow up. At 5 years, 39% of patients had never received any ADT and 55% had not started ADT for relapse with a median time to ADT for relapse of 5.5 years. There were 2 grade 3 toxicities (rib fracture and lymphoedema), and no local failures. CONCLUSION PSMA-PET guided SBRT for oligo-metachronous PCa recurrence in appropriately triaged patients results in excellent local control, low toxicity and over 50% ADT free at 5 years.
Collapse
Affiliation(s)
- Riche Mohan
- Northern Sydney Cancer Centre, Royal North Shore Hospital, St Leonards, NSW, 2065, Australia.
- Northern Clinical School, University of Sydney, St Leonards, NSW, 2065, Australia.
| | - A Kneebone
- Northern Sydney Cancer Centre, Royal North Shore Hospital, St Leonards, NSW, 2065, Australia
- Northern Clinical School, University of Sydney, St Leonards, NSW, 2065, Australia
| | - T Eade
- Northern Sydney Cancer Centre, Royal North Shore Hospital, St Leonards, NSW, 2065, Australia
- Northern Clinical School, University of Sydney, St Leonards, NSW, 2065, Australia
| | - E Hsiao
- Northern Sydney Cancer Centre, Royal North Shore Hospital, St Leonards, NSW, 2065, Australia
- Northern Clinical School, University of Sydney, St Leonards, NSW, 2065, Australia
| | - L Emmett
- Northern Sydney Cancer Centre, Royal North Shore Hospital, St Leonards, NSW, 2065, Australia
- Northern Clinical School, University of Sydney, St Leonards, NSW, 2065, Australia
- Garvan Institute of Medical Research, Darlinghurst, 2010, Australia
| | - Christopher Brown
- Northern Sydney Cancer Centre, Royal North Shore Hospital, St Leonards, NSW, 2065, Australia
- Northern Clinical School, University of Sydney, St Leonards, NSW, 2065, Australia
| | - J Hunter
- Northern Sydney Cancer Centre, Royal North Shore Hospital, St Leonards, NSW, 2065, Australia
- Northern Clinical School, University of Sydney, St Leonards, NSW, 2065, Australia
| | - G Hruby
- Northern Sydney Cancer Centre, Royal North Shore Hospital, St Leonards, NSW, 2065, Australia
- Northern Clinical School, University of Sydney, St Leonards, NSW, 2065, Australia
| |
Collapse
|
2
|
Asso R, Degrande F, Fernandes da Silva J, Leite E. Postoperative radiotherapy in prostate cancer: When and how? – An update review. Cancer Radiother 2022; 26:742-748. [DOI: 10.1016/j.canrad.2021.10.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 07/15/2021] [Accepted: 10/12/2021] [Indexed: 11/17/2022]
|
3
|
Wenzel M, Hussein R, Maurer T, Karakiewicz PI, Tilki D, Graefen M, Würnschimmel C. PSMA PET predicts metastasis-free survival in the setting of salvage radiotherapy after radical prostatectomy. Urol Oncol 2021; 40:7.e1-7.e8. [PMID: 34340868 DOI: 10.1016/j.urolonc.2021.06.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 05/04/2021] [Accepted: 06/13/2021] [Indexed: 10/20/2022]
Abstract
INTRODUCTION To evaluate the impact of PSMA PET (prostate specific membrane antigen positron emission tomography) findings prior to salvage radiotherapy (SRT) in recurrent prostate cancer (PCa) after radical prostatectomy (RP) on metastasis-free survival (MFS). PATIENTS AND METHODS Between 01/2012 and 12/2018, 1,599 patients received SRT for biochemical recurrence after RP at our institution. Five-year MFS of "positive PSMA PET" (n = 49) vs. "negative PSMA PET" (n = 106) vs. "no PSMA PET" (n = 1,599) prior to SRT was determined. For all time to event analyses, uni- and multivariable Cox's proportional hazards models and univariable Kaplan-Meier analyses were applied, with a significance threshold of P < 0.05. Further 4:1 propensity score matching for patient, cancer and treatment characteristics was performed to account for residual differences between groups. RESULTS Of PSMA PET patients, 106 patients exhibited "negative PSMA PET" (68.4%) and 49 exhibited "positive PSMA PET" (31.6%). Median PSA at recurrence did not differ between groups (0.2 ng/ml; P= 0.4). After 4:1 propensity score matching, 5-year MFS between "no PSMA PET" and "negative PSMA PET" was 94.4 vs. 93.0%, respectively (P = 0.8). For "no PSMA PET" versus "positive PSMA PET", 5-year MFS was significantly lower in "positive PSMA PET" (92.3 vs. 48.5%, respectively P < 0.0001). Finally, "positive PSMA PET" was independently associated with worse MFS compared to "no PSMA PET" after multivariable adjustment in the overall cohort (HR 13.8, CI 7.5-25.2, P < 0.001). CONCLUSIONS Locoregional positive PSMA PET findings in recurrent patients after RP are highly predictive of worse MFS in the setting of SRT.
