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Mell LK, Pugh SL, Jones CU, Nelson TJ, Zakeri K, Rose BS, Zeitzer KL, Gore EM, Bahary JP, Souhami L, Michalski JM, Hartford AC, Mishra MV, Roach M, Parliament MB, Choi KN, Pisansky TM, Husain SM, Malone SC, Horwitz EM, Feng F. Effects of Androgen Deprivation Therapy on Prostate Cancer Outcomes According to Competing Event Risk: Secondary Analysis of a Phase 3 Randomised Trial. Eur Urol 2024; 85:373-381. [PMID: 36710205 PMCID: PMC10372191 DOI: 10.1016/j.eururo.2023.01.020] [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] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 12/22/2022] [Accepted: 01/17/2023] [Indexed: 01/29/2023]
Abstract
BACKGROUND Previous studies indicate that the benefit of short-term androgen deprivation therapy (ADT) with radiotherapy (RT) for prostate cancer depends on competing risks. OBJECTIVE To determine whether a quantitative method to stratify patients by risk for competing events (omega score) could identify subgroups that selectively benefit from ADT. DESIGN, SETTING, AND PARTICIPANTS An ancillary analysis of NRG/RTOG 9408 phase 3 trial (NCT00002597) involving 1945 prostate cancer patients was conducted. INTERVENTION Short-term ADT. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS We applied generalised competing event regression models incorporating age, performance status, comorbidity, T category, Gleason score (GS), and prostate-specific antigen (PSA), to stratify patients according to relative hazards for primary cancer-related events (distant metastasis or prostate cancer death) versus competing noncancer mortality. We tested interactions between ADT and subgroups defined by standard risk criteria versus relative risk (RR) using the omega score. RESULTS AND LIMITATIONS T2b, higher GS, and higher PSA were associated with an increased RR for cancer-related versus competing mortality events (a higher omega score); increased age and comorbidity were associated with a decreased omega score. Of 996 patients with low-risk/favourable intermediate-risk (FIR) disease, 286 (28.7%) had a high omega score (≥0.314). Of 768 patients with unfavourable intermediate-risk disease, 175 (22.8%) had a low omega score. The overall discordance in risk classification was 26.1%. Both standard criteria and omega score identified significant interactions for the effect of ADT on cancer-related events and late mortality in low- versus high-risk subgroups. Within the low-risk/FIR subgroup, a higher omega score identified patients in whom ADT significantly reduced cancer events and improved event-free survival. Limitations are the need for external/prospective validation and lower RT doses than contemporary standards. CONCLUSIONS Stratification based on competing event risk is useful for identifying prostate cancer patients who selectively benefit from ADT. PATIENT SUMMARY We analysed the effectiveness of androgen deprivation therapy (ADT) for localised prostate cancer among patients, defined by the relative risk (RR) for cancer versus noncancer events. Among patients with traditional low-risk/favourable intermediate-risk disease, those with a higher RR benefitted from short-term ADT.
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Affiliation(s)
- Loren K Mell
- University of California San Diego, Moores Cancer Center, San Diego, CA, USA.
| | - Stephanie L Pugh
- NRG Oncology Statistics and Data Management Center, Philadelphia, PA, USA
| | | | - Tyler J Nelson
- University of California San Diego, Moores Cancer Center, San Diego, CA, USA
| | - Kaveh Zakeri
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Brent S Rose
- University of California San Diego, Moores Cancer Center, San Diego, CA, USA
| | | | - Elizabeth M Gore
- Froedtert and the Medical College of Wisconsin, Milwaukee, WI, USA
| | - Jean-Paul Bahary
- CHUM - Centre Hospitalier de l'Universite de Montreal, Montreal, QC, Canada
| | - Luis Souhami
- The Research Institute of the McGill University Health Centre (MUHC), Montreal, QC, Canada
| | | | - Alan C Hartford
- Dartmouth-Hitchcock Medical Center/Norris Cotton Cancer Center, Lebanon, NH, USA
| | - Mark V Mishra
- University of Maryland/Greenebaum Cancer Center, Baltimore, MD, USA
| | - Mack Roach
- UCSF Medical Center-Mount Zion, San Francisco, CA, USA
| | | | - Kwang N Choi
- State University of New York Downstate Medical Center, Brooklyn, NY, USA
| | | | | | | | | | - Felix Feng
- UCSF Medical Center-Mount Zion, San Francisco, CA, USA
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2
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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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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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4
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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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Hallemeier CL, Moughan J, Haddock MG, Herskovic AM, Minsky BD, Suntharalingam M, Zeitzer KL, Garg MK, Greenwald BD, Komaki RU, Puckett LL, Kim H, Lloyd S, Bush DA, Kim HE, Lad TE, Meyer JE, Okawara GS, Raben A, Schefter TE, Barker JL, Falkson CI, Videtic GMM, Jacob R, Winter KA, Crane CH. Association of Radiotherapy Duration With Clinical Outcomes in Patients With Esophageal Cancer Treated in NRG Oncology Trials: A Secondary Analysis of NRG Oncology Randomized Clinical Trials. JAMA Netw Open 2023; 6:e238504. [PMID: 37083668 PMCID: PMC10122174 DOI: 10.1001/jamanetworkopen.2023.8504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 12/01/2022] [Accepted: 03/02/2023] [Indexed: 04/22/2023] Open
Abstract
Importance For many types of epithelial malignant neoplasms that are treated with definitive radiotherapy (RT), treatment prolongation and interruptions have an adverse effect on outcomes. Objective To analyze the association between RT duration and outcomes in patients with esophageal cancer who were treated with definitive chemoradiotherapy (CRT). Design, Setting, and Participants This study was an unplanned, post hoc secondary analysis of 3 prospective, multi-institutional phase 3 randomized clinical trials (Radiation Therapy Oncology Group [RTOG] 8501, RTOG 9405, and RTOG 0436) of the National Cancer Institute-sponsored NRG Oncology (formerly the National Surgical Adjuvant Breast and Bowel Project, RTOG, and Gynecologic Oncology Group). Enrolled patients with nonmetastatic esophageal cancer underwent definitive CRT in the trials between 1986 and 2013, with follow-up occurring through 2014. Data analyses were conducted between March 2022 to February 2023. Exposures Treatment groups in the trials used standard-dose RT (50 Gy) and concurrent chemotherapy. Main Outcomes and Measures The outcomes were local-regional failure (LRF), distant failure, disease-free survival (DFS), and overall survival (OS). Multivariable models were used to examine the associations between these outcomes and both RT duration and interruptions. Radiotherapy duration was analyzed as a dichotomized variable using an X-Tile software to choose a cut point and its median value as a cut point, as well as a continuous variable. Results The analysis included 509 patients (median [IQR] age, 64 [57-70] years; 418 males [82%]; and 376 White individuals [74%]). The median (IQR) follow-up was 4.01 (2.93-4.92) years for surviving patients. The median cut point of RT duration was 39 days or less in 271 patients (53%) vs more than 39 days in 238 patients (47%), and the X-Tile software cut point was 45 days or less in 446 patients (88%) vs more than 45 days in 63 patients (12%). Radiotherapy interruptions occurred in 207 patients (41%). Female (vs male) sex and other (vs White) race and ethnicity were associated with longer RT duration and RT interruptions. In the multivariable models, RT duration longer than 45 days was associated with inferior DFS (hazard ratio [HR], 1.34; 95% CI, 1.01-1.77; P = .04). The HR for OS was 1.33, but the results were not statistically significant (95% CI, 0.99-1.77; P = .05). Radiotherapy duration longer than 39 days (vs ≤39 days) was associated with a higher risk of LRF (HR, 1.32; 95% CI, 1.06-1.65; P = .01). As a continuous variable, RT duration (per 1 week increase) was associated with DFS failure (HR, 1.14; 95% CI, 1.01-1.28; P = .03). The HR for LRF 1.13, but the result was not statistically significant (95% CI, 0.99-1.28; P = .07). Conclusions and Relevance Results of this study indicated that in patients with esophageal cancer receiving definitive CRT, prolonged RT duration was associated with inferior outcomes; female patients and those with other (vs White) race and ethnicity were more likely to have longer RT duration and experience RT interruptions. Radiotherapy interruptions should be minimized to optimize outcomes.
