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Solanki AJ, Kamrava M, Posadas EM, Freedland SJ, Ballas L, Sandler HM, Bairey Merz CN, Atkins KM, Nikolova AP. A practical guide for assessing and managing cardiovascular risk during androgen-deprivation therapy in patients with prostate cancer. Cancer 2024; 130:1916-1929. [PMID: 38529566 DOI: 10.1002/cncr.35285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 02/23/2024] [Accepted: 02/26/2024] [Indexed: 03/27/2024]
Abstract
Prostate cancer is the most common malignancy among men worldwide, and androgen-deprivation therapy (ADT) is a mainstay of treatment. There are observational data demonstrating an increased risk of cardiovascular events in patients who receive ADT, particularly those who have an elevated baseline cardiovascular risk. Because, for most patients with prostate cancer, death is predominantly from noncancer-related causes, cardiovascular disease and its risk factors should be optimized during cancer treatment. This review provides an overview of the landscape of ADT treatment and serves as a guide for appropriate cardiovascular screening and risk-mitigation strategies. The authors emphasize the importance of shared communication between the multidisciplinary cancer team and primary care to improve baseline cardiovascular screening and treatment of modifiable risk factors within this higher risk population.
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Affiliation(s)
- Aum J Solanki
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Mitchell Kamrava
- Department of Radiation Oncology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Edwin M Posadas
- Department of Medicine, Division of Hematology Oncology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Stephen J Freedland
- Department of Urology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Leslie Ballas
- Department of Radiation Oncology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Howard M Sandler
- Department of Radiation Oncology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - C Noel Bairey Merz
- Department of Cardiology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Katelyn M Atkins
- Department of Radiation Oncology, Cedars-Sinai Medical Center, Los Angeles, California, USA
- Department of Cardiology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Andriana P Nikolova
- Department of Cardiology, Cedars-Sinai Medical Center, Los Angeles, California, USA
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2
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Lee WR, Dignam JJ, Amin MB, Bruner DW, Low D, Swanson GP, Shah AB, D'Souza D, Michalski JM, Dayes IS, Seaward SA, Hall WA, Nguyen PL, Pisansky TM, Faria SL, Chen Y, Rodgers JP, Sandler HM. Long-Term Analysis of NRG Oncology RTOG 0415: A Randomized Phase III Noninferiority Study Comparing Two Fractionation Schedules in Patients With Low-Risk Prostate Cancer. J Clin Oncol 2024:JCO2302445. [PMID: 38759121 DOI: 10.1200/jco.23.02445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 01/16/2024] [Accepted: 03/12/2024] [Indexed: 05/19/2024] Open
Abstract
Clinical trials frequently include multiple end points that mature at different times. The initial report, typically based on the primary end point, may be published when key planned co-primary or secondary analyses are not yet available. Clinical Trial Updates provide an opportunity to disseminate additional results from studies, published in JCO or elsewhere, for which the primary end point has already been reported.NRG Oncology RTOG 0415 is a randomized phase III noninferiority (NI) clinical trial comparing conventional fractionation (73.8 Gy in 41 fractions) radiotherapy (C-RT) with hypofractionation (H-RT; 70 Gy in 28) in patients with low-risk prostate cancer. The study included 1,092 protocol-eligible patients initially reported in 2016 with a median follow-up of 5.8 years. Updated results with median follow-up of 12.8 years are now presented. The estimated 12-year disease-free survival (DFS) is 56.1% (95% CI, 51.5 to 60.5) for C-RT and 61.8% (95% CI, 57.2 to 66.0) for H-RT. The DFS hazard ratio (H-RT/C-RT) is 0.85 (95% CI, 0.71 to 1.03), confirming NI (P < .001). Twelve-year cumulative incidence of biochemical failure (BF) was 17.0% (95% CI, 13.8 to 20.5) for C-RT and 9.9% (95% CI, 7.5 to 12.6) for H-RT. The HR (H-RT/C-RT) comparing biochemical recurrence between the two arms was 0.55 (95% CI, 0.39 to 0.78). Late grade ≥3 GI adverse event (AE) incidence is 3.2% (C-RT) versus 4.4% (H-RT), with relative risk (RR) for H-RT versus C-RT 1.39 (95% CI, 0.75 to 2.55). Late grade ≥3 genitourinary (GU) AE incidence is 3.4% (C-RT) versus 4.2% (H-RT), RR 1.26 (95% CI, 0.69 to 2.30). Long-term DFS is noninferior with H-RT compared with C-RT. BF is less with H-RT. No significant differences in late grade ≥3 GI/GU AEs were observed between assignments (ClinicalTrials.gov identifier: NCT00331773).
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Affiliation(s)
| | - James J Dignam
- Department of Public Health Sciences, University of Chicago, Chicago, IL
- NRG Oncology Statistics and Data Management Center, Philadelphia, PA
| | | | | | - Daniel Low
- University of California, Los Angeles, Los Angeles, CA
| | | | | | | | | | | | | | | | - Paul L Nguyen
- Dana-Farber Cancer Institute and Brigham and Women's Hospital, Boston, MA
| | | | | | - Yuhchyau Chen
- University of Rochester Medical Center, Wilmot Cancer Institute, Rochester, NY
| | - Joseph P Rodgers
- NRG Oncology Statistics and Data Management Center, Philadelphia, PA
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3
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Dahl DM, Karrison TG, Michaelson MD, Pham HT, Wu CL, Swanson GP, Shipley WU, Vuky J, Lee RJ, Zietman AL, Souhami L, Chang BK, Deming RL, Ellerton JA, Sandler HM, Rodgers JP, Feng FY, Efstathiou JA. Long-term Outcomes of Chemoradiation for Muscle-invasive Bladder Cancer in Noncystectomy Candidates. Final Results of NRG Oncology RTOG 0524-A Phase 1/2 Trial of Paclitaxel + Trastuzumab with Daily Radiation or Paclitaxel Alone with Daily Irradiation. Eur Urol Oncol 2024; 7:83-90. [PMID: 37442672 PMCID: PMC10782593 DOI: 10.1016/j.euo.2023.05.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 04/27/2023] [Accepted: 05/30/2023] [Indexed: 07/15/2023]
Abstract
BACKGROUND Chemo-radiation is a well-established alternative to radical cystectomy in patients with muscle-invasive bladder cancer. Many patients due to age or medical comorbidity are unfit for either radical cystectomy, or standard cisplatin- or 5-fluorouracil-based chemoradiation, and do not receive appropriate treatment with curative intent. We treated patients with a less aggressive protocol employing seven weekly doses of paclitaxel and daily irradiation. In those whose tumors showed overexpression of her2/neu, seven weekly doses of trastuzumab were also administered. OBJECTIVE To report the long-term survival outcomes and toxicity results of the of NRG Oncology RTOG 0524 study. DESIGN, SETTING, AND PARTICIPANTS Seventy patients were enrolled and 65 (median age: 76 yr) were deemed eligible. Patients were assigned to daily radiation and weekly paclitaxel + trastuzumab (group 1, 20 patients) or to daily radiation plus weekly paclitaxel (group 2, 45 patients) based on tumor her2/neu overexpression. Radiation was delivered in 1.8 Gy fractions to a total dose of 64.8 Gy. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS The primary endpoint was unresolved treatment-related toxicity. The secondary endpoints were complete response rate, protocol completion rate, and disease-free and overall survival. RESULTS AND LIMITATIONS Protocol therapy was completed by 60% (group 1) and 76% (group 2); complete response rates at 12 wk were 62% in each group. Acute treatment-related adverse events (AEs) of grade ≥3 were observed in 80% in group 1 and 58% in group 2. There was one treatment-related grade 5 AE in group 1. Unresolved acute treatment-related toxicity was 35% in group 1 and 31% in group 2. The median follow-up was 2.3 yr in all patients and 7.2 yr in surviving patients. Overall survival at 5 yr was 25.0% in group 1 and 37.8% in group 2 (33.8% overall). At 5 yr, disease-free survival was 15.0% in group 1 and 31.1% in group 2. CONCLUSIONS In a cohort of patients with muscle-invasive bladder cancer who are not candidates for cystectomy or cisplatin chemotherapy, chemoradiation therapy offers a treatment with a significant response rate and 34% 5-yr overall survival. While there were many AEs in this medically fragile group, there were few grade 4 events and one grade 5 event attributable to therapy. PATIENT SUMMARY Patients with invasive bladder cancer who cannot tolerate surgery were treated with radiation and systemic therapy without surgically removing their bladders. Most patients tolerated the treatment, were able to keep their bladders, and showed a significant treatment response rate.
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Affiliation(s)
- Douglas M Dahl
- Massachusetts General Hospital Cancer Center, Boston, MA, USA.
| | - Theodore G Karrison
- NRG Oncology Statistics and Data Management Center, Philadelphia, PA, USA; University of Chicago, Chicago, IL, USA
| | | | | | - Chin-Lee Wu
- Massachusetts General Hospital Cancer Center, Boston, MA, USA
| | | | | | - Jacqueline Vuky
- OHSU Knight Cancer Institute, Accrual-Virginia Mason CCOP, Portland, OR, USA
| | - R Jeffrey Lee
- Intermountain Medical Center, Salt Lake City, UT, USA
| | | | - Luis Souhami
- The Research Institute of the McGill University Health Centre (MUHC), Montreal, QC, Canada
| | | | - Richard L Deming
- Mercy Medical Center - Des Moines, Accrual-Penrose Cancer Center, Penrose-St. Francis Health Services, Des Moines, IA, USA
| | | | | | - Joseph P Rodgers
- NRG Oncology Statistics and Data Management Center, Philadelphia, PA, USA
| | - Felix Y Feng
- UCSF Medical Center-Mission Bay, San Francisco, CA, USA
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4
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Mak KS, Scannell Bryan M, Dignam JJ, Shipley WU, Lin Y, Peters CA, Gore EM, Rosenthal SA, Zeitzer KL, D'Souza DP, Horwitz EM, Pisansky TM, Maier JM, Chafe SM, Robin TP, Roach M, Tran PT, Souhami L, Michalski JM, Hartford AC, Feng FY, Sandler HM, Efstathiou JA. Cardiovascular Mortality and Duration of Androgen Deprivation in Locally Advanced Prostate Cancer: Long-term Update of NRG/RTOG 9202. Eur Urol Focus 2024:S2405-4569(24)00011-7. [PMID: 38307806 DOI: 10.1016/j.euf.2024.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 12/11/2023] [Accepted: 01/15/2024] [Indexed: 02/04/2024]
Abstract
BACKGROUND Androgen deprivation therapy (ADT) has been associated with coronary heart disease and myocardial infarction (MI) in prostate cancer patients, but controversy persists regarding its effects on cardiovascular mortality (CVM). OBJECTIVE We assessed the long-term relationship between ADT and CVM in a prostate cancer randomized trial (NRG Oncology/Radiation Therapy Oncology Group 9202). DESIGN, SETTING, AND PARTICIPANTS From 1992 to 1995, 1554 men with locally advanced prostate cancer (T2c-T4, prostate-specific antigen <150 ng/ml) received radiotherapy with 4 mo (short-term [STADT]) versus 28 mo (longer-term [LTADT]) of ADT. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Using the Fine-Gray and Cox regression models, the relationship between ADT and mortality was evaluated. RESULTS AND LIMITATIONS With a median follow-up of 19.6 yr, LTADT was associated with improved overall survival (OS) versus STADT (adjusted hazard ratio [HR] 0.88; p = 0.03) and prostate cancer survival (subdistribution HR [sHR] 0.70, p = 0.003). Comparing LTADT with STADT, prostate cancer mortality improved by 6.0% (15.6% [95% confidence interval 13.0-18.3%] vs 21.6% [18.6-24.7%]) at 15 yr, while CVM increased by 2.2% (14.9% [12.4-17.6%] vs 12.7% [10.4-15.3%]). In multivariable analyses, LTADT was not associated with increased CVM versus STADT (sHR 1.22 [0.93-1.59]; p = 0.15). An association between LTADT and MI death was detected (sHR 1.58 [1.00-2.50]; p = 0.05), particularly in patients with prevalent cardiovascular disease (CVD; sHR 2.54 [1.16-5.58]; p = 0.02). CONCLUSIONS With 19.6 yr of follow-up, LTADT was not significantly associated with increased CVM in men with locally advanced prostate cancer. Patients may have increased MI mortality with LTADT, particularly those with baseline CVD. Overall, there remained a prostate cancer mortality benefit and no OS detriment with LTADT. PATIENT SUMMARY In a long-term analysis of a large randomized prostate cancer trial, radiation with 28 mo of hormone therapy did not increase the risk of cardiovascular death significantly versus 4 mo of hormone therapy. Future studies are needed for patients with pre-existing heart disease, who may have an increased risk of myocardial infarction death with longer hormone use.
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Affiliation(s)
- Kimberley S Mak
- Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA.
| | | | - James J Dignam
- University of Chicago, Chicago, IL, USA; NRG Oncology Statistics and Data Management Center, Philadelphia, PA, USA
| | - William U Shipley
- Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Yue Lin
- Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | | | - Elizabeth M Gore
- Medical College of Wisconsin and the Zablocki Veteran Affairs Medical Center, Milwaukee, WI, USA
| | | | | | | | | | | | - Jordan M Maier
- Wayne State University-Karmanos Cancer Institute, Detroit, MI, USA
| | | | | | - Mack Roach
- University of California San Francisco, San Francisco, CA, USA
| | | | - Luis Souhami
- The Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | | | - Alan C Hartford
- Dartmouth-Hitchcock Medical Center/Norris Cotton Cancer Center, Lebanon, NH, USA
| | - Felix Y Feng
- University of California San Francisco, San Francisco, CA, USA
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5
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Ross AE, Zhang J, Huang HC, Yamashita R, Keim-Malpass J, Simko JP, DeVries S, Morgan TM, Souhami L, Dobelbower MC, McGinnis LS, Jones CU, Dess RT, Zeitzer KL, Choi K, Hartford AC, Michalski JM, Raben A, Gomella LG, Sartor AO, Rosenthal SA, Sandler HM, Spratt DE, Pugh SL, Mohamad O, Esteva A, Chen E, Schaeffer EM, Tran PT, Feng FY. External Validation of a Digital Pathology-based Multimodal Artificial Intelligence Architecture in the NRG/RTOG 9902 Phase 3 Trial. Eur Urol Oncol 2024:S2588-9311(24)00029-4. [PMID: 38302323 DOI: 10.1016/j.euo.2024.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 12/02/2023] [Accepted: 01/05/2024] [Indexed: 02/03/2024]
Abstract
BACKGROUND Accurate risk stratification is critical to guide management decisions in localized prostate cancer (PCa). Previously, we had developed and validated a multimodal artificial intelligence (MMAI) model generated from digital histopathology and clinical features. Here, we externally validate this model on men with high-risk or locally advanced PCa treated and followed as part of a phase 3 randomized control trial. OBJECTIVE To externally validate the MMAI model on men with high-risk or locally advanced PCa treated and followed as part of a phase 3 randomized control trial. DESIGN, SETTING, AND PARTICIPANTS Our validation cohort included 318 localized high-risk PCa patients from NRG/RTOG 9902 with available histopathology (337 [85%] of the 397 patients enrolled into the trial had available slides, of which 19 [5.6%] failed due to poor image quality). OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Two previously locked prognostic MMAI models were validated for their intended endpoint: distant metastasis (DM) and PCa-specific mortality (PCSM). Individual clinical factors and the number of National Comprehensive Cancer Network (NCCN) high-risk features served as comparators. Subdistribution hazard ratio (sHR) was reported per standard deviation increase of the score with corresponding 95% confidence interval (CI) using Fine-Gray or Cox proportional hazards models. RESULTS AND LIMITATIONS The DM and PCSM MMAI algorithms were significantly and independently associated with the risk of DM (sHR [95% CI] = 2.33 [1.60-3.38], p < 0.001) and PCSM, respectively (sHR [95% CI] = 3.54 [2.38-5.28], p < 0.001) when compared against other prognostic clinical factors and NCCN high-risk features. The lower 75% of patients by DM MMAI had estimated 5- and 10-yr DM rates of 4% and 7%, and the highest quartile had average 5- and 10-yr DM rates of 19% and 32%, respectively (p < 0.001). Similar results were observed for the PCSM MMAI algorithm. CONCLUSIONS We externally validated the prognostic ability of MMAI models previously developed among men with localized high-risk disease. MMAI prognostic models further risk stratify beyond the clinical and pathological variables for DM and PCSM in a population of men already at a high risk for disease progression. This study provides evidence for consistent validation of our deep learning MMAI models to improve prognostication and enable more informed decision-making for patient care. PATIENT SUMMARY This paper presents a novel approach using images from pathology slides along with clinical variables to validate artificial intelligence (computer-generated) prognostic models. When implemented, clinicians can offer a more personalized and tailored prognostic discussion for men with localized prostate cancer.
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Affiliation(s)
- Ashley E Ross
- Department of Urology, Northwestern Medicine, Chicago, IL, USA.
| | | | | | | | | | - Jeffry P Simko
- University of California San Francisco, San Francisco, CA, USA
| | - Sandy DeVries
- University of California San Francisco, San Francisco, CA, USA
| | | | - Luis Souhami
- The Research Institute of the McGill University Health Centre (MUHC), Montreal, QC, Canada
| | | | | | | | | | | | - Kwang Choi
- Brooklyn MB-CCOP/SUNY Downstate, Brooklyn, NY, USA
| | | | | | - Adam Raben
- Christiana Care Health Services, Inc. CCOP, Wilmington, DE, USA
| | | | - A Oliver Sartor
- Tulane University Health Sciences Center, New Orleans, LA, USA
| | | | | | - Daniel E Spratt
- UH Seidman Cancer Center, Case Western Reserve University, Cleveland, OH, USA
| | - Stephanie L Pugh
- NRG Oncology Statistics and Data Management Center and American College of Radiology, Philadelphia, PA, USA
| | - Osama Mohamad
- University of California San Francisco, San Francisco, CA, USA
| | | | | | | | | | - Felix Y Feng
- University of California San Francisco, San Francisco, CA, USA
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6
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Michalski JM, Moughan J, Purdy JA, Bruner DW, Amin M, Bahary JP, Lau H, Duclos M, Yee D, Morton G, Dess RT, Doncals DE, Lock MI, Lukka H, Baumann BC, Vigneault E, Kwok Y, Robertson J, Schwartz DL, Sandler HM. Long-Term Outcomes of NRG/RTOG 0126, a Randomized Trial of High Dose (79.2 Gy) vs. Standard Dose (70.2 Gy) Radiation Therapy (RT) for Men with Localized Prostate Cancer. Int J Radiat Oncol Biol Phys 2023; 117:S4-S5. [PMID: 37784491 DOI: 10.1016/j.ijrobp.2023.06.210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) NRG/RTOG 0126, a phase III trial for men with localized prostate cancer testing whether dose escalation to 79.2 Gy with 3DCRT/IMRT improved overall survival (OS). Long-term results of this trial are presented. MATERIALS/METHODS Patients with clinical stage T1b-T2b and either Gleason Score (GS) 2-6 and 10 ≤ PSA < 20 or GS 7 and PSA < 15 were eligible and randomized to receive 79.2 Gy or 70.2 Gy. No previous or concurrent androgen withdrawal therapy was administered. Treatment was delivered with 3DCRT/IMRT to a dose of 79.2 Gy in 44 fractions or 70.2 Gy in 39 fractions to the PTV encompassing the prostate and seminal vesicles. Image guidance was not required. ASTRO and Phoenix definitions were used for biochemical failure (ABF and PBF, respectively). OS was estimated by the Kaplan-Meier method and arms compared with the log-rank test. ABF, PBF, local progression (LP), distant metastases (DM) and time to late GI/GU toxicities were estimated by the cumulative incidence method and arms compared with Gray's test. RESULTS One thousand five hundred thirty-two men were randomized, 763 to 79.2 Gy and 769 to 70.2 Gy. 1499 were eligible, 748 and 751 in the 79.2 Gy and 70.2 Gy arms respectively. Median age was 71, 70% had PSA < 10 ng/ml, 84% with GS 7, 57% had T1 disease, and 66% treated with 3D-CRT. Outcomes are shown in the TABLE: . With a median follow up of 12 years, there was no significant difference in OS. There was a statistically significant decrease in the cumulative incidence of ABF, PBF, DM, LP, and salvage therapies in the 79.2 Gy arm. There were significantly higher rates of grade 2+ GI and GU toxicity in the 79.2 Gy arm. There were no statistically significant differences in the rates of grade 3+ GU or GI toxicity between either arm. CONCLUSION Long term follow up confirms no improvement in OS with dose escalation in this study population. However, there are significant improvements in ABF, PBF, DM, LP, and need for salvage therapy. Despite the use of more salvage therapy in the low dose arm, dose escalated RT resulted in lower rates of DM, a clinically relevant endpoint. Patients receiving dose escalation do experience a higher rate of grade 2+ GU and GI toxicity but no worse grade 3+ toxicities.
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Affiliation(s)
- J M Michalski
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO
| | - J Moughan
- NRG Oncology Statistics and Data Management Center/ACR, Philadelphia, PA
| | | | | | - M Amin
- University of Tennessee Health Science Center, Memphis, TN
| | - J P Bahary
- Centre Hospitalier de l'Université de Montreal, Montreal, QC, Canada
| | - H Lau
- University of Calgary, Calgary, AB, Canada
| | - M Duclos
- McGill University Health Centre, Division of Radiation Oncology, Montreal, QC, Canada
| | - D Yee
- Cross Cancer Institute, Edmonton, AB, Canada
| | - G Morton
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - R T Dess
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI
| | | | - M I Lock
- London Health Sciences Centre, London, ON, Canada
| | - H Lukka
- Juravinski Cancer Centre, Hamilton, ON, Canada
| | - B C Baumann
- Washington University School of Medicine in St. Louis, Department of Radiation Oncology, St. Louis, MO
| | - E Vigneault
- CHU de Quebec-L'Hotel-Dieu de Quebec (HDQ), Québec, QC, Canada
| | - Y Kwok
- Department of Radiation Oncology, University of Maryland Proton Treatment Center, Baltimore, MD
| | - J Robertson
- Department of Radiation Oncology, Corewell Health William Beaumont University Hospital, Royal Oak, MI
| | | | - H M Sandler
- Cedars-Sinai Medical Center, Los Angeles, CA
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7
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Spratt DE, Liu VYT, Michalski J, Davicioni E, Berlin A, Simko JP, Efstathiou JA, Tran PT, Sandler HM, Hall WA, Thompson DJS, Parliament MB, Dayes IS, Correa RJM, Robertson JM, Gore EM, Doncals DE, Vigneault E, Souhami L, Karrison TG, Feng FY. Genomic Classifier Performance in Intermediate-Risk Prostate Cancer: Results From NRG Oncology/RTOG 0126 Randomized Phase 3 Trial. Int J Radiat Oncol Biol Phys 2023; 117:370-377. [PMID: 37137444 PMCID: PMC10949135 DOI: 10.1016/j.ijrobp.2023.04.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 03/15/2023] [Accepted: 04/12/2023] [Indexed: 05/05/2023]
Abstract
PURPOSE Intermediate-risk prostate cancer is a heterogeneous disease state with diverse treatment options. The 22-gene Decipher genomic classifier (GC) retrospectively has shown to improve risk stratification in these patients. We assessed the performance of the GC in men with intermediate-risk disease enrolled in NRG Oncology/RTOG 01-26 with updated follow-up. METHODS AND MATERIALS After National Cancer Institute approval, biopsy slides were collected from NRG Oncology/RTOG 01-26, a randomized phase 3 trial of men with intermediate-risk prostate cancer randomized to 70.2 Gy versus 79.2 Gy of radiation therapy without androgen deprivation therapy. RNA was extracted from the highest-grade tumor foci to generate the locked 22-gene GC model. The primary endpoint for this ancillary project was disease progression (composite of biochemical failure, local failure, distant metastasis, prostate cancer-specific mortality, and use of salvage therapy). Individual endpoints were also assessed. Fine-Gray or cause-specific Cox multivariable models were constructed adjusting for randomization arm and trial stratification factors. RESULTS Two-hundred fifteen patient samples passed quality control for analysis. The median follow-up was 12.8 years (range, 2.4-17.7). On multivariable analysis, the 22-gene GC (per 0.1 unit) was independently prognostic for disease progression (subdistribution hazard ratio [sHR], 1.12; 95% confidence interval [CI], 1.00-1.26; P = .04), biochemical failure (sHR, 1.22; 95% CI, 1.10-1.37; P < .001), distant metastasis (sHR, 1.28; 95% CI, 1.06-1.55; P = .01), and prostate cancer-specific mortality (sHR, 1.45; 95% CI, 1.20-1.76; P < .001). Ten-year distant metastasis in GC low-risk patients was 4% compared with 16% for GC high-risk patients. In patients with lower GC scores, the 10-year difference in metastasis-free survival rate between arms was -7%, compared with 21% for higher GC patients (P-interaction = .04). CONCLUSIONS This study represents the first validation of a biopsy-based gene expression classifier, assessing both its prognostic and predictive value, using data from a randomized phase 3 trial of intermediate-risk prostate cancer. Decipher improves risk stratification and can aid in treatment decision-making in men with intermediate-risk disease.