Collapse
Affiliation(s)
- Mike Wenzel
- Department of Urology, University Hospital Frankfurt, Frankfurt am Main, Germany; Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, Québec, Canada
| | - Rada Hussein
- Martini-Klinik Prostate Cancer Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Tobias Maurer
- Martini-Klinik Prostate Cancer Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany; Department of Urology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Pierre I Karakiewicz
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, Québec, Canada
| | - Derya Tilki
- Martini-Klinik Prostate Cancer Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany; Department of Urology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Markus Graefen
- Martini-Klinik Prostate Cancer Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Christoph Würnschimmel
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, Québec, Canada; Martini-Klinik Prostate Cancer Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany.
| |
Collapse
|
4
|
68Ga-PSMA-PET screening and transponder-guided salvage radiotherapy to the prostate bed alone for biochemical recurrence following prostatectomy: interim outcomes of a phase II trial. World J Urol 2021; 39:4117-4125. [PMID: 34076753 PMCID: PMC8571130 DOI: 10.1007/s00345-021-03735-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 05/13/2021] [Indexed: 11/09/2022] Open
Abstract
Purpose To evaluate outcomes for men with biochemically recurrent prostate cancer who were selected for transponder-guided salvage radiotherapy (SRT) to the prostate bed alone by 68Ga-labelled prostate-specific membrane antigen positron emission tomography (68Ga-PSMA-PET). Methods This is a single-arm, prospective study of men with a prostate-specific antigen (PSA) level rising to 0.1–2.5 ng/mL following radical prostatectomy. Patients were staged with 68Ga-PSMA-PET and those with a negative finding, or a positive finding localised to the prostate bed, continued to SRT only to the prostate bed alone with real-time target-tracking using electromagnetic transponders. The primary endpoint was freedom from biochemical relapse (FFBR, PSA > 0.2 ng/mL from the post-radiotherapy nadir). Secondary endpoints were time to biochemical relapse, toxicity and patient-reported quality of life (QoL). Results Ninety-two patients (median PSA of 0.18 ng/ml, IQR 0.12–0.36), were screened with 68Ga-PSMA-PET and metastatic disease was found in 20 (21.7%) patients. Sixty-nine of 72 non-metastatic patients elected to proceed with SRT. At the interim (3-year) analysis, 32 (46.4%) patients (95% CI 34.3–58.8%) were FFBR. The median time to biochemical relapse was 16.1 months. The rate of FFBR was 82.4% for ISUP grade-group 2 patients. Rates of grade 2 or higher gastrointestinal and genitourinary toxicity were 0% and 15.2%, respectively. General health and disease-specific QoL remained stable. Conclusion Pre-SRT 68Ga-PSMA-PET scans detect metastatic disease in a proportion of patients at low PSA levels but fail to improve FFBR. Transponder-guided SRT to the prostate bed alone is associated with a favourable toxicity profile and preserved QoL. Trial registration number ACTRN12615001183572, 03/11/2015, retrospectively registered. Supplementary Information The online version contains supplementary material available at 10.1007/s00345-021-03735-0.