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Affiliation(s)
| | - Jennifer Moughan
- NRG Oncology Statistics and Data Management Center/American College of Radiology, Philadelphia, Pennsylvania
| | | | - Arnold M. Herskovic
- Department of Radiation Oncology, Rush University Medical Center, Chicago, Illinois
| | - Bruce D. Minsky
- Department of Radiation Oncology, The University of Texas, MD Anderson Cancer Center, Houston
| | - Mohan Suntharalingam
- Department of Radiation Oncology, University of Maryland and Greenebaum Comprehensive Cancer Center, Baltimore
| | - Kenneth L. Zeitzer
- Department of Radiation Oncology, Albert Einstein Medical Center, Philadelphia, Pennsylvania
| | - Madhur K. Garg
- Department of Radiation Oncology, Montefiore Medical Center–Moses Campus, Bronx, New York
| | - Bruce D. Greenwald
- Department of Gastroenterology and Hepatology, University of Maryland and Greenebaum Cancer Center, Baltimore
| | - Ritsuko U. Komaki
- Department of Radiation Oncology, The University of Texas, MD Anderson Cancer Center, Houston
| | - Lindsay L. Puckett
- Department of Radiation Oncology, Medical College of Wisconsin and Zablocki Veterans' Administration Medical Center, Milwaukee
| | - Hyun Kim
- Department of Radiation Oncology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Shane Lloyd
- Department of Radiation Oncology, University of Utah Health Science Center, Salt Lake City
| | - David A. Bush
- Department of Radiation Oncology, Loma Linda University Cancer Institute, Loma Linda, California
| | - Harold E. Kim
- Department of Radiation Oncology, Wayne State University/Karmanos Cancer Institute, Detroit, Michigan
| | - Thomas E. Lad
- Department of Medical Oncology, John H. Stroger Jr Hospital of Cook County, Chicago, Illinois
| | - Joshua E. Meyer
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Gordon S. Okawara
- Department of Radiation Oncology, McMaster University, Juravinski Cancer Centre, Hamilton, Ontario, Canada
| | - Adam Raben
- Department of Radiation Oncology, Christiana Care Health Services Inc Community Clinical Oncology Program, Newark, Delaware
| | | | - Jerry L. Barker
- Department of Radiation Oncology, US Oncology Texas Oncology-Sugar Land, Fort Worth
| | - Carla I. Falkson
- Department of Medicine, Hematology/Oncology, University of Rochester, Rochester, New York
| | | | - Rojymon Jacob
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham
| | - Kathryn A. Winter
- NRG Oncology Statistics and Data Management Center/American College of Radiology, Philadelphia, Pennsylvania
| | - Christopher H. Crane
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
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6
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Salami AC, Stone JM, Greenberg RH, Leighton JC, Miick R, Zavala SR, Zeitzer KL, Bakhos CT. Early Prophylactic Gastrectomy for the Management of Gastric Adenomatous Proximal Polyposis Syndrome (GAPPS). ACS Case Rev Surg 2022; 3:62-68. [PMID: 36909251 PMCID: PMC9997706] [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] [Subscribe] [Scholar Register] [Indexed: 03/14/2023]
Abstract
Background Gastric adenomatous proximal polyposis syndrome (GAPPS) is a recently described, rare, autosomal dominant condition characterized by the extensive involvement of the proximal stomach with hundreds of heterogeneous fundic gland polyps with antral and duodenal sparing. GAPPS is caused by a point mutation of the APC gene promoter 1B and is associated with a risk of malignant transformation, distant metastasis, and death. There are no surveillance, screening, or treatment guidelines for managing GAPPS. The few reported cases have been variably managed with endoscopic surveillance or prophylactic gastrectomy. However, there is no consensus on the optimal management approach. Summary In this case series, we review the relevant literature on GAPPS and present two siblings who underwent early prophylactic total gastrectomies with good outcomes. Conclusion Due to the poor correlation between the endoscopic findings on sampled polyps and the risk of harboring invasive gastric cancer, patients with GAPPS should be strongly considered for early prophylactic total gastrectomies in the absence of prohibitive comorbidities.
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Affiliation(s)
- A C Salami
- Division of Thoracic and Foregut Surgery University of Minnesota Minneapolis, MN 55455
| | - J M Stone
- Department of Surgery Albert Einstein Healthcare Network Philadelphia, PA 19141
| | - R H Greenberg
- Division of Medical Oncology Albert Einstein Healthcare Network Philadelphia, PA 19141
| | - J C Leighton
- Department of Surgery Albert Einstein Healthcare Network Philadelphia, PA 19141
| | - R Miick
- Department of Pathology and Laboratory Medicine Albert Einstein Healthcare Network Philadelphia, PA 19141
| | - S R Zavala
- South Jersey Gastroenterology Marlton, NJ 08053
| | - K L Zeitzer
- Division of Radiation Oncology Albert Einstein Healthcare Network Philadelphia, PA 19141
| | - C T Bakhos
- Department of Thoracic Medicine and Surgery Temple University Hospital Philadelphia, PA 19140.,Department of Surgical Oncology Fox Chase Cancer Center Philadelphia, PA 19111
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7
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Jackson WC, Tang M, Schipper MJ, Sandler HM, Zumsteg ZS, Efstathiou JA, Shipley WU, Seiferheld W, Lukka HR, Bahary JP, Zietman AL, Pisansky TM, Zeitzer KL, Hall WA, Dess RT, Lovett RD, Balogh AG, Feng FY, Spratt DE. Biochemical Failure Is Not a Surrogate End Point for Overall Survival in Recurrent Prostate Cancer: Analysis of NRG Oncology/RTOG 9601. J Clin Oncol 2022; 40:3172-3179. [PMID: 35737923 PMCID: PMC9514834 DOI: 10.1200/jco.21.02741] [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: 12/01/2021] [Revised: 04/05/2022] [Accepted: 05/16/2022] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Metastasis-free survival (MFS), but not event-free survival, is a validated surrogate end point for overall survival (OS) in men treated for localized prostate cancer. It remains unknown if this holds true in biochemically recurrent disease after radical prostatectomy. Leveraging NRG/RTOG 9601, we aimed to determine the performance of intermediate clinical end points (ICEs) as surrogate end points for OS in recurrent prostate cancer. MATERIALS AND METHODS NRG/RTOG 9601 randomly assigned 760 men with recurrence after prostatectomy to salvage radiation therapy with 2 years of placebo versus bicalutamide 150 mg daily. ICEs assessed were biochemical failure (BF) per NRG/RTOG 9601 (prostate-specific antigen nadir + 0.3-0.5 ng/mL or initiation of salvage hormone therapy; [BF1]) and NRG/RTOG 0534 (prostate-specific antigen nadir+2 ng/mL; [BF2]), distant metastasis (DM), and MFS (DM or death). Surrogacy was assessed by the Prentice criteria and a two-stage meta-analytic approach (condition one assessed at the patient level with Kendall's τ and condition two assessed by randomly dividing the entire trial cohort into 10 pseudo trial centers and calculating the average R2 between treatment hazard ratios for ICE and OS). RESULTS BF1, BF2, DM, and MFS satisfied the four Prentice criteria. However, with the two-condition meta-analytic approach, there was strong correlation between MFS and OS (τ = 0.86), moderate correlation between DM and OS (τ = 0.66), and weaker correlation between BF1 (τ = 0.25) or BF2 (τ = 0.40) and OS. Similarly, for condition two, the treatment effect of antiandrogen therapy on MFS and OS were correlated (R2 = 0.67), but this was not true for BF1 (R2 = 0.09), BF2 (R2 = 0.12), or DM (R2 = 0.18) and OS. CONCLUSION MFS is also a strong surrogate for OS in men receiving salvage radiation therapy for recurrence after prostatectomy. Caution should be used when inferring survival benefit from effects on BF in biochemically recurrent prostate cancer. Lack of comorbidity data did not allow us to assess whether BF in men with no/minimal comorbidity could serve as a surrogate for OS.
