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Brand DH, Brüningk SC, Wilkins A, Naismith O, Gao A, Syndikus I, Dearnaley DP, Hall E, van As N, Tree AC, Gulliford S. Gastrointestinal Toxicity Prediction Not Influenced by Rectal Contour or Dose-Volume Histogram Definition. Int J Radiat Oncol Biol Phys 2023; 117:1163-1173. [PMID: 37433374 PMCID: PMC10680426 DOI: 10.1016/j.ijrobp.2023.07.002] [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] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 06/01/2023] [Accepted: 07/03/2023] [Indexed: 07/13/2023]
Abstract
PURPOSE Rectal dose delivered during prostate radiation therapy is associated with gastrointestinal toxicity. Treatment plans are commonly optimized using rectal dose-volume constraints, often whole-rectum relative-volumes (%). We investigated whether improved rectal contouring, use of absolute-volumes (cc), or rectal truncation might improve toxicity prediction. METHODS AND MATERIALS Patients from the CHHiP trial (receiving 74 Gy/37 fractions [Fr] vs 60 Gy/20 Fr vs 57 Gy/19 Fr) were included if radiation therapy plans were available (2350/3216 patients), plus toxicity data for relevant analyses (2170/3216 patients). Whole solid rectum relative-volumes (%) dose-volume-histogram (DVH), as submitted by treating center (original contour), was assumed standard-of-care. Three investigational rectal DVHs were generated: (1) reviewed contour per CHHiP protocol; (2) original contour absolute volumes (cc); and (3) truncated original contour (2 versions; ±0 and ±2 cm from planning target volume [PTV]). Dose levels of interest (V30, 40, 50, 60, 70, 74 Gy) in 74 Gy arm were converted by equivalent-dose-in-2 Gy-Fr (EQD2α/β= 3 Gy) for 60 Gy/57 Gy arms. Bootstrapped logistic models predicting late toxicities (frequency G1+/G2+, bleeding G1+/G2+, proctitis G1+/G2+, sphincter control G1+, stricture/ulcer G1+) were compared by area-undercurve (AUC) between standard of care and the 3 investigational rectal definitions. RESULTS The alternative dose/volume parameters were compared with the original relative-volume (%) DVH of the whole rectal contour, itself fitted as a weak predictor of toxicity (AUC range, 0.57-0.65 across the 8 toxicity measures). There were no significant differences in toxicity prediction for: (1) original versus reviewed rectal contours (AUCs, 0.57-0.66; P = .21-.98); (2) relative- versus absolute-volumes (AUCs, 0.56-0.63; P = .07-.91); and (3) whole-rectum versus truncation at PTV ± 2 cm (AUCs, 0.57-0.65; P = .05-.99) or PTV ± 0 cm (AUCs, 0.57-0.66; P = .27-.98). CONCLUSIONS We used whole-rectum relative-volume DVH, submitted by the treating center, as the standard-of-care dosimetric predictor for rectal toxicity. There were no statistically significant differences in prediction performance when using central rectal contour review, with the use of absolute-volume dosimetry, or with rectal truncation relative to PTV. Whole-rectum relative-volumes were not improved upon for toxicity prediction and should remain standard-of-care.
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Affiliation(s)
- Douglas H Brand
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, United Kingdom; Department of Medical Physics and Biomedical Engineering, University College London, London, United Kingdom.
| | - Sarah C Brüningk
- Department of Health Science and Technology, ETH Zurich, Basel, Switzerland; Swiss Institute for Bioinformatics (SIB), Lausanne, Switzerland
| | - Anna Wilkins
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, United Kingdom; Urology Unit
| | - Olivia Naismith
- Radiotherapy Trials QA Group (RTTQA), Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Annie Gao
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, United Kingdom; Urology Unit
| | - Isabel Syndikus
- Radiotherapy Department, Clatterbridge Cancer Centre, Liverpool, United Kingdom
| | - David P Dearnaley
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, United Kingdom; Urology Unit
| | - Emma Hall
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, United Kingdom
| | - Nicholas van As
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, United Kingdom; Urology Unit
| | - Alison C Tree
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, United Kingdom; Urology Unit
| | - Sarah Gulliford
- Department of Medical Physics and Biomedical Engineering, University College London, London, United Kingdom; Department of Radiotherapy Physics, University College London Hospitals NHS Foundation Trust, London, United Kingdom
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Van As NJ, Tree A, Ostler PJ, van der Voet H, Ford D, Tolan S, Wells P, Mahmood R, Winkler M, Chan A, Thompson A, Ogden C, Brown S, Pugh J, Burnett SM, Griffin C, Patel J, Naismith O, Hall E. PACE-A: An international phase 3 randomised controlled trial (RCT) comparing stereotactic body radiotherapy (SBRT) to surgery for localised prostate cancer (LPCa)—Primary endpoint analysis. J Clin Oncol 2023. [DOI: 10.1200/jco.2023.41.6_suppl.298] [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: 03/16/2023] Open