Collapse
|
5
|
Genomic Strategies to Personalize Use of Androgen Deprivation Therapy With Radiotherapy. ACTA ACUST UNITED AC 2021; 26:13-20. [PMID: 31977380 DOI: 10.1097/ppo.0000000000000419] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The use of combination RT and androgen deprivation therapy in many prostate cancer curative-intent treatment scenarios is supported by level 1 evidence. However, in our current clinical paradigm, we have no ability to determine a priori which patients truly benefit from combination therapy and therefore apply the combination RT and androgen deprivation therapy intensification strategy to all patients, which results in overtreatment or undertreatment of the majority of our patients. Genomics has the ability to more deeply and objectively characterize the disease, in turn refining our prognostication capabilities and enabling the individualization of treatments. We review the commercially available prostate cancer genomic tests, focusing on those able to predict patient outcomes following radiotherapy or guide radiotherapy treatment decisions.
Collapse
|
6
|
Vigna‐Taglianti R, Boriano A, Gianello L, Melano A, Bergesio F, Merlotti AM, Reali A, Petrucci R, Russi EG. Predictive value of Prostate Specific Antigen variations in the last week of salvage radiotherapy for biochemical recurrence of prostate cancer after surgery: A practical approach. Cancer Rep (Hoboken) 2020; 3:e1285. [PMID: 32881424 PMCID: PMC7941543 DOI: 10.1002/cnr2.1285] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 07/01/2020] [Accepted: 08/02/2020] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND About a third of patients who underwent radical prostatectomy for prostate cancer (Pca) develop a biochemical failure (BF) within 10 years from surgery, and about a half of them receive salvage radiation therapy (SRT). Factors to predict risk to relapse after SRT are still lacking. Dynamic models, based on the assessment of changes in Prostate Specific Antigen (PSA) postsurgery seem to show good reliability. AIMS The goal of the study was to identify a simple analytical method for the postsalvage radiation therapy biochemical failure (post-SRTBF) prediction before the end of the SRT, regardless of the PSA value at the beginning of the treatment (PSA start), measuring the PSA values at the start and 1 week before the end of SRT. METHODS In a series of 83 patients treated with SRT for BF of Pca we measured PSA values at the first day and 1 week before the end of SRT. These values were used to define an analytical method for the post-SRTBF prediction. RESULTS PSA value in patients without post-SRTBF show a significant difference in term of difference during the SRT with respect to patients with post-SRTBF. Starting from this difference, we identified a simple and practical analytical method for the post-SRTBF prediction before the end of the SRT. The data corresponds with the model and the analytical method is highly predictive (Sensitivity = 81%, Specificity = 85%, Accuracy = 83%). CONCLUSION This study offers a new tool to early predict Pca relapse overtime and to select patients who can benefit from an early additional systemic treatment.
Collapse
Affiliation(s)
| | - Alberto Boriano
- Medical Physics DepartmentSanta Croce and Carle HospitalCuneoItaly
| | - Luca Gianello
- Radiation Oncology DepartmentSanta Croce and Carle HospitalCuneoItaly
| | - Antonella Melano
- Radiation Oncology DepartmentSanta Croce and Carle HospitalCuneoItaly
| | | | | | - Alessia Reali
- Radiation Oncology DepartmentSanta Croce and Carle HospitalCuneoItaly
| | - Rachele Petrucci
- Radiation Oncology DepartmentSanta Croce and Carle HospitalCuneoItaly
| | - Elvio G. Russi
- Radiation Oncology DepartmentSanta Croce and Carle HospitalCuneoItaly
| |
Collapse
|
7
|