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Affiliation(s)
| | - Ming Tang
- University of Michigan, Ann Arbor, MI
| | | | | | | | - Jason A. Efstathiou
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - William U. Shipley
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | | | | | - Jean-Paul Bahary
- Centre Hospitalier de l'Universite de Montreal, Montreal, QC, Canada
| | - Anthony L. Zietman
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | | | | | - William A. Hall
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI
| | - Robert T. Dess
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI
| | | | | | - Felix Y. Feng
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA
| | - Daniel E. Spratt
- Department of Radiation Oncology, University Hospitals, Cleveland, OH
- Department of Radiation Oncology, Case Western Reserve University School of Medicine, Cleveland, OH
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8
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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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9
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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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10
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Xiao C, Moughan J, Movsas B, Konski AA, Hanks GE, Cox JD, Roach M, Zeitzer KL, Lawton CA, Peters CA, Rosenthal SA, Hsu ICJ, Horwitz EM, Mishra MV, Michalski JM, Parliament MB, D'Souza DP, Pugh SL, Bruner DW. Risk factors for late bowel and bladder toxicities in NRG Oncology prostate cancer trials of high-risk patients: A meta-analysis of physician-rated toxicities. Adv Radiat Oncol 2018; 3:405-411. [PMID: 30202809 PMCID: PMC6128023 DOI: 10.1016/j.adro.2018.04.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Accepted: 04/29/2018] [Indexed: 01/03/2023] Open
Abstract
Purpose A meta-analysis of sociodemographic variables and their association with late (>180 days from start of radiation therapy[RT]) bowel, bladder, and clustered bowel and bladder toxicities was conducted in patients with high-risk (clinical stages T2c-T4b or Gleason score 8-10 or prostate-specific antigen level >20) prostate cancer. Methods and materials Three NRG trials (RTOG 9202, RTOG 9413, and RTOG 9406) that accrued from 1992 to 2000 were used. Late toxicities were measured with the Radiation Therapy Oncology Group Late Radiation Morbidity Scale. After controlling for study, age, Karnofsky Performance Status, and year of accrual, sociodemographic variables were added to the model for each outcome variable of interest in a stepwise fashion using the Fine-Gray regression models with an entry criterion of 0.05. Results A total of 2432 patients were analyzed of whom most were Caucasian (76%), had a KPS score of 90 to 100 (92%), and received whole-pelvic RT+HT (67%). Of these patients, 13 % and 16% experienced late grade ≥2 bowel and bladder toxicities, respectively, and 2% and 3% experienced late grade ≥3 bowel and bladder toxicities, respectively. Late grade ≥2 clustered bowel and bladder toxicities were seen in approximately 1% of patients and late grade ≥3 clustered toxicities were seen in 2 patients (<1%). The multivariate analysis showed that patients who received prostate-only RT+HT had a lower risk of experiencing grade ≥2 bowel toxicities than those who received whole-pelvic RT+long-term (LT) HT (hazard ratio: 0.36; 95% confidence interval, 0.18-0.73; P = .0046 and hazard ratio: 0.43; 95% confidence interval, 0.23-0.80; P = .008, respectively). Patients who received whole-pelvic RT had similar chances of having grade ≥2 bowel or bladder toxicities no matter whether they received LT or short-term HT. Conclusions Patients with high-risk prostate cancer who receive whole-pelvic RT+LT HT are more likely to have a grade ≥2 bowel toxicity than those who receive prostate-only RT. LT bowel and bladder toxicities were infrequent. Future studies will need to confirm these findings utilizing current radiation technology and patient-reported outcomes.
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Affiliation(s)
| | - Jennifer Moughan
- NRG Oncology Statistics and Data Management Center, Philadelphia, Pennsylvania
| | | | | | | | | | - Mack Roach
- UCSF Medical Center-Mount Zion, San Francisco, California
| | - Kenneth L Zeitzer
- Albert Einstein Medical Center (current) and Thomas Jefferson University Hospital (accruals), Philadelphia, Pennsylvania
| | - Colleen A Lawton
- Froedtert and the Medical College of Wisconsin and the VAMC, Milwaukee, Wisconsin
| | | | - Seth A Rosenthal
- Sutter Cancer Center (current) and Radiological Associates of Sacramento (accruals), Sacramento, California
| | - I-Chow Joe Hsu
- UCSF Medical Center-Mount Zion, San Francisco, California
| | | | - Mark V Mishra
- University of Maryland Medical Systems, Baltimore, Maryland
| | | | | | | | - Stephanie L Pugh
- NRG Oncology Statistics and Data Management Center, Philadelphia, Pennsylvania
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11
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Nichols RC, Hu C, Bahary JP, Zeitzer KL, Souhami L, Leibenhaut MH, Rotman M, Gore EM, Balogh AG, McGowan D, Michalski J, Raben A, Rudoler S, Jones CU, Sandler H. Serum testosterone changes in patients treated with radiation therapy alone for prostate cancer on NRG oncology RTOG 9408. Adv Radiat Oncol 2017; 2:608-614. [PMID: 29204528 PMCID: PMC5707413 DOI: 10.1016/j.adro.2017.07.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Revised: 06/27/2017] [Accepted: 07/12/2017] [Indexed: 12/02/2022] Open
Abstract
Objectives We reviewed testosterone changes for patients who were treated with radiation therapy (RT) alone on NRG oncology RTOG 9408. Methods and materials Patients (T1b-T2b, prostate-specific antigen <20 ng/mL) were randomized between RT alone and RT plus 4 months of androgen ablation. Serum testosterone (ST) levels were investigated at enrollment, RT completion, and the first follow-up 3 months after RT. The Wilcoxon signed rank test was used to compare pre- and post-treatment ST levels in patients who were randomized to the RT-alone arm. Results Of 2028 patients enrolled, 992 patients were randomized to receive RT alone and 917 (92.4%) had baseline ST values available and completed RT. Of these 917 patients, immediate and 3-month post-RT testosterone levels were available for 447 and 373 patients, respectively. Excluding 2 patients who received hormonal therapy off protocol after RT, 447 and 371 patients, respectively, were analyzed. For all patients, the median change in ST values at completion of RT and at 3-month follow-up were −30.0 ng/dL (p5-p95; −270.0 to 162.0; P < .001) and −34.0 ng/dL (p5-p95, −228.0 to 160.0; P < .01), respectively. Conclusion RT for prostate cancer was associated with a median 9.2% decline in ST at completion of RT and a median 9.3% decline 3 months after RT. These changes were statistically significant.
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Affiliation(s)
| | - Chen Hu
- NRG Oncology Statistics and Data Management Center, Philadelphia, Pennsylvania.,Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jean-Paul Bahary
- Centre Hospitalier de l'Université de Montréal-Notre Dame, Montreal, Quebec, Canada
| | | | | | | | | | - Elizabeth M Gore
- Medical College of Wisconsin and Zablocki VA Medical Center, Milwaukee, Wisconsin
| | | | | | | | - Adam Raben
- Christiana Care Health Services, Inc. CCOP, Newark, Delaware
| | - Shari Rudoler
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
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12
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Lawton CAF, Lin X, Hanks GE, Lepor H, Grignon DJ, Brereton HD, Bedi M, Rosenthal SA, Zeitzer KL, Venkatesan VM, Horwitz EM, Pisansky TM, Kim H, Parliament MB, Rabinovitch R, Roach M, Kwok Y, Dignam JJ, Sandler HM. Duration of Androgen Deprivation in Locally Advanced Prostate Cancer: Long-Term Update of NRG Oncology RTOG 9202. Int J Radiat Oncol Biol Phys 2017; 98:296-303. [PMID: 28463149 DOI: 10.1016/j.ijrobp.2017.02.004] [Citation(s) in RCA: 87] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Revised: 01/27/2017] [Accepted: 02/06/2017] [Indexed: 11/12/2022]
Abstract
PURPOSE Trial RTOG 9202 was a phase 3 randomized trial designed to determine the optimal duration of androgen deprivation therapy (ADT) when combined with definitive radiation therapy (RT) in the treatment of locally advanced nonmetastatic adenocarcinoma of the prostate. Long-term follow-up results of this study now available are relevant to the management of this disease. METHODS AND MATERIALS Men (N=1554) with adenocarcinoma of the prostate (cT2c-T4, N0-Nx) with a prostate-specific antigen (PSA) <150 ng/mL and no evidence of distant metastasis were randomized (June 1992 to April 1995) to short-term ADT (STAD: 4 months of flutamide 250 mg 3 times per day and goserelin 3.6 mg per month) and definitive RT versus long-term ADT (LTAD: STAD with definitive RT plus an additional 24 months of monthly goserelin). RESULTS Among 1520 protocol-eligible and evaluable patients, the median follow-up time for this analysis was 19.6 years. In analysis adjusted for prognostic covariates, LTAD improved disease-free survival (29% relative reduction in failure rate, P<.0001), local progression (46% relative reduction, P=.02), distant metastases (36% relative reduction, P<.0001), disease-specific survival (30% relative reduction, P=.003), and overall survival (12% relative reduction, P=.03). Other-cause mortality (non-prostate cancer) did not differ (5% relative reduction, P=.48). CONCLUSIONS LTAD and RT is superior to STAD and RT for the treatment of locally advanced nonmetastatic adenocarcinoma of the prostate and should be considered the standard of care.