Abstract
298 Background: People presenting with early-stage LPCa have several treatment options. There is therapeutic equipoise with lack of randomised evidence for superiority of radiotherapy or surgery. PACE-A aimed to determine if there is improved quality of life (QoL) following SBRT compared to surgery. Methods: PACE (NCT01584258) is a phase 3 open-label multiple-cohort RCT. In PACE-A, people with LPCa, T1-T2, Gleason≤3+4, PSA≤20ng/mL & suitable for surgery were randomised (1:1) to SBRT or surgery. SBRT dose was 36.25Gy/5 fractions in 1-2 weeks; surgery was laparoscopic or robotically assisted prostatectomy. Androgen deprivation was not permitted. Co-primary endpoints were patient reported outcomes (PROs) of Expanded Prostate Index Composite (EPIC-26) questionnaire number of absorbent pads per day & EPIC bowel subdomain score at 2 years. Target sample size was 234 participants (pts) to detect 9% difference in urinary incontinence (80% power, 5% 2-sided alpha) & 5-point difference in mean bowel subdomain score (90% power, 5% 2-sided alpha) with higher EPIC score (range 0-100) indicating better QoL. Secondary endpoints included clinician reported toxicity and additional PROs (1% significance level). Analysis is by treatment received. Results: From Aug 2012 to Feb 2022, 123 men from 10 UK centres were randomised. The IDMC advised stopping recruitment after a 2-year gap in during COVID. Pts had median age 66years (IQR: 61, 69), median PSA 8ng/ml (6, 11) with 52% tumours ≥T2b and 79% Gleason 3+4; 93% pts were of white race. 58/63 pts received SBRT as allocated (2 received surgery, 2 unknown, 1 withdrawn); 48/60 received surgery as allocated (1 received SBRT, 3 received CRT, 2 unknown, 6 withdrawn). 8 laparoscopic and 42 robotic assisted operations were performed. Median follow-up is 50 months (IQR 41, 74). At 2 years, fewer SBRT pts reported use of urinary pads: 2/43 (4.5%) vs 15/32 (46.9%), p<0.001. SBRT pts had significantly worse bowel subdomain score (mean (SD) 88.4 (12.7) vs 97.3 (5.5), p<0.001). 7/45 (15.6%) SBRT and 0/31 (0%) surgery pts reported moderate/big problem with bowel symptoms (p=0.04). SBRT pts reported less EPIC sexual subdomain score (58.0 (31.9) vs 29.3 (20.5), p<0.001); there was no evidence of a difference in urinary subdomain score (85.5 (19.8) vs 80.5 (20.8), p=0.29). At 2 years, CTCAE genitourinary grade 2 or higher(G2+) toxicity was seen in 5/54 (9.3%) SBRT vs 4/42 (9.5%) surgery pts (p=0.97); there was no G2+ gastrointestinal (GI) events seen in either group. Conclusions: PACE-A contributes the first randomised data to the comparison of SBRT with surgery in LPCa providing PRO data relevant to informed decision making. Compared to surgery, pts receiving SBRT had better urinary continence & sexual bother score; clinician reported GI toxicity was low but SBRT pts reported more bowel bother at 2 years. Clinical trial information: NCT01584258 .
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Affiliation(s)
- Nicholas John Van As
- The Royal Marsden NHS Foundation Trust/Institute of Cancer Research, United Kingdom, London, United Kingdom
| | - Alison Tree
- The Royal Marsden NHS Foundation Trust/Institute of Cancer Research, London, United Kingdom
| | | | | | - Daniel Ford
- Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - Shaun Tolan
- The Clatterbridge Cancer Centre NHS Foundation Trust, Wirral, United Kingdom
| | - Paula Wells
- St Bartholomew's Hospital, London, United Kingdom
| | - Rana Mahmood
- Colchester General Hospital, Colchester, United Kingdom
| | | | - Andrew Chan
- University Hospitals Coventry & Warwickshire NHS Trust, Coventry, United Kingdom
| | - Alan Thompson
- The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | | | | | - Julia Pugh
- The Institute of Cancer Research, London, United Kingdom
| | | | - Clare Griffin
- The Institute of Cancer Research, London, United Kingdom
| | - Jaymini Patel
- The Institute of Cancer Research, London, United Kingdom
| | - Olivia Naismith
- Radiotherapy Trials Quality Assurance (RTTQA), Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Emma Hall
- The Institute of Cancer Research, Clinical Trials and Statistics Unit, London, United Kingdom
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Brand DH, Brüningk SC, Wilkins A, Naismith O, Gao A, Syndikus I, Dearnaley DP, van As N, Hall E, Gulliford S, Tree AC. The Fraction Size Sensitivity of Late Genitourinary Toxicity: Analysis of Alpha/Beta (α/β) Ratios in the CHHiP Trial. Int J Radiat Oncol Biol Phys 2023; 115:327-336. [PMID: 35985457 DOI: 10.1016/j.ijrobp.2022.08.030] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 08/04/2022] [Accepted: 08/06/2022] [Indexed: 01/14/2023]
Abstract