Sachdev S, Carroll P, Sandler H, Nguyen PL, Wafford E, Auffenberg G, Schaeffer E, Roach M, Evans CP, Hussain M. Assessment of Postprostatectomy Radiotherapy as Adjuvant or Salvage Therapy in Patients With Prostate Cancer: A Systematic Review. JAMA Oncol 2020; 6:1793-1800. [PMID: 32852528 DOI: 10.1001/jamaoncol.2020.2832] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Importance After radical prostatectomy, adverse pathologic features and postoperative prostate-specific antigen (PSA) levels can herald disease recurrence or progression. Postoperative radiotherapy (RT) remains beneficial in this setting. Objective To examine the evidence supporting the use of postoperative RT as well as recent advances that help determine timing, scope, and use in combination with androgen deprivation therapy (ADT) with or without lymphatic irradiation. Evidence Review A search was conducted of MEDLINE (Ovid), Embase (Elsevier), and the Cochrane Library (Wiley) databases, in addition to clinical trial registries. The reference list of included studies was reviewed for relevant articles. The search was limited to studies published between January 1, 2014, and December 31, 2019. Findings After 548 citations were screened, 27 articles were selected for inclusion. In addition to conventional imaging, positron-emission tomographic (PET)-based radiotracers can aid in disease localization. While PET imaging may influence management with RT, studies are underway examining this issue, and several limitations must be considered, such as limited detectability at lower PSA levels and regional sensitivity. Available genomic classifiers can risk stratify patients or assess potential added benefit of RT. Prospective validation is underway with cooperative group trials. Adjuvant RT, on the basis of adverse pathologic features (such as extraprostatic extension or positive margins) is beneficial in terms of disease control, but it is unclear whether this therapy translates into more meaningful clinical benefit (eg, improved overall survival and a reduction in metastasis), which has been demonstrated by only 1 older, prospective randomized study. Preliminary data suggest that for a relatively favorable-risk population (low Gleason score but with positive margins), PSA monitoring may be a reasonable alternative in some men. Use of androgen deprivation therapy and lymphatic irradiation should be considered in higher-risk cohorts (those with high PSA, high Gleason score, seminal vesicle invasion or node positivity) in conjunction with postoperative RT. Conclusions and Relevance The findings of this review suggest that postprostatectomy RT should be considered for men with prostate cancer in the setting of adverse pathologic features; in carefully selected patients with favorable characteristics, close PSA monitoring is an option. Androgen deprivation therapy and pelvic lymphatic irradiation should be considered for higher risk cohorts (eg, higher PSA values, higher Gleason score). PET imaging and molecular studies remain unproven as decision tools.
Collapse
Affiliation(s)
- Sean Sachdev
- Robert H. Lurie Comprehensive Cancer Center, Department of Radiation Oncology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Peter Carroll
- UCSF Hellen Diller Family Comprehensive Cancer Center, Department of Urology, University of California, San Francisco
| | - Howard Sandler
- Samuel Oschin Cancer Institute, Department of Radiation Oncology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Paul L Nguyen
- Dana Farber Cancer Institute, Department of Radiation Oncology, Brigham and Women's Hospital, Cambridge, Illinois
| | - Eileen Wafford
- Galter Health Sciences Library, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Gregory Auffenberg
- Robert H. Lurie Comprehensive Cancer Center, Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Edward Schaeffer
- Robert H. Lurie Comprehensive Cancer Center, Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Mack Roach
- UCSF Hellen Diller Family Comprehensive Cancer Center, Department of Radiation Oncology, University of California, San Francisco
| | - Christopher P Evans
- UC Davis Comprehensive Cancer Center, Department of Urologic Surgery, University of California, Davis, Sacramento
| | - Maha Hussain
- Robert H. Lurie Comprehensive Cancer Center, Division of Hematology/Oncology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| |
Collapse
|
8
|