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Affiliation(s)
| | | | | | | | | | | | - Meena Bedi
- Medical College of Wisconsin, Milwaukee, Wisconsin
| | | | | | | | | | | | - Harold Kim
- Wayne State University-Karmanos Cancer Institute, Detroit, Michigan
| | | | | | - Mack Roach
- University of California, San Francisco, California
| | - Young Kwok
- University of Maryland Medical System, Baltimore, Maryland
| | - James J Dignam
- University of Chicago, Chicago, Illinois; NRG Oncology Statistics and Data Management Center, Philadelphia, Pennsylvania
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13
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Shipley WU, Seiferheld W, Lukka HR, Major PP, Heney NM, Grignon DJ, Sartor O, Patel MP, Bahary JP, Zietman AL, Pisansky TM, Zeitzer KL, Lawton CAF, Feng FY, Lovett RD, Balogh AG, Souhami L, Rosenthal SA, Kerlin KJ, Dignam JJ, Pugh SL, Sandler HM. Radiation with or without Antiandrogen Therapy in Recurrent Prostate Cancer. N Engl J Med 2017; 376:417-428. [PMID: 28146658 PMCID: PMC5444881 DOI: 10.1056/nejmoa1607529] [Citation(s) in RCA: 438] [Impact Index Per Article: 62.6] [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] [Indexed: 12/15/2022]
Abstract
BACKGROUND Salvage radiation therapy is often necessary in men who have undergone radical prostatectomy and have evidence of prostate-cancer recurrence signaled by a persistently or recurrently elevated prostate-specific antigen (PSA) level. Whether antiandrogen therapy with radiation therapy will further improve cancer control and prolong overall survival is unknown. METHODS In a double-blind, placebo-controlled trial conducted from 1998 through 2003, we assigned 760 eligible patients who had undergone prostatectomy with a lymphadenectomy and had disease, as assessed on pathological testing, with a tumor stage of T2 (confined to the prostate but with a positive surgical margin) or T3 (with histologic extension beyond the prostatic capsule), no nodal involvement, and a detectable PSA level of 0.2 to 4.0 ng per milliliter to undergo radiation therapy and receive either antiandrogen therapy (24 months of bicalutamide at a dose of 150 mg daily) or daily placebo tablets during and after radiation therapy. The primary end point was the rate of overall survival. RESULTS The median follow-up among the surviving patients was 13 years. The actuarial rate of overall survival at 12 years was 76.3% in the bicalutamide group, as compared with 71.3% in the placebo group (hazard ratio for death, 0.77; 95% confidence interval, 0.59 to 0.99; P=0.04). The 12-year incidence of death from prostate cancer, as assessed by means of central review, was 5.8% in the bicalutamide group, as compared with 13.4% in the placebo group (P<0.001). The cumulative incidence of metastatic prostate cancer at 12 years was 14.5% in the bicalutamide group, as compared with 23.0% in the placebo group (P=0.005). The incidence of late adverse events associated with radiation therapy was similar in the two groups. Gynecomastia was recorded in 69.7% of the patients in the bicalutamide group, as compared with 10.9% of those in the placebo group (P<0.001). CONCLUSIONS The addition of 24 months of antiandrogen therapy with daily bicalutamide to salvage radiation therapy resulted in significantly higher rates of long-term overall survival and lower incidences of metastatic prostate cancer and death from prostate cancer than radiation therapy plus placebo. (Funded by the National Cancer Institute and AstraZeneca; RTOG 9601 ClinicalTrials.gov number, NCT00002874 .).
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Affiliation(s)
- William U Shipley
- From Massachusetts General Hospital and Harvard Medical School, Boston (W.U.S., N.M.H., A.L.Z.); NRG Oncology Statistics and Data Management Center (W.S., J.J.D., S.L.P.) and Einstein Medical Center (K.L.Z.), Philadelphia; Juravinski Cancer Centre at Hamilton Health Sciences, Hamilton, ON (H.R.L., P.P.M., M.P.P.), Hospital Notre-Dame du Centre Hospitalier de l'Université de Montréal (J.-P.B.) and McGill University Health Centre (L.S.), Montreal, and Tom Baker Cancer Centre, Calgary, AB (A.G.B.) - all in Canada; Indiana University, Indianapolis (D.J.G.); Tulane University, New Orleans (O.S.); Mayo Clinic, Rochester, MN (T.M.P.); Medical College of Wisconsin, Milwaukee (C.A.F.L.); University of Michigan, Ann Arbor (F.Y.F.); University of Vermont Medical Center, Burlington (R.D.L.); Radiation Oncology Center, Sacramento (S.A.R.), and Cedars-Sinai Medical Center, Los Angeles (H.M.S.) - both in California; Wayne Radiation Oncology, Goldsboro, NC (K.J.K.); and the University of Chicago, Chicago (J.J.D.)
| | - Wendy Seiferheld
- From Massachusetts General Hospital and Harvard Medical School, Boston (W.U.S., N.M.H., A.L.Z.); NRG Oncology Statistics and Data Management Center (W.S., J.J.D., S.L.P.) and Einstein Medical Center (K.L.Z.), Philadelphia; Juravinski Cancer Centre at Hamilton Health Sciences, Hamilton, ON (H.R.L., P.P.M., M.P.P.), Hospital Notre-Dame du Centre Hospitalier de l'Université de Montréal (J.-P.B.) and McGill University Health Centre (L.S.), Montreal, and Tom Baker Cancer Centre, Calgary, AB (A.G.B.) - all in Canada; Indiana University, Indianapolis (D.J.G.); Tulane University, New Orleans (O.S.); Mayo Clinic, Rochester, MN (T.M.P.); Medical College of Wisconsin, Milwaukee (C.A.F.L.); University of Michigan, Ann Arbor (F.Y.F.); University of Vermont Medical Center, Burlington (R.D.L.); Radiation Oncology Center, Sacramento (S.A.R.), and Cedars-Sinai Medical Center, Los Angeles (H.M.S.) - both in California; Wayne Radiation Oncology, Goldsboro, NC (K.J.K.); and the University of Chicago, Chicago (J.J.D.)
| | - Himanshu R Lukka
- From Massachusetts General Hospital and Harvard Medical School, Boston (W.U.S., N.M.H., A.L.Z.); NRG Oncology Statistics and Data Management Center (W.S., J.J.D., S.L.P.) and Einstein Medical Center (K.L.Z.), Philadelphia; Juravinski Cancer Centre at Hamilton Health Sciences, Hamilton, ON (H.R.L., P.P.M., M.P.P.), Hospital Notre-Dame du Centre Hospitalier de l'Université de Montréal (J.-P.B.) and McGill University Health Centre (L.S.), Montreal, and Tom Baker Cancer Centre, Calgary, AB (A.G.B.) - all in Canada; Indiana University, Indianapolis (D.J.G.); Tulane University, New Orleans (O.S.); Mayo Clinic, Rochester, MN (T.M.P.); Medical College of Wisconsin, Milwaukee (C.A.F.L.); University of Michigan, Ann Arbor (F.Y.F.); University of Vermont Medical Center, Burlington (R.D.L.); Radiation Oncology Center, Sacramento (S.A.R.), and Cedars-Sinai Medical Center, Los Angeles (H.M.S.) - both in California; Wayne Radiation Oncology, Goldsboro, NC (K.J.K.); and the University of Chicago, Chicago (J.J.D.)