PURPOSE Moderately hypofractionated external beam intensity modulated radiation therapy (RT) for prostate cancer is now standard-of-care. Normal tissue toxicity responses to fraction size alteration are nonlinear: the linear-quadratic model is a widely used framework accounting for this, through the α/β ratio. Few α/β ratio estimates exist for human late genitourinary endpoints; here we provide estimates derived from a hypofractionation trial. METHODS AND MATERIALS The CHHiP trial randomized 3216 men with localized prostate cancer 1:1:1 between conventionally fractionated intensity modulated RT (74 Gy/37 fractions (Fr)) and 2 moderately hypofractionated regimens (60 Gy/20 Fr and 57 Gy/19 Fr). RT plan and suitable follow-up assessment was available for 2206 men. Three prospectively assessed clinician-reported toxicity scales were amalgamated for common genitourinary endpoints: dysuria, hematuria, incontinence, reduced flow/stricture, and urine frequency. Per endpoint, only patients with baseline zero toxicity were included. Three models for endpoint grade ≥1 (G1+) and G2+ toxicity were fitted: Lyman Kutcher-Burman (LKB) without equivalent dose in 2 Gy/Fr (EQD2) correction [LKB-NoEQD2]; LKB with EQD2-correction [LKB-EQD2]; LKB-EQD2 with dose-modifying-factor (DMF) inclusion [LKB-EQD2-DMF]. DMFs were age, diabetes, hypertension, pelvic surgery, prior transurethral resection of prostate (TURP), overall treatment time and acute genitourinary toxicity (G2+). Bootstrapping generated 95% confidence intervals and unbiased performance estimates. Models were compared by likelihood ratio test. RESULTS The LKB-EQD2 model significantly improved performance over LKB-NoEQD2 for just 3 endpoints: dysuria G1+ (α/β = 2.0 Gy; 95% confidence interval [CI], 1.2-3.2 Gy), hematuria G1+ (α/β = 0.9 Gy; 95% CI, 0.1-2.2 Gy) and hematuria G2+ (α/β = 0.6 Gy; 95% CI, 0.1-1.7 Gy). For these 3 endpoints, further incorporation of 2 DMFs improved on LKB-EQD2: acute genitourinary toxicity and prior TURP (hematuria G1+ only), but α/β ratio estimates remained stable. CONCLUSIONS Inclusion of EQD2-correction significantly improved model fitting for dysuria and hematuria endpoints, where fitted α/β ratio estimates were low: 0.6 to 2 Gy. This suggests therapeutic gain for clinician-reported GU toxicity, through hypofractionation, might be lower than expected by typical late α/β ratio assumptions of 3 to 5 Gy.
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Affiliation(s)
- Douglas H Brand
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, United Kingdom; Urology Unit, Royal Marsden NHS Foundation Trust, London, United Kingdom; Department of Medical Physics and Biomedical Engineering, University College London, London, United Kingdom.
| | - Sarah C Brüningk
- Department of Biosystems Science and Engineering, ETH Zurich, Basel, Switzerland; Swiss Institute for Bioinformatics (SIB), Lausanne, Switzerland
| | - Anna Wilkins
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, United Kingdom; Urology Unit, Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Olivia Naismith
- Radiotherapy Trials QA Group (RTTQA), Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Annie Gao
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, United Kingdom; Urology Unit, Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Isabel Syndikus
- Radiotherapy Department, Clatterbridge Cancer Centre, Liverpool, United Kingdom
| | - David P Dearnaley
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, United Kingdom; Urology Unit, Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Nicholas van As
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, United Kingdom; Urology Unit, Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Emma Hall
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, United Kingdom
| | - Sarah Gulliford
- Department of Medical Physics and Biomedical Engineering, University College London, London, United Kingdom; Department of Radiotherapy Physics, University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Alison C Tree
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, United Kingdom; Urology Unit, Royal Marsden NHS Foundation Trust, London, United Kingdom
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Murray J, Cruickshank C, Bird T, Bell P, Braun J, Chuter D, Ferreira MR, Griffin C, Hassan S, Hujairi N, Melcher A, Miles E, Naismith O, Panades M, Philipps L, Reid A, Rekowski J, Sankey P, Staffurth J, Syndikus I, Tree A, Wilkins A, Hall E. PEARLS - A multicentre phase II/III trial of extended field radiotherapy for androgen sensitive prostate cancer patients with PSMA-avid pelvic and/or para-aortic lymph nodes at presentation. Clin Transl Radiat Oncol 2022; 37:130-136. [PMID: 36238579 PMCID: PMC9550847 DOI: 10.1016/j.ctro.2022.09.003] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 09/18/2022] [Indexed: 11/24/2022] Open
Abstract
PEARLS is a multi-stage randomised controlled trial for prostate cancer patients with pelvic and/or para-aortic PSMA-avid lymph node disease at presentation. The aim of the trial is to determine whether extending the radiotherapy field to cover the para-aortic lymph nodes (up to L1/L2 vertebral interspace) can improve outcomes for this patient group.