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Affiliation(s)
- Daniel E Spratt
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Cleveland, Ohio.
| | | | - Jeff Michalski
- Department of Radiation Oncology, Washington University, St. Louis, Missouri
| | | | - Alejandro Berlin
- Princess Margaret Cancer Centre, Cancer Clinical Research Unit, Toronto, Ontario, Canada
| | - Jeffry P Simko
- Department of Pathology, UCSF Medical Center-Mount Zion, San Francisco, California
| | - Jason A Efstathiou
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Phuoc T Tran
- Department of Pathology, University of Maryland, Baltimore, Maryland
| | - Howard M Sandler
- Department of Radiation Oncology, Cedars-Sinai Medical Center, Los Angeles, California
| | - William A Hall
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | | | - Matthew B Parliament
- Division of Radiation Oncology, Cross Cancer Institute, Edmonton, Alberta, Canada
| | - Ian S Dayes
- Division of Radiation Oncology, Hamilton Regional Cancer Centre, Ontario, Canada
| | | | - John M Robertson
- Department of Radiation Oncology, Beaumont Health CCOP, Royal Oak, Michigan
| | - Elizabeth M Gore
- Department of Radiation Oncology, Milwaukee VA Medical Center, Milwaukee, Wisconsin
| | | | - Eric Vigneault
- Department of Radiation Oncology, CHU de Quebec Universite Laval, Quebec, Canada
| | - Luis Souhami
- Department of Radiation Oncology, Cedars Cancer Centre, McGill University, Quebec, Canada
| | - Theodore G Karrison
- NRG Oncology Statistics and Data Management Center, Philadelphia, Pennsylvania
| | - Felix Y Feng
- Department of Radiation Oncology, University of California San Francisco, San Francisco, California
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8
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Phillips R, Proudfoot J, Davicioni E, Spratt DE, Feng FY, Simko J, Den RB, Pollack A, Rosenthal SA, Sartor O, Sweeney C, Attard G, Patel SI, Hall WA, Efstathiou JA, Shah AB, Hoffman KE, Pugh S, Sandler HM, Tran PT. Validation of a Genomic Classifier in the NRG Oncology/RTOG 0521 Phase III Trial of Docetaxel with Androgen Suppression and Radiotherapy for Localized High-Risk Prostate Cancer. Int J Radiat Oncol Biol Phys 2023; 117:S34-S35. [PMID: 37784480 DOI: 10.1016/j.ijrobp.2023.06.300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) Decipher is a prognostic genomic classifier (GC) validated in several prospective NRG Oncology Phase III trials. Herein, we validate the GC in pre-treatment biopsy samples for risk stratification in a cohort of high-risk men treated with definitive radiotherapy and androgen suppression with or without docetaxel chemotherapy. MATERIALS/METHODS As per a pre-specified and approved NCI analysis plan (Navigator #1061), we obtained available formalin-fixed paraffin-embedded tissue from biopsy specimens from the NRG biobank from patients enrolled on the NRG/RTOG 0521 randomized phase III trial. After central review, the highest-grade tumors were profiled on clinical-grade whole-transcriptome arrays (Veracyte, San Diego, CA) and GC scores were obtained. Pre-specified categorical GC scores, adjusted for archival tissue analysis, were used to define higher (>0.46) and lower (≤0.46) risk groups. The primary objective was to validate the independent prognostic ability of GC for metastasis-free survival (MFS) with Cox multivariable analyses (MVA). RESULTS Samples were obtained from 283 consented, evaluable patients with tissue (50% of trial) yielding 183 (65%) GC scores that passed quality metrics, 91 from control and 92 from the interventional arm. Median age was 66 years, median PSA was 19.3 ng/uL (IQR: 8.1-41.4), 81% had clinical stage ≥T2 and 80% had Gleason score ≥8 (47% ≥9). Median GC score was 0.55 (IQR: 0.38-0.78) and overall the arms were balanced for key covariates. With a median follow-up of 9.9 years (IQR: 9.3, 10.7), 67 MFS events including 34 distant metastases (DM) were observed. On MVA, only the GC (per 0.1 unit) was independently associated with MFS (HR 1.12, 95% CI 1.01-1.25) as well as DM (sHR 1.22, 95% CI 1.06-1.41), whereas the 4 pre-defined trial risk groups used for stratification (based on Gleason score, T-stage and PSA), randomization and patient age were not. For categorical GC, on MVA, higher-risk GC patients (65%) had worse DM (sHR 2.82, 95% CI 1.1-7.3) compared to those with lower GC. Cumulative incidence of DM at 10-years was 27% for higher GC vs 9% (95% CI 7-18%) for lower GC. No biomarker-by-treatment interaction with GC and the addition of docetaxel was detected. CONCLUSION In pre-treatment biopsy samples from a randomized Phase 3 trial cohort, GC demonstrated its ability to further risk stratify clinically high-risk men demonstrating an independent association of GC score with DM and MFS. High-risk prostate cancer is a heterogeneous disease state and GC can improve risk stratification to help personalize shared decision-making. NRG-GU009/PREDICT-RT (NCT04513717) aims to determine the optimal therapy based on GC score for high-risk prostate cancer.
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Affiliation(s)
- R Phillips
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
| | | | | | - D E Spratt
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center and Case Western Reserve University, Cleveland, OH
| | - F Y Feng
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA
| | | | - R B Den
- Department of Radiation Oncology, Sidney Kimmel Medical College & Cancer Center at Thomas Jefferson University, Philadelphia, PA
| | - A Pollack
- Department of Radiation Oncology, University of Miami/Sylvester Comprehensive Cancer Center, Miami, FL
| | - S A Rosenthal
- Sutter Medical Group and Cancer Center, Sacramento, CA
| | - O Sartor
- Tulane University, New Orleans, LA
| | - C Sweeney
- South Australian Immunogenomics Cancer Institute, Adelaide, Australia
| | - G Attard
- The Institute of Cancer Research, London, United Kingdom
| | - S I Patel
- Division of Radiation Oncology, University of Alberta, Edmonton, AB, Canada
| | - W A Hall
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI
| | - J A Efstathiou
- Department of Radiation Oncology, Harvard School of Medicine, Boston, MA
| | - A B Shah
- York Cancer Center, York, PA, United States
| | - K E Hoffman
- Department of Breast Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - S Pugh
- NRG Oncology Statistics and Data Management Center, Philadelphia, PA
| | - H M Sandler
- Cedars-Sinai Medical Center, Los Angeles, CA
| | - P T Tran
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD
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9
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Lee JY, Dess RT, Zelefsky MJ, Davis BJ, Horwitz EM, Cooperberg MR, Zaorsky NG, Jia AY, Sandler HM, Efstathiou JA, Pisansky TM, Hall E, Tree A, Roy S, Bolla M, Nabid A, Zapatero A, Kishan AU, Spratt DE, Sun Y. Individual Patient Data Analysis of 17 Randomized Trials vs. Real-World Data for Men with Localized Prostate Cancer Receiving Radiotherapy. Int J Radiat Oncol Biol Phys 2023; 117:e404-e405. [PMID: 37785347 DOI: 10.1016/j.ijrobp.2023.06.1543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) Prior work has demonstrated poor correlation between the results of randomized controlled trials (RCTs) and real-world evidence (RWD). However, patients enrolled in RCTs are often considered to poorly represent the real-world population. Herein, we utilize multiple large data repositories to determine differences in baseline characteristics and long-term outcomes between patients enrolled in RCTs and RWD that received radiotherapy for localized prostate cancer. MATERIALS/METHODS Meta-Analysis of Randomized trials in Cancer of the Prostate (MARCAP) Consortium was leveraged, and 17 phase III randomized trials were included. RWD were accessed through the Staging Collaboration for Cancer of the Prostate (STAR-CAP) cohort, a cohort that is comprised of >60 centers across the United States and Europe. Additionally, RWD was assessed via the Surveillance, Epidemiology, and End Results (SEER) database. MARCAP and STAR-CAP both contain outcomes for distant metastasis (DM), metastasis-free survival (MFS), prostate cancer-specific mortality (PCSM), and overall survival (OS). SEER only contains PCSM and OS. Wilcoxon signed-rank test and chi-square test were used to compare continuous and categorical variables, respectively. Inverse probability of treatment weighting (IPTW) analysis was conducted, balancing for age, PSA, Gleason score, T stage, and treatment year in the three cohorts. Cox and Fine-Gray regression models were used to compare disease outcomes between RCTs vs. RWD. RESULTS Data from 10,666 patients from RCTs, 6,530 patients in STAR-CAP, and 117,586 patients in SEER were included. SEER patients were slightly younger (p<0.001, median age 68 (IQR 62-73) than those in RCTs (70, IQR 65-74) and in STAR-CAP (70, IQR 64-74). 10-year OS in RCTs was 65.4%, STAR-CAP 70.2%, SEER 64.1%. OS was superior in STAR-CAP (RCTs as reference; HR 0.91, 95% CI 0.85-0.96, p<0.0001), but there was no significant difference between SEER and RCTs (HR 0.96, 95% CI 0.91-1.02, p = 0.22). 10-year PCSM cumulative incidence was 7.4% in RCTs, 8.1% in STAR-CAP, and 11.0% in SEER. There was no significant difference in PCSM between STAR-CAP RWD and RCTs (HR 0.88, 95% CI 0.78-1.01, p = 0.08), whereas PCSM was worse in SEER than RCTs (HR 1.37, 95% CI 1.21-1.55, p<0.0001). There was no significant difference in DM between STAR-CAP RWD and RCTs (HR 0.93, 95% CI 0.83-1.04, p = 0.2). CONCLUSION While baseline differences exist in patients enrolled on localized prostate cancer RCTs and real-world datasets, there were small if any significant relative differences in oncologic outcomes. This provides reassurance that RCT results are generally applicable to patients in routine practice.
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Affiliation(s)
- J Y Lee
- Case Western Reserve University School of Medicine, Cleveland, OH; University Hospitals Cleveland Medical Center, Cleveland, OH
| | - R T Dess
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI
| | - M J Zelefsky
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - B J Davis
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
| | - E M Horwitz
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA
| | - M R Cooperberg
- University of California, San Francisco, San Francisco, CA
| | - N G Zaorsky
- University Hospitals Seidman Cancer Center, Case Western Reserve University, Cleveland, OH
| | - A Y Jia
- Weill Cornell Medical College/New York Presbyterian Hospital, New York, NY
| | - H M Sandler
- Cedars-Sinai Medical Center, Los Angeles, CA
| | - J A Efstathiou
- Department of Radiation Oncology, Harvard School of Medicine, Boston, MA
| | - T M Pisansky
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
| | - E Hall
- The Institute of Cancer Research, Clinical Trials and Statistics Unit, London, United Kingdom
| | - A Tree
- Radiotherapy and Imaging Division, Institute of Cancer Research, London, United Kingdom
| | - S Roy
- Rush University Medical Centre, Chicago, IL
| | - M Bolla
- Department of Radiation Oncology. CHU Grenoble, Grenoble, France
| | - A Nabid
- Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC, Canada
| | - A Zapatero
- Hospital Universitario de La Princesa, Madrid, Spain
| | - A U Kishan
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA
| | - D E Spratt
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center and Case Western Reserve University, Cleveland, OH
| | - Y Sun
- University Hospitals Seidman Cancer Center, Case Western Reserve School of Medicine, Cleveland, OH
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10
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Lee WR, Dignam JJ, Amin M, Bruner DW, Low D, Swanson GP, Shah AB, D'Souza DP, Michalski JM, Dayes I, Seaward SA, Hall WA, Nguyen PL, Pisansky TM, Faria SL, Chen Y, Rodgers J, Sandler HM. Long-Term Follow-Up Analysis of NRG Oncology RTOG 0415: A Randomized Phase III Non-Inferiority Study Comparing Two Fractionation Schedules in Patients with Favorable-Risk Prostate Cancer. Int J Radiat Oncol Biol Phys 2023; 117:S3-S4. [PMID: 37784471 DOI: 10.1016/j.ijrobp.2023.06.209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) To assess whether the efficacy of a hypofractionated (H) schedule is no worse than a conventional (C) schedule in men with low-risk prostate cancer. MATERIALS/METHODS Accrual began April 2006 and ended in December 2009. 1115 men with favorable-risk prostate cancer were randomly assigned 1:1 to a conventional (C) schedule (73.8 Gy in 41 fractions over 8.2 weeks) or to a hypofractionated (H) schedule (70 Gy in 28 fractions over 5.6 weeks). The trial was designed to establish with 90% power and alpha = 0.05 that (H) results in 5-year disease-free survival (DFS) that is not lower than (C) by more than 7% (hazard ratio (HR) < 1.52). Protocol specified secondary endpoints evaluated for noninferiority include: biochemical recurrence (BR), local progression, disease-specific survival, and overall survival. RESULTS One thousand ninety-two protocol eligible men were analyzed: 542 to C and 550 to H. Median follow-up is 12.75 years. Baseline characteristics were not different according to treatment arm. The estimated 12-year DFS is 56.1% (95% CI 51.5, 60.5) in the C arm and 61.8% (57.2, 66.0) in the H arm. The DFS hazard ratio (H/C) is 0.85 (0.71-1.03), confirming non-inferiority (p<0.001). Twelve-year cumulative incidence of biochemical recurrence (BR) was 17.0% (CI 13.8, 20.5) in the C-RT and 9.9% (CI 7.5, 12.6) in the H-RT arm; (HR = 0.56, (0.40-0.78) suggesting improved efficacy with H. Additional pre-specified secondary endpoints were non-inferior Late Grade ≥ 3 GI toxicity is 3.2% (C) vs. 4.4% (H), Relative risk (RR) for H vs. C 1.39 (CI 0.75, 2.55) Late Grade ≥ 3 GU toxicity is 3.4% (C) vs. 4.2% (H), RR = 1.26 (CI 0.69, 2.30). CONCLUSION In men with favorable-risk prostate cancer, long-term disease-free survival is non-inferior with 70 Gy in 28 fractions compared to 73.8 Gy in 41 fractions. The risk of BR is reduced with moderate hypofractionation. No differences in late Grade ≥3 GI/GU toxicity were observed between the arms. (ClinicalTrials.gov identifier: NCT00331773).
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Affiliation(s)
- W R Lee
- Duke University Medical Center, Department of Radiation Oncology, Durham, NC
| | - J J Dignam
- NRG Oncology Statistics and Data Management Center, Philadelphia, PA
| | - M Amin
- University of Tennessee Health Science Center, Memphis, TN
| | | | - D Low
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA
| | | | - A B Shah
- York Cancer Center, York, PA, United States
| | - D P D'Souza
- Department of Oncology, Division of Radiation Oncology, London Health Sciences Centre, Western University, London, ON, Canada
| | - J M Michalski
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO
| | - I Dayes
- Juravinski Cancer Centre, Hamilton, ON, Canada
| | | | - W A Hall
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI
| | - P L Nguyen
- Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, MA
| | - T M Pisansky
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
| | - S L Faria
- McGill University Health Centre, Montreal, QC, Canada
| | - Y Chen
- Department of Radiation Oncology, University of Rochester Medical Center, Rochester, NY
| | - J Rodgers
- NRG Oncology Statistics and Data Management Center, Philadelphia, PA
| | - H M Sandler
- Cedars-Sinai Medical Center, Los Angeles, CA
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11
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Nguyen AT, Dar TB, Viramontes J, Stevens S, Jang JK, Ko E, Lu DJ, Chung EM, Zhang SC, Atkins KM, Kamrava M, Sandler HM, Guarnerio J, Knott S, Zumsteg ZS, Underhill D, Shiao SL. Non-Redundant Mechanisms of Immune Resistance to Radiotherapy Converge on Innate Immunity. Int J Radiat Oncol Biol Phys 2023; 117:S71. [PMID: 37784560 DOI: 10.1016/j.ijrobp.2023.06.379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) Despite evidence of preclinical synergy between radiotherapy (RT) and immune checkpoint blockade (ICB), randomized trials of RT/ICB have demonstrated limited benefit in solid tumors. We performed single-cell RNA sequencing (scRNA-seq) and CITE-seq (cellular indexing of transcriptomes and epitopes) to address the discordance between preclinical and clinical data. We hypothesized that multiple orthogonal inhibitory immune pathways restrain the local and systemic efficacy of RT beyond T-cell oriented immune checkpoints. MATERIALS/METHODS We used the EO771 syngeneic murine model of breast cancer to characterize the immune tumor microenvironment following RT with or without ICB. RT (16 Gy x 1) was delivered using the X-RAD SmART platform with CT image guidance. Neutralizing antibodies (anti-PD-1/Ly6G/Gr-1/CD47) were delivered by intraperitoneal injections. scRNA-seq analysis were performed by Seurat and BBrowser (BioTuring). RESULTS We found that adaptive ICB (anti-PD-1) reprogrammed the immune response to RT by promoting an M1-like interferon-primed state (ISG15, CXCL10) in tumor associated macrophages (TAMs) and by increasing the late recruitment of intratumoral neutrophils. Given that neutrophils may drive resistance to RT in other models, we evaluated the effect of intratumoral neutrophil depletion using anti-Ly6G or anti-Gr-1 on the antitumor efficacy of RT/ICB. Both neutrophil depletion strategies led to enhanced tumor control and improved survival in advanced EO771 tumors compared to RT/ICB alone (P<0.001). In parallel to this approach, we found that TAMs upregulated several innate immune checkpoints including SIRPα in response to RT. Disruption of the SIRPα-CD47 interaction by anti-CD47 antibodies similarly enhanced the antitumor efficacy of RT/ICB by improving tumor control and survival (P<0.001). Using scRNA-seq and unbiased clustering, we found that anti-CD47 eliminated an entire cluster of chronically inflamed TAMs, characterized by pro-inflammatory markers (IL1A, NOS2) and chemokines (CCL3, CXCL1/2/3). Anti-CD47 also reduced intratumoral neutrophils by eliminating a cluster of pathologically activated neutrophils, termed myeloid-derived suppressor cells (PMN-MDSCs) that expressed several markers of ferroptosis (TFRC, PTGS2, SLC3A2). Consistent with the potent immunosuppressive capacity of PMN-MDSCs, we found that anti-CD47 increased tumor-infiltrating lymphocytes including central memory TCF7+ T cells and CD19+ B cells. Lastly, by inference and analysis of cell-cell communication (CellChat), we found that anti-CD47 strengthened the interactions between TAMs and CD8+ T cells compared to RT/ICB alone. CONCLUSION Our data collectively indicate that resistance to RT/ICB in the EO771 model Is driven by innate immune cells including neutrophils and chronically inflamed TAMs. Targeted disruption of the CD47-SIRPα axis is a promising approach to overcoming immune resistance by reprogramming TAMs and eliminating PMN-MDSCs.
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Affiliation(s)
- A T Nguyen
- Department of Radiation Oncology, Cedars-Sinai Medical Center, Los Angeles, CA
| | - T B Dar
- Cedars-Sinai Medical Center, Los Angeles, CA
| | - J Viramontes
- Department of Radiation Oncology, Cedars-Sinai Medical Center, Los Angeles, CA
| | - S Stevens
- Department of Radiation Oncology, Cedars-Sinai Medical Center, Los Angeles, CA
| | - J K Jang
- Department of Radiation Oncology, Cedars-Sinai Medical Center, Los Angeles, CA
| | - E Ko
- Cedars-Sinai Medical Center, Los Angeles, CA
| | - D J Lu
- Cedars-Sinai Medical Center, Los Angeles, CA
| | - E M Chung
- Cedars-Sinai Medical Center, Los Angeles, CA
| | - S C Zhang
- Cedars-Sinai Medical Center, Los Angeles, CA
| | - K M Atkins
- Cedars-Sinai Medical Center, Los Angeles, CA
| | - M Kamrava
- Department of Radiation Oncology, Cedars-Sinai Medical Center, Los Angeles, CA
| | - H M Sandler
- Cedars-Sinai Medical Center, Los Angeles, CA
| | - J Guarnerio
- Department of Radiation Oncology, Cedars-Sinai Medical Center, Los Angeles, CA
| | - S Knott
- Cedars-Sinai Medical Center, Los Angeles, CA
| | - Z S Zumsteg
- Cedars-Sinai Medical Center, Los Angeles, CA
| | - D Underhill
- Cedars-Sinai Medical Center, Los Angeles, CA
| | - S L Shiao
- Cedars-Sinai Medical Center, Los Angeles, CA
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12
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Bruner DW, Karrison TG, Pollack A, Michalski JM, Balogh A, Rodrigues G, Horwitz EM, Faria S, Camarata AS, Lee RJ, Lukka H, Zelefsky MJ, Seiferheld W, Sandler HM, Movsas B. Quality of Life Results of Addition of Androgen Deprivation Therapy and Pelvic Lymph Node Treatment to Prostate Bed Salvage Radiotherapy: NRG Oncology/RTOG 0534 SPPORT. Int J Radiat Oncol Biol Phys 2023; 117:S24. [PMID: 37784459 DOI: 10.1016/j.ijrobp.2023.06.281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) Report the quality of life (QOL) analysis of the SPPORT trial of men with a detectable prostate specific antigen (PSA) after prostatectomy for prostate cancer randomized to (Arm 1) salvage prostate bed radiotherapy (PBRT), (Arm 2) 4-6 months of short-term androgen deprivation therapy (STADT) + PBRT, and (Arm 3) pelvic lymph node radiotherapy (PLNRT) + STADT + PBRT. Primary analysis established a benefit of adding PLNRT and STADT to PBRT. There was higher short term but no statistically significant difference in long term adverse events with the exception of blood or bone marrow events. MATERIALS/METHODS QOL endpoints were assessed at baseline, 6 weeks after RT start, 1 and 5 years, including Expanded Prostate Cancer Index Composite (EPIC) (bowel, urinary, sexual, and hormonal domains), Hopkins Symptom Checklist (HSCL-25) (depressive symptoms), and the EuroQol (EQ-5D) (health state weights used in quality adjusted life years (QALYs). In addition to statistical significance, differences in scores were assessed using 0.5 standard deviation (SD) as the criterion for clinical importance. Difference among arms was assessed using pairwise t-tests, Fisher's exact test, and mixed effects regression modeling. To control for multiplicity, the p-value required for statistical significance is p<0.025. RESULTS Six hundred forty-four patients consented to QOL, about 210 on each arm. Baseline characteristics were not significantly different among arms: 81% were white and 54% <65 years. For EPIC, bowel domain scores decreased at 6 weeks post-RT then increased by years 1 and 5, although not to baseline levels. One clinically significant difference in bowel scores was Arm 3 vs. Arm 1 at 6 weeks. For the urinary domain, scores decreased at 6 weeks post-RT and remained below baseline at 1 and 5 years, but there were no significant differences among arms. For the sexual domain, there were statistically significant differences between arms at 6 weeks and 1 year with patients receiving STADT exhibiting poorer sexual QOL scores. By year 5 the differences were no longer significant. A similar pattern was seen for the hormonal domain. For HSCL-25, differences at 6 weeks were statistically but not clinically significant, and there were no significant differences at the later time points. Comparisons of QALYs for overall survival over an 8-year horizon showed no significant group differences, with a mean of about 7.8 in each arm. Regarding freedom from progression, QALY means were 5.7, 6.5, and 7.4 years for Arms 1, 2, and 3, respectively, with a significant difference between Arms 3 and 1 (p = <.001) favoring the more intensive treatment. CONCLUSION While QOL generally declined among all arms at 6 weeks post RT, there were no clinically significant differences in QOL among arms at 5 years. QALYs for freedom from progression favored STADT + PLNRT + PBRT for salvage treatment of prostate cancer.