| | - Pierre P Major
- From Massachusetts General Hospital and Harvard Medical School, Boston (W.U.S., N.M.H., A.L.Z.); NRG Oncology Statistics and Data Management Center (W.S., J.J.D., S.L.P.) and Einstein Medical Center (K.L.Z.), Philadelphia; Juravinski Cancer Centre at Hamilton Health Sciences, Hamilton, ON (H.R.L., P.P.M., M.P.P.), Hospital Notre-Dame du Centre Hospitalier de l'Université de Montréal (J.-P.B.) and McGill University Health Centre (L.S.), Montreal, and Tom Baker Cancer Centre, Calgary, AB (A.G.B.) - all in Canada; Indiana University, Indianapolis (D.J.G.); Tulane University, New Orleans (O.S.); Mayo Clinic, Rochester, MN (T.M.P.); Medical College of Wisconsin, Milwaukee (C.A.F.L.); University of Michigan, Ann Arbor (F.Y.F.); University of Vermont Medical Center, Burlington (R.D.L.); Radiation Oncology Center, Sacramento (S.A.R.), and Cedars-Sinai Medical Center, Los Angeles (H.M.S.) - both in California; Wayne Radiation Oncology, Goldsboro, NC (K.J.K.); and the University of Chicago, Chicago (J.J.D.)
| | - Niall M Heney
- From Massachusetts General Hospital and Harvard Medical School, Boston (W.U.S., N.M.H., A.L.Z.); NRG Oncology Statistics and Data Management Center (W.S., J.J.D., S.L.P.) and Einstein Medical Center (K.L.Z.), Philadelphia; Juravinski Cancer Centre at Hamilton Health Sciences, Hamilton, ON (H.R.L., P.P.M., M.P.P.), Hospital Notre-Dame du Centre Hospitalier de l'Université de Montréal (J.-P.B.) and McGill University Health Centre (L.S.), Montreal, and Tom Baker Cancer Centre, Calgary, AB (A.G.B.) - all in Canada; Indiana University, Indianapolis (D.J.G.); Tulane University, New Orleans (O.S.); Mayo Clinic, Rochester, MN (T.M.P.); Medical College of Wisconsin, Milwaukee (C.A.F.L.); University of Michigan, Ann Arbor (F.Y.F.); University of Vermont Medical Center, Burlington (R.D.L.); Radiation Oncology Center, Sacramento (S.A.R.), and Cedars-Sinai Medical Center, Los Angeles (H.M.S.) - both in California; Wayne Radiation Oncology, Goldsboro, NC (K.J.K.); and the University of Chicago, Chicago (J.J.D.)
| | - David J Grignon
- From Massachusetts General Hospital and Harvard Medical School, Boston (W.U.S., N.M.H., A.L.Z.); NRG Oncology Statistics and Data Management Center (W.S., J.J.D., S.L.P.) and Einstein Medical Center (K.L.Z.), Philadelphia; Juravinski Cancer Centre at Hamilton Health Sciences, Hamilton, ON (H.R.L., P.P.M., M.P.P.), Hospital Notre-Dame du Centre Hospitalier de l'Université de Montréal (J.-P.B.) and McGill University Health Centre (L.S.), Montreal, and Tom Baker Cancer Centre, Calgary, AB (A.G.B.) - all in Canada; Indiana University, Indianapolis (D.J.G.); Tulane University, New Orleans (O.S.); Mayo Clinic, Rochester, MN (T.M.P.); Medical College of Wisconsin, Milwaukee (C.A.F.L.); University of Michigan, Ann Arbor (F.Y.F.); University of Vermont Medical Center, Burlington (R.D.L.); Radiation Oncology Center, Sacramento (S.A.R.), and Cedars-Sinai Medical Center, Los Angeles (H.M.S.) - both in California; Wayne Radiation Oncology, Goldsboro, NC (K.J.K.); and the University of Chicago, Chicago (J.J.D.)
| | - Oliver Sartor
- From Massachusetts General Hospital and Harvard Medical School, Boston (W.U.S., N.M.H., A.L.Z.); NRG Oncology Statistics and Data Management Center (W.S., J.J.D., S.L.P.) and Einstein Medical Center (K.L.Z.), Philadelphia; Juravinski Cancer Centre at Hamilton Health Sciences, Hamilton, ON (H.R.L., P.P.M., M.P.P.), Hospital Notre-Dame du Centre Hospitalier de l'Université de Montréal (J.-P.B.) and McGill University Health Centre (L.S.), Montreal, and Tom Baker Cancer Centre, Calgary, AB (A.G.B.) - all in Canada; Indiana University, Indianapolis (D.J.G.); Tulane University, New Orleans (O.S.); Mayo Clinic, Rochester, MN (T.M.P.); Medical College of Wisconsin, Milwaukee (C.A.F.L.); University of Michigan, Ann Arbor (F.Y.F.); University of Vermont Medical Center, Burlington (R.D.L.); Radiation Oncology Center, Sacramento (S.A.R.), and Cedars-Sinai Medical Center, Los Angeles (H.M.S.) - both in California; Wayne Radiation Oncology, Goldsboro, NC (K.J.K.); and the University of Chicago, Chicago (J.J.D.)
| | - Maltibehn P Patel
- From Massachusetts General Hospital and Harvard Medical School, Boston (W.U.S., N.M.H., A.L.Z.); NRG Oncology Statistics and Data Management Center (W.S., J.J.D., S.L.P.) and Einstein Medical Center (K.L.Z.), Philadelphia; Juravinski Cancer Centre at Hamilton Health Sciences, Hamilton, ON (H.R.L., P.P.M., M.P.P.), Hospital Notre-Dame du Centre Hospitalier de l'Université de Montréal (J.-P.B.) and McGill University Health Centre (L.S.), Montreal, and Tom Baker Cancer Centre, Calgary, AB (A.G.B.) - all in Canada; Indiana University, Indianapolis (D.J.G.); Tulane University, New Orleans (O.S.); Mayo Clinic, Rochester, MN (T.M.P.); Medical College of Wisconsin, Milwaukee (C.A.F.L.); University of Michigan, Ann Arbor (F.Y.F.); University of Vermont Medical Center, Burlington (R.D.L.); Radiation Oncology Center, Sacramento (S.A.R.), and Cedars-Sinai Medical Center, Los Angeles (H.M.S.) - both in California; Wayne Radiation Oncology, Goldsboro, NC (K.J.K.); and the University of Chicago, Chicago (J.J.D.)
| | - Jean-Paul Bahary
- From Massachusetts General Hospital and Harvard Medical School, Boston (W.U.S., N.M.H., A.L.Z.); NRG Oncology Statistics and Data Management Center (W.S., J.J.D., S.L.P.) and Einstein Medical Center (K.L.Z.), Philadelphia; Juravinski Cancer Centre at Hamilton Health Sciences, Hamilton, ON (H.R.L., P.P.M., M.P.P.), Hospital Notre-Dame du Centre Hospitalier de l'Université de Montréal (J.-P.B.) and McGill University Health Centre (L.S.), Montreal, and Tom Baker Cancer Centre, Calgary, AB (A.G.B.) - all in Canada; Indiana University, Indianapolis (D.J.G.); Tulane University, New Orleans (O.S.); Mayo Clinic, Rochester, MN (T.M.P.); Medical College of Wisconsin, Milwaukee (C.A.F.L.); University of Michigan, Ann Arbor (F.Y.F.); University of Vermont Medical Center, Burlington (R.D.L.); Radiation Oncology Center, Sacramento (S.A.R.), and Cedars-Sinai Medical Center, Los Angeles (H.M.S.) - both in California; Wayne Radiation Oncology, Goldsboro, NC (K.J.K.); and the University of Chicago, Chicago (J.J.D.)