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Affiliation(s)
- Julia Murray
- The Royal Marsden NHS Foundation Trust, London, UK
- The Institute of Cancer Research, London, UK
| | | | - Thomas Bird
- University Hospitals Bristol & Weston NHS Foundation Trust, Bristol, UK
| | | | - John Braun
- RMH Radiotherapy Focus Group & RMH Biomedical Research Centre Consumer Group, Sutton, UK
| | - Dave Chuter
- NCRI Consumer Forum, London, UK
- NCRI Living With & Beyond Cancer (Acute and Toxicities Workstream), London, UK
| | | | | | | | | | - Alan Melcher
- The Royal Marsden NHS Foundation Trust, London, UK
- The Institute of Cancer Research, London, UK
| | - Elizabeth Miles
- Radiotherapy Trials QA Group (RTTQA), Mount Vernon Hospital, Northwood, UK
| | - Olivia Naismith
- Radiotherapy Trials QA Group (RTTQA), Royal Marsden NHS Foundation Trust, London, UK
| | | | - Lara Philipps
- The Royal Marsden NHS Foundation Trust, London, UK
- The Institute of Cancer Research, London, UK
| | - Alison Reid
- The Royal Marsden NHS Foundation Trust, London, UK
| | | | - Pete Sankey
- University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - John Staffurth
- Velindre University NHS Trust and Cardiff University, Cardiff, UK
| | | | - Alison Tree
- The Royal Marsden NHS Foundation Trust, London, UK
- The Institute of Cancer Research, London, UK
| | - Anna Wilkins
- The Royal Marsden NHS Foundation Trust, London, UK
- The Institute of Cancer Research, London, UK
| | - Emma Hall
- The Institute of Cancer Research, London, UK
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Tree AC, Ostler P, van der Voet H, Chu W, Loblaw A, Ford D, Tolan S, Jain S, Martin A, Staffurth J, Armstrong J, Camilleri P, Kancherla K, Frew J, Chan A, Dayes IS, Duffton A, Brand DH, Henderson D, Morrison K, Brown S, Pugh J, Burnett S, Mahmud M, Hinder V, Naismith O, Hall E, van As N. Intensity-modulated radiotherapy versus stereotactic body radiotherapy for prostate cancer (PACE-B): 2-year toxicity results from an open-label, randomised, phase 3, non-inferiority trial. Lancet Oncol 2022; 23:1308-1320. [PMID: 36113498 DOI: 10.1016/s1470-2045(22)00517-4] [Citation(s) in RCA: 99] [Impact Index Per Article: 49.5] [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: 05/31/2022] [Revised: 08/10/2022] [Accepted: 08/11/2022] [Indexed: 10/14/2022]
Abstract
BACKGROUND Localised prostate cancer is commonly treated with external beam radiotherapy and moderate hypofractionation is non-inferior to longer schedules. Stereotactic body radiotherapy (SBRT) allows shorter treatment courses without impacting acute toxicity. We report 2-year toxicity findings from PACE-B, a randomised trial of conventionally fractionated or moderately hypofractionated radiotherapy versus SBRT. METHODS PACE is an open-label, multicohort, randomised, controlled, phase 3 trial conducted at 35 hospitals in the UK, Ireland, and Canada. In PACE-B, men aged 18 years and older with a WHO performance status 0-2 and low-risk or intermediate-risk histologically-confirmed prostate adenocarcinoma (Gleason 4 + 3 excluded) were randomly allocated (1:1) by computerised central randomisation with permuted blocks (size four and six), stratified by centre and risk group to control radiotherapy (CRT; 78 Gy in 39 fractions over 7·8 weeks or, following protocol amendment on March 24, 2016, 62 Gy in 20 fractions over 4 weeks) or SBRT (36·25 Gy in five fractions over 1-2 weeks). Androgen deprivation was not permitted. Co-primary outcomes for this toxicity analysis were Radiation Therapy Oncology Group (RTOG) grade 2 or worse gastrointestinal and genitourinary toxicity at 24 months after radiotherapy. Analysis was by treatment received and included all patients with at least one fraction of study treatment assessed for late toxicity. Recruitment is complete. Follow-up for oncological outcomes continues. The trial is registered with ClinicalTrials.gov, NCT01584258. FINDINGS We enrolled and randomly assigned 874 men between Aug 7, 2012, and Jan 4, 2018 (441 to CRT and 433 to SBRT). In this analysis, 430 patients were analysed in the CRT group and 414 in the SBRT group; a total of 844 (97%) of 874 randomly assigned patients. At 24 months, RTOG grade 2 or worse genitourinary toxicity was seen in eight (2%) of 381 participants assigned to CRT and 13 (3%) of 384 participants assigned to SBRT (absolute difference 1·3% [95% CI -1·3 to 4·0]; p=0·39); RTOG grade 2 or worse gastrointestinal toxicity was seen in 11 (3%) of 382 participants in the CRT group versus six (2%) of 384 participants in the SBRT group (absolute difference -1·3% [95% CI -3·9 to 1·1]; p=0·32). No serious adverse events (defined as RTOG grade 4 or worse) or treatment-related deaths were reported within the analysis timeframe. INTERPRETATION In the PACE-B trial, 2-year RTOG toxicity rates were similar for five fraction SBRT and conventional schedules of radiotherapy. Prostate SBRT was found to be safe and associated with low rates of side-effects. Biochemical outcomes are awaited. FUNDING Accuray.