Sargos P, Chabaud S, Latorzeff I, Magné N, Benyoucef A, Supiot S, Pasquier D, Abdiche MS, Gilliot O, Graff-Cailleaud P, Silva M, Bergerot P, Baumann P, Belkacemi Y, Azria D, Brihoum M, Soulié M, Richaud P. Adjuvant radiotherapy versus early salvage radiotherapy plus short-term androgen deprivation therapy in men with localised prostate cancer after radical prostatectomy (GETUG-AFU 17): a randomised, phase 3 trial. Lancet Oncol 2020; 21:1341-1352. [PMID: 33002438 DOI: 10.1016/s1470-2045(20)30454-x] [Citation(s) in RCA: 159] [Impact Index Per Article: 39.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 06/29/2020] [Accepted: 07/03/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Adjuvant radiotherapy reduces the risk of biochemical progression in prostate cancer patients after radical prostatectomy. We aimed to compare adjuvant versus early salvage radiotherapy after radical prostatectomy, combined with short-term hormonal therapy, in terms of oncological outcomes and tolerance. METHODS GETUG-AFU 17 was a randomised, open-label, multicentre, phase 3 trial done at 46 French hospitals. Men aged at least 18 years who had an Eastern Cooperative Oncology Group performance status of 1 or less, localised adenocarcinoma of the prostate treated with radical prostatectomy, who had pathologically-staged pT3a, pT3b, or pT4a (with bladder neck invasion), pNx (without pelvic lymph nodes dissection), or pN0 (with negative lymph nodes dissection) disease, and who had positive surgical margins were eligible for inclusion in the study. Eligible patients were randomly assigned (1:1) to either immediate adjuvant radiotherapy or delayed salvage radiotherapy at the time of biochemical relapse. Random assignment, by minimisation, was done using web-based software and stratified by Gleason score, pT stage, and centre. All patients received 6 months of triptorelin (intramuscular injection every 3 months). The primary endpoint was event-free survival. Efficacy and safety analyses were done on the intention-to-treat population. The trial is registered with ClinicalTrials.gov, NCT00667069. FINDINGS Between March 7, 2008, and June 23, 2016, 424 patients were enrolled. We planned to enrol 718 patients, with 359 in each study group. However, on May 20, 2016, the independent data monitoring committee recommended early termination of enrolment because of unexpectedly low event rates. At database lock on Dec 19, 2019, the overall median follow-up time from random assignment was 75 months (IQR 50-100), 74 months (47-100) in the adjuvant radiotherapy group and 78 months (52-101) in the salvage radiotherapy group. In the salvage radiotherapy group, 115 (54%) of 212 patients initiated study treatment after biochemical relapse. 205 (97%) of 212 patients started treatment in the adjuvant group. 5-year event-free survival was 92% (95% CI 86-95) in the adjuvant radiotherapy group and 90% (85-94) in the salvage radiotherapy group (HR 0·81, 95% CI 0·48-1·36; log-rank p=0·42). Acute grade 3 or worse toxic effects occurred in six (3%) of 212 patients in the adjuvant radiotherapy group and in four (2%) of 212 patients in the salvage radiotherapy group. Late grade 2 or worse genitourinary toxicities were reported in 125 (59%) of 212 patients in the adjuvant radiotherapy group and 46 (22%) of 212 patients in the salvage radiotherapy group. Late genitourinary adverse events of grade 2 or worse were reported in 58 (27%) of 212 patients in the adjuvant radiotherapy group versus 14 (7%) of 212 patients in the salvage radiotherapy group (p<0·0001). Late erectile dysfunction was grade 2 or worse in 60 (28%) of 212 in the adjuvant radiotherapy group and 17 (8%) of 212 in the salvage radiotherapy group (p<0·0001). INTERPRETATION Although our analysis lacked statistical power, we found no benefit for event-free survival in patients assigned to adjuvant radiotherapy compared with patients assigned to salvage radiotherapy. Adjuvant radiotherapy increased the risk of genitourinary toxicity and erectile dysfunction. A policy of early salvage radiotherapy could spare men from overtreatment with radiotherapy and the associated adverse events. FUNDING French Health Ministry and Ipsen.