| | - Anthony L Zietman
- From Massachusetts General Hospital and Harvard Medical School, Boston (W.U.S., N.M.H., A.L.Z.); NRG Oncology Statistics and Data Management Center (W.S., J.J.D., S.L.P.) and Einstein Medical Center (K.L.Z.), Philadelphia; Juravinski Cancer Centre at Hamilton Health Sciences, Hamilton, ON (H.R.L., P.P.M., M.P.P.), Hospital Notre-Dame du Centre Hospitalier de l'Université de Montréal (J.-P.B.) and McGill University Health Centre (L.S.), Montreal, and Tom Baker Cancer Centre, Calgary, AB (A.G.B.) - all in Canada; Indiana University, Indianapolis (D.J.G.); Tulane University, New Orleans (O.S.); Mayo Clinic, Rochester, MN (T.M.P.); Medical College of Wisconsin, Milwaukee (C.A.F.L.); University of Michigan, Ann Arbor (F.Y.F.); University of Vermont Medical Center, Burlington (R.D.L.); Radiation Oncology Center, Sacramento (S.A.R.), and Cedars-Sinai Medical Center, Los Angeles (H.M.S.) - both in California; Wayne Radiation Oncology, Goldsboro, NC (K.J.K.); and the University of Chicago, Chicago (J.J.D.)
| | - Thomas M Pisansky
- From Massachusetts General Hospital and Harvard Medical School, Boston (W.U.S., N.M.H., A.L.Z.); NRG Oncology Statistics and Data Management Center (W.S., J.J.D., S.L.P.) and Einstein Medical Center (K.L.Z.), Philadelphia; Juravinski Cancer Centre at Hamilton Health Sciences, Hamilton, ON (H.R.L., P.P.M., M.P.P.), Hospital Notre-Dame du Centre Hospitalier de l'Université de Montréal (J.-P.B.) and McGill University Health Centre (L.S.), Montreal, and Tom Baker Cancer Centre, Calgary, AB (A.G.B.) - all in Canada; Indiana University, Indianapolis (D.J.G.); Tulane University, New Orleans (O.S.); Mayo Clinic, Rochester, MN (T.M.P.); Medical College of Wisconsin, Milwaukee (C.A.F.L.); University of Michigan, Ann Arbor (F.Y.F.); University of Vermont Medical Center, Burlington (R.D.L.); Radiation Oncology Center, Sacramento (S.A.R.), and Cedars-Sinai Medical Center, Los Angeles (H.M.S.) - both in California; Wayne Radiation Oncology, Goldsboro, NC (K.J.K.); and the University of Chicago, Chicago (J.J.D.)
| | - Kenneth L Zeitzer
- From Massachusetts General Hospital and Harvard Medical School, Boston (W.U.S., N.M.H., A.L.Z.); NRG Oncology Statistics and Data Management Center (W.S., J.J.D., S.L.P.) and Einstein Medical Center (K.L.Z.), Philadelphia; Juravinski Cancer Centre at Hamilton Health Sciences, Hamilton, ON (H.R.L., P.P.M., M.P.P.), Hospital Notre-Dame du Centre Hospitalier de l'Université de Montréal (J.-P.B.) and McGill University Health Centre (L.S.), Montreal, and Tom Baker Cancer Centre, Calgary, AB (A.G.B.) - all in Canada; Indiana University, Indianapolis (D.J.G.); Tulane University, New Orleans (O.S.); Mayo Clinic, Rochester, MN (T.M.P.); Medical College of Wisconsin, Milwaukee (C.A.F.L.); University of Michigan, Ann Arbor (F.Y.F.); University of Vermont Medical Center, Burlington (R.D.L.); Radiation Oncology Center, Sacramento (S.A.R.), and Cedars-Sinai Medical Center, Los Angeles (H.M.S.) - both in California; Wayne Radiation Oncology, Goldsboro, NC (K.J.K.); and the University of Chicago, Chicago (J.J.D.)
| | - Colleen A F Lawton
- From Massachusetts General Hospital and Harvard Medical School, Boston (W.U.S., N.M.H., A.L.Z.); NRG Oncology Statistics and Data Management Center (W.S., J.J.D., S.L.P.) and Einstein Medical Center (K.L.Z.), Philadelphia; Juravinski Cancer Centre at Hamilton Health Sciences, Hamilton, ON (H.R.L., P.P.M., M.P.P.), Hospital Notre-Dame du Centre Hospitalier de l'Université de Montréal (J.-P.B.) and McGill University Health Centre (L.S.), Montreal, and Tom Baker Cancer Centre, Calgary, AB (A.G.B.) - all in Canada; Indiana University, Indianapolis (D.J.G.); Tulane University, New Orleans (O.S.); Mayo Clinic, Rochester, MN (T.M.P.); Medical College of Wisconsin, Milwaukee (C.A.F.L.); University of Michigan, Ann Arbor (F.Y.F.); University of Vermont Medical Center, Burlington (R.D.L.); Radiation Oncology Center, Sacramento (S.A.R.), and Cedars-Sinai Medical Center, Los Angeles (H.M.S.) - both in California; Wayne Radiation Oncology, Goldsboro, NC (K.J.K.); and the University of Chicago, Chicago (J.J.D.)
| | - Felix Y Feng
- From Massachusetts General Hospital and Harvard Medical School, Boston (W.U.S., N.M.H., A.L.Z.); NRG Oncology Statistics and Data Management Center (W.S., J.J.D., S.L.P.) and Einstein Medical Center (K.L.Z.), Philadelphia; Juravinski Cancer Centre at Hamilton Health Sciences, Hamilton, ON (H.R.L., P.P.M., M.P.P.), Hospital Notre-Dame du Centre Hospitalier de l'Université de Montréal (J.-P.B.) and McGill University Health Centre (L.S.), Montreal, and Tom Baker Cancer Centre, Calgary, AB (A.G.B.) - all in Canada; Indiana University, Indianapolis (D.J.G.); Tulane University, New Orleans (O.S.); Mayo Clinic, Rochester, MN (T.M.P.); Medical College of Wisconsin, Milwaukee (C.A.F.L.); University of Michigan, Ann Arbor (F.Y.F.); University of Vermont Medical Center, Burlington (R.D.L.); Radiation Oncology Center, Sacramento (S.A.R.), and Cedars-Sinai Medical Center, Los Angeles (H.M.S.) - both in California; Wayne Radiation Oncology, Goldsboro, NC (K.J.K.); and the University of Chicago, Chicago (J.J.D.)
| | - Richard D Lovett
- From Massachusetts General Hospital and Harvard Medical School, Boston (W.U.S., N.M.H., A.L.Z.); NRG Oncology Statistics and Data Management Center (W.S., J.J.D., S.L.P.) and Einstein Medical Center (K.L.Z.), Philadelphia; Juravinski Cancer Centre at Hamilton Health Sciences, Hamilton, ON (H.R.L., P.P.M., M.P.P.), Hospital Notre-Dame du Centre Hospitalier de l'Université de Montréal (J.-P.B.) and McGill University Health Centre (L.S.), Montreal, and Tom Baker Cancer Centre, Calgary, AB (A.G.B.) - all in Canada; Indiana University, Indianapolis (D.J.G.); Tulane University, New Orleans (O.S.); Mayo Clinic, Rochester, MN (T.M.P.); Medical College of Wisconsin, Milwaukee (C.A.F.L.); University of Michigan, Ann Arbor (F.Y.F.); University of Vermont Medical Center, Burlington (R.D.L.); Radiation Oncology Center, Sacramento (S.A.R.), and Cedars-Sinai Medical Center, Los Angeles (H.M.S.) - both in California; Wayne Radiation Oncology, Goldsboro, NC (K.J.K.); and the University of Chicago, Chicago (J.J.D.)