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Affiliation(s)
- Alison C Tree
- The Royal Marsden Hospital, London, UK; The Institute of Cancer Research, London, UK.
| | | | | | - William Chu
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Andrew Loblaw
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Daniel Ford
- University Hospitals Birmingham, Birmingham, UK
| | - Shaun Tolan
- The Clatterbridge Cancer Centre, Liverpool, UK
| | | | - Alexander Martin
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | | | - John Armstrong
- Cancer Trials Ireland, Dublin, Ireland; St Luke's Radiation Oncology Network, St Lukes Hospital, Dublin, Ireland
| | | | | | | | - Andrew Chan
- University Hospitals Coventry & Warwickshire, Coventry, UK
| | - Ian S Dayes
- Department of Oncology, McMaster University, Hamilton, ON, Canada
| | | | - Douglas H Brand
- The Royal Marsden Hospital, London, UK; The Institute of Cancer Research, London, UK
| | | | - Kirsty Morrison
- The Royal Marsden Hospital, London, UK; The Institute of Cancer Research, London, UK
| | | | - Julia Pugh
- The Institute of Cancer Research, London, UK
| | | | | | | | - Olivia Naismith
- The Royal Marsden Hospital, London, UK; Radiotherapy Trials QA Group, London, UK
| | - Emma Hall
- The Institute of Cancer Research, London, UK
| | - Nicholas van As
- The Royal Marsden Hospital, London, UK; The Institute of Cancer Research, London, UK
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Murray J, Cruickshank C, Bird T, Bell P, Braun J, Chuter D, Davda R, Ferreira MR, Griffin C, Hujairi N, Melcher A, Miles E, Naismith O, Rekowski J, Staffurth J, Syndikus I, Tree A, Wilkins A, Hall E. PEARLS: A multicenter phase II/III trial of extended field radiotherapy for androgen-sensitive prostate cancer patients with PSMA‐avid pelvic and para-aortic lymph nodes at presentation. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.6_suppl.tps199] [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
TPS199 Background: Optimal management for lymph node (LN) positive prostate cancer has not yet been determined. With the emerging role of PSMA-PET/CT in diagnostic staging, identification of this disease status is increasing. The superior border for prostate nodal radiotherapy is variable across different centres. PEARLS (CRUK/19/016) aims to show that extending the radiotherapy field to cover the para-aortic LN (up to L1/L2 vertebral interspace) can improve outcomes for prostate cancer patients with PSMA-avid pelvic LN at presentation. The trial is registered: ISRCTN36344989. Methods: PEARLS is a multi‐stage randomised controlled trial. Men with histologically confirmed prostate cancer with PSMA‐avid nodal disease within the pelvis +/‐ para‐aortic region receiving androgen deprivation therapy +/‐ androgen receptor targeted therapy or docetaxel chemotherapy are eligible. Two cohorts defined by extent of LN disease determined by PSMA‐PET/CT will be recruited: cohort A (pelvic LN at or below the L4/L5 vertebral interspace) and cohort B (para-aortic LN below L1/L2 vertebral interspace). Patients are randomly allocated (1:1) to standard field (dependent on cohort) intensity modulated radiotherapy (IMRT) (control) or extended-field IMRT (experimental) in 20 fractions over 4 weeks. In the control group, cohort A will receive 60Gy to the prostate and 44Gy to the pelvis with an integrated boost of 51Gy to PSMA-avid LN and cohort B will receive 60Gy to the prostate only. In the experimental group, participants in both cohorts will receive 60Gy to the prostate and 44Gy to the pelvis and para‐aortic region with an integrated boost of 51Gy to involved LN. In phase II, the primary endpoint is lower gastrointestinal RTOG grade 2+ toxicity at week 18 from start of radiotherapy. Assuming acceptable toxicity in the first 75 participants receiving extended-field IMRT, the study will move to phase III where the primary endpoint is metastasis‐free survival. The trial aims to recruit 714 patients with pelvic LN to detect a hazard ratio of 0.62 in favour of extended-field IMRT and a further 179 patients with para‐aortic LN disease. The trial was launched in the UK on 25 June 2021. Phase II will be conducted in 20 NHS Trusts across the UK. Clinical trial information: ISRCTN36344989.