Collapse
Affiliation(s)
| | | | | | - Nicolas Magné
- Institut de Cancérologie de la Loire, Saint-Priest-en-Jarèz, France
| | | | - Stéphane Supiot
- Institut de Cancérologie de l'Ouest, Site René Gauducheau, Saint-Herblain, France
| | - David Pasquier
- Centre Oscar Lambret and Lille University, Lille, France
| | | | | | | | | | - Philippe Bergerot
- Clinique Mutualiste de l'Estuaire, Cité Sanitaire, Saint-Nazaire, France
| | | | - Yazid Belkacemi
- Hôpitaux Universitaires Henri Mondor, Université Paris Est Créteil, Creteil, France
| | - David Azria
- Institut Régional du Cancer de Montpellier Val d'Aurelle, Montpellier, France
| | | | | | | |
Collapse
|
9
|
Zaorsky NG, Yu JB, McBride SM, Dess RT, Jackson WC, Mahal BA, Chen R, Choudhury A, Henry A, Syndikus I, Mitin T, Tree A, Kishan AU, Spratt DE. Prostate Cancer Radiation Therapy Recommendations in Response to COVID-19. Adv Radiat Oncol 2020; 5:659-665. [PMID: 32292839 PMCID: PMC7118610 DOI: 10.1016/j.adro.2020.03.010] [Citation(s) in RCA: 123] [Impact Index Per Article: 30.8] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2020] [Revised: 03/24/2020] [Accepted: 03/24/2020] [Indexed: 02/06/2023] Open
Abstract
PURPOSE During a global pandemic, the benefit of routine visits and treatment of patients with cancer must be weighed against the risks to patients, staff, and society. Prostate cancer is one of the most common cancers radiation oncology departments treat, and efficient resource utilization is essential in the setting of a pandemic. Herein, we aim to establish recommendations and a framework by which to evaluate prostate radiation therapy management decisions. METHODS AND MATERIALS Radiation oncologists from the United States and the United Kingdom rapidly conducted a systematic review and agreed upon recommendations to safely manage patients with prostate cancer during the COVID-19 pandemic. A RADS framework was created: remote visits, and avoidance, deferment, and shortening of radiation therapy was applied to determine appropriate approaches. RESULTS Recommendations were provided by the National Comprehensive Cancer Network risk group regarding clinical node-positive, postprostatectomy, oligometastatic, and low-volume M1 disease. Across all prostate cancer stages, telemedicine consultations and return visits were recommended when resources/staff available. Delays in consultations and return visits of between 1 and 6 months were deemed safe based on stage of disease. Treatment can be avoided or delayed until safe for very low, low, and favorable intermediate-risk disease. Unfavorable intermediate-risk, high-risk, clinical node-positive, recurrence postsurgery, oligometastatic, and low-volume M1 disease can receive neoadjuvant hormone therapy for 4 to 6 months as necessary. Ultrahypofractionation is preferred for localized, oligometastatic, and low-volume M1, and moderate hypofractionation is preferred for postprostatectomy and clinical node positive disease. Salvage is preferred to adjuvant radiation. CONCLUSIONS Resources can be reduced for all identified stages of prostate cancer. The RADS (remote visits, and avoidance, deferment, and shortening of radiation therapy) framework can be applied to other disease sites to help with decision making in a global pandemic.
Collapse
Affiliation(s)
- Nicholas G. Zaorsky
- Department of Radiation Oncology, Penn State Cancer Institute, Hershey, Pennsylvania
| | - James B. Yu
- Department of Therapeutic Radiology/Radiation Oncology, Yale, New Haven, Connecticut
| | - Sean M. McBride
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Robert T. Dess
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - William C. Jackson
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Brandon A. Mahal
- Department of Radiation Oncology, Dana Farber, Boston, Massachusetts
| | - Ronald Chen
- Department of Radiation Oncology, University of Kansas, Kansas City, Kansas
| | - Ananya Choudhury
- Division of Cancer Sciences, University of Manchester and The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Ann Henry
- Department of Clinical Oncology, Leeds Teaching Hospitals NHS Trust and the University of Leeds, Leeds, United Kingdom
| | - Isabel Syndikus
- Department of Clinical Oncology, The Clatterbridge Cancer Centre NHS Foundation Trust, Liverpool, United Kingdom
| | - Timur Mitin
- Knight Cancer Institute, Department of Radiation Medicine, Oregon Health and Science University, Portland, Oregon
| | - Alison Tree
- Radiotherapy and Imaging Division, Institute of Cancer Research, Sutton, London, United Kingdom
| | - Amar U. Kishan
- Department of Radiation Oncology, UCLA, Los Angeles, California
| | - Daniel E. Spratt