| | - Alexander G Balogh
- From Massachusetts General Hospital and Harvard Medical School, Boston (W.U.S., N.M.H., A.L.Z.); NRG Oncology Statistics and Data Management Center (W.S., J.J.D., S.L.P.) and Einstein Medical Center (K.L.Z.), Philadelphia; Juravinski Cancer Centre at Hamilton Health Sciences, Hamilton, ON (H.R.L., P.P.M., M.P.P.), Hospital Notre-Dame du Centre Hospitalier de l'Université de Montréal (J.-P.B.) and McGill University Health Centre (L.S.), Montreal, and Tom Baker Cancer Centre, Calgary, AB (A.G.B.) - all in Canada; Indiana University, Indianapolis (D.J.G.); Tulane University, New Orleans (O.S.); Mayo Clinic, Rochester, MN (T.M.P.); Medical College of Wisconsin, Milwaukee (C.A.F.L.); University of Michigan, Ann Arbor (F.Y.F.); University of Vermont Medical Center, Burlington (R.D.L.); Radiation Oncology Center, Sacramento (S.A.R.), and Cedars-Sinai Medical Center, Los Angeles (H.M.S.) - both in California; Wayne Radiation Oncology, Goldsboro, NC (K.J.K.); and the University of Chicago, Chicago (J.J.D.)
| | - Luis Souhami
- From Massachusetts General Hospital and Harvard Medical School, Boston (W.U.S., N.M.H., A.L.Z.); NRG Oncology Statistics and Data Management Center (W.S., J.J.D., S.L.P.) and Einstein Medical Center (K.L.Z.), Philadelphia; Juravinski Cancer Centre at Hamilton Health Sciences, Hamilton, ON (H.R.L., P.P.M., M.P.P.), Hospital Notre-Dame du Centre Hospitalier de l'Université de Montréal (J.-P.B.) and McGill University Health Centre (L.S.), Montreal, and Tom Baker Cancer Centre, Calgary, AB (A.G.B.) - all in Canada; Indiana University, Indianapolis (D.J.G.); Tulane University, New Orleans (O.S.); Mayo Clinic, Rochester, MN (T.M.P.); Medical College of Wisconsin, Milwaukee (C.A.F.L.); University of Michigan, Ann Arbor (F.Y.F.); University of Vermont Medical Center, Burlington (R.D.L.); Radiation Oncology Center, Sacramento (S.A.R.), and Cedars-Sinai Medical Center, Los Angeles (H.M.S.) - both in California; Wayne Radiation Oncology, Goldsboro, NC (K.J.K.); and the University of Chicago, Chicago (J.J.D.)
| | - Seth A Rosenthal
- From Massachusetts General Hospital and Harvard Medical School, Boston (W.U.S., N.M.H., A.L.Z.); NRG Oncology Statistics and Data Management Center (W.S., J.J.D., S.L.P.) and Einstein Medical Center (K.L.Z.), Philadelphia; Juravinski Cancer Centre at Hamilton Health Sciences, Hamilton, ON (H.R.L., P.P.M., M.P.P.), Hospital Notre-Dame du Centre Hospitalier de l'Université de Montréal (J.-P.B.) and McGill University Health Centre (L.S.), Montreal, and Tom Baker Cancer Centre, Calgary, AB (A.G.B.) - all in Canada; Indiana University, Indianapolis (D.J.G.); Tulane University, New Orleans (O.S.); Mayo Clinic, Rochester, MN (T.M.P.); Medical College of Wisconsin, Milwaukee (C.A.F.L.); University of Michigan, Ann Arbor (F.Y.F.); University of Vermont Medical Center, Burlington (R.D.L.); Radiation Oncology Center, Sacramento (S.A.R.), and Cedars-Sinai Medical Center, Los Angeles (H.M.S.) - both in California; Wayne Radiation Oncology, Goldsboro, NC (K.J.K.); and the University of Chicago, Chicago (J.J.D.)
| | - Kevin J Kerlin
- From Massachusetts General Hospital and Harvard Medical School, Boston (W.U.S., N.M.H., A.L.Z.); NRG Oncology Statistics and Data Management Center (W.S., J.J.D., S.L.P.) and Einstein Medical Center (K.L.Z.), Philadelphia; Juravinski Cancer Centre at Hamilton Health Sciences, Hamilton, ON (H.R.L., P.P.M., M.P.P.), Hospital Notre-Dame du Centre Hospitalier de l'Université de Montréal (J.-P.B.) and McGill University Health Centre (L.S.), Montreal, and Tom Baker Cancer Centre, Calgary, AB (A.G.B.) - all in Canada; Indiana University, Indianapolis (D.J.G.); Tulane University, New Orleans (O.S.); Mayo Clinic, Rochester, MN (T.M.P.); Medical College of Wisconsin, Milwaukee (C.A.F.L.); University of Michigan, Ann Arbor (F.Y.F.); University of Vermont Medical Center, Burlington (R.D.L.); Radiation Oncology Center, Sacramento (S.A.R.), and Cedars-Sinai Medical Center, Los Angeles (H.M.S.) - both in California; Wayne Radiation Oncology, Goldsboro, NC (K.J.K.); and the University of Chicago, Chicago (J.J.D.)
| | - James J Dignam
- From Massachusetts General Hospital and Harvard Medical School, Boston (W.U.S., N.M.H., A.L.Z.); NRG Oncology Statistics and Data Management Center (W.S., J.J.D., S.L.P.) and Einstein Medical Center (K.L.Z.), Philadelphia; Juravinski Cancer Centre at Hamilton Health Sciences, Hamilton, ON (H.R.L., P.P.M., M.P.P.), Hospital Notre-Dame du Centre Hospitalier de l'Université de Montréal (J.-P.B.) and McGill University Health Centre (L.S.), Montreal, and Tom Baker Cancer Centre, Calgary, AB (A.G.B.) - all in Canada; Indiana University, Indianapolis (D.J.G.); Tulane University, New Orleans (O.S.); Mayo Clinic, Rochester, MN (T.M.P.); Medical College of Wisconsin, Milwaukee (C.A.F.L.); University of Michigan, Ann Arbor (F.Y.F.); University of Vermont Medical Center, Burlington (R.D.L.); Radiation Oncology Center, Sacramento (S.A.R.), and Cedars-Sinai Medical Center, Los Angeles (H.M.S.) - both in California; Wayne Radiation Oncology, Goldsboro, NC (K.J.K.); and the University of Chicago, Chicago (J.J.D.)
| | - Stephanie L Pugh
- From Massachusetts General Hospital and Harvard Medical School, Boston (W.U.S., N.M.H., A.L.Z.); NRG Oncology Statistics and Data Management Center (W.S., J.J.D., S.L.P.) and Einstein Medical Center (K.L.Z.), Philadelphia; Juravinski Cancer Centre at Hamilton Health Sciences, Hamilton, ON (H.R.L., P.P.M., M.P.P.), Hospital Notre-Dame du Centre Hospitalier de l'Université de Montréal (J.-P.B.) and McGill University Health Centre (L.S.), Montreal, and Tom Baker Cancer Centre, Calgary, AB (A.G.B.) - all in Canada; Indiana University, Indianapolis (D.J.G.); Tulane University, New Orleans (O.S.); Mayo Clinic, Rochester, MN (T.M.P.); Medical College of Wisconsin, Milwaukee (C.A.F.L.); University of Michigan, Ann Arbor (F.Y.F.); University of Vermont Medical Center, Burlington (R.D.L.); Radiation Oncology Center, Sacramento (S.A.R.), and Cedars-Sinai Medical Center, Los Angeles (H.M.S.) - both in California; Wayne Radiation Oncology, Goldsboro, NC (K.J.K.); and the University of Chicago, Chicago (J.J.D.)
| | - Howard M Sandler
- From Massachusetts General Hospital and Harvard Medical School, Boston (W.U.S., N.M.H., A.L.Z.); NRG Oncology Statistics and Data Management Center (W.S., J.J.D., S.L.P.) and Einstein Medical Center (K.L.Z.), Philadelphia; Juravinski Cancer Centre at Hamilton Health Sciences, Hamilton, ON (H.R.L., P.P.M., M.P.P.), Hospital Notre-Dame du Centre Hospitalier de l'Université de Montréal (J.-P.B.) and McGill University Health Centre (L.S.), Montreal, and Tom Baker Cancer Centre, Calgary, AB (A.G.B.) - all in Canada; Indiana University, Indianapolis (D.J.G.); Tulane University, New Orleans (O.S.); Mayo Clinic, Rochester, MN (T.M.P.); Medical College of Wisconsin, Milwaukee (C.A.F.L.); University of Michigan, Ann Arbor (F.Y.F.); University of Vermont Medical Center, Burlington (R.D.L.); Radiation Oncology Center, Sacramento (S.A.R.), and Cedars-Sinai Medical Center, Los Angeles (H.M.S.) - both in California; Wayne Radiation Oncology, Goldsboro, NC (K.J.K.); and the University of Chicago, Chicago (J.J.D.)