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Affiliation(s)
| | | | - A Pollack
- Department of Radiation Oncology, University of Miami/Sylvester Comprehensive Cancer Center, Miami, FL
| | - J M Michalski
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO
| | - A Balogh
- Tom Baker Cancer Centre, Calgary, AB, Canada
| | - G Rodrigues
- London Health Sciences Centre, London, ON, Canada
| | - E M Horwitz
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA
| | - S Faria
- McGill University Health Center, Montreal, QC, Canada
| | | | - R J Lee
- Intermountain Medical Center, Murray, UT
| | - H Lukka
- Juravinski Cancer Centre, Hamilton, ON, Canada
| | - M J Zelefsky
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | | | - H M Sandler
- Cedars-Sinai Medical Center, Los Angeles, CA
| | - B Movsas
- Henry Ford Hospital, Detroit, MI
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13
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Spratt DE, Tang S, Sun Y, Huang HC, Chen E, Mohamad O, Armstrong AJ, Tward JD, Nguyen PL, Lang JM, Zhang J, Mitani A, Simko JP, DeVries S, van der Wal D, Pinckaers H, Monson JM, Campbell HA, Wallace J, Ferguson MJ, Bahary JP, Schaeffer EM, Sandler HM, Tran PT, Rodgers JP, Esteva A, Yamashita R, Feng FY. Artificial Intelligence Predictive Model for Hormone Therapy Use in Prostate Cancer. NEJM Evid 2023; 2:EVIDoa2300023. [PMID: 38320143 DOI: 10.1056/evidoa2300023] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
Predictive Model for Hormone Therapy in Prostate CancerDigital pathology images and clinical data from pretreatment prostate tissue were used to generate a predictive model to determine patients who would benefit from androgen deprivation therapy (ADT). In model-positive patients, ADT significantly reduced the risk of distant metastasis compared with radiotherapy alone.
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Affiliation(s)
- Daniel E Spratt
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Case Western Reserve University, Cleveland
| | - Siyi Tang
- Department of Electrical Engineering, Stanford University, Stanford, CA
- Artera, Inc., Los Altos, CA
| | - Yilun Sun
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Case Western Reserve University, Cleveland
- Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland
| | | | | | - Osama Mohamad
- Department of Radiation Oncology, University of California, San Francisco, San Francisco
| | - Andrew J Armstrong
- Duke Cancer Institute Center for Prostate and Urologic Cancer, Division of Medical Oncology, Department of Medicine, Duke University, Durham, NC
| | - Jonathan D Tward
- Department of Radiation Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City
| | - Paul L Nguyen
- Department of Radiation Oncology, Dana-Farber/Brigham Cancer Center, Boston
| | - Joshua M Lang
- Division of Hematology/Medical Oncology, University of Wisconsin, Madison, WI
| | | | | | - Jeffry P Simko
- Department of Radiation Oncology, University of California, San Francisco, San Francisco
| | - Sandy DeVries
- NRG Oncology Biospecimen Bank, University of California, San Francisco, San Francisco
| | | | | | - Jedidiah M Monson
- Department of Radiation Oncology, Saint Agnes Medical Center, Fresno, CA
| | - Holly A Campbell
- Department of Radiation Oncology, Saint John Regional Hospital, Saint John, NB, Canada
| | - James Wallace
- University of Chicago Medicine Medical Group, Chicago
| | - Michelle J Ferguson
- Department of Radiation Oncology, Allan Blair Cancer Centre, Regina, SK, Canada
| | - Jean-Paul Bahary
- Department of Radiation Oncology, Centre Hospitalier de l'Universite de Montreal, Montreal
| | - Edward M Schaeffer
- Department of Urology, Northwestern University Feinberg School of Medicine, Chicago
| | - Howard M Sandler
- Department of Radiation Oncology, Cedars-Sinai Medical Center, Los Angeles
| | - Phuoc T Tran
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore
| | - Joseph P Rodgers
- Statistics and Data Management Center, NRG Oncology, Philadelphia
- Statistics and Data Management Center, American College of Radiology, Philadelphia
| | | | | | - Felix Y Feng
- Department of Radiation Oncology, University of California, San Francisco, San Francisco
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14
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Sartor O, Karrison TG, Sandler HM, Gomella LG, Amin MB, Purdy J, Michalski JM, Garzotto MG, Pervez N, Balogh AG, Rodrigues GB, Souhami L, Reaume MN, Williams SG, Hannan R, Jones CU, Horwitz EM, Rodgers JP, Feng FY, Rosenthal SA. Androgen Deprivation and Radiotherapy with or Without Docetaxel for Localized High-risk Prostate Cancer: Long-term Follow-up from the Randomized NRG Oncology RTOG 0521 Trial. Eur Urol 2023; 84:156-163. [PMID: 37179241 PMCID: PMC10662642 DOI: 10.1016/j.eururo.2023.04.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 03/18/2023] [Accepted: 04/20/2023] [Indexed: 05/15/2023]
Abstract
BACKGROUND Intensification of therapy may improve outcomes for patients with high-risk localized prostate cancer. OBJECTIVE To provide long-term follow-up data from phase III RTOG 0521, which compared a combination of androgen deprivation therapy (ADT) + external beam radiation therapy (EBRT) + docetaxel with ADT + EBRT. DESIGN, SETTING, AND PARTICIPANTS High-risk localized prostate cancer patients (>50% of patients had Gleason 9-10 disease) were prospectively randomized to 2 yr of ADT + EBRT or ADT + EBRT + six cycles of docetaxel. A total of 612 patients were accrued, and 563 were eligible and included in the modified intent-to-treat analysis. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS The primary endpoint was overall survival (OS). Analyses with Cox proportional hazards were performed as prespecified in the protocol; however, there was evidence of nonproportional hazards. Thus, a post hoc analysis was performed using the restricted mean survival time (RMST). The secondary endpoints included biochemical failure, distant metastasis (DM) as detected by conventional imaging, and disease-free survival (DFS). RESULTS AND LIMITATIONS After 10.4 yr of median follow-up among survivors, the hazard ratio (HR) for OS was 0.89 (90% confidence interval [CI] 0.70-1.14; one-sided log-rank p = 0.22). Survival at 10 yr was 64% for ADT + EBRT and 69% for ADT + EBRT + docetaxel. The RMST at 12 yr was 0.45 yr and not statistically significant (one-sided p = 0.053). No differences were detected in the incidence of DFS (HR = 0.92, 95% CI 0.73-1.14), DM (HR = 0.84, 95% CI 0.73-1.14), or prostate-specific antigen recurrence risk (HR = 0.97, 95% CI 0.74-1.29). Two patients had grade 5 toxicity in the chemotherapy arm and zero patients in the control arm. CONCLUSIONS After a median follow-up of 10.4 yr among surviving patients, no significant differences are observed in clinical outcomes between the experimental and control arms. These data suggest that docetaxel should not be used for high-risk localized prostate cancer. Additional research may be warranted using novel predictive biomarkers. PATIENT SUMMARY No significant differences in survival were noted after long-term follow-up for high-risk localized prostate cancer patients in a large prospective trial where patients were treated with androgen deprivation therapy + radiation to the prostate ± docetaxel.
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Affiliation(s)
- Oliver Sartor
- Tulane University Health Services Center, New Orleans, LA, USA.
| | - Theodore G Karrison
- NRG Oncology Statistics and Data Management Center, Chicago, IL and Philadelphia, PA, USA
| | | | | | - Mahul B Amin
- Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - James Purdy
- UC Davis Medical Center, Sacramento, CA, USA
| | | | | | | | | | | | | | - M Neil Reaume
- The Ottawa Hospital Cancer Centre, Ottawa, Ontario, Canada
| | | | - Raquibul Hannan
- University of Texas Southwestern Medical School, Dallas, TX, USA
| | - Christopher U Jones
- Sutter Cancer Center (accruals under Radiological Associates of Sacramento), Sacramento, CA, USA
| | | | - Joseph P Rodgers
- NRG Oncology Statistics and Data Management Center, Chicago, IL and Philadelphia, PA, USA
| | | | - Seth A Rosenthal
- Sutter Cancer Center (accruals under Radiological Associates of Sacramento), Sacramento, CA, USA
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15
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Lukka HR, Deshmukh S, Bruner DW, Bahary JP, Lawton CAF, Efstathiou JA, Kudchadker RJ, Ponsky LE, Seaward SA, Dayes IS, Gopaul DD, Michalski JM, Delouya G, Kaplan ID, Horwitz EM, Roach M, Feng FY, Pugh SL, Sandler HM, Kachnic LA. Five-Year Patient-Reported Outcomes in NRG Oncology RTOG 0938, Evaluating Two Ultrahypofractionated Regimens for Prostate Cancer. Int J Radiat Oncol Biol Phys 2023; 116:770-778. [PMID: 36592721 PMCID: PMC10619484 DOI: 10.1016/j.ijrobp.2022.12.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 11/28/2022] [Accepted: 12/12/2022] [Indexed: 01/02/2023]
Abstract
PURPOSE There is considerable interest in very short (ultrahypofractionated) radiation therapy regimens to treat prostate cancer based on potential radiobiological advantages, patient convenience, and resource allocation benefits. Our objective is to demonstrate that detectable changes in health-related quality of life measured by the bowel and urinary domains of the Expanded Prostate Cancer Index Composite (EPIC-50) were not substantially worse than baseline scores. METHODS AND MATERIALS NRG Oncology's RTOG 0938 is a nonblinded randomized phase 2 study of National Comprehensive Cancer Network low-risk prostate cancer in which each arm is compared with a historical control. Patients were randomized to 5 fractions (7.25 Gy in 2 week and a day [twice a week]) or 12 fractions (4.3Gy in 2.5 weeks [5 times a week]). Secondary objectives assessed patient-reported toxicity at 5 years using the EPIC. Chi-square tests were used to assess the proportion of patients with a deterioration from baseline of >5 points for bowel, >2 points for urinary, and >11 points for sexual score. RESULTS The study enrolled 127 patients to 5 fractions (121 eligible) and 128 patients to 12 fractions (125 eligible). The median follow-up for all patients at the time of analysis was 5.38 years. The 5-year frequency for >5 point change in bowel score were 38.4% (P = .27) and 23.4% (P = 0.98) for 5 and 12 fractions, respectively. The 5-year frequencies for >2 point change in urinary score were 46.6% (P = .15) and 36.4% (P = .70) for 5 and 12 fractions, respectively. For 5 fractions, 49.3% (P = .007) of patients had a drop in 5-year EPIC-50 sexual score of ≥11 points; for 12 fractions, 54% (P < .001) of patients had a drop in 5-year EPIC-50 sexual score of ≥11 points. Disease-free survival at 5 years is 89.6% (95% CI: 84.0-95.2) in the 5-fraction arm and 92.3% (95% CI: 87.4-97.1) in the 12-fraction arm. There was no late grade 4 or 5 treatment-related urinary or bowel toxicity. CONCLUSIONS This study confirms that, based on long-term changes in bowel and urinary domains and toxicity, the 5- and 12-fraction regimens are well tolerated. These ultrahypofractionated approaches need to be compared with current standard radiation therapy regimens.
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Affiliation(s)
- Himanshu R Lukka
- Juravinski Cancer Centre at Hamilton Health Sciences, Hamilton, Canada.
| | - Snehal Deshmukh
- NRG Oncology Statistics and Data Management Center, Philadelphia, Pennsylvania
| | | | - Jean-Paul Bahary
- Centre Hospitalier de l'Universite´ de Montreal (CHUM), Montreal, Canada
| | | | | | | | - Lee E Ponsky
- Case Western Reserve University, Cleveland, Ohio
| | | | - Ian S Dayes
- Juravinski Cancer Centre at Hamilton Health Sciences, Hamilton, Canada
| | | | | | - Guila Delouya
- Centre Hospitalier de l'Universite´ de Montreal (CHUM), Montreal, Canada
| | | | | | - Mack Roach
- University of California-San Francisco Medical Center, San Francisco, California
| | - Felix Y Feng
- University of California-San Francisco Medical Center, San Francisco, California
| | - Stephanie L Pugh
- NRG Oncology Statistics and Data Management Center, Philadelphia, Pennsylvania
| | | | - Lisa A Kachnic
- Juravinski Cancer Centre at Hamilton Health Sciences, Hamilton, Canada
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16
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Nguyen PL, Huang HCR, Spratt DE, Davicioni E, Sandler HM, Shipley WU, Efstathiou JA, Simko JP, Pollack A, Dicker AP, Roach M, Rosenthal SA, Zeitzer KL, Mendez LC, Hartford AC, Hall WA, Desai AB, Rabinovitch RA, Peters CA, Rodgers JP, Tran P, Feng FY. Analysis of a Biopsy-Based Genomic Classifier in High-Risk Prostate Cancer: Meta-Analysis of the NRG Oncology/Radiation Therapy Oncology Group 9202, 9413, and 9902 Phase 3 Randomized Trials. Int J Radiat Oncol Biol Phys 2023; 116:521-529. [PMID: 36596347 PMCID: PMC10281690 DOI: 10.1016/j.ijrobp.2022.12.035] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 12/03/2022] [Accepted: 12/19/2022] [Indexed: 01/02/2023]
Abstract
PURPOSE Decipher is a genomic classifier (GC) prospectively validated postprostatectomy. We validated the performance of the GC in pretreatment biopsy samples within the context of 3 randomized phase 3 high-risk definitive radiation therapy trials. METHODS AND MATERIALS A prespecified analysis plan (NRG-GU-TS006) was approved to obtain formalin-fixed paraffin-embedded tissue from biopsy specimens from the NRG biobank from patients enrolled in the NRG/Radiation Therapy Oncology Group (RTOG) 9202, 9413, and 9902 phase 3 randomized trials. After central review, the highest-grade tumors were profiled on clinical-grade whole-transcriptome arrays and GC scores were obtained. The primary objective was to validate the independent prognostic ability for the GC for distant metastases (DM), and secondary for prostate cancer-specific mortality (PCSM) and overall survival (OS) with Cox univariable and multivariable analyses. RESULTS GC scores were obtained on 385 samples, of which 265 passed microarray quality control (69%) and had a median follow-up of 11 years (interquartile range, 9-13). In the pooled cohort, on univariable analysis, the GC was shown to be a prognostic factor for DM (per 0.1 unit; subdistribution hazard ratio [sHR], 1.29; 95% confidence interval [CI], 1.18-1.41; P < .001), PCSM (sHR, 1.28; 95% CI, 1.16-1.41; P < .001), and OS (hazard ratio [HR], 1.16; 95% CI, 1.08-1.22; P < .001). On multivariable analyses, the GC (per 0.1 unit) was independently associated with DM (sHR, 1.22; 95% CI, 1.09-1.36), PCSM (sHR, 1.23; 95% CI, 1.09-1.39), and OS (HR, 1.12; 95% CI, 1.05-1.20) after adjusting for age, Prostate Specific Antigen, Gleason score, cT stage, trial, and randomized treatment arm. GC had similar prognostic ability in patients receiving short-term or long-term androgen-deprivation therapy, but the absolute improvement in outcome varied by GC risk. CONCLUSIONS This is the first validation of a gene expression biomarker on pretreatment prostate cancer biopsy samples from prospective randomized trials and demonstrates an independent association of GC score with DM, PCSM, and OS. High-risk prostate cancer is a heterogeneous disease state, and GC can improve risk stratification to help personalize shared decision making.
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Affiliation(s)
- Paul L Nguyen
- Department of Radiation Oncology, Brigham and Women's Hospital, Boston, Massachusetts; Department of Radiation Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts.
| | - Huei-Chung Rebecca Huang
- GenomeDx Inc, Vancouver, British Columbia, Canada; Decipher Biosciences, San Diego, California; Veracyte, South San Francisco CA
| | - Daniel E Spratt
- Department of Radiation Oncology, UH Cleveland Medical Center, Cleveland, Ohio
| | - Elai Davicioni
- Decipher Biosciences, San Diego, California; Veracyte, South San Francisco CA
| | - Howard M Sandler
- Department of Radiation Oncology, Cedars-Sinai Medical Center, Los Angeles, California
| | - William U Shipley
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jason A Efstathiou
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jeffry P Simko
- Department of Pathology, UCSF Medical Center-Mount Zion, San Francisco, California
| | - Alan Pollack
- Department of Radiation Oncology, University of Miami Miller School of Medicine, Miami, Florida
| | - Adam P Dicker
- Department of Radiation Oncology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Mack Roach
- Department of Pathology, UCSF Medical Center-Mount Zion, San Francisco, California
| | - Seth A Rosenthal
- Department of Radiation Oncology, Sutter Cancer Centers Radiation Oncology Services, Roseville, California
| | - Kenneth L Zeitzer
- Department of Radiation Oncology, Einstein Medical Center, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Lucas C Mendez
- Department of Radiation Oncology, London Regional Cancer Program, London, Ontario, Canada
| | - Alan C Hartford
- Department of Radiation Oncology, Dartmouth-Hitchcock Medical Center/Norris Cotton Cancer Center, Lebanon, New Hampshire
| | - William A Hall
- Department of Radiation Oncology, Froedtert and the Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Anand B Desai
- Department of Radiation Oncology, Summa Health System, Akron, Ohio
| | - Rachel A Rabinovitch
- Department of Radiation Oncology, University of Colorado Denver, Aurora, Colorado
| | - Christopher A Peters
- Department of Radiation Oncology, Northeast Radiation Oncology Center, Dunmore, Pennsylvania
| | | | - Phuoc Tran
- Department of Radiation Oncology, University of Maryland, Baltimore, Maryland
| | - Felix Y Feng
- Department of Radiation Oncology, UCSF Medical Center-Mission Bay, San Francisco, California
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17
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Bai J, Pugh SL, Eldridge R, Yeager KA, Zhang Q, Lee WR, Shah AB, Dayes IS, D'Souza DP, Michalski JM, Efstathiou JA, Longo JM, Pisansky TM, Maier JM, Faria SL, Desai AB, Seaward SA, Sandler HM, Cooley ME, Bruner DW. Neighborhood Deprivation and Rurality Associated With Patient-Reported Outcomes and Survival in Men With Prostate Cancer in NRG Oncology RTOG 0415. Int J Radiat Oncol Biol Phys 2023; 116:39-49. [PMID: 36736921 PMCID: PMC10106367 DOI: 10.1016/j.ijrobp.2023.01.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 01/18/2023] [Accepted: 01/20/2023] [Indexed: 02/04/2023]
Abstract
PURPOSE Rurality and neighborhood deprivation can contribute to poor patient-reported outcomes, which have not been systematically evaluated in patients with specific cancers in national trials. Our objective was to examine the effect of rurality and neighborhood socioeconomic and environmental deprivation on patient-reported outcomes and survival in men with prostate cancer in NRG Oncology RTOG 0415. METHODS AND MATERIALS Data from men with prostate cancer in trial NRG Oncology RTOG 0415 were analyzed; 1,092 men were randomized to receive conventional radiation therapy or hypofractionated radiation therapy. Rurality was categorized as urban or rural. Neighborhood deprivation was assessed using the area deprivation index and air pollution indicators (nitrogen dioxide and particulate matter with a diameter less than 2.5 micrometers) via patient ZIP codes. Expanded Prostate Cancer Index Composite measured cancer-specific quality of life. The Hopkins symptom checklist measured anxiety and depression. EuroQoL-5 Dimension assessed general health. RESULTS We analyzed 751 patients in trial NRG Oncology RTOG 0415. At baseline, patients from the most deprived neighborhoods had worse bowel (P = .011), worse sexual (P = .042), and worse hormonal (P = .015) scores; patients from the most deprived areas had worse self-care (P = .04) and more pain (P = .047); and patients from rural areas had worse urinary (P = .03) and sexual (P = .003) scores versus patients from urban areas. Longitudinal analyses showed that the 25% most deprived areas (P = .004) and rural areas (P = .002) were associated with worse EuroQoL-5 Dimension visual analog scale score. Patients from urban areas (hazard ratio, 1.81; P = .033) and the 75% less-deprived neighborhoods (hazard ratio, 0.68; P = .053) showed relative decrease in risk of recurrence or death (disease-free survival). CONCLUSIONS Patients with prostate cancer from the most deprived neighborhoods and rural areas had low quality of life at baseline, poor general health longitudinally, and worse disease-free survival. Interventions should screen populations from deprived neighborhoods and rural areas to improve patient access to supportive care services.
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Affiliation(s)
- Jinbing Bai
- Emory University Nell Hodgson Woodruff School of Nursing, Atlanta, Georgia.
| | - Stephanie L Pugh
- NRG Oncology Statistics and Data Management Center, Philadelphia, Pennsylvania
| | - Ronald Eldridge
- Emory University Nell Hodgson Woodruff School of Nursing, Atlanta, Georgia
| | - Katherine A Yeager
- Emory University Nell Hodgson Woodruff School of Nursing, Atlanta, Georgia
| | - Qi Zhang
- Department of Geography, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - W Robert Lee
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - Amit B Shah
- WellSpan York Cancer Center, York, Pennsylvania
| | - Ian S Dayes
- McMaster University, Juravinski Cancer Center, Hamilton Health Science, Hamilton, Ontario, Canada
| | - David P D'Souza
- School of Medicine & Dentistry, University of Western Ontario Schulich, London, Ontario, Canada
| | | | | | - John M Longo
- Zablocki VAMC and the Medical College of Wisconsin, Milwaukee, Wisconsin
| | | | - Jordan M Maier
- Karmanos Cancer Institute, Wayne State University, Detroit, Michigan
| | - Sergio L Faria
- Department of Radiation Oncology, McGill University, Montreal, Quebec, Canada
| | | | | | | | - Mary E Cooley
- Dana-Farber/Harvard Cancer Center, Boston, Massachusetts
| | - Deborah W Bruner
- Emory University Nell Hodgson Woodruff School of Nursing, Atlanta, Georgia
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18
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Movsas B, Rodgers JP, Elshaikh MA, Martinez AA, Morton GC, Krauss DJ, Yan D, Citrin DE, Hershatter BW, Michalski JM, Ellis RJ, Kavadi VS, Gore EM, Gustafson GS, Schulz CA, Velker VM, Olson AC, Cury FL, Papagikos MA, Karrison TG, Sandler HM, Bruner DW. Dose-Escalated Radiation Alone or in Combination With Short-Term Total Androgen Suppression for Intermediate-Risk Prostate Cancer: Patient-Reported Outcomes From NRG/Radiation Therapy Oncology Group 0815 Randomized Trial. J Clin Oncol 2023:JCO2202389. [PMID: 37104723 DOI: 10.1200/jco.22.02389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/29/2023] Open
Abstract
PURPOSE To report patient-reported outcomes (PROs) of a phase III trial evaluating total androgen suppression (TAS) combined with dose-escalated radiation therapy (RT) for patients with intermediate-risk prostate cancer. METHODS Patients with intermediate-risk prostate cancer were randomly assigned to dose-escalated RT alone (arm 1) or RT plus TAS (arm 2) consisting of luteinizing hormone-releasing hormone agonist/antagonist with oral antiandrogen for 6 months. The primary PRO was the validated Expanded Prostate Cancer Index Composite (EPIC-50). Secondary PROs included Patient-Reported Outcome Measurement Information System (PROMIS)-fatigue and EuroQOL five-dimensions scale questionnaire (EQ-5D). PRO change scores, calculated for each patient as the follow-up score minus baseline score (at the end of RT and at 6, 12, and 60 months), were compared between treatment arms using a two-sample t test. An effect size of 0.50 standard deviation was considered clinically meaningful. RESULTS For the primary PRO instrument (EPIC), the completion rates were ≥86% through the first year of follow-up and 70%-75% at 5 years. For the EPIC hormonal and sexual domains, there were clinically meaningful (P < .0001) deficits in the RT + TAS arm. However, there were no clinically meaningful differences by 1 year between arms. There were also no clinically meaningful differences at any time points between arms for PROMIS-fatigue, EQ-5D, and EPIC bowel/urinary scores. CONCLUSION Compared with dose-escalated RT alone, adding TAS demonstrated clinically meaningful declines only in EPIC hormonal and sexual domains. However, even these PRO differences were transient, and there were no clinically meaningful differences between arms by 1 year.
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Affiliation(s)
| | - Joseph P Rodgers
- NRG Oncology Statistics and Data Management Center, Philadelphia, PA
| | | | | | - Gerard C Morton
- Odette Cancer Centre-Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | | | - Di Yan
- William Beaumont Hospital, Royal Oak, MI
| | - Deborah E Citrin
- Center for Cancer Research, National Cancer Institute, Bethesda, MD
| | | | | | - Rodney J Ellis
- Penn State Milton Hershey Medical Center, Hershey, PA
- Case Western Reserve University, Cleveland, OH
| | | | - Elizabeth M Gore
- Froedtert and the Medical College of Wisconsin and Zablocki VAMC, Milwaukee, WI
| | | | - Craig A Schulz
- Columbia Saint Mary's Water Tower Medical Commons, Milwaukee, WI
| | | | - Adam C Olson
- University of Pittsburgh Cancer Institute, Pittsburgh, PA
| | - Fabio L Cury
- The Research Institute of the McGill University Health Centre (MUHC), Montreal, QC, Canada
| | - Michael A Papagikos
- Novant Health New Hanover Regional Medical Center-Zimmer Cancer Institute, Wilmington, NC
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19
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Spratt DE, Tang S, Sun Y, Huang HC, Chen E, Mohamad O, Armstrong AJ, Tward JD, Nguyen PL, Lang JM, Zhang J, Mitani A, Simko JP, DeVries S, van der Wal D, Pinckaers H, Monson JM, Campbell HA, Wallace J, Ferguson MJ, Bahary JP, Schaeffer EM, Sandler HM, Tran PT, Rodgers JP, Esteva A, Yamashita R, Feng FY. Artificial Intelligence Predictive Model for Hormone Therapy Use in Prostate Cancer. Res Sq 2023:rs.3.rs-2790858. [PMID: 37131691 PMCID: PMC10153374 DOI: 10.21203/rs.3.rs-2790858/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
Background Androgen deprivation therapy (ADT) with radiotherapy can benefit patients with localized prostate cancer. However, ADT can negatively impact quality of life and there remain no validated predictive models to guide its use. Methods Digital pathology image and clinical data from pre-treatment prostate tissue from 5,727 patients enrolled on five phase III randomized trials treated with radiotherapy +/- ADT were used to develop and validate an artificial intelligence (AI)-derived predictive model to assess ADT benefit with the primary endpoint of distant metastasis. After the model was locked, validation was performed on NRG/RTOG 9408 (n = 1,594) that randomized men to radiotherapy +/- 4 months of ADT. Fine-Gray regression and restricted mean survival times were used to assess the interaction between treatment and predictive model and within predictive model positive and negative subgroup treatment effects. Results In the NRG/RTOG 9408 validation cohort (14.9 years of median follow-up), ADT significantly improved time to distant metastasis (subdistribution hazard ratio [sHR] = 0.64, 95%CI [0.45-0.90], p = 0.01). The predictive model-treatment interaction was significant (p-interaction = 0.01). In predictive model positive patients (n = 543, 34%), ADT significantly reduced the risk of distant metastasis compared to radiotherapy alone (sHR = 0.34, 95%CI [0.19-0.63], p < 0.001). There were no significant differences between treatment arms in the predictive model negative subgroup (n = 1,051, 66%; sHR = 0.92, 95%CI [0.59-1.43], p = 0.71). Conclusions Our data, derived and validated from completed randomized phase III trials, show that an AI-based predictive model was able to identify prostate cancer patients, with predominately intermediate-risk disease, who are likely to benefit from short-term ADT.
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20
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Mantz CA, Yashar CM, Bajaj GK, Sandler HM. Recent Trends in Medicare Payments for Outpatient Cancer Care at the End of Life. Int J Radiat Oncol Biol Phys 2023:S0360-3016(23)00028-7. [PMID: 36657498 DOI: 10.1016/j.ijrobp.2023.01.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 01/02/2023] [Accepted: 01/05/2023] [Indexed: 01/19/2023]
Abstract
PURPOSE Outpatient care for cancer patients compromises 60 - 70% of healthcare costs over the last 6 months of life. Recent approvals for expensive biologics and growing support for lower-cost hypofractionated radiotherapy in the palliative management of advanced cancer have introduced offsetting spending effects on end-of-life care that may shift overall expenditures for this patient cohort. METHODS AND MATERIALS In this descriptive retrospective cohort study, end-of-life care is defined as the aggregate of medical services and supplies, including drugs, furnished to cancer patients in the outpatient setting over the last 6 months of life. 84,744 Medicare beneficiaries with a cancer diagnosis were identified as having died between Jan 1 2016 and Dec 31 2019. Beneficiaries with Medicare Advantage are not included in this study. Medicare Standard Analytic Files were abstracted for all paid claims for these beneficiaries over the last 6 months of life, and provider payments were summed according to service/supply category and year of death. Comparisons of service and supply utilization and costs between patient groups were performed using Pearson's chi square test. RESULTS Average total Medicare Part B payments per treated beneficiary over the last 6 month of life increased by 12.0% between 2016 - 2019 (from $14,487 to $16,227) with the greatest absolute cost increase observed for the Medical Oncology category (from $7,030 to $9,436 [+34.2%]). Within the Medical Oncology category, drug utilization shifted away from less costly chemotherapy and hormone therapy agents and toward more expensive immunotherapy agents. The increase in immunotherapy utilization and drug costs alone accounted for 84% of the increase in total Part B payments for all categories during the period. CONCLUSION While costs related to end-of-life care for nearly all cost categories have remained relatively stable, oncology drug costs overall and immunotherapy costs specifically have accelerated and account almost entirely for the observed overall increase in outpatient cost burden for Medicare.
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Affiliation(s)
| | - Catheryn M Yashar
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA
| | - Gopal K Bajaj
- Department of Advanced Radiation Oncology and Proton Therapy, Inova Schar Cancer Institute, Fairfax, VA
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21
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Chung EM, Zhang SC, Nguyen AT, Atkins KM, Sandler HM, Kamrava M. Feasibility and acceptability of ChatGPT generated radiology report summaries for cancer patients. Digit Health 2023; 9:20552076231221620. [PMID: 38130802 PMCID: PMC10734360 DOI: 10.1177/20552076231221620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 11/30/2023] [Indexed: 12/23/2023] Open
Abstract
Objective Patients now have direct access to their radiology reports, which can include complex terminology and be difficult to understand. We assessed ChatGPT's ability to generate summarized MRI reports for patients with prostate cancer and evaluated physician satisfaction with the artificial intelligence (AI)-summarized report. Methods We used ChatGPT to summarize five full MRI reports for patients with prostate cancer performed at a single institution from 2021 to 2022. Three summarized reports were generated for each full MRI report. Full MRI and summarized reports were assessed for readability using Flesch-Kincaid Grade Level (FK) score. Radiation oncologists were asked to evaluate the AI-summarized reports via an anonymous questionnaire. Qualitative responses were given on a 1-5 Likert-type scale. Fifty newly diagnosed prostate cancer patient MRIs performed at a single institution were additionally assessed for physician online portal response rates. Results Fifteen summarized reports were generated from five full MRI reports using ChatGPT. The median FK score for the full MRI reports and summarized reports was 9.6 vs. 5.0, (p < 0.05), respectively. Twelve radiation oncologists responded to our questionnaire. The mean [SD] ratings for summarized reports were factual correctness (4.0 [0.6], understanding 4.0 [0.7]), completeness (4.1 [0.5]), potential for harm (3.5 [0.9]), overall quality (3.4 [0.9]), and likelihood to send to patient (3.1 [1.1]). Current physician online portal response rates were 14/50 (28%) at our institution. Conclusions We demonstrate a novel application of ChatGPT to summarize MRI reports at a reading level appropriate for patients. Physicians were likely to be satisfied with the summarized reports with respect to factual correctness, ease of understanding, and completeness. Physicians were less likely to be satisfied with respect to potential for harm, overall quality, and likelihood to send to patients. Further research is needed to optimize ChatGPT's ability to summarize radiology reports and understand what factors influence physician trust in AI-summarized reports.
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Affiliation(s)
- Eric M Chung
- Department of Radiation Oncology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Samuel C Zhang
- Department of Radiation Oncology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Anthony T Nguyen
- Department of Radiation Oncology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Katelyn M Atkins
- Department of Radiation Oncology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Howard M Sandler
- Department of Radiation Oncology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Mitchell Kamrava
- Department of Radiation Oncology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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22
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Hall WA, Karrison TG, Rosenthal SA, Amin MB, Gomella LG, Purdy JA, Sartor AO, Michalski JM, Garzotto MG, Bergom C, Jani AB, Lawton CAF, Simko JP, Moore JK, Gore EM, Lee WR, Nguyen PL, Danielson BL, Sandler HM, Feng FY. The Influence of the Pretreatment Immune State on Response to Radiation Therapy in High-Risk Prostate Cancer: A Validation Study From NRG/RTOG 0521. Int J Radiat Oncol Biol Phys 2022; 114:266-274. [PMID: 35675855 PMCID: PMC9444930 DOI: 10.1016/j.ijrobp.2022.05.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 05/25/2022] [Accepted: 05/31/2022] [Indexed: 11/22/2022]
Abstract
PURPOSE The immunoinflammatory state has been shown to be associated with poor outcomes after radiation therapy (RT). We conducted an a priori designed validation study using serum specimens from Radiation Therapy Oncology Group (RTOG) 0521. It was hypothesized the pretreatment inflammatory state would correlate with clinical outcomes. METHODS AND MATERIALS Patients on RTOG 0521 had serum banked for biomarker validation. This study was designed to validate previous findings showing an association between elevations in C-reactive protein (CRP) and shorter biochemical disease free survival (bDFS). CRP levels were measured in pretreatment samples. An exploratory panel of related cytokines was also measured including: monocyte chemotactic protein-1, granulocyte-macrophage colony-stimulating factor, interferon-γ, interleukin (IL)-1b, IL-2, IL-4, IL-5, IL-6, IL-8, IL-10, IL-12, IL-13, IL-17A, IL-23, and tumor necrosis factor. The primary endpoint examined was bDFS. Additional exploratory endpoints included overall survival, distant metastases, and toxicity events attributed to RT. RESULTS Two hundred and two patients in RTOG/NRG 0521 had serum samples available. Median age was 66 years (48-83), and 90% of patients were White. There was not an association between CRP and bDFS (adjusted hazard ratio [HR], 1.07 per 1 log increase in CRP; 95% confidence interval, 0.83-1.38; P = .60). In the exploratory, unplanned analysis, pretreatment IL-10 was significantly associated with worse bDFS (adjusted HR, 1.61 per log increase; P = .0027) and distant metastases (HR, 1.55 per log increase; P = .028). The association of IL-10 with bDFS was maintained on a multiplicity adjustment. The exploratory analyses of pretreatment levels of interferon-γ, IL-1b, IL-2, IL-13, IL-23 were negatively associated with grade 2 or higher pollakiuria (adjusted odds ratio, 0.64, 0.65, 0.71, 0.72, and 0.74, respectively, all P < .05), and IL-6 was negatively associated with grade 2 or higher erectile dysfunction (odds ratio, 0.62; P = .027). CONCLUSIONS Pretreatment CRP was not associated with a poorer bDFS after RT. In a hypothesis- generating analysis, higher baseline levels of IL-10 were associated with lower rates of bDFS. These findings require additional prospective evaluation.
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Affiliation(s)
- William A Hall
- Department of Radiation Oncology, Froedtert and the Medical College of Wisconsin, Milwaukee, Wisconsin.
| | | | - Seth A Rosenthal
- Radiation Oncology Center, Sutter Cancer Centers Radiation Oncology Services
| | - Mahul B Amin
- Department of Pathology, University of Tennessee Health Science Center
| | | | | | - A Oliver Sartor
- Medicine and Urology Departments, Tulane University Health Sciences Center
| | - Jeff M Michalski
- Department of Radiation Oncology, Washington University School of Medicine
| | | | - Carmen Bergom
- Department of Radiation Oncology, Washington University School of Medicine
| | - Ashesh B Jani
- Department of Radiation Oncology, Emory University Hospital/Winship Cancer Institute
| | - Colleen A F Lawton
- Department of Radiation Oncology, Froedtert and the Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Jeffry P Simko
- Department of Pathology, UC San Francisco Medical Center
| | | | - Elizabeth M Gore
- Department of Radiation Oncology, Froedtert and the Medical College of Wisconsin, Milwaukee, Wisconsin; Department of Radiation Oncology, Zablocki Veterans Administration Medical Center
| | - W Robert Lee
- Department of Radiation Oncology, Duke University Medical Center
| | - Paul L Nguyen
- Department of Radiation Oncology, Brigham and Women's Hospital
| | | | | | - Felix Y Feng
- Department of Radiation Oncology, UC San Francisco Medical Center
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23
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Pollack A, Karrison TG, Feng F, Sartor O, Sandler HM. The addition of pelvic lymph node treatment to prostate bed salvage radiotherapy - Authors' reply. Lancet 2022; 400:885-886. [PMID: 36116477 DOI: 10.1016/s0140-6736(22)01434-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Accepted: 07/27/2022] [Indexed: 11/26/2022]
Affiliation(s)
- Alan Pollack
- Department of Radiation Oncology, University of Miami Miller School of Medicine and Sylvester Comprehensive Cancer Center, Miami, FL 33136, USA.
| | - Theodore G Karrison
- Department of Public Health Sciences, University of Chicago, Chicago, IL, USA; NRG Oncology, Philadelphia, PA, USA
| | - Felix Feng
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA, USA
| | - Oliver Sartor
- Department of Medicine, Tulane University, New Orleans, LA, USA
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24
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Nguyen AT, Luu M, Nguyen VP, Lu DJ, Shiao SL, Kamrava M, Atkins KM, Mita AC, Scher KS, Spratt DE, Faries MB, Daskivich TJ, Lin DC, Chen MM, Clair JMS, Sandler HM, Ho AS, Zumsteg ZS. Quantitative Nodal Burden and Mortality Across Solid Cancers. J Natl Cancer Inst 2022; 114:1003-1011. [PMID: 35311991 PMCID: PMC9275768 DOI: 10.1093/jnci/djac059] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 01/10/2022] [Accepted: 03/16/2022] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Nodal staging systems vary substantially across solid tumors, implying heterogeneity in the behavior of nodal variables in various contexts. We hypothesized, in contradiction to this, that metastatic lymph node (LN) number is a universal and dominant predictor of outcome across solid tumors. METHODS We performed a retrospective cohort analysis of 1 304 498 patients in the National Cancer Database undergoing surgery between 2004 and 2015 across 16 solid cancer sites. Multivariable Cox regression analyses were constructed using restricted cubic splines to model the association between nodal number and mortality. Recursive partitioning analysis (RPA) was used to derive nodal classification systems for each solid cancer based on metastatic LN count. The reproducibility of these findings was assessed in 1 969 727 patients from the Surveillance, Epidemiology, and End Results registry. Two-sided tests were used for all statistical analyses. RESULTS Consistently across disease sites, mortality risk increased continuously with increasing number of metastatic LNs (P < .001 for all spline segments). Each RPA-derived nodal classification system produced multiple prognostic groups spanning a wide spectrum of mortality risk (P < .001). Multivariable models using these RPA-derived nodal classifications demonstrated improved concordance with mortality compared with models using American Joint Committee on Cancer staging in sites where nodal classification is not based on metastatic LN count. Each RPA-derived nodal classification system was reproducible in a large validation cohort for all-cause and cause-specific mortality (P < .001). High quantitative nodal burden was the single strongest tumor-intrinsic variable associated with mortality in 12 of 16 disease sites. CONCLUSIONS Quantitative metastatic LN burden is a fundamental driver of mortality across solid cancers and should serve as a foundation for pathologic nodal staging across solid tumors.
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Affiliation(s)
- Anthony T Nguyen
- Department of Radiation Oncology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Michael Luu
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Department of Biostatistics and Bioinformatics, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Vina P Nguyen
- Department of Medicine, Division of Hematology & Oncology, UCLA School of Medicine, Los Angeles, CA, USA
| | - Diana J Lu
- Department of Radiation Oncology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Stephen L Shiao
- Department of Radiation Oncology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Mitchell Kamrava
- Department of Radiation Oncology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Katelyn M Atkins
- Department of Radiation Oncology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Alain C Mita
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Department of Medical Oncology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Kevin S Scher
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Department of Medical Oncology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Daniel E Spratt
- Department of Radiation Oncology, University Hospitals, Case Western Reserve, Cleveland, OH, USA
| | - Mark B Faries
- Cedars-Sinai Medical Center, The Angeles Clinic and Research Institute, Los Angeles, CA, USA
| | - Timothy J Daskivich
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Department of Surgery, Division of Urology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - De-Chen Lin
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Michelle M Chen
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Jon Mallen-St Clair
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Howard M Sandler
- Department of Radiation Oncology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Allen S Ho
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Zachary S Zumsteg
- Correspondence to: Zachary S. Zumsteg, MD, Department of Radiation Oncology, Cedars-Sinai Medical Center, 8700 Beverly Blvd, Los Angeles, CA 90048, USA (e-mail: )
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25
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Kishan AU, Wang X, Sun Y, Romero T, Michalski JM, Ma TM, Feng FY, Sandler HM, Bolla M, Maingon P, De Reijke T, Neven A, Steigler A, Denham JW, Joseph D, Nabid A, Carrier N, Souhami L, Sydes MR, Dearnaley DP, Syndikus I, Tree AC, Incrocci L, Heemsbergen WD, Pos FJ, Zapatero A, Efstathiou JA, Guerrero A, Alvarez A, San-Segundo CG, Maldonado X, Xiang M, Rettig MB, Reiter RE, Zaorsky NG, Ong WL, Dess RT, Steinberg ML, Nickols NG, Roy S, Garcia JA, Spratt DE. High-dose Radiotherapy or Androgen Deprivation Therapy (HEAT) as Treatment Intensification for Localized Prostate Cancer: An Individual Patient-data Network Meta-analysis from the MARCAP Consortium. Eur Urol 2022; 82:106-114. [PMID: 35469702 DOI: 10.1016/j.eururo.2022.04.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 03/22/2022] [Accepted: 04/04/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND The relative benefits of radiotherapy (RT) dose escalation and the addition of short-term or long-term androgen deprivation therapy (STADT or LTADT) in the treatment of prostate cancer are unknown. OBJECTIVE To perform a network meta-analysis (NMA) of relevant randomized trials to compare the relative benefits of RT dose escalation ± STADT or LTADT. DESIGN, SETTING, AND PARTICIPANTS An NMA of individual patient data from 13 multicenter randomized trials was carried out for a total of 11862 patients. Patients received one of the six permutations of low-dose RT (64 to <74 Gy) ± STADT or LTADT, high-dose RT (≥74 Gy), or high-dose RT ± STADT or LTADT. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSES Metastasis-free survival (MFS) was the primary endpoint. Frequentist and Bayesian NMAs were performed to rank the various treatment strategies by MFS and biochemical recurrence-free survival (BCRFS). RESULTS AND LIMITATIONS Median follow-up was 8.8 yr (interquartile range 5.7-11.5). The greatest relative improvement in outcomes was seen for addition of LTADT, irrespective of RT dose, followed by addition of STADT, irrespective of RT dose. RT dose escalation did not improve MFS either in the absence of ADT (hazard ratio [HR] 0.97, 95% confidence interval [CI] 0.80-1.18) or with STADT (HR 0.99, 95% CI 0.8-1.23) or LTADT (HR 0.94, 95% CI 0.65-1.37). According to P-score ranking and rankogram analysis, high-dose RT + LTADT was the optimal treatment strategy for both BCRFS and longer-term outcomes. CONCLUSIONS Conventionally escalated RT up to 79.2 Gy, alone or in the presence of ADT, does not improve MFS, while addition of STADT or LTADT to RT alone, regardless of RT dose, consistently improves MFS. RT dose escalation does provide a high probability of improving BCRFS and, provided it can be delivered without compromising quality of life, may represent the optimal treatment strategy when used in conjunction with ADT. PATIENT SUMMARY Using a higher radiotherapy dose when treating prostate cancer does not reduce the chance of developing metastases or death, but it does reduce the chance of having a rise in prostate-specific antigen (PSA) signifying recurrence of cancer. Androgen deprivation therapy improves all outcomes. A safe increase in radiotherapy dose in conjunction with androgen deprivation therapy may be the optimal treatment.
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Affiliation(s)
- Amar U Kishan
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA, USA; Department of Urology, University of California Los Angeles, Los Angeles, CA, USA.
| | - Xiaoyan Wang
- Division of General Internal Medicine and Health Services Research, University of California Los Angeles, Los Angeles, CA, USA
| | - Yilun Sun
- Department of Population Quantitative Health Sciences, Case Western Reserve University, Cleveland, OH, USA; Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Tahmineh Romero
- Division of General Internal Medicine and Health Services Research, University of California Los Angeles, Los Angeles, CA, USA
| | - Jeff M Michalski
- Department of Radiation Oncology, Washington University, St. Louis, MO, USA
| | - Ting Martin Ma
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA, USA
| | - Felix Y Feng
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA, USA
| | - Howard M Sandler
- Department of Radiation Oncology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Michel Bolla
- Radiotherapy Department, University Hospital, Grenoble, France
| | - Philippe Maingon
- Department of Oncology, Hematology, and Supportive Care, Sorbonne University, Paris, France
| | - Theo De Reijke
- Department of Urology, Prostate Cancer Network in the Netherlands, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Anouk Neven
- Statistics Department, European Organisation for Research and Treatment of Cancer Headquarters, Brussels, Belgium; Competence Center for Methodology and Statistics, Luxembourg Institute of Health, Strassen, Luxembourg
| | - Allison Steigler
- School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia
| | - James W Denham
- School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia
| | - David Joseph
- Department of Medicine and Surgery, University of Western Australia, Perth, WA, Australia
| | - Abdenour Nabid
- Department of Radiation Oncology, Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC, Canada
| | - Nathalie Carrier
- Clinical Research Center, Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC, Canada
| | - Luis Souhami
- Department of Radiation Oncology, McGill University Health Centre, Montréal, QC, Canada
| | - Matt R Sydes
- Medical Research Council Clinical Trials Unit, University College London, London, UK
| | | | | | | | - Luca Incrocci
- Department of Radiation Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Wilma D Heemsbergen
- Department of Radiation Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Floris J Pos
- Department of Radiation Oncology, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, the Netherlands
| | | | - Jason A Efstathiou
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA
| | | | - Ana Alvarez
- Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | | | | | - Michael Xiang
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA, USA
| | - Matthew B Rettig
- Department of Medical Oncology, University of California Los Angeles, Los Angeles, CA, USA
| | - Robert E Reiter
- Department of Urology, University of California Los Angeles, Los Angeles, CA, USA
| | - Nicholas G Zaorsky
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Wee Loon Ong
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Robert T Dess
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, USA
| | - Michael L Steinberg
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA, USA
| | - Nicholas G Nickols
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA, USA
| | - Soumyajit Roy
- Department of Radiation Oncology, Rush University, Chicago, IL, USA
| | - Jorge A Garcia
- Division of Oncology, Seidman Cancer Center, Cleveland, OH, USA
| | - Daniel E Spratt
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA
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26
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Esteva A, Feng J, van der Wal D, Huang SC, Simko JP, DeVries S, Chen E, Schaeffer EM, Morgan TM, Sun Y, Ghorbani A, Naik N, Nathawani D, Socher R, Michalski JM, Roach M, Pisansky TM, Monson JM, Naz F, Wallace J, Ferguson MJ, Bahary JP, Zou J, Lungren M, Yeung S, Ross AE, Sandler HM, Tran PT, Spratt DE, Pugh S, Feng FY, Mohamad O. Prostate cancer therapy personalization via multi-modal deep learning on randomized phase III clinical trials. NPJ Digit Med 2022; 5:71. [PMID: 35676445 PMCID: PMC9177850 DOI: 10.1038/s41746-022-00613-w] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 05/19/2022] [Indexed: 12/02/2022] Open
Abstract
Prostate cancer is the most frequent cancer in men and a leading cause of cancer death. Determining a patient's optimal therapy is a challenge, where oncologists must select a therapy with the highest likelihood of success and the lowest likelihood of toxicity. International standards for prognostication rely on non-specific and semi-quantitative tools, commonly leading to over- and under-treatment. Tissue-based molecular biomarkers have attempted to address this, but most have limited validation in prospective randomized trials and expensive processing costs, posing substantial barriers to widespread adoption. There remains a significant need for accurate and scalable tools to support therapy personalization. Here we demonstrate prostate cancer therapy personalization by predicting long-term, clinically relevant outcomes using a multimodal deep learning architecture and train models using clinical data and digital histopathology from prostate biopsies. We train and validate models using five phase III randomized trials conducted across hundreds of clinical centers. Histopathological data was available for 5654 of 7764 randomized patients (71%) with a median follow-up of 11.4 years. Compared to the most common risk-stratification tool-risk groups developed by the National Cancer Center Network (NCCN)-our models have superior discriminatory performance across all endpoints, ranging from 9.2% to 14.6% relative improvement in a held-out validation set. This artificial intelligence-based tool improves prognostication over standard tools and allows oncologists to computationally predict the likeliest outcomes of specific patients to determine optimal treatment. Outfitted with digital scanners and internet access, any clinic could offer such capabilities, enabling global access to therapy personalization.
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Affiliation(s)
| | - Jean Feng
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA, USA
| | | | - Shih-Cheng Huang
- Department of Biomedical Data Science, Stanford University, Stanford, CA, USA
| | - Jeffry P Simko
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA, USA
| | - Sandy DeVries
- NRG Oncology Biospecimen Bank, San Francisco, CA, USA
| | | | | | - Todd M Morgan
- Division of Urologic Oncology, University of Michigan Comprehensive Cancer Center, Ann Arbor, MI, USA
| | - Yilun Sun
- Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, OH, USA
| | | | | | | | | | - Jeff M Michalski
- Department of Radiation Oncology, Washington University School of Medicine, Saint Louis, MO, USA
| | - Mack Roach
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA, USA
| | | | | | - Farah Naz
- Department of Radiation Oncology, Horizon Health Network-Saint John Regional Hospital, Saint John, JB E2L 4L2, CA, Canada
| | - James Wallace
- Department of Hematology and Oncology, Ingalls Memorial Hospital, Harvey, IL, USA
| | - Michelle J Ferguson
- Department of Radiation Oncology, Allan Blair Cancer Centre, Regina, SK S4T 7T1, CA, Canada
| | - Jean-Paul Bahary
- Department of Radiation Oncology, CHUM - Centre Hospitalier de l'Universite de Montreal, Montreal, QC H2X 3E4, CA, Canada
| | - James Zou
- Department of Biomedical Data Science, Stanford University, Stanford, CA, USA
| | - Matthew Lungren
- Department of Biomedical Data Science, Stanford University, Stanford, CA, USA
| | - Serena Yeung
- Department of Biomedical Data Science, Stanford University, Stanford, CA, USA
| | - Ashley E Ross
- Department of Urology, Northwestern University, Evanston, IL, USA
| | - Howard M Sandler
- Department of Radiation Oncology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Phuoc T Tran
- Department of Radiation Oncology, University of Maryland, Baltimore, MD, USA
| | - Daniel E Spratt
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Case Western Reserve University, Cleveland, OH, USA
| | - Stephanie Pugh
- NRG Oncology Statistics and Data Management Center, Philadelphia, PA, USA
| | - Felix Y Feng
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA, USA
| | - Osama Mohamad
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA, USA
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27
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Khairnar R, DeMora L, Sandler HM, Lee WR, Villalonga-Olives E, Mullins CD, Palumbo FB, Bruner DW, Shaya FT, Bentzen SM, Shah AB, Malone S, Michalski JM, Dayes IS, Seaward SA, Albert M, Currey AD, Pisansky TM, Chen Y, Horwitz EM, DeNittis AS, Feng F, Mishra MV. Methodological Comparison of Mapping the Expanded Prostate Cancer Index Composite to EuroQoL-5D-3L Using Cross-Sectional and Longitudinal Data: Secondary Analysis of NRG/RTOG 0415. JCO Clin Cancer Inform 2022; 6:e2100188. [PMID: 35776901 DOI: 10.1200/cci.21.00188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To compare the predictive ability of mapping algorithms derived using cross-sectional and longitudinal data. METHODS This methodological assessment used data from a randomized controlled noninferiority trial of patients with low-risk prostate cancer, conducted by NRG Oncology (ClinicalTrials.gov identifier: NCT00331773), which examined the efficacy of conventional schedule versus hypofractionated radiation therapy (three-dimensional conformal external beam radiation therapy/IMRT). Health-related quality-of-life data were collected using the Expanded Prostate Cancer Index Composite (EPIC), and health utilities were obtained using EuroQOL-5D-3L (EQ-5D) at baseline and 6, 12, 24, and 60 months postintervention. Mapping algorithms were estimated using ordinary least squares regression models through five-fold cross-validation in baseline cross-sectional data and combined longitudinal data from all assessment periods; random effects specifications were also estimated in longitudinal data. Predictive performance was compared using root mean square error. Longitudinal predictive ability of models obtained using baseline data was examined using mean absolute differences in the reported and predicted utilities. RESULTS A total of 267 (and 199) patients in the estimation sample had complete EQ-5D and EPIC domain (and subdomain) data at baseline and at all subsequent assessments. Ordinary least squares models using combined data showed better predictive ability (lowest root mean square error) in the validation phase for algorithms with EPIC domain/subdomain data alone, whereas models using baseline data outperformed other specifications in the validation phase when patient covariates were also modeled. The mean absolute differences were lower for models using EPIC subdomain data compared with EPIC domain data and generally decreased as the time of assessment increased. CONCLUSION Overall, mapping algorithms obtained using baseline cross-sectional data showed the best predictive performance. Furthermore, these models demonstrated satisfactory longitudinal predictive ability.
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Affiliation(s)
- Rahul Khairnar
- Department of Pharmaceutical Health Services Research, University of Maryland School of Pharmacy, Baltimore, MD
| | - Lyudmila DeMora
- NRG Oncology Statistics and Data Management Center, Philadelphia, PA
| | - Howard M Sandler
- Department of Radiation Oncology, Cedars-Sinai Medical Center, Los Angeles, CA
| | - W Robert Lee
- Department of Radiation Oncology, Duke University, Durham, NC
| | - Ester Villalonga-Olives
- Department of Pharmaceutical Health Services Research, University of Maryland School of Pharmacy, Baltimore, MD
| | - C Daniel Mullins
- Department of Pharmaceutical Health Services Research, University of Maryland School of Pharmacy, Baltimore, MD
| | - Francis B Palumbo
- Department of Pharmaceutical Health Services Research, University of Maryland School of Pharmacy, Baltimore, MD
| | | | - Fadia T Shaya
- Department of Pharmaceutical Health Services Research, University of Maryland School of Pharmacy, Baltimore, MD
| | - Soren M Bentzen
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD
| | - Amit B Shah
- WellSpan Health-York Cancer Center, York, PA
| | - Shawn Malone
- Ottawa Hospital and Cancer Center, Ottawa, Ontario, Canada
| | - Jeff M Michalski
- Department of Radiation Oncology, Washington University, St Louis, MO
| | - Ian S Dayes
- Juravinski Cancer Center at Hamilton Health Sciences, Hamilton, Ontario, Canada
| | | | | | - Adam D Currey
- Zablocki VAMC and the Medical College of Wisconsin, Milwaukee, WI
| | - Thomas M Pisansky
- Department of Radiation Oncology, Mayo Clinic Rochester, Rochester, MN
| | - Yuhchyau Chen
- Department of Radiation Oncology, University of Rochester, Rochester, NY
| | - Eric M Horwitz
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA
| | | | - Felix Feng
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA
| | - Mark V Mishra
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD
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Pollack A, Karrison TG, Balogh AG, Gomella LG, Low DA, Bruner DW, Wefel JS, Martin AG, Michalski JM, Angyalfi SJ, Lukka H, Faria SL, Rodrigues GB, Beauchemin MC, Lee RJ, Seaward SA, Allen AM, Monitto DC, Seiferheld W, Sartor O, Feng F, Sandler HM. The addition of androgen deprivation therapy and pelvic lymph node treatment to prostate bed salvage radiotherapy (NRG Oncology/RTOG 0534 SPPORT): an international, multicentre, randomised phase 3 trial. Lancet 2022; 399:1886-1901. [PMID: 35569466 PMCID: PMC9819649 DOI: 10.1016/s0140-6736(21)01790-6] [Citation(s) in RCA: 85] [Impact Index Per Article: 42.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 07/02/2021] [Accepted: 07/29/2021] [Indexed: 01/11/2023]
Abstract
BACKGROUND In men with a detectable prostate-specific antigen (PSA) level after prostatectomy for prostate cancer, salvage prostate bed radiotherapy (PBRT) results in about 70% of patients being free of progression at 5 years. A three-group randomised trial was designed to determine whether incremental gains in patient outcomes can be achieved by adding either 4-6 months of short-term androgen deprivation therapy (ADT) to PBRT, or both short-term ADT and pelvic lymph node radiotherapy (PLNRT) to PBRT. METHODS The international, multicentre, randomised, controlled SPPORT trial was done at 283 radiation oncology cancer treatment centres in the USA, Canada, and Israel. Eligible patients (aged ≥18 years) were those who after prostatectomy for adenocarcinoma of the prostate had a persistently detectable or an initially undetectable and rising PSA of between 0·1 and 2·0 ng/mL. Patients with and without lymphadenectomy (N0/Nx) were eligible if there was no clinical or pathological evidence of lymph node involvement. Other eligibility criteria included pT2 or pT3 disease, prostatectomy Gleason score of 9 or less, and a Zubrod performance status of 0-1. Eligible patients were randomly assigned to receive PBRT alone at a dose of 64·8-70·2 Gy at 1·8 Gy per fraction daily (group 1), PBRT plus short-term ADT (group 2), or PLNRT (45 Gy at 1·8 Gy per fraction, and then a volume reduction made to the planning target volume for the remaining 19·8-25 ·2 Gy) plus PBRT plus short-term ADT (group 3). The primary endpoint was freedom from progression, in which progression was defined as biochemical failure according to the Phoenix definition (PSA ≥2 ng/mL over the nadir PSA), clinical failure (local, regional, or distant), or death from any cause. A planned interim analysis of 1191 patents with minimum potential follow-up time of 5 years applied a Haybittle-Peto boundary of p<0·001 (one sided) for comparison of 5-year freedom from progression rates between the treatment groups. This trial is registered with ClinicalTrials.gov, NCT00567580. The primary objectives of the trial have been completed, although long-term follow-up is continuing. FINDINGS Between March 31, 2008, and March 30, 2015, 1792 eligible patients were enrolled and randomly assigned to the three treatment groups (592 to group 1 [PBRT alone], 602 to group 2 [PBRT plus short-term ADT], and 598 to group 3 [PLNRT plus PBRT plus short-term ADT]). 76 patients subsequently found to be ineligible were excluded from the analyses; thus, the evaluable patient population comprised 1716 patients. At the interim analysis (n=1191 patients; data cutoff May 23, 2018), the Haybittle-Peto boundary for 5-year freedom from progression was exceeded when group 1 was compared with group 3 (difference 17·9%, SE 2·9%; p<0·0001). The difference between groups 2 and 3 did not exceed the boundary (p=0·0063). With additional follow-up beyond the interim analysis (the final planned analysis; data cutoff May 26, 2021), at a median follow-up among survivors of 8·2 years (IQR 6·6-9·4), the 5-year freedom from progression rates in all 1716 eligible patients were 70·9% (95% CI 67·0-74·9) in group 1, 81·3% (78·0-84·6) in group 2, and 87·4% (84·7-90·2) in group 3. Per protocol criteria, freedom from progression in group 3 was superior to groups 1 and 2. Acute (≤3 months after radiotherapy) grade 2 or worse adverse events were significantly more common in group 3 (246 [44%] of 563 patients) than in group 2 (201 [36%] of 563; p=0·0034), which, in turn, were more common than in group 1 (98 [18%] of 547; p<0·0001). Similar findings were observed for grade 3 or worse adverse events. However, late toxicity (>3 months after radiotherapy) did not differ significantly between the groups, apart from more late grade 2 or worse blood or bone marrow events in group 3 versus group 2 (one-sided p=0·0060) attributable to the addition of PLNRT in this group. INTERPRETATION The results of this randomised trial establish the benefit of adding short-term ADT to PBRT to prevent progression in prostate cancer. To our knowledge, these are the first such findings to show that extending salvage radiotherapy to treat the pelvic lymph nodes when combined with short-term ADT results in meaningful reductions in progression after prostatectomy in patients with prostate cancer. FUNDING National Cancer Institute.
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Affiliation(s)
- Alan Pollack
- Department of Radiation Oncology, University of Miami Miller School of Medicine and Sylvester Comprehensive Cancer Center, Miami, FL, USA.
| | - Theodore G Karrison
- Department of Public Health Sciences, University of Chicago, Chicago, IL, USA; NRG Oncology, Philadelphia, PA, USA
| | | | - Leonard G Gomella
- Sidney Kimmel Cancer Center of Thomas Jefferson University, Philadelphia, PA, USA
| | - Daniel A Low
- Department of Radiation Oncology, University of California at Los Angeles, Los Angeles, CA, USA
| | - Deborah W Bruner
- Nell Hodgson Woodruff School of Nursing, and Winship Cancer Institute at Emory University, Atlanta, GA, USA
| | - Jeffrey S Wefel
- Department of Neuro-Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Andre-Guy Martin
- CHU de Quebec-Université Laval (L'Hotel-Dieu de Quebec), Quebec, QC, Canada
| | - Jeff M Michalski
- Department of Radiation Oncology, Washington University School of Medicine, St Louis, MO, USA
| | - Steve J Angyalfi
- Tom Baker Cancer Center, University of Calgary, Calgary, AB, Canada
| | - Himanshu Lukka
- Department of Oncology, McMaster University, Hamilton, ON, Canada
| | | | - George B Rodrigues
- Department of Oncology, London Regional Cancer Program, Western University, London, ON, Canada
| | - Marie-Claude Beauchemin
- Department of Radiation Oncology, CHUM-Centre Hospitalier de l'Université de Montréal, Montreal, QC, Canada
| | - R Jeffrey Lee
- Intermountain Medical Center, Salt Lake City, UT, USA
| | | | - Aaron M Allen
- Davidoff Center, Rabin Medical Center, Tel Aviv, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Drew C Monitto
- Spartanburg Regional Medical Center, Spartanburg, SC, USA
| | | | - Oliver Sartor
- Department of Medicine, Tulane University, New Orleans, LA, USA
| | - Felix Feng
- Department of Radiation Oncology, University of California at San Francisco, San Francisco, CA , USA
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29
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Jones CU, Pugh SL, Sandler HM, Chetner MP, Amin MB, Bruner DW, Zietman AL, Den RB, Leibenhaut MH, Longo JM, Bahary JP, Rosenthal SA, Souhami L, Michalski JM, Hartford AC, Amin PP, Roach M, Yee D, Efstathiou JA, Rodgers JP, Feng FY, Shipley WU. Adding Short-Term Androgen Deprivation Therapy to Radiation Therapy in Men With Localized Prostate Cancer: Long-Term Update of the NRG/RTOG 9408 Randomized Clinical Trial. Int J Radiat Oncol Biol Phys 2022; 112:294-303. [PMID: 34481017 PMCID: PMC8748315 DOI: 10.1016/j.ijrobp.2021.08.031] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 08/18/2021] [Accepted: 08/24/2021] [Indexed: 02/07/2023]
Abstract
PURPOSE For men with localized prostate cancer, NRG Oncology/Radiation Therapy Oncology Group (RTOG) 9408 demonstrated that adding short-term androgen deprivation therapy (ADT) to radiation therapy (RT) improved the primary endpoint of overall survival (OS) and improved disease-specific mortality (DSM), biochemical failure (BF), local progression, and freedom from distant metastases (DM). This study was performed to determine whether the short-term ADT continued to improve OS, DSM, BF, and freedom from DM with longer follow-up. METHODS AND MATERIALS From 1994 to 2001, NRG/RTOG 9408 randomized 2028 men from 212 North American institutions with T1b-T2b, N0 prostate adenocarcinoma and prostate-specific antigen (PSA) ≤20ng/mL to RT alone or RT plus short-term ADT. Patients were stratified by PSA, tumor grade, and surgical versus clinical nodal staging. ADT was flutamide with either goserelin or leuprolide for 4 months. Prostate RT (66.6 Gy) was started after 2 months. OS was calculated at the date of death from any cause or at last follow-up. Secondary endpoints were DSM, BF, local progression, and DM. Acute and late toxic effects were assessed using RTOG toxicity scales. RESULTS Median follow-up in surviving patients was 14.8 years (range, 0.16-21.98). The 10-year and 18-year OS was 56% and 23%, respectively, with RT alone versus 63% and 23% with combined therapy (HR 0.94; 95% confidence interval [CI], 0.85-1.05; P = .94). The hazards were not proportional (P = .003). Estimated restricted mean survival time at 18 years was 11.8 years (95% CI, 11.4-12.1) with combined therapy versus 11.3 years with RT alone (95% CI, 10.9-11.6; P = .05). The 10-year and 18-year DSM was 7% and 14%, respectively, with RT alone versus 3% and 8% with combined therapy (HR 0.56; 95% CI, 0.41-0.75; P < .01). DM and BF favored combined therapy at 18 years. Rates of late grade ≥3 hepatic, gastrointestinal, and genitourinary toxicity were ≤1%, 3%, and 8%, respectively, with combined therapy versus ≤1%, 2%, and 5% with RT alone. CONCLUSIONS Further follow-up demonstrates that OS converges at approximately 15 years, by which point the administration of 4 months of ADT had conferred an estimated additional 6 months of life.
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Affiliation(s)
| | - Stephanie L Pugh
- NRG Oncology Statistics and Data Management Center, Philadelphia, Pennsylvania
| | | | | | - Mahul B Amin
- University of Tennessee Health Science Center, Memphis, Tennessee
| | | | | | - Robert B Den
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | | | - John M Longo
- Froedtert and the Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Jean-Paul Bahary
- Centre Hospitalier De L`Université De Montréal-Notre Dame, Montréal, Quebec, Canada
| | | | - Luis Souhami
- The Research Institute of the McGill University Health Centre, Montréal, Quebec, Canada
| | | | | | - Pradip P Amin
- University of Maryland/Greenebaum Cancer Center, Baltimore, Maryland
| | - Mack Roach
- UCSF Medical Center-Mount Zion, San Francisco, California
| | - Don Yee
- Cross Cancer Institute, Edmonton, Alberta, Canada
| | | | - Joseph P Rodgers
- NRG Oncology Statistics and Data Management Center, Philadelphia, Pennsylvania
| | - Felix Y Feng
- UCSF Medical Center-Mount Zion, San Francisco, California
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30
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Kishan AU, Sun Y, Hartman H, Pisansky TM, Bolla M, Neven A, Steigler A, Denham JW, Feng FY, Zapatero A, Armstrong JG, Nabid A, Carrier N, Souhami L, Dunne MT, Efstathiou JA, Sandler HM, Guerrero A, Joseph D, Maingon P, de Reijke TM, Maldonado X, Ma TM, Romero T, Wang X, Rettig MB, Reiter RE, Zaorsky NG, Steinberg ML, Nickols NG, Jia AY, Garcia JA, Spratt DE. Androgen deprivation therapy use and duration with definitive radiotherapy for localised prostate cancer: an individual patient data meta-analysis. Lancet Oncol 2022; 23:304-316. [DOI: 10.1016/s1470-2045(21)00705-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 11/23/2021] [Accepted: 11/26/2021] [Indexed: 12/22/2022]
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31
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Hall WA, Deshmukh S, Bruner DW, Michalski JM, Purdy JA, Bosch W, Bahary JP, Patel MP, Parliament MB, Lock MI, Lau HY, Souhami L, Fisher SA, Kwok Y, Seider MJ, Vigneault E, Rosenthal SA, Gustafson GS, Gay HA, Pugh SL, Sandler HM, Movsas B. Quality of Life Implications of Dose-Escalated External Beam Radiation for Localized Prostate Cancer: Results of a Prospective Randomized Phase 3 Clinical Trial, NRG/RTOG 0126. Int J Radiat Oncol Biol Phys 2022; 112:83-92. [PMID: 34919884 PMCID: PMC8789217 DOI: 10.1016/j.ijrobp.2021.07.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 05/13/2021] [Accepted: 07/02/2021] [Indexed: 02/07/2023]
Abstract
PURPOSE External beam radiation therapy (EBRT) dose escalation has been tested in multiple prospective trials. However, the impact on patient reported outcomes (PROs) associated with higher doses of EBRT remain poorly understood. We sought to assess the differences in PROs between men treated with a dose of 70.2 Gy versus 79.2 Gy of EBRT for prostate cancer. METHODS AND MATERIALS The phase 3 clinical trial RTOG 0126 randomized 1532 patients with prostate cancer between March 2002 and August 2008 to 79.2 Gy over 44 fractions versus 70.2 Gy over 39 fractions. Eligible patients participated in the PRO data collection. PROs completed included the International Index of Erectile Function Questionnaire (IIEF), Functional Alterations due to Changes in Elimination (FACE), and the Spitzer Quality of Life Index (SQLI). The timepoints for the IIEF were collected pre-entry and at 6, 12, and 24 months. The FACE and SQLI were collected pre-entry and at 3, 6, 12, 18, and 24 months. The impact of EBRT dose to normal structures (penile bulb, rectum, and bladder) on PROs was also examined. Mixed effects models were used to analyze trends across time. RESULTS In total, 1144 patients completed baseline IIEF forms and of these, 56%, 64%, and 61% completed the IIEF at 6, 12, and 24 months, respectively; 1123 patients completed the FACE score at baseline and 50%, 61%, 73%, 61%, and 65% completed all 15 items for the FACE metric at timepoints of 3, 6, 12, 18, and 24 months, respectively. Erectile dysfunction at 12 months based on the single question was not significantly different between arms (38.1% for the standard dose radiation therapy arm vs 49.7% for the dose escalated radiation therapy arm; P = .051). Treatment arm (70.2 vs 79.2) had no significant impact on any PRO metrics measured across all collected domains. Comprehensive dosimetric analyses are presented and reveal multiple significant differences to regional organs at risk. CONCLUSIONS Compliance with PRO data collection was lower than anticipated in this phase 3 trial. Examining the available data, dose escalated EBRT did not appear to be associated with any detriment to PROs across numerous prospectively collected domains. These data, notwithstanding limitations, add to our understanding of the implications of EBRT dose escalation in prostate cancer. Furthermore, these results illustrate challenges associated with PRO data collection.
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Affiliation(s)
- William A Hall
- Medical College of Wisconsin,Corresponding Author: Froedtert and the Medical College of Wisconsin, 8701 W Watertown Plank Rd, Milwaukee, WI 53226, Telephone: 414-805-4477, Fax: 414-805-4369, , this has been previously presented at the American Society of Radiation Oncology meeting
| | | | | | | | | | | | | | | | | | | | | | | | | | - Young Kwok
- University of Maryland/Greenebaum Cancer Center
| | | | | | - Seth A Rosenthal
- Sutter Cancer Centers Radiation Oncology Services-accruals under Radiological Associates of Sacramento
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Lu DJ, King B, Sandler HM, Tarbell NJ, Kamrava M, Atkins KM. Paid Parental Leave Policies Among U.S. News & World Report 2020-2021 Best Hospitals and Best Hospitals for Cancer. JAMA Netw Open 2021; 4:e218518. [PMID: 33974058 PMCID: PMC8114142 DOI: 10.1001/jamanetworkopen.2021.8518] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
This cross-sectional study examines paid parental leave policies for faculty and staff physicians at leading US hospitals and cancer centers.
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Affiliation(s)
- Diana J Lu
- Department of Radiation Oncology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Benjamin King
- Department of Radiation Oncology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Howard M Sandler
- Department of Radiation Oncology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Nancy J Tarbell
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston
| | - Mitchell Kamrava
- Department of Radiation Oncology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Katelyn M Atkins
- Department of Radiation Oncology, Cedars-Sinai Medical Center, Los Angeles, California
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Feng FY, Huang HC, Spratt DE, Zhao SG, Sandler HM, Simko JP, Davicioni E, Nguyen PL, Pollack A, Efstathiou JA, Dicker AP, Todorovic T, Margrave J, Liu YS, Dabbas B, Thompson DJS, Das R, Dignam JJ, Sweeney C, Attard G, Bahary JP, Lukka HR, Hall WA, Pisansky TM, Shah AB, Pugh SL, Shipley WU, Tran PT. Validation of a 22-Gene Genomic Classifier in Patients With Recurrent Prostate Cancer: An Ancillary Study of the NRG/RTOG 9601 Randomized Clinical Trial. JAMA Oncol 2021; 7:544-552. [PMID: 33570548 PMCID: PMC7879385 DOI: 10.1001/jamaoncol.2020.7671] [Citation(s) in RCA: 72] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Question Can a genomic biomarker estimate the risk of prostate cancer clinical end points in men
who received salvage radiation for rising prostate-specific antigen levels after
surgery? Findings In this ancillary study of 352 men randomized to placebo or hormone therapy in the
NRG/RTOG 9601 clinical trial of salvage radiation, the Decipher genomic classifier was
independently associated with the risk of metastasis, prostate cancer–specific
mortality, and overall survival. Meaning These findings suggest that the Decipher genomic classifier is a promising biomarker to
risk stratify men to better enable hormone therapy treatment decisions for biochemical
recurrence of their prostate cancer after surgery. Importance Decipher (Decipher Biosciences Inc) is a genomic classifier (GC) developed to estimate
the risk of distant metastasis (DM) after radical prostatectomy (RP) in patients with
prostate cancer. Objective To validate the GC in the context of a randomized phase 3 trial. Design, Setting, and Participants This ancillary study used RP specimens from the phase 3 placebo-controlled NRG/RTOG
9601 randomized clinical trial conducted from March 1998 to March 2003. The specimens
were centrally reviewed, and RNA was extracted from the highest-grade tumor available in
2019 with a median follow-up of 13 years. Clinical-grade whole transcriptomes from
samples passing quality control were assigned GC scores (scale, 0-1). A National
Clinical Trials Network–approved prespecified statistical plan included the
primary objective of validating the independent prognostic ability of GC for DM, with
secondary end points of prostate cancer–specific mortality (PCSM) and overall
survival (OS). Data were analyzed from September 2019 to December 2019. Intervention Salvage radiotherapy (sRT) with or without 2 years of bicalutamide. Main Outcomes and Measures The preplanned primary end point of this study was the independent association of the
GC with the development of DM. Results In this ancillary study of specimens from a phase 3 randomized clinical trial, GC
scores were generated from 486 of 760 randomized patients with a median follow-up of 13
years; samples from a total of 352 men (median [interquartile range] age, 64.5 (60-70)
years; 314 White [89.2%] participants) passed microarray quality control and comprised
the final cohort for analysis. On multivariable analysis, the GC (continuous variable,
per 0.1 unit) was independently associated with DM (hazard ratio [HR], 1.17; 95% CI,
1.05-1.32; P = .006), PCSM (HR, 1.39; 95% CI, 1.20-1.63;
P < .001), and OS (HR, 1.17; 95% CI, 1.06-1.29;
P = .002) after adjusting for age, race/ethnicity,
Gleason score, T stage, margin status, entry prostate-specific antigen, and treatment
arm. Although the original planned analysis was not powered to detect a treatment effect
interaction by GC score, the estimated absolute effect of bicalutamide on 12-year OS was
less when comparing patients with lower vs higher GC scores (2.4% vs 8.9%), which was
further demonstrated in men receiving early sRT at a prostate-specific antigen level
lower than 0.7 ng/mL (−7.8% vs 4.6%). Conclusions and Relevance This ancillary validation study of the Decipher GC in a randomized trial cohort
demonstrated association of the GC with DM, PCSM, and OS independent of standard
clinicopathologic variables. These results suggest that not all men with biochemically
recurrent prostate cancer after surgery benefit equally from the addition of hormone
therapy to sRT. Trial Registration ClinicalTrials.gov identifier: NCT00002874
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Affiliation(s)
- Felix Y Feng
- Department of Radiation Oncology, UCSF Medical Center, San Francisco, California.,Department of Medicine, UCSF Medical Center, San Francisco, California.,Department of Urology, UCSF Medical Center, San Francisco, California
| | | | - Daniel E Spratt
- Department of Radiation Oncology, University of Michigan, Ann Arbor
| | | | - Howard M Sandler
- Department of Radiation Oncology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Jeffry P Simko
- NRG Biorepository, Department of Pathology, UCSF Medical Center, San Francisco, California
| | | | - Paul L Nguyen
- Department of Radiation Oncology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Alan Pollack
- Department of Radiation Oncology, University of Miami Miller School of Medicine, Miami, Florida
| | - Jason A Efstathiou
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Adam P Dicker
- Department of Radiation Oncology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | | | | | | | | | | | - Rajdeep Das
- Department of Radiation Oncology, UCSF Medical Center, San Francisco, California.,Department of Medicine, UCSF Medical Center, San Francisco, California.,Department of Urology, UCSF Medical Center, San Francisco, California
| | - James J Dignam
- NRG Oncology Statistics and Data Management Center, Philadelphia, Pennsylvania.,Department of Public Health, University of Chicago, Chicago, Illinois
| | - Christopher Sweeney
- Department of Medicine, Dana-Farber/Harvard Cancer Center, Boston, Massachusetts
| | - Gerhardt Attard
- Department of Oncology, University College London, London, United Kingdom
| | - Jean-Paul Bahary
- Department of Radiation Oncology, Centre Hospitalier de l'Université de Montréal-Notre Dame, Montreal, Quebec, Canada
| | - Himanshu R Lukka
- Department of Radiation Oncology, Juravinski Cancer Centre at Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - William A Hall
- Department of Radiation Oncology, Froedtert and the Medical College of Wisconsin, Madison, Wisconsin
| | | | - Amit B Shah
- Department of Radiation Oncology, WellSpan Health-York Cancer Center accruals under Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Stephanie L Pugh
- NRG Oncology Statistics and Data Management Center, Philadelphia, Pennsylvania
| | - William U Shipley
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Phuoc T Tran
- Department of Radiation Oncology, Johns Hopkins University, Baltimore, Maryland.,Department of Oncology, Johns Hopkins University, Baltimore, Maryland.,Department of Urology, Johns Hopkins University, Baltimore, Maryland
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Freedland SJ, Allen J, Jarman A, Oyekunle T, Armstrong AJ, Moul JW, Sandler HM, Posadas E, Levin D, Wiggins E, Howard LE, Wu Y, Lin PH. Correction: A Randomized Controlled Trial of a 6-Month Low-Carbohydrate Intervention on Disease Progression in Men with Recurrent Prostate Cancer: Carbohydrate and Prostate Study 2 (CAPS2). Clin Cancer Res 2021; 27:1823. [PMID: 33712498 DOI: 10.1158/1078-0432.ccr-21-0372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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35
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Hall WA, Paulson E, Davis BJ, Spratt DE, Morgan TM, Dearnaley D, Tree AC, Efstathiou JA, Harisinghani M, Jani AB, Buyyounouski MK, Pisansky TM, Tran PT, Karnes RJ, Chen RC, Cury FL, Michalski JM, Rosenthal SA, Koontz BF, Wong AC, Nguyen PL, Hope TA, Feng F, Sandler HM, Lawton CAF. NRG Oncology Updated International Consensus Atlas on Pelvic Lymph Node Volumes for Intact and Postoperative Prostate Cancer. Int J Radiat Oncol Biol Phys 2021; 109:174-185. [PMID: 32861817 PMCID: PMC7736505 DOI: 10.1016/j.ijrobp.2020.08.034] [Citation(s) in RCA: 60] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 07/31/2020] [Accepted: 08/07/2020] [Indexed: 02/08/2023]
Abstract
PURPOSE In 2009, the Radiation Therapy Oncology Group (RTOG) genitourinary members published a consensus atlas for contouring prostate pelvic nodal clinical target volumes (CTVs). Data have emerged further informing nodal recurrence patterns. The objective of this study is to provide an updated prostate pelvic nodal consensus atlas. METHODS AND MATERIALS A literature review was performed abstracting data on nodal recurrence patterns. Data were presented to a panel of international experts, including radiation oncologists, radiologists, and urologists. After data review, participants contoured nodal CTVs on 3 cases: postoperative, intact node positive, and intact node negative. Radiation oncologist contours were analyzed qualitatively using count maps, which provided a visual assessment of controversial regions, and quantitatively analyzed using Sorensen-Dice similarity coefficients and Hausdorff distances compared with the 2009 RTOG atlas. Diagnostic radiologists generated a reference table outlining considerations for determining clinical node positivity. RESULTS Eighteen radiation oncologists' contours (54 CTVs) were included. Two urologists' volumes were examined in a separate analysis. The mean CTV for the postoperative case was 302 cm3, intact node positive case was 409 cm3, and intact node negative case was 342 cm3. Compared with the original RTOG consensus, the mean Sorensen-Dice similarity coefficient for the postoperative case was 0.63 (standard deviation [SD] 0.13), the intact node positive case was 0.68 (SD 0.13), and the intact node negative case was 0.66 (SD 0.18). The mean Hausdorff distance (in cm) for the postoperative case was 0.24 (SD 0.13), the intact node positive case was 0.23 (SD 0.09), and intact node negative case was 0.33 (SD 0.24). Four regions of CTV controversy were identified, and consensus for each of these areas was reached. CONCLUSIONS Discordance with the 2009 RTOG consensus atlas was seen in a group of experienced NRG Oncology and international genitourinary radiation oncologists. To address areas of variability and account for new data, an updated NRG Oncology consensus contour atlas was developed.
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Affiliation(s)
- William A Hall
- Medical College of Wisconsin, Department of Radiation Oncology, Milwaukee, Wisconsin.
| | - Eric Paulson
- Medical College of Wisconsin, Department of Radiation Oncology, Milwaukee, Wisconsin
| | - Brian J Davis
- Mayo Clinic, Department of Radiation Oncology, Rochester, Minnesota
| | - Daniel E Spratt
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Todd M Morgan
- Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - David Dearnaley
- The Royal Marsden NHS Foundation Trust and The Institute of Cancer Research, London, UK
| | - Alison C Tree
- The Royal Marsden NHS Foundation Trust and The Institute of Cancer Research, London, UK
| | - Jason A Efstathiou
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Mukesh Harisinghani
- Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Ashesh B Jani
- Department of Radiation Oncology, Emory University, Atlanta, Georgia
| | | | | | - Phuoc T Tran
- Department of Radiation Oncology, Johns Hopkins, Baltimore, Maryland
| | | | - Ronald C Chen
- Department of Radiation Oncology, University of Kansas, Kansas City, Kansas
| | - Fabio L Cury
- Department of Radiation Oncology, McGill University, Montreal, Canada
| | - Jeff M Michalski
- Department of Radiation Oncology, Washington University, St. Louis, Missouri
| | - Seth A Rosenthal
- Department of Radiation Oncology, Sutter Medical Group, Roseville, California
| | - Bridget F Koontz
- Department of Radiation Oncology, Duke Cancer Institute, Durham, North Carolina
| | - Anthony C Wong
- Department of Radiation Oncology, University of California San Francisco, San Francisco, California
| | - Paul L Nguyen
- Department of Radiation Oncology, Dana Farber Harvard Cancer Center, Boston, Massachusetts
| | - Thomas A Hope
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California
| | - Felix Feng
- Department of Radiation Oncology, University of California San Francisco, San Francisco, California
| | - Howard M Sandler
- Department of Radiation Oncology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Colleen A F Lawton
- Medical College of Wisconsin, Department of Radiation Oncology, Milwaukee, Wisconsin
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Spratt DE, Malone S, Roy S, Grimes S, Eapen L, Morgan SC, Malone J, Craig J, Dess RT, Jackson WC, Hartman HE, Kishan AU, Mehra R, Kaffenberger S, Morgan TM, Reichert ZR, Alumkal JJ, Michalski J, Lee WR, Pisansky TM, Feng FY, Shipley W, Sandler HM, Schipper MJ, Roach M, Sun Y, Lawton CAF. Prostate Radiotherapy With Adjuvant Androgen Deprivation Therapy (ADT) Improves Metastasis-Free Survival Compared to Neoadjuvant ADT: An Individual Patient Meta-Analysis. J Clin Oncol 2020; 39:136-144. [PMID: 33275486 DOI: 10.1200/jco.20.02438] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE There remains a lack of clarity regarding the influence of sequencing of androgen deprivation therapy (ADT) and radiotherapy (RT) on outcomes in prostate cancer (PCa). Herein, we evaluate the optimal sequencing of ADT with prostate-directed RT in localized PCa. METHODS MEDLINE (1966-2018), Embase (1982-2018), ClinicalTrials.gov, and conference proceedings (1990-2018) were searched to identify randomized trials evaluating the sequencing, but not duration, of ADT with RT. Two randomized phase III trials were identified, and individual patient data were obtained: Ottawa 0101 and NRG Oncology's Radiation Therapy Oncology Group 9413. Ottawa 0101 randomly assigned patients to neoadjuvant or concurrent versus concurrent or adjuvant short-term ADT. Radiation Therapy Oncology Group 9413, a 2 × 2 factorial trial, included a random assignment of neoadjuvant or concurrent versus adjuvant short-term ADT. The neoadjuvant or concurrent ADT arms of both trials were combined into the neoadjuvant group, and the arms receiving adjuvant ADT were combined into the adjuvant group. The primary end point of this meta-analysis was progression-free survival (PFS). RESULTS The median follow-up was 14.9 years. Overall, 1,065 patients were included (531 neoadjuvant and 534 adjuvant). PFS was significantly improved in the adjuvant group (15-year PFS, 29% v 36%, hazard ratio [HR], 1.25 [95% CI, 1.07 to 1.47], P = .01). Biochemical failure (subdistribution HR [sHR], 1.37 [95% CI, 1.12 to 1.68], P = .002), distant metastasis (sHR, 1.40 [95% CI, 1.00 to 1.95], P = .04), and metastasis-free survival (HR, 1.17 [95% CI, 1.00 to 1.37], P = .050) were all significantly improved in the adjuvant group. There were no differences in late grade ≥ 3 gastrointestinal (2% v 3%, P = .33) or genitourinary toxicity (5% v 5%, P = .76) between groups. CONCLUSION The sequencing of ADT with prostate-directed RT has significant association with long-term PFS and MFS in localized PCa. Our findings favor use of an adjuvant over a neoadjuvant approach, without any increase in long-term toxicity.
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Affiliation(s)
- Daniel E Spratt
- Department of Radiation Oncology, University of Michigan School of Medicine, Ann Arbor, MI
| | - Shawn Malone
- The Ottawa Hospital Cancer Centre, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Soumyajit Roy
- The Ottawa Hospital Cancer Centre, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,New York Medical College, New York, NY
| | - Scott Grimes
- The Ottawa Hospital Cancer Centre, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Libni Eapen
- The Ottawa Hospital Cancer Centre, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Mayo Clinic, Rochester, MN
| | - Scott C Morgan
- The Ottawa Hospital Cancer Centre, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Julia Malone
- The Ottawa Hospital Cancer Centre, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Julia Craig
- The Ottawa Hospital Cancer Centre, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Robert T Dess
- Department of Radiation Oncology, University of Michigan School of Medicine, Ann Arbor, MI
| | - William C Jackson
- Department of Radiation Oncology, University of Michigan School of Medicine, Ann Arbor, MI
| | - Holly E Hartman
- Department of Radiation Oncology, University of Michigan School of Medicine, Ann Arbor, MI.,Department of Biostatistics, University of Michigan, Ann Arbor, MI
| | - Amar U Kishan
- University of California Los Angeles, Los Angeles, CA
| | - Rohit Mehra
- Department of Pathology, University of Michigan, Ann Arbor, MI
| | | | - Todd M Morgan
- Department of Urology, University of Michigan, Ann Arbor, MI
| | | | - Joshi J Alumkal
- Department of Medicine, University of Michigan, Ann Arbor, MI
| | | | | | | | | | | | | | - Mathew J Schipper
- Department of Radiation Oncology, University of Michigan School of Medicine, Ann Arbor, MI
| | | | - Yilun Sun
- Department of Radiation Oncology, University of Michigan School of Medicine, Ann Arbor, MI
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Hsu IC, Rodgers JP, Shinohara K, Purdy J, Michalski J, Roach M, Vigneault E, Ivker RA, Pryzant RM, Kuettel M, Taussky D, Gustafson GS, Raben A, Sandler HM. Long-Term Results of NRG Oncology/RTOG 0321: A Phase II Trial of Combined High Dose Rate Brachytherapy and External Beam Radiation Therapy for Adenocarcinoma of the Prostate. Int J Radiat Oncol Biol Phys 2020; 110:700-707. [PMID: 33186617 DOI: 10.1016/j.ijrobp.2020.11.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 10/19/2020] [Accepted: 11/19/2020] [Indexed: 02/07/2023]
Abstract
PURPOSE To report the long-term outcome of patients with prostate cancer treated with external beam radiation therapy and high dose rate (HDR) brachytherapy from a prospective multi-institutional trial conducted by NRG Oncology/RTOG. METHODS AND MATERIALS Patients with clinically localized (T1c-T3b) prostate cancer without prior history of transurethral resection of prostate or hip prosthesis were eligible for this study. All patients were treated with a combination of 45 Gy in 25 fractions from external beam radiation therapy and one HDR implant delivering 19 Gy in 2 fractions. Adverse events (AE) were collected using Common Toxicity Criteria for Adverse Events, version 3. Cumulative incidence was used to estimate time to severe late gastrointestinal (GI)/genitourinary (GU) toxicity, biochemical failure, disease-specific mortality, local failure, and distant failure. Overall survival was estimated using the Kaplan-Meier method. RESULTS One hundred and twenty-nine patients were enrolled from July 2004 to May 2006. AE data was available for 115 patients. Patients were National Comprehensive Cancer Network (NCCN) intermediate to very high risk. The median age was 68, T1c-T2c 91%, T3a-T3b 9%, PSA ≤10 70%, PSA >10 to ≤20 30%, GS 6 10%, GS 7 72%, and GS 8 to 10 18%. Forty-three percent of patients received hormonal therapy. At a median follow-up time of 10 years, there were 6 (5%) patients with grade 3 GI and GU treatment-related AEs, and no late grade 4 to 5 GI and GU AEs. At 5 and 10 years, the rate of late grade 3 gastrointestinal and genitourinary AEs was 4% and 5%, respectively. Five- and 10-year overall survival rates were 95% and 76%. Biochemical failure rates per Phoenix definition at 5 and 10 years were 14% and 23%. The 10-year rate of disease-specific mortality was 6%. At 5 and 10 years, the rates of distant failure were 4% and 8%, respectively. The rates of local failure at 5 and 10 years were 2% at both time points. CONCLUSIONS Combined modality treatment using HDR prostate brachytherapy leads to excellent long-term clinical outcomes in this prospective multi-institutional trial.
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Affiliation(s)
- I-Chow Hsu
- University of California, San Francisco, California.
| | | | | | - James Purdy
- University of California Davis, Davis, California
| | | | - Mack Roach
- University of California, San Francisco, California
| | | | | | | | | | - Daniel Taussky
- Center Hospitalier de l'Université de Montréal-Notre Dame
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38
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Jackson WC, Hartman HE, Dess RT, Birer SR, Soni PD, Hearn JWD, Reichert ZR, Kishan AU, Mahal BA, Zumsteg ZS, Efstathiou JA, Kaffenberger S, Morgan TM, Mehra R, Showalter TN, Krauss DA, Nguyen PL, Schipper MJ, Feng FY, Sandler HM, Hoskin PJ, Roach M, Spratt DE. Addition of Androgen-Deprivation Therapy or Brachytherapy Boost to External Beam Radiotherapy for Localized Prostate Cancer: A Network Meta-Analysis of Randomized Trials. J Clin Oncol 2020; 38:3024-3031. [PMID: 32396488 DOI: 10.1200/jco.19.03217] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
PURPOSE In men with localized prostate cancer, the addition of androgen-deprivation therapy (ADT) or a brachytherapy boost (BT) to external beam radiotherapy (EBRT) have been shown to improve various oncologic end points. Practice patterns indicate that those who receive BT are significantly less likely to receive ADT, and thus we sought to perform a network meta-analysis to compare the predicted outcomes of a randomized trial of EBRT plus ADT versus EBRT plus BT. MATERIALS AND METHODS A systematic review identified published randomized trials comparing EBRT with or without ADT, or EBRT (with or without ADT) with or without BT, that reported on overall survival (OS). Standard fixed-effects meta-analyses were performed for each comparison, and a meta-regression was conducted to adjust for use and duration of ADT. Network meta-analyses were performed to compare EBRT plus ADT versus EBRT plus BT. Bayesian analyses were also performed, and a rank was assigned to each treatment after Markov Chain Monte Carlo analyses to create a surface under the cumulative ranking curve. RESULTS Six trials compared EBRT with or without ADT (n = 4,663), and 3 compared EBRT with or without BT (n = 718). The addition of ADT to EBRT improved OS (hazard ratio [HR], 0.71 [95% CI, 0.62 to 0.81]), whereas the addition of BT did not significantly improve OS (HR, 1.03 [95% CI, 0.78 to 1.36]). In a network meta-analysis, EBRT plus ADT had improved OS compared with EBRT plus BT (HR, 0.68 [95% CI, 0.52 to 0.89]). Bayesian modeling demonstrated an 88% probability that EBRT plus ADT resulted in superior OS compared with EBRT plus BT. CONCLUSION Our findings suggest that current practice patterns of omitting ADT with EBRT plus BT may result in inferior OS compared with EBRT plus ADT in men with intermediate- and high-risk prostate cancer. ADT for these men should remain a critical component of treatment regardless of radiotherapy delivery method until randomized evidence demonstrates otherwise.
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Affiliation(s)
- William C Jackson
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI
| | - Holly E Hartman
- Department of Biostatistics, University of Michigan, Ann Arbor, MI
| | - Robert T Dess
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI
| | - Sam R Birer
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI
| | - Payal D Soni
- Department of Radiation Oncology, Hunter Holmes McGuire Veterans Affairs Medical Center, Richmond, VA
| | - Jason W D Hearn
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI
| | - Zachary R Reichert
- Department of Hematology/Oncology, University of Michigan, Ann Arbor, MI
| | - Amar U Kishan
- Department of Radiation Oncology, University of California, Los Angeles, CA
| | - Brandon A Mahal
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Boston, MA
| | | | - Jason A Efstathiou
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Boston, MA
| | | | - Todd M Morgan
- Department of Urology, University of Michigan, Ann Arbor, MI
| | - Rohit Mehra
- Department of Pathology, University of Michigan, Ann Arbor, MI
| | - Timothy N Showalter
- Department of Radiation Oncology, University of Virginia, Charlottesville, MD
| | - Daniel A Krauss
- Department of Radiation Oncology, Oakland University William Beaumont School of Medicine, Royal Oak, MI
| | - Paul L Nguyen
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Matthew J Schipper
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI.,Department of Biostatistics, University of Michigan, Ann Arbor, MI
| | - Felix Y Feng
- Department of Radiation Oncology, University of California, San Francisco, CA
| | | | | | - Mack Roach
- Department of Radiation Oncology, University of California, San Francisco, CA
| | - Daniel E Spratt
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI
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39
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Dess RT, Sun Y, Jackson WC, Jairath NK, Kishan AU, Wallington DG, Mahal BA, Stish BJ, Zumsteg ZS, Den RB, Hall WA, Gharzai LA, Jaworski EM, Reichert ZR, Morgan TM, Mehra R, Schaeffer EM, Sartor O, Nguyen PL, Lee WR, Rosenthal SA, Michalski JM, Schipper MJ, Dignam JJ, Pisansky TM, Zietman AL, Sandler HM, Efstathiou JA, Feng FY, Shipley WU, Spratt DE. Association of Presalvage Radiotherapy PSA Levels After Prostatectomy With Outcomes of Long-term Antiandrogen Therapy in Men With Prostate Cancer. JAMA Oncol 2020; 6:735-743. [PMID: 32215583 PMCID: PMC7189892 DOI: 10.1001/jamaoncol.2020.0109] [Citation(s) in RCA: 59] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Importance In men with recurrent prostate cancer, addition of long-term antiandrogen therapy to salvage radiotherapy (SRT) was associated with overall survival (OS) in the NRG/RTOG 9601 study. However, hormone therapy has associated morbidity, and there are no validated predictive biomarkers to identify which patients derive most benefit from treatment. Objective To examine the role of pre-SRT prostate-specific antigen (PSA) levels to personalize hormone therapy use with SRT. Interventions Men were randomized to SRT plus high-dose nonsteroidal antiandrogen (bicalutamide, 150 mg/d) or placebo for 2 years. Design, Setting, and Participants In this secondary analysis of the multicenter RTOG 9601 double-blind, placebo-controlled randomized clinical trial conducted from 1998 to 2003 by a multinational cooperative group, men with a positive surgical margin or pathologic T3 disease after radical prostatectomy with pre-SRT PSA of 0.2 to 4.0 ng/mL were included. Analysis was performed between March 4, 2019, and December 20, 2019. Main Outcomes and Measures The primary outcome was overall survival (OS). Secondary end points included distant metastasis (DM), other-cause mortality (OCM), and grades 3 to 5 cardiac and neurologic toxic effects. Subgroup analyses were performed using the protocol-specified PSA stratification variable (1.5 ng/mL) and additional PSA cut points, including test for interaction. Competing risk analyses were performed for DM and other-cause mortality (OCM). Results Overall, 760 men with PSA elevation after radical prostatectomy for prostate cancer were included. The median (range) age of particpants was 65 (40-83) years. Antiandrogen assignment was associated with an OS benefit in the PSA stratum greater than 1.5 ng/mL (n = 118) with a 25% 12-year absolute benefit (hazard ratio [HR], 0.45; 95% CI, 0.25-0.81), but not in the PSA of 1.5 ng/mL or less stratum (n = 642) (1% 12-year absolute difference; HR, 0.87; 95% CI, 0.66-1.16). In a subanalysis of men with PSA of 0.61 to 1.5 (n = 253), there was an OS benefit associated with antiandrogen assignment (HR, 0.61; 95% CI, 0.39-0.94). In those receiving early SRT (PSA ≤0.6 ng/mL, n = 389), there was no improvement in OS (HR, 1.16; 95% CI, 0.79-1.70), an increased OCM hazard (subdistribution HR, 1.94; 95% CI, 1.17-3.20; P = .01), and an increased odds of late grades 3 to 5 cardiac and neurologic toxic effects (odds ratio, 3.57; 95% CI, 1.09-15.97; P = .05). Conclusions and Relevance These results suggest that pre-SRT PSA level may be a prognostic biomarker for outcomes of antiandrogen treatment with SRT. In patients receiving late SRT (PSA >0.6 ng/mL, hormone therapy was associated with improved outcomes. In men receiving early SRT (PSA ≤0.6 ng/mL), long-term antiandrogen treatment was not associated with improved OS. Future randomized clinical trials are needed to determine hormonal therapy benefit in this population. Trial Registration ClinicalTrials.gov Identifier: NCT00002874.
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Affiliation(s)
- Robert T Dess
- Department of Radiation Oncology, University of Michigan, Ann Arbor
| | - Yilun Sun
- Department of Radiation Oncology, University of Michigan, Ann Arbor
- Department of Biostatistics, University of Michigan, Ann Arbor
| | | | - Neil K Jairath
- Department of Radiation Oncology, University of Michigan, Ann Arbor
| | - Amar U Kishan
- Department of Radiation Oncology, University of California, Los Angeles
| | | | - Brandon A Mahal
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Bradley J Stish
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Zachery S Zumsteg
- Department of Radiation Oncology, Cedars-Sinai Medical Center, West Hollywood, California
| | - Robert B Den
- Department of Radiation Oncology, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - William A Hall
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee
| | - Laila A Gharzai
- Department of Radiation Oncology, University of Michigan, Ann Arbor
| | | | | | - Todd M Morgan
- Department of Urology, University of Michigan, Ann Arbor
| | - Rohit Mehra
- Department of Pathology, University of Michigan, Ann Arbor
| | | | - Oliver Sartor
- Department of Medicine, Tulane Cancer Center, New Orleans, Louisiana
| | - Paul L Nguyen
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | | | - Seth A Rosenthal
- Department of Radiation Oncology, Sutter Medical Group, Sacramento, California
| | - Jeff M Michalski
- Department of Radiation Oncology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Matthew J Schipper
- Department of Radiation Oncology, University of Michigan, Ann Arbor
- Department of Biostatistics, University of Michigan, Ann Arbor
| | - James J Dignam
- Department of Public Health Sciences, University of Chicago, Chicago, Illinois
| | | | - Anthony L Zietman
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Howard M Sandler
- Department of Radiation Oncology, Cedars-Sinai Medical Center, West Hollywood, California
| | - Jason A Efstathiou
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Felix Y Feng
- Department of Radiation Oncology, University of California, San Francisco
- Department of Urology, University of California, San Francisco
- Department of Medicine, University of California, San Francisco
| | - William U Shipley
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Daniel E Spratt
- Department of Radiation Oncology, University of Michigan, Ann Arbor
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40
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Freedland SJ, Allen J, Jarman A, Oyekunle T, Armstrong AJ, Moul JW, Sandler HM, Posadas E, Levin D, Wiggins E, Howard LE, Wu Y, Lin PH. A Randomized Controlled Trial of a 6-Month Low-Carbohydrate Intervention on Disease Progression in Men with Recurrent Prostate Cancer: Carbohydrate and Prostate Study 2 (CAPS2). Clin Cancer Res 2020; 26:3035-3043. [PMID: 32108029 DOI: 10.1158/1078-0432.ccr-19-3873] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 01/22/2020] [Accepted: 02/24/2020] [Indexed: 11/16/2022]
Abstract
PURPOSE Both weight loss and low-carbohydrate diets (LCD) without weight loss prolong survival in prostate cancer models. Few human trials have tested weight loss or LCD on prostate cancer. EXPERIMENTAL DESIGN We conducted a multi-site randomized 6-month trial of LCD versus control on PSA doubling time (PSADT) in patients with prostate cancer with biochemical recurrence (BCR) after local treatment. Eligibility included body mass index (BMI) ≥ 24 kg/m2 and PSADT 3 to 36 months. The LCD arm was instructed to eat [Formula: see text]20 g/carbs/day; the control arm instructed to avoid dietary changes. Primary outcome was PSADT. Secondary outcomes included weight, lipids, glucose metabolism, and diet. RESULTS Of 60 planned patients, the study stopped early after an interim analysis showed futility. Twenty-seven LCD and 18 control patients completed the study. At 6 months, although both arms consumed similar protein and fats, the LCD arm reduced carbohydrates intake (-117 vs. 8 g, P < 0.001) and lost weight (-12.1 vs. -0.50 kg, P < 0.001). The LCD arm reduced HDL, triglycerides, and HbA1c with no difference in total cholesterol or glucose. Mean PSADT was similar between LCD (21 months) and control (15 months, P = 0.316) arms. In a post hoc exploratory analysis accounting for prestudy PSADT, baseline PSA, primary treatment, and hemoconcentration, PSADT was significantly longer in LCD versus control (28 vs. 13 months, P = 0.021) arms. Adverse events were few, usually mild, and returned to baseline by 6 months. CONCLUSIONS Among BCR patients, LCD induced weight loss and metabolic benefits with acceptable safety without affecting PSADT, suggesting LCD does not adversely affect prostate cancer growth and is safe. Given exploratory findings of longer PSADT, larger studies testing LCD on disease progression are warranted.
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Affiliation(s)
- Stephen J Freedland
- Cedars-Sinai Medical Center, Los Angeles, California. .,Durham VA Medical Center, Durham, North Carolina
| | - Jenifer Allen
- Duke Clinical and Translational Science Institute, Duke University, Durham, North Carolina
| | - Aubrey Jarman
- Cedars-Sinai Medical Center, Los Angeles, California
| | - Taofik Oyekunle
- Duke University Medical Center, Duke Cancer Institute, Durham, North Carolina
| | - Andrew J Armstrong
- Duke University Medical Center, Duke Cancer Institute, Durham, North Carolina
| | - Judd W Moul
- Duke University Medical Center, Duke Cancer Institute, Durham, North Carolina
| | | | - Edwin Posadas
- Cedars-Sinai Medical Center, Los Angeles, California
| | - Dana Levin
- Cedars-Sinai Medical Center, Los Angeles, California
| | | | - Lauren E Howard
- Durham VA Medical Center, Durham, North Carolina.,Duke University School of Medicine, Durham, North Carolina
| | - Yuan Wu
- Duke University School of Medicine, Durham, North Carolina
| | - Pao-Hwa Lin
- Duke University School of Medicine, Durham, North Carolina
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41
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Ennis RD, Movsas B, Park C, Sandler HM, Smith BD, Wilson L, Deweese TL. Examinations in Radiation Oncology: Listening, Learning, and Looking Forward Together. Int J Radiat Oncol Biol Phys 2020; 106:29-31. [PMID: 31647971 DOI: 10.1016/j.ijrobp.2019.10.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 09/27/2019] [Accepted: 09/27/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Ronald D Ennis
- Cancer Institute of New Jersey, Rutgers University, New Brunswick, New Jersey.
| | | | - Catherine Park
- University of California, San Francisco, San Francisco, California
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42
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Kishan AU, Wang X, Seiferheld W, Collette L, Sandler KA, Sandler HM, Bolla M, Maingon P, De Reijke T, Hanks GE, Nickols NG, Rettig M, Drakaki A, Reiter RE, Spratt DE, Kupelian PA, Steinberg ML, King CR. Association of Gleason Grade With Androgen Deprivation Therapy Duration and Survival Outcomes: A Systematic Review and Patient-Level Meta-analysis. JAMA Oncol 2019; 5:91-96. [PMID: 30326032 DOI: 10.1001/jamaoncol.2018.3732] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Importance Androgen deprivation therapy (ADT) improves survival outcomes in patients with high-risk prostate cancer (PCa) treated with radiotherapy (RT). Whether this benefit differs between patients with Gleason grade group (GG) 4 (formerly Gleason score 8) and GG 5 (formerly Gleason score 9-10) disease remains unknown. Objective To determine whether the effectiveness of ADT duration varies between patients with GG 4 vs GG 5 PCa. Design, Setting, and Participants Traditional and network individual patient data meta-analyses of 992 patients (593 GG 4 and 399 GG 5) who were enrolled in 6 randomized clinical trials were carried out. Main Outcomes and Measures Multivariable Cox proportional hazard models were used to obtain hazard ratio (HR) estimates of ADT duration effects on overall survival (OS) and distant metastasis-free survival (DMFS). Cause-specific competing risk models were used to estimate HRs for cancer-specific survival (CSS). The interaction of ADT with GS was incorporated into the multivariable models. Traditional and network meta-analysis frameworks were used to compare outcomes of patients treated with RT alone, short-term ADT (STADT), long-term ADT (LTADT), and lifelong ADT. Results Five hundred ninety-three male patients (mean age, 70 years; range, 43-88 years) with GG 4 and 399 with GG 5 were identified. Median follow-up was 6.4 years. Among GG 4 patients, LTADT and STADT improved OS over RT alone (HR, 0.43; 95% CI, 0.26-0.70 and HR, 0.59; 95% CI, 0.38-0.93, respectively; P = .03 for both), whereas lifelong ADT did not (HR, 0.84; 95% CI, 0.54-1.30; P = .44). Among GG 5 patients, lifelong ADT improved OS (HR, 0.48; 95% CI, 0.31-0.76; P = .04), whereas neither LTADT nor STADT did (HR, 0.80; 95% CI, 0.45-1.44 and HR, 1.13; 95% CI, 0.69-1.87; P = .45 and P = .64, respectively). Among all patients, and among those receiving STADT, GG 5 patients had inferior OS compared with GG 4 patients (HR, 1.25; 95% CI, 1.07-1.47 and HR, 1.40; 95% CI, 1.05-1.88, respectively; P = .02). There was no significant OS difference between GG 5 and GG 4 patients receiving LTADT or lifelong ADT (HR, 1.21; 95% CI, 0.89-1.65 and HR, 0.85; 95% CI, 0.53-1.37; P = .23 and P = .52, respectively). Conclusions and Relevance These data suggest that prolonged durations of ADT improve survival outcomes in both GG 4 disease and GG 5 disease, albeit with different optimal durations. Strategies to maintain the efficacy of ADT while minimizing its duration (potentially with enhanced potency agents) should be investigated.
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Affiliation(s)
- Amar U Kishan
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles.,Department of Urology, University of California, Los Angeles, Los Angeles
| | - Xiaoyan Wang
- Department of General Internal Medicine and Health Services Research, University of California, Los Angeles, Los Angeles
| | - Wendy Seiferheld
- NRG Oncology Statistics and Data Management Center, Philadelphia, Pennsylvania
| | - Laurence Collette
- European Organization for Research and Treatment of Cancer Headquarters, Brussels, Belgium
| | - Kiri A Sandler
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles
| | - Howard M Sandler
- Department of Radiation Oncology, Cedars Sinai, Los Angeles, California
| | - Michel Bolla
- Department of Radiation Oncology, Centre Hospitalier Universitaire de Grenoble, Grenoble, France
| | - Philippe Maingon
- Centre Georges-François Leclerc, Dijon, Sorbonne Université Paris, Paris, France
| | - Theo De Reijke
- Amsterdam University Medical Centers, Academic Medical Center, Amsterdam, the Netherlands
| | - Gerald E Hanks
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Nicholas G Nickols
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles.,Department of Radiation Oncology, Veteran Affairs Greater Los Angeles Healthcare System, Los Angeles, California
| | - Matthew Rettig
- Division of Hematology and Oncology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles.,Division of Hematology and Oncology, VA Greater Los Angeles Healthcare System, Los Angeles, Los Angeles, California
| | - Alexandra Drakaki
- Division of Hematology and Oncology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles
| | - Robert E Reiter
- Department of Urology, University of California, Los Angeles, Los Angeles
| | - Daniel E Spratt
- Department of Radiation Oncology, University of Michigan, Ann Arbor
| | - Patrick A Kupelian
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles
| | - Michael L Steinberg
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles
| | - Christopher R King
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles
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Kishan AU, Chu FI, King CR, Seiferheld W, Spratt DE, Tran P, Wang X, Pugh SE, Sandler KA, Bolla M, Maingon P, De Reijke T, Nickols NG, Rettig M, Drakaki A, Liu ST, Reiter RE, Chang AJ, Feng FY, Sajed D, Nguyen PL, Kupelian PA, Steinberg ML, Boutros PC, Elashoff D, Collette L, Sandler HM. Local Failure and Survival After Definitive Radiotherapy for Aggressive Prostate Cancer: An Individual Patient-level Meta-analysis of Six Randomized Trials. Eur Urol 2019; 77:201-208. [PMID: 31718822 DOI: 10.1016/j.eururo.2019.10.008] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2019] [Accepted: 10/15/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND The importance of local failure (LF) after treatment of high-grade prostate cancer (PCa) with definitive radiotherapy (RT) remains unknown. OBJECTIVE To evaluate the clinical implications of LF after definitive RT. DESIGN, SETTING, AND PARTICIPANTS Individual patient data meta-analysis of 992 patients (593 Gleason grade group [GG] 4 and 399 GG 5) enrolled in six randomized clinical trials. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Multivariable Cox proportional hazard models were developed to evaluate the relationship between overall survival (OS), PCa-specific survival (PCSS), and distant metastasis (DM)-free survival (DMFS) and LF as a time-dependent covariate. Markov proportional hazard models were developed to evaluate the impact of specific transitions between disease states on these endpoints. RESULTS AND LIMITATIONS Median follow-up was 6.4 yr overall and 7.2 yr for surviving patients. LF was significantly associated with OS (hazard ratio [HR] 1.70 [95% confidence interval {CI} 1.37-2.10]), PCSS (3.10 [95% CI 2.33-4.12]), and DMFS (HR 1.92 [95% CI 1.54-2.39]), p < 0.001 for all). Patients who had not transitioned to the LF state had a significantly lower hazard of transitioning to a PCa-specific death state than those who transitioned to the LF state (HR 0.13 [95% CI 0.04-0.41], p < 0.001). Additionally, patients who transitioned to the LF state had a greater hazard of DM or death (HR 2.46 [95% CI 1.22-4.93], p = 0.01) than those who did not. CONCLUSIONS LF is an independent prognosticator of OS, PCSS, and DMFS in high-grade localized PCa and a subset of DM events that are anteceded by LF events. LF events warrant consideration for intervention, potentially suggesting a rationale for upfront treatment intensification. However, whether these findings apply to all men or just those without significant comorbidity remains to be determined. PATIENT SUMMARY Men who experience a local recurrence of high-grade prostate cancer after receiving upfront radiation therapy are at significantly increased risks of developing metastases and dying of prostate cancer.
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Affiliation(s)
- Amar U Kishan
- Department of Radiation Oncology, University of California, Los Angeles, CA, USA; Department of Urology, University of California, Los Angeles, CA, USA.
| | - Fang-I Chu
- Department of Radiation Oncology, University of California, Los Angeles, CA, USA
| | - Christopher R King
- Department of Radiation Oncology, University of California, Los Angeles, CA, USA
| | - Wendy Seiferheld
- NRG Oncology Statistics and Data Management Center, Philadelphia, PA, USA
| | - Daniel E Spratt
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, USA
| | - Phuoc Tran
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Xiaoyan Wang
- Department of General Internal Medicine and Health Services Research, University of California, Los Angeles, CA, USA
| | - Stephanie E Pugh
- NRG Oncology Statistics and Data Management Center, Philadelphia, PA, USA
| | - Kiri A Sandler
- Department of Radiation Oncology, University of California, Los Angeles, CA, USA
| | - Michel Bolla
- Department of Radiation Oncology, Centre Hospitalier Universitaire de Grenoble, Grenoble, France
| | - Philippe Maingon
- Centre Georges-François Leclerc, Dijon, France; Sorbonne Université Paris, Paris, France
| | - Theo De Reijke
- Department of Urology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Nicholas G Nickols
- Department of Radiation Oncology, University of California, Los Angeles, CA, USA; Department of Radiation Oncology, Veteran Affairs Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Matthew Rettig
- Division of Hematology and Oncology, David Geffen School of Medicine, University of California, Los Angeles, CA, USA; Division of Hematology and Oncology, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Alexandra Drakaki
- Division of Hematology and Oncology, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Sandy T Liu
- Division of Hematology and Oncology, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Robert E Reiter
- Department of Urology, University of California, Los Angeles, CA, USA
| | - Albert J Chang
- Department of Radiation Oncology, University of California, Los Angeles, CA, USA
| | - Felix Y Feng
- Departments of Radiation Oncology, Urology, and Medicine, University of California, San Francisco, CA, USA
| | - Dipti Sajed
- Department of Pathology, University of California, Los Angeles, CA, USA
| | - Paul L Nguyen
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Patrick A Kupelian
- Department of Radiation Oncology, University of California, Los Angeles, CA, USA
| | - Michael L Steinberg
- Department of Radiation Oncology, University of California, Los Angeles, CA, USA
| | - Paul C Boutros
- Department of Urology, University of California, Los Angeles, CA, USA; Department of Human Genetics, University of California, Los Angeles, CA, USA
| | - David Elashoff
- Department of General Internal Medicine and Health Services Research, University of California, Los Angeles, CA, USA
| | - Laurence Collette
- European Organization for Research and Treatment of Cancer Headquarters, Brussels, Belgium
| | - Howard M Sandler
- Department of Radiation Oncology, Cedars Sinai, Los Angeles, CA, USA
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Dess RT, Hartman HE, Mahal BA, Soni PD, Jackson WC, Cooperberg MR, Amling CL, Aronson WJ, Kane CJ, Terris MK, Zumsteg ZS, Butler S, Osborne JR, Morgan TM, Mehra R, Salami SS, Kishan AU, Wang C, Schaeffer EM, Roach M, Pisansky TM, Shipley WU, Freedland SJ, Sandler HM, Halabi S, Feng FY, Dignam JJ, Nguyen PL, Schipper MJ, Spratt DE. Association of Black Race With Prostate Cancer-Specific and Other-Cause Mortality. JAMA Oncol 2019; 5:975-983. [PMID: 31120534 PMCID: PMC6547116 DOI: 10.1001/jamaoncol.2019.0826] [Citation(s) in RCA: 261] [Impact Index Per Article: 52.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Importance Black men are more likely to die of prostate cancer than white men. In men with similar stages of disease, the contribution of biological vs nonbiological differences to this observed disparity is unclear. Objective To quantify the association of black race with long-term survival outcomes after controlling for known prognostic variables and access to care among men with prostate cancer. Design, Setting, and Participants This multiple-cohort study included updated individual patient-level data of men with clinical T1-4N0-1M0 prostate cancer from the following 3 cohorts: Surveillance, Epidemiology, and End Results (SEER [n = 296 273]); 5 equal-access regional medical centers within the Veterans Affairs health system (VA [n = 3972]); and 4 pooled National Cancer Institute-sponsored Radiation Therapy Oncology Group phase 3 randomized clinical trials (RCTs [n = 5854]). Data were collected in the 3 cohorts from January 1, 1992, through December 31, 2013, and analyzed from April 27, 2017, through April 13, 2019. Exposures In the VA and RCT cohorts, all patients received surgery and radiotherapy, respectively, with curative intent. In SEER, radical treatment, hormone therapy, or conservative management were received. Main Outcomes and Measures Prostate cancer-specific mortality (PCSM). Secondary measures included other-cause mortality (OCM). To adjust for demographic-, cancer-, and treatment-related baseline differences, inverse probability weighting (IPW) was performed. Results Among the 306 100 participants included in the analysis (mean [SD] age, 64.9 [8.9] years), black men constituted 52 840 patients (17.8%) in the SEER cohort, 1513 (38.1%) in the VA cohort, and 1129 (19.3%) in the RCT cohort. Black race was associated with an increased age-adjusted PCSM hazard (subdistribution hazard ratio [sHR], 1.30; 95% CI, 1.23-1.37; P < .001) within the SEER cohort. After IPW adjustment, black race was associated with a 0.5% (95% CI, 0.2%-0.9%) increase in PCSM at 10 years after diagnosis (sHR, 1.09; 95% CI, 1.04-1.15; P < .001), with no significant difference for high-risk men (sHR, 1.04; 95% CI, 0.97-1.12; P = .29). No significant differences in PCSM were found in the VA IPW cohort (sHR, 0.85; 95% CI, 0.56-1.30; P = .46), and black men had a significantly lower hazard in the RCT IPW cohort (sHR, 0.81; 95% CI, 0.66-0.99; P = .04). Black men had a significantly increased hazard of OCM in the SEER (sHR, 1.30; 95% CI, 1.27-1.34; P < .001) and RCT (sHR, 1.17; 95% CI, 1.06-1.29; P = .002) IPW cohorts. Conclusions and Relevance In this study, after adjustment for nonbiological differences, notably access to care and standardized treatment, black race did not appear to be associated with inferior stage-for-stage PCSM. A large disparity remained in OCM for black men with nonmetastatic prostate cancer.
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Affiliation(s)
- Robert T Dess
- Department of Radiation Oncology, University of Michigan, Ann Arbor
| | - Holly E Hartman
- Department of Biostatistics, University of Michigan, Ann Arbor
| | - Brandon A Mahal
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Payal D Soni
- Department of Radiation Oncology, Hunter Holmes McGuire Veterans Affairs Medical Center, Richmond, Virginia
| | | | | | | | | | | | | | - Zachary S Zumsteg
- Department of Radiation Oncology, Cedars Sinai, West Hollywood, California
| | - Santino Butler
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | | | - Todd M Morgan
- Department of Urology, University of Michigan, Ann Arbor
| | - Rohit Mehra
- Department of Pathology, University of Michigan, Ann Arbor
| | - Simpa S Salami
- Department of Urology, University of Michigan, Ann Arbor
| | - Amar U Kishan
- Department of Radiation Oncology, University of California, Los Angeles
| | - Chenyang Wang
- Department of Radiation Oncology, University of California, Los Angeles
| | | | - Mack Roach
- Department of Urology, University of California, San Francisco
- Department of Radiation Oncology, University of California, San Francisco
| | | | - William U Shipley
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Stephen J Freedland
- Department of Urology, Cedars-Sinai Medical Center, Los Angeles, California
- Section of Urology, Durham VA Medical Center, Durham, North Carolina
| | - Howard M Sandler
- Department of Radiation Oncology, Cedars Sinai, West Hollywood, California
| | - Susan Halabi
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina
| | - Felix Y Feng
- Department of Urology, University of California, San Francisco
- Department of Radiation Oncology, University of California, San Francisco
| | - James J Dignam
- Department of Biostatistics, University of Chicago, Chicago, Illinois
| | - Paul L Nguyen
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Matthew J Schipper
- Department of Radiation Oncology, University of Michigan, Ann Arbor
- Department of Biostatistics, University of Michigan, Ann Arbor
| | - Daniel E Spratt
- Department of Radiation Oncology, University of Michigan, Ann Arbor
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Bruner DW, Pugh SL, Lee WR, Hall WA, Dignam JJ, Low D, Swanson GP, Shah AB, Malone S, Michalski JM, Dayes IS, Seaward SA, Nguyen PL, Pisansky TM, Chen Y, Sandler HM, Movsas B. Quality of Life in Patients With Low-Risk Prostate Cancer Treated With Hypofractionated vs Conventional Radiotherapy: A Phase 3 Randomized Clinical Trial. JAMA Oncol 2019; 5:664-670. [PMID: 30763425 PMCID: PMC6459051 DOI: 10.1001/jamaoncol.2018.6752] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
IMPORTANCE Hypofractionated radiotherapy (HRT) would be more convenient for men with low-risk prostate cancer and cost less than conventional radiotherapy (CRT) as long as HRT is noninferior to CRT in terms of survival and quality of life (QOL) is not found to be worse. OBJECTIVE To assess differences in QOL between men with low-risk prostate cancer who are treated with HRT vs CRT. DESIGN, SETTING, AND PARTICIPANTS In this phase 3 randomized clinical trial, men with low-risk prostate cancer were enrolled from sites within the National Cancer Institute's National Clinical Trials Network in the United States, Canada, and Switzerland. INTERVENTIONS Random assignment to CRT (73.8 Gy in 41 fractions over 8.2 weeks) or to HRT (70 Gy in 28 fractions over 5.6 weeks). MAIN OUTCOMES AND MEASURES Quality of life was assessed using the Expanded Prostate Index Composite questionnaire measuring bowel, urinary, sexual, and hormonal domains; the 25-item Hopkins Symptom Checklist measuring anxiety and depression; and the EuroQol-5 Dimension questionnaire measuring global QOL. All data were collected at baseline and 6, 12, 24, and 60 months. Change scores were compared between treatment arms using the Wilcoxon signed rank test. A significance level of .0125 to adjust for multiple comparisons was used for an overall 2-sided type 1 error of .05. Clinical significance was determined for the Expanded Prostate Index Composite change scores by an effect size of 0.5. RESULTS Of 1092 patients analyzable for the primary end point, 962 (mean [SD] age, 66.6 [7.4] years) consented to the QOL component. No statistically significant differences with regard to baseline characteristics nor any of the QOL baseline domains were measured between arms. There were no differences in change score between arms with respect to any of the Expanded Prostate Index Composite questionnaire domain scores except at 12 months when the HRT arm had a larger decline than the CRT arm in the bowel domain (mean score, -7.5 vs -3.7, respectively; P<.001), but it did not reach clinical significance (effect size = 0.29). There were no differences between arms at any time point for the Hopkins Symptom Checklist nor EuroQol-5 Dimension questionnaire. CONCLUSIONS AND RELEVANCE Treatment with HRT is noninferior to CRT in men with low-risk prostate cancer in terms of disease-free survival and, as shown in the present study, in prostate cancer-specific (eg, bowel, bladder, sexual) and general QOL, as well as in anxiety and depression. This study provides evidence to affirm that HRT is a practice standard for men with low-risk prostate cancer. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT00331773.
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Affiliation(s)
| | - Stephanie L Pugh
- NRG Oncology Statistics and Data Management Center, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - W Robert Lee
- Duke University Medical Center, Durham, North Carolina
| | | | - James J Dignam
- NRG Oncology Statistics and Data Management Center, University of Pittsburgh, Pittsburgh, Pennsylvania.,University of Chicago, Chicago, Illinois
| | - Daniel Low
- Washington University in St Louis, St Louis, Missouri
| | - Gregory P Swanson
- University of Texas Health Science Center at San Antonio, San Antonio
| | - Amit B Shah
- WellSpan York Cancer Center, York, Pennsylvania
| | - Shawn Malone
- London Regional Cancer Program, London, Ontario, Canada
| | | | - Ian S Dayes
- Juravinski Cancer Centre, McMaster University, Hamilton, Ontario, Canada
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Hallemeier CL, Zhang P, Pisansky TM, Hanks GE, McGowan DG, Roach M, Zeitzer KL, Firat SY, Husain SM, D'Souza DP, Souhami L, Parliament MB, Rosenthal SA, Lukka HR, Rotman M, Horwitz EM, Miles EF, Paulus R, Sandler HM. Prostate-Specific Antigen After Neoadjuvant Androgen Suppression in Prostate Cancer Patients Receiving Short-Term Androgen Suppression and External Beam Radiation Therapy: Pooled Analysis of Four NRG Oncology Radiation Therapy Oncology Group Randomized Clinical Trials. Int J Radiat Oncol Biol Phys 2019; 104:1057-1065. [PMID: 30959123 DOI: 10.1016/j.ijrobp.2019.03.049] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Revised: 03/22/2019] [Accepted: 03/31/2019] [Indexed: 11/12/2022]
Abstract
PURPOSE To validate whether prostate-specific antigen (PSA) level after neoadjuvant androgen suppression (neoAS) is associated with long-term outcome after neoAS and external beam radiation therapy (RT) with concurrent short-term androgen suppression (AS) in patients with prostate cancer. METHODS AND MATERIALS This study included 2404 patients. The patients were treated with neoAS before RT and concurrent AS (without post-RT AS) and were pooled from NRG Oncology/RTOG trials 9202, 9408, 9413, and 9910. Multivariable models were used to test associations between the prespecified dichotomized post-neoAS, pre-RT PSA level (≤0.1 vs >0.1 ng/mL) groupings, and clinical outcomes. RESULTS The median follow-up for surviving patients was 9.4 years. The median post-neoAS, pre-RT PSA level was 0.3 ng/mL, with 32% of patients having levels ≤0.1 ng/mL. Race, Gleason score, tumor stage, node stage, pretreatment PSA level, and duration of neoAS were associated with the groups of patients with PSA levels ≤0.1 and >0.1 ng/mL. In univariate analyses, post-neoAS, pre-RT PSA level >0.1 ng/mL was associated with increased risks of biochemical failure (hazard ratio [HR], 2.04; P < .0001); local failure (HR, 2.51; P < .0001); distant metastases (HR, 1.73; P = .0006); cause-specific mortality (HR, 2.36; P < .0001); and all-cause mortality (HR, 1.24; P = .005). In multivariable models that also included baseline and treatment variables, post-neoAS, pre-RT PSA level >0.1 ng/mL was independently associated with increased risk of biochemical failure (HR, 2.00; P < .0001); local failure (HR, 2.33; P < .0001); and cause-specific mortality (HR, 1.75; P = .03). CONCLUSIONS Patients with a PSA level >0.1 ng/mL after neoAS and before the start of RT had less favorable clinical outcomes than patients whose PSA level was ≤0.1 ng/mL. The role of post-neoAS, pre-RT PSA level relative to PSA levels obtained along the continuum of medical care is not presently defined but could be tested in future clinical trials.
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Affiliation(s)
| | - Peixin Zhang
- NRG Oncology Statistics and Data Management Center, Philadelphia, Pennsylvania
| | | | | | | | - Mack Roach
- University of California, San Francisco, San Francisco, California
| | | | - Selim Y Firat
- Medical College of Wisconsin-Zablocki VA Medical Center, Milwaukee, Wisconsin
| | | | | | - Luis Souhami
- McGill University Health Centre, Montreal, Quebec, Canada
| | | | | | - Himanshu R Lukka
- McMaster University, Juravinski Cancer Center, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | | | | | - Edward F Miles
- Naval Medical Center Accruals Dartmouth Hitchcock Medical Center, Portsmouth, Virginia
| | - Rebecca Paulus
- NRG Oncology Statistics and Data Management Center, Philadelphia, Pennsylvania
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Thor M, Deasy JO, Paulus R, Robert Lee W, Amin MB, Bruner DW, Low DA, Shah AB, Malone SC, Michalski JM, Dayes IS, Seaward SA, Gore EM, Albert M, Pisansky TM, Faria SL, Chen Y, Koontz BF, Swanson GP, Pugh SL, Sandler HM. Tolerance doses for late adverse events after hypofractionated radiotherapy for prostate cancer on trial NRG Oncology/RTOG 0415. Radiother Oncol 2019; 135:19-24. [PMID: 31015166 DOI: 10.1016/j.radonc.2019.02.014] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 02/13/2019] [Accepted: 02/17/2019] [Indexed: 12/23/2022]
Abstract
PURPOSE/OBJECTIVE Hypofractionated radiotherapy (HRT) regimens for prostate cancer are emerging, but tolerance doses for late adverse events are scarce. The purpose of this study is to define dose-volume predictors for late gastrointestinal and genitourinary (GI and GU) toxicities after HRT in the multi-center NRG Oncology/RTOG 0415 low-risk prostate cancer trial (N = 521). MATERIAL/METHODS Treatment in the studied HRT arm was delivered as 70 Gy at 2.5 Gy/fraction with 3D-CRT/IMRT (N = 108/413). At a median follow-up of 5.9 years, the crude late ≥Grade 2 GI and GU toxicities were 19% and 29%, respectively. For modeling, the complete HRT cohort was randomly split into training and validation (70% and 30%; preserved toxicity rates). Within training, dose-response modeling was based on dose-volume cut-points (EQD2Gy; bladder/rectum: α/β = 6 Gy/3Gy), age, acute ≥Grade 2 toxicity, and treatment technique using univariate and multivariate logistic regression on bootstrapping (UVA and MVA). Candidate predictors were determined at p ≤ 0.05, and the selected MVA models were explored on validation where model generalizability was judged if the area under the receiver-operating curve in validation (AUCvalidation) was within AUCtraining ± SD with p ≤ 0.05, and with an Hosmer-Lemeshow p-value (pHL) > 0.05. RESULTS Three candidate predictors were suggested for late GI toxicity: the minimum dose to the hottest 5% rectal volume (D5%[Gy]), the absolute rectal volume <35 Gy, and acute GI toxicity (AUC = 0.59-0.63; p = 0.02-0.04). The two generalizable MVA models, i.e., D5%[Gy] with or without acute GI toxicity (AUCvalidation = 0.64, 0.65; p = 0.01, 0.03; pHL = 0.45-0.56), suggest that reducing late GI toxicity from 20% to 10% would require reducing D5%[Gy] from ≤65 Gy to ≤62 Gy (logistic function argument: 17+(0.24D5%[Gy])). Acute GU toxicity showed only a trend to predict late GU toxicity (AUCtraining = 0.57; p = 0.07). CONCLUSION Late GI toxicity, following moderate HRT for low-risk prostate cancer, increases with higher doses to small rectal volumes. This work provides quantitative evidence that limiting small rectal dose 'hotspots' in clinical practice of such HRT regimens is likely to further reduce the associated rates of GI toxicity.
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Affiliation(s)
- Maria Thor
- Memorial Sloan Kettering Cancer Center, United States.
| | | | | | | | - Mahul B Amin
- University of Tennessee Health Science Center, United States
| | | | | | - Amit B Shah
- WellSpan Health-York Cancer Center (current) -Thomas Jefferson University Hospital (accrual), United States
| | | | | | | | - Samantha A Seaward
- Kaiser Permanente Northern California (current) University of California San Francisco (accruals), United States
| | - Elizabeth M Gore
- Medical College of Wisconsin and Zablocki Veterans Administration Medical Center, United States
| | - Michele Albert
- Saint Anne's Hospital (current) Massachusetts General Hospital (accruals), United States
| | | | | | | | | | | | - Stephanie L Pugh
- NRG Oncology Statistics and Data Management Center, United States
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Sandler HM. Role of Overall Treatment Time in the Management of Prostate Cancer Patients: How to Manage Unscheduled Treatment Interruptions. Int J Radiat Oncol Biol Phys 2019; 100:841-842. [PMID: 29485058 DOI: 10.1016/j.ijrobp.2017.12.278] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Accepted: 12/19/2017] [Indexed: 12/01/2022]
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Dignam JJ, Hamstra DA, Lepor H, Grignon D, Brereton H, Currey A, Rosenthal S, Zeitzer KL, Venkatesan VM, Horwitz EM, Pisansky TM, Sandler HM. Time Interval to Biochemical Failure as a Surrogate End Point in Locally Advanced Prostate Cancer: Analysis of Randomized Trial NRG/RTOG 9202. J Clin Oncol 2018; 37:213-221. [PMID: 30526194 DOI: 10.1200/jco.18.00154] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND In prostate cancer, end points that reliably portend prognosis and treatment benefit (surrogate end points) can accelerate therapy development. Although surrogate end point candidates have been evaluated in the context of radiotherapy and short-term androgen deprivation (AD), potential surrogates under long-term (24 month) AD, a proven therapy in high-risk localized disease, have not been investigated. MATERIALS AND METHODS In the NRG/RTOG 9202 randomized trial (N = 1,520) of short-term AD (4 months) versus long-term AD (LTAD; 28 months), the time interval free of biochemical failure (IBF) was evaluated in relation to clinical end points of prostate cancer-specific survival (PCSS) and overall survival (OS). Survival modeling and landmark analysis methods were applied to evaluate LTAD benefit on IBF and clinical end points, association between IBF and clinical end points, and the mediating effect of IBF on LTAD clinical end point benefits. RESULTS LTAD was superior to short-term AD for both biochemical failure (BF) and the clinical end points. Men remaining free of BF for 3 years had relative risk reductions of 39% for OS and 73% for PCSS. Accounting for 3-year IBF status reduced the LTAD OS benefit from 12% (hazard ratio [HR], 0.88; 95% CI, 0.79 to 0.98) to 6% (HR, 0.94; 95% CI, 0.83 to 1.07). For PCSS, the LTAD benefit was reduced from 30% (HR, 0.70; 95% CI, 0.52 to 0.82) to 6% (HR, 0.94; 95% CI, 0.72 to 1.22). Among men with BF, by 3 years, 50% of subsequent deaths were attributed to prostate cancer, compared with 19% among men free of BF through 3 years. CONCLUSION The IBF satisfied surrogacy criteria and identified the benefit of LTAD on disease-specific survival and OS. The IBF may serve as a valid end point in clinical trials and may also aid in risk monitoring after initial treatment.
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Affiliation(s)
- James J Dignam
- 1 NRG Oncology Statistics and Data Management Center, University of Chicago, Chicago, IL
| | | | | | | | | | - Adam Currey
- 6 Medical College of Wisconsin, Milwaukee, WI
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Coen JJ, Zhang P, Saylor PJ, Lee CT, Wu CL, Parker W, Lautenschlaeger T, Zietman AL, Efstathiou JA, Jani AB, Kucuk O, Souhami L, Rodgers JP, Sandler HM, Shipley WU. Bladder Preservation With Twice-a-Day Radiation Plus Fluorouracil/Cisplatin or Once Daily Radiation Plus Gemcitabine for Muscle-Invasive Bladder Cancer: NRG/RTOG 0712-A Randomized Phase II Trial. J Clin Oncol 2018; 37:44-51. [PMID: 30433852 DOI: 10.1200/jco.18.00537] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Fluorouracil plus cisplatin and radiation twice a day (FCT) is an established chemoradiation (CRT) regimen for selective bladder-sparing treatment of muscle-invasive bladder cancer. Gemcitabine and once daily radiation (GD) is a well-supported alternative. The current trial evaluates these regimens. METHODS Patients with cT2-4a muscle-invasive bladder cancer were randomly assigned to FCT or GD. Patients underwent transurethral resection and induction CRT to 40 Gy. Patients who achieved a complete response (CR) received consolidation CRT to 64 Gy and others underwent cystectomy. We administered adjuvant gemcitabine/cisplatin chemotherapy. The primary end point was the rate of freedom from distant metastasis at 3 years (DMF3). The trial was not statistically powered to compare regimens, but to assess whether either regimen exceeded a DMF3 benchmark of 75%. Toxicity and efficacy end points, including CR and bladder-intact distant metastasis free survival at 3 years (BI-DMFS3), were assessed. RESULTS From December 2008 to April 2014, 70 patients were enrolled, of which 66 were eligible for analysis, 33 per arm. Median follow-up was 5.1 years (range, 0.4 to 7.8 years) for eligible living patients. DMF3 was 78% and 84% for FCT and GD, respectively. BI-DMFS3 was 67% and 72%, respectively. Postinduction CR rates were 88% and 78%, respectively. Of 33 patients in the FCT arm, 21 (64%) experienced treatment-related grade 3 and 4 toxicities during protocol treatment, with 18 (55%), two (6%), and two patients (6%) experiencing grade 3 and 4 hematologic, GI, and genitourinary toxicity, respectively. For the 33 patients in the GD arm, these figures were 18 (55%) overall and 14 (42%), three (9%) and two patients (6%), respectively. CONCLUSION Both regimens demonstrated DMF3 greater than 75%. There were fewer toxicities observed in the GD arm. Either gemcitabine and once daily radiation or a cisplatin-based regimen could serve as a base for future trials of systemic therapy.
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Affiliation(s)
| | | | - Philip J Saylor
- 3 Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | | | - Chin-Lee Wu
- 3 Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - William Parker
- 5 McGill University Health Centre, Montreal, Quebec, Canada
| | | | - Anthony L Zietman
- 3 Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | | | | | - Omer Kucuk
- 7 Cedars-Sinai Medical Center, Los Angeles, CA
| | - Luis Souhami
- 5 McGill University Health Centre, Montreal, Quebec, Canada
| | | | | | - William U Shipley
- 3 Massachusetts General Hospital and Harvard Medical School, Boston, MA
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