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Affiliation(s)
- Julia Murray
- The Royal Marsden NHS Foundation Trust and The Institute of Cancer Research, London, United Kingdom
| | | | - Thomas Bird
- University Hospitals Bristol & Weston NHS Foundation Trust, Bristol, United Kingdom
| | | | - John Braun
- RMH Radiotherapy Focus Group & RMH Biomedical Research Centre Consumer group, London, United Kingdom
| | | | - Reena Davda
- University College London NHS Foundation Trust, London, United Kingdom
| | | | - Clare Griffin
- The Institute of Cancer Research, London, United Kingdom
| | - Nabil Hujairi
- The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Alan Melcher
- The Institute of Cancer Research & Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Elizabeth Miles
- Radiotherapy Trials QA Group (RTTQA), Mount Vernon Hospital, Northwood, United Kingdom
| | - Olivia Naismith
- Radiotherapy Trials Quality Assurance (RTTQA), Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Jan Rekowski
- The Institute of Cancer Research, London, United Kingdom
| | - John Staffurth
- Velindre NHS Trust and Cardiff University, Cardiff, UK, United Kingdom
| | | | - Alison Tree
- The Royal Marsden NHS Foundation Trust and the Institute of Cancer Research, London, United Kingdom
| | - Anna Wilkins
- The Institute of Cancer Research & The Crick Institute, London, United Kingdom
| | - Emma Hall
- The Institute of Cancer Research, London, United Kingdom
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Tree A, Hall E, Ostler P, van der Voet H, Loblaw A, Chu W, Ford D, Tolan S, Jain S, Martin A, Staffurth J, Camilleri P, Kancherla K, Frew J, Brand D, Chan A, Dayes I, Brown S, Pugh J, Burnett S, Dufton A, Griffin C, Mahmud M, Naismith O, van As N, of the O. OC-0289 Comparison of side effects at 2 years in the randomised PACE-B trial (SBRT vs standard radiotherapy). Radiother Oncol 2021. [DOI: 10.1016/s0167-8140(21)06839-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Brand DH, Brüningk SC, Wilkins A, Fernandez K, Naismith O, Gao A, Syndikus I, Dearnaley DP, Tree AC, van As N, Hall E, Gulliford S. Estimates of Alpha/Beta (α/β) Ratios for Individual Late Rectal Toxicity Endpoints: An Analysis of the CHHiP Trial. Int J Radiat Oncol Biol Phys 2021; 110:596-608. [PMID: 33412260 PMCID: PMC8129972 DOI: 10.1016/j.ijrobp.2020.12.041] [Citation(s) in RCA: 12] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 12/10/2020] [Accepted: 12/24/2020] [Indexed: 12/04/2022]
Abstract
PURPOSE Changes in fraction size of external beam radiation therapy exert nonlinear effects on subsequent toxicity. Commonly described by the linear-quadratic model, fraction size sensitivity of normal tissues is expressed by the α/β ratio. We sought to study individual α/β ratios for different late rectal effects after prostate external beam radiation therapy. METHODS AND MATERIALS The CHHiP trial (ISRCTN97182923) randomized men with nonmetastatic prostate cancer 1:1:1 to 74 Gy/37 fractions (Fr), 60 Gy/20 Fr, or 57 Gy/19 Fr. Patients in the study had full dosimetric data and zero baseline toxicity. Toxicity scales were amalgamated to 6 bowel endpoints: bleeding, diarrhea, pain, proctitis, sphincter control, and stricture. Lyman-Kutcher-Burman models with or without equivalent dose in 2 Gy/Fr correction were log-likelihood fitted by endpoint, estimating α/β ratios. The α/β ratio estimate sensitivity was assessed using sequential inclusion of dose modifying factors (DMFs): age, diabetes, hypertension, inflammatory bowel or diverticular disease (IBD/diverticular), and hemorrhoids. 95% confidence intervals (CIs) were bootstrapped. Likelihood ratio testing of 632 estimator log-likelihoods compared the models. RESULTS Late rectal α/β ratio estimates (without DMF) ranged from bleeding (G1 + α/β = 1.6 Gy; 95% CI, 0.9-2.5 Gy) to sphincter control (G1 + α/β = 3.1 Gy; 95% CI, 1.4-9.1 Gy). Bowel pain modelled poorly (α/β, 3.6 Gy; 95% CI, 0.0-840 Gy). Inclusion of IBD/diverticular disease as a DMF significantly improved fits for stool frequency G2+ (P = .00041) and proctitis G1+ (P = .00046). However, the α/β ratios were similar in these no-DMF versus DMF models for both stool frequency G2+ (α/β 2.7 Gy vs 2.5 Gy) and proctitis G1+ (α/β 2.7 Gy vs 2.6 Gy). Frequency-weighted averaging of endpoint α/β ratios produced: G1 + α/β ratio = 2.4 Gy; G2 + α/β ratio = 2.3 Gy. CONCLUSIONS We estimated α/β ratios for several common late adverse effects of rectal radiation therapy. When comparing dose-fractionation schedules, we suggest using late a rectal α/β ratio ≤ 3 Gy.
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Affiliation(s)
- Douglas H Brand
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, United Kingdom; Urology Unit, Royal Marsden NHS Foundation Trust, London, United Kingdom.
| | - Sarah C Brüningk
- Department of Biosystems Science and Engineering, ETH Zurich, Basel, Switzerland
| | - Anna Wilkins
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, United Kingdom; Urology Unit, Royal Marsden NHS Foundation Trust, London, United Kingdom; Tumour Cell Biology Laboratory, The Francis Crick Institute, London, United Kingdom
| | - Katie Fernandez
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, United Kingdom
| | - Olivia Naismith
- Radiotherapy Trials QA Group, Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Annie Gao
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, United Kingdom; Urology Unit, Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Isabel Syndikus
- Radiotherapy Department, Clatterbridge Cancer Centre, United Kingdom
| | - David P Dearnaley
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, United Kingdom; Urology Unit, Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Alison C Tree
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, United Kingdom; Urology Unit, Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Nicholas van As
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, United Kingdom; Urology Unit, Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Emma Hall
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, United Kingdom
| | - Sarah Gulliford
- Department of Medical Physics and Biomedical Engineering, University College London, London, United Kingdom; Department of Radiotherapy Physics, University College London Hospitals NHS Foundation Trust, London, United Kingdom
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9
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Mayles H, Naismith O, Snelson N, Syndikus I. PO-1800: Successful Implementation of Treatment Planning Trial QA for the PIVOTALboost Trial. Radiother Oncol 2020. [DOI: 10.1016/s0167-8140(21)01818-1] [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: 10/22/2022]
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10
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Syndikus I, Cruickshank C, Staffurth J, Tree A, Henry A, Naismith O, Mayles H, Snelson N, Hassan S, Brown S, Porta N, Griffin C, Hall E. PIVOTALboost: A phase III randomised controlled trial of prostate and pelvis versus prostate alone radiotherapy with or without prostate boost (CRUK/16/018). Clin Transl Radiat Oncol 2020; 25:22-28. [PMID: 32995575 PMCID: PMC7508714 DOI: 10.1016/j.ctro.2020.08.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 08/24/2020] [Indexed: 01/16/2023] Open
Abstract
•PIVOTALboost evaluates benefits/toxicity of pelvic node RT and focal boost dose escalation.•Unfavourable intermediate/high risk and bulky local disease are most likely to benefit.•Functional MRI imaging is used to select patients for different types of dose escalation.•HDR brachytherapy or focal dose escalation with IMRT are used as options.•Training and support is provided to reduce variations of contouring and radiotherapy planning.•The trial is recruiting patients in 38 radiotherapy centres through the UK.
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Affiliation(s)
| | - Clare Cruickshank
- Clinical Trials and Statistics Unit, The Institute of Cancer Research (ICR-CTSU), London, UK
| | | | - Alison Tree
- The Royal Marsden NHS Foundation Trust/The Institute of Cancer Research, London, UK
| | - Ann Henry
- The Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Olivia Naismith
- National Radiotherapy Trials Quality Assurance Group, The Royal Marsden NHS Foundation Trust, London, UK
| | - Helen Mayles
- National Radiotherapy Trials Quality Assurance Group, The Clatterbridge Cancer Centre, Wirral. UK
| | - Nicola Snelson
- National Radiotherapy Trials Quality Assurance Group, The Clatterbridge Cancer Centre, Wirral. UK
| | - Shama Hassan
- Clinical Trials and Statistics Unit, The Institute of Cancer Research (ICR-CTSU), London, UK
| | - Stephanie Brown
- Clinical Trials and Statistics Unit, The Institute of Cancer Research (ICR-CTSU), London, UK
| | - Nuria Porta
- Clinical Trials and Statistics Unit, The Institute of Cancer Research (ICR-CTSU), London, UK
| | - Clare Griffin
- Clinical Trials and Statistics Unit, The Institute of Cancer Research (ICR-CTSU), London, UK
| | - Emma Hall
- Clinical Trials and Statistics Unit, The Institute of Cancer Research (ICR-CTSU), London, UK
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11
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Wilkins A, Naismith O, Brand D, Fernandez K, Hall E, Dearnaley D, Gulliford S. Derivation of Dose/Volume Constraints for the Anorectum from Clinician- and Patient-Reported Outcomes in the CHHiP Trial of Radiation Therapy Fractionation. Int J Radiat Oncol Biol Phys 2020; 106:928-938. [PMID: 31987974 DOI: 10.1016/j.ijrobp.2020.01.003] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Revised: 12/20/2019] [Accepted: 01/03/2020] [Indexed: 12/19/2022]
Abstract
PURPOSE The CHHiP trial randomized 3216 men with localized prostate cancer (1:1:1) to 3 radiation therapy fractionation schedules: 74 Gy in 37 fractions over 7.4 weeks; 60 Gy in 20 fractions over 4 weeks; and 57 Gy in 19 fractions over 3.8 weeks. Literature-based dose constraints were applied with arithmetic adjustment for the hypofractionated arms. This study aimed to derive anorectal dose constraints using prospectively collected clinician-reported outcomes (CROs) and patient-reported outcomes (PROs) and to assess the added predictive value of spatial dose metrics. METHODS AND MATERIALS A case-control study design was used; 7 CRO and 5 PRO bowel symptoms were evaluated. Cases experienced a moderate or worse symptom 1 to 5 years after-radiation therapy and did not have the symptom before radiation therapy. Controls did not experience the symptom at baseline or between 1 to 5 years after radiation therapy. The anorectum was recontoured from the anal verge to the rectosigmoid junction; dose/volume parameters were extracted. Univariate logistic regression, atlases of complication indices, and bootstrapped receiver-operating-characteristic analysis (1000 replicates, balanced outcomes) were used to derive dose constraints for the whole cohort (hypofractionated schedules were converted to 2-Gy equivalent schedules using α/β = 3 Gy) and separate hypofractionated/conventional fractionation cohorts. Only areas under the curve with 95% confidence interval lower limits >0.5 were considered statistically significant. Any constraint derived in <95% to 99% of bootstraps was excluded. RESULTS Statistically significant dose constraints were derived for CROs but not PROs. Intermediate to high doses were important for rectal bleeding, whereas intermediate doses were important for increased bowel frequency, fecal incontinence, and rectal pain. Spatial dose metrics did not improve prediction of CROs or PROs. A new panel of dose constraints for hypofractionated schedules to 60 Gy or 57 Gy are V20Gy <85%, V30Gy <57%, V40Gy <38%, V50Gy <22%, and V60Gy <0.01%. CONCLUSIONS Dose constraints differed among symptoms, indicating potentially different pathogenesis of radiation-induced side effects. Derived dose constraints were stricter than those used in CHHiP and may reduce bowel symptoms after radiation therapy.
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Affiliation(s)
- Anna Wilkins
- Division of Clinical Studies, Institute of Cancer Research, London, United Kingdom; The Royal Marsden Hospital, London, United Kingdom.
| | - Olivia Naismith
- The Royal Marsden Hospital, London, United Kingdom; Radiotherapy Trials Quality Assurance Group, London, United Kingdom
| | - Douglas Brand
- The Royal Marsden Hospital, London, United Kingdom; Division of Radiotherapy and Imaging, Institute of Cancer Research, London, United Kingdom
| | - Katie Fernandez
- Division of Radiotherapy and Imaging, Institute of Cancer Research, London, United Kingdom
| | - Emma Hall
- Division of Clinical Studies, Institute of Cancer Research, London, United Kingdom
| | - David Dearnaley
- The Royal Marsden Hospital, London, United Kingdom; Division of Radiotherapy and Imaging, Institute of Cancer Research, London, United Kingdom
| | - Sarah Gulliford
- Division of Radiotherapy and Imaging, Institute of Cancer Research, London, United Kingdom
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Murray J, Gulliford S, Griffin C, Wilkins A, Syndikus I, Staffurth J, Panades M, Scrase C, Parker C, Khoo V, Dean J, Mayles H, Mayles P, Thomas S, Naismith O, Mossop H, Cruickshank C, Hall E, Dearnaley D. Evaluation of erectile potency and radiation dose to the penile bulb using image guided radiotherapy in the CHHiP trial. Clin Transl Radiat Oncol 2020; 21:77-84. [PMID: 32072028 PMCID: PMC7013161 DOI: 10.1016/j.ctro.2019.12.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [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: 12/24/2019] [Accepted: 12/29/2019] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND AND PURPOSE The penile bulb (PB) dose may be critical in development of post prostate radiotherapy erectile dysfunction (ED). This study aimed to generate PB dose constraints based on dose-volume histograms (DVHs) in patients treated with prostate radiotherapy, and to identify clinical and dosimetric parameters that predict the risk of ED post prostate radiotherapy. MATERIALS AND METHODS Penile bulb DVHs were generated for 276 patients treated within the randomised IGRT substudy of the multicentre randomised trial, CHHiP. Incidence of ED in relation to dose and randomised IGRT groups were evaluated using Wilcoxon rank sum, Chi-squared test and atlases of complication incidence. Youden index was used to find dose-volume constraints that discriminated for ED. Multivariate analysis (MVA) of effect of dosimetry, clinical and patient-related variables was performed. RESULTS Reduced treatment margins using IGRT (IGRT-R) produced significantly reduced mean PB dose compared with standard margins (IGRT-S) (median: 25 Gy (IGRT-S) versus 11 Gy (IGRT-R); p < 0.0001). Significant difference in both mean (median: 23 Gy (ED) vs. 18 Gy (no ED); p = 0.011) and maximum (median: 59 Gy (ED) vs. 52 Gy (no ED); p = 0.018) PB doses between those with and without clinician reported ED were identified. Mean PB dose cut-point for ED was derived at around 20 Gy. On MVA, PB mean dose and age predicted for impotence. CONCLUSION PB dose appears predictive of post-radiotherapy ED with calculated threshold mean dose of around 20 Gy, substantially lower than published recommendations. IGRT-R enables favourable PB dosimetry and can be recommended provided prostate coverage is not compromised.
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Affiliation(s)
- Julia Murray
- The Institute of Cancer Research, London, UK
- Royal Marsden NHS Foundation Trust, London, UK
| | - Sarah Gulliford
- The Institute of Cancer Research, London, UK
- Department of Radiotherapy, University College London Hospitals NHS Foundation Trust, UK
| | | | | | | | | | | | | | - Chris Parker
- The Institute of Cancer Research, London, UK
- Royal Marsden NHS Foundation Trust, London, UK
| | - Vincent Khoo
- The Institute of Cancer Research, London, UK
- Royal Marsden NHS Foundation Trust, London, UK
| | - Jamie Dean
- The Institute of