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| |
Collapse
|
10
|
Sanmamed N, Glicksman RM, Herrera-Caceres J, Lehrer EJ, Heaton J, Hansen AR, Chung P, Fleshner NE, Den RB, Zaorsky NG, Berlin A. Use of combined androgen deprivation therapy with postoperative radiation treatment for prostate cancer: Impact of randomized trials on clinical practice. Urol Oncol 2020; 38:848.e1-848.e7. [PMID: 32553790 DOI: 10.1016/j.urolonc.2020.04.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 04/01/2020] [Accepted: 04/18/2020] [Indexed: 11/19/2022]
Abstract
PURPOSE To assess the impact of RTOG-9601 and GETUG-AFU-16 on the routine use of combination androgen deprivation therapy (ADT) with postoperative radiotherapy (PORT) for prostate cancer (CaP). MATERIAL AND METHODS Patients with localized CaP treated with radical prostatectomy (RP) and PORT with or without ADT at a comprehensive cancer center from January 2006 to June 2007 (Period 1 = P1), July 2011 to December 2012 (Period 2 = P2), and January 2017 to June 2018 (Period 3 = P3) were included. Clinicopathologic features and treatment characteristics were analyzed and compared. Multivariable logistic regression was used to assess prognostic factors and association with ADT use. Statistical tests were two-sided and a P value <0.05 was considered significant. To validate the findings, United States National Cancer Database (NCDB) and Surveillance, Epidemiology, and End Results (SEER) data were collected to assess rates of combined ADT and PORT from 2004 to 2015. RESULTS Five hundred and two patients were included: 152 (P1), 185 (P2), and 165 (P3). PORT was most commonly delivered as early SRT (delivered >1 year post-RP with undetectable PSA or PSA >0.05 and ≤0.5 ng/ml) in all periods. The use of combination PORT and ADT increased over time: 14.5% (P1), 32% (P2), and 41% (P3) (P < 0.001). The proportion of patients that met eligibility criteria for either GETUG-AFU-16 or RTOG-9601 decreased from 47% (P1) to 35% (P3) (P = 0.04). International Society of Urological Pathology grade ≥4 (P < 0.002) and pre-PORT PSA >0.5 ng/ml (P < 0.001) were associated with use of ADT. Positive surgical margin status had a negative association (RR 0.5, P < 0.002). The NCDB demonstrated similar trends for use of combined ADT with PORT, increasing from 37% to 49% from 2004 to 2015. CONCLUSION The use of combined ADT with PORT increased over time. However, only a third of contemporary patients undergoing PORT are represented in the major trials supporting the evidence for combination treatment, highlighting the need to characterize the modern impact of this intensification strategy.
Collapse
Affiliation(s)
- Noelia Sanmamed
- Department of Radiation Oncology, University of Toronto, Toronto, Canada; Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Canada; Department of Radiation Oncology, Hospital Clinico San Carlos, Madrid, Spain.
| | - Rachel M Glicksman
- Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Jaime Herrera-Caceres
- Division of Urology, Department of Surgery, Princess Margaret Cancer Centre, University Health Network, Canada
| | - Eric J Lehrer
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, Mount Sinai, NY
| | - Jaqueline Heaton
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Canada
| | - Aaron R Hansen
- Division of Medical Oncology, Princess Margaret Cancer Centre, University Health Network, Canada
| | - Peter Chung
- Department of Radiation Oncology, University of Toronto, Toronto, Canada; Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Canada
| | - Neil E Fleshner
- Division of Urology, Department of Surgery, Princess Margaret Cancer Centre, University Health Network, Canada
| | - Robert B Den
- Department of Radiation Oncology, Sidney Kimmel Medical College and Cancer Center, Thomas Jefferson University, Philadelphia, PA
| | - Nicholas G Zaorsky
- Department of Radiation Oncology, Penn State Cancer Institute, and the Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA
| | - Alejandro Berlin
- Department of Radiation Oncology, University of Toronto, Toronto, Canada; Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Canada; Techna Institute, University Health Network, Canada.
| |
Collapse
|
11
|
Salvage Treatment for Biochemical Failure After Radical Prostatectomy: Do We Now Have the Answers? Eur Urol 2020; 77:699-700. [DOI: 10.1016/j.eururo.2020.01.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 01/23/2020] [Indexed: 11/22/2022]
|
12
|
Ghadjar P, Wiegel T. Androgen deprivation therapy plus salvage radiotherapy after prostatectomy. Lancet Oncol 2020; 21:e11. [DOI: 10.1016/s1470-2045(19)30730-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Accepted: 10/25/2019] [Indexed: 10/25/2022]
|