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14
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Krauss DJ, Hu C, Bahary JP, Souhami L, Gore EM, Chafe SMJ, Leibenhaut MH, Narayan S, Torres-Roca J, Michalski J, Zeitzer KL, Donavanik V, Sandler H, McGowan DG, Jones CU, Shipley WU. Importance of Local Control in Early-Stage Prostate Cancer: Outcomes of Patients With Positive Post-Radiation Therapy Biopsy Results Treated in RTOG 9408. Int J Radiat Oncol Biol Phys 2015; 92:863-73. [PMID: 26104939 DOI: 10.1016/j.ijrobp.2015.03.017] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Revised: 03/16/2015] [Accepted: 03/18/2015] [Indexed: 11/25/2022]
Abstract
PURPOSE The purpose of this study was to assess the association between positive post-radiation therapy (RT) biopsy results and subsequent clinical outcomes in males with localized prostate cancer. METHODS AND MATERIALS Radiation Therapy Oncology Group study 94-08 analyzed 1979 males with prostate cancer, stage T1b-T2b and prostate-specific antigen concentrations of ≤ 20 ng/dL, to investigate whether 4 months of total androgen suppression (TAS) added to RT improved survival compared to RT alone. Patients randomized to receive TAS received flutamide with luteinizing hormone releasing hormone (LHRH) agonist. According to protocol, patients without evidence of clinical recurrence or initiation of additional endocrine therapy underwent repeat prostate biopsy 2 years after RT completion. Statistical analysis was performed to evaluate the impact of positive post-RT biopsy results on clinical outcomes. RESULTS A total of 831 patients underwent post-RT biopsy, 398 were treated with RT alone and 433 with RT plus TAS. Patients with positive post-RT biopsy results had higher rates of biochemical failure (hazard ratio [HR] = 1.7; 95% confidence interval [CI] = 1.3-2.1) and distant metastasis (HR = 2.4; 95% CI = 1.3-4.4) and inferior disease-specific survival (HR = 3.8; 95% CI = 1.9-7.5). Positive biopsy results remained predictive of such outcomes after correction for potential confounders such as Gleason score, tumor stage, and TAS administration. Prior TAS therapy did not prevent elevated risk of adverse outcome in the setting of post-RT positive biopsy results. Patients with Gleason score ≥ 7 with a positive biopsy result additionally had inferior overall survival compared to those with a negative biopsy result (HR = 1.56; 95% CI = 1.04-2.35). CONCLUSIONS Positive post-RT biopsy is associated with increased rates of distant metastases and inferior disease-specific survival in patients treated with definitive RT and was associated with inferior overall survival in patients with high-grade tumors.
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Affiliation(s)
- Daniel J Krauss
- Department of Radiation Oncology, Oakland University William Beaumont School of Medicine, Royal Oak, Michigan.
| | - Chen Hu
- NRG Statistics and Data Management Center, Philadelphia, Pennsylvania
| | - Jean-Paul Bahary
- Centre Hospitalier de l'Université de Montréal-Notre Dame, Montreal, Quebec, Canada
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15
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Asbell SO, Raimane KC, Montesano AT, Zeitzer KL, Asbell MD, Vijayakumar S. Prostate-specific antigen and androgens in African-American and white normal subjects and prostate cancer patients. J Natl Med Assoc 2000; 92:445-9. [PMID: 11052458 PMCID: PMC2608532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
Abstract
Prostate cancer in African Americans is more aggressive and common than in any other racial group. An endocrine mechanism has been proposed to account for this racial difference. However, androgen levels in African-American elderly normal subjects and prostate cancer patients have been insufficiently studied. Because the Albert Einstein Medical Center (AEMC) has a large African-American population, we could contribute racial data from which observations could be made within this study and in past and future studies. Blood from 38 screened men (mean age 65) with prostate-specific antigen (PSA) less than 4 ng/mL and normal rectal examination seen at the AEMC Cancer Center was studied using standard radioimmunoassays. The blood samples also served as our control. Our experimental group consisted of 51 prostate cancer patients (mean age 71 years), all of whom had nonmetastatic prostate cancer. Subjects were categorized by cancer status, race, and age group. In our screened subjects, PSA, testosterone, and dihydrotestosterone were not higher in African Americans than in whites. Furthermore, our prostate cancer patients demonstrated no significant racial variation for PSA, testosterone, and dihydrotestosterone. Our data also did not indicate any correlation between PSA and androgen levels in our cancer patients. In our population of elderly men, no racial differences in androgen levels were found. Androgen levels did not correlate with PSA levels in prostate cancer patients.
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Affiliation(s)
- S O Asbell
- Albert Einstein Medical Center, Department of Radiation Oncology, Philadelphia, Pennsylvania, USA
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16
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Mohiuddin M, Zeitzer KL, Moylan DJ, Yelovich RM, Rose L. Non-uniform dose/time fractionated radiation therapy and chemotherapy for non-small cell lung cancer. Lung Cancer 1995; 13:57-67. [PMID: 8528640 DOI: 10.1016/0169-5002(95)00476-h] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
PURPOSE A Non-uniform Fractionation schedule of large priming doses combined with concurrent chemotherapy and protracted RT was undertaken for the treatment of NSCLC. With several 5-year survivors, this study is reviewed with regard to local control, toxicity, and survival of patients. METHODS AND MATERIALS Forty-two patients with unresectable NSCLC were treated prospectively with initial priming doses followed by large field irradiation to the tumor and regional nodes to 3500 cGy. Patients were given a 1-week break and the treatment was repeated. A total dose of 7000 cGy was delivered over 9 weeks. Thirteen patients (Group A) were treated with RT alone. Twenty-nine patients (Group B) received concurrent chemotherapy; Cisplatin, 100 mg/m2, and 5-FU, 1 g/m2 for 24 h times 5 days. Sixteen patients also received Vinblastine, 3 mg/m2 on a weekly schedule. All patients have been followed more than 5 years. RESULTS Overall complete response rate was 36% and partial response rate was 57%. Absolute survival at 2 years was 26% and at 5 years was 14%. Local failure occurred in 28/42 (67%) patients. Late complications included pulmonary fibrosis (3), and osteochondritis (2). CONCLUSION This approach of high-dose Non-uniform fractionated radiation therapy has yielded an absolute 5-year survival of 14%, which appears better than the long-term results often seen in treatment of NSCL cancer.
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Affiliation(s)
- M Mohiuddin
- Department of Radiation Medicine, A.B. Chandler Medical Center, University of Kentucky, Lexington 40536, USA
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17
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Zeitzer KL, Moylan DJ, Yelovich RM, Rose L, Mohiuddin M. A novel approach to non-small cell lung cancer using protracted fractionation radiation therapy: Long-term results. Int J Radiat Oncol Biol Phys 1993. [DOI: 10.1016/0360-3016(93)90868-v] [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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18
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Komarnicky LT, Ayyangar KM, Huq M, Zeitzer KL, Mansfield CM, Schwartz GF. Placement of electron boost field as a part of primary breast irradiation using CT and 3-D treatment planning. Int J Radiat Oncol Biol Phys 1992. [DOI: 10.1016/0360-3016(92)90396-y] [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: 10/20/2022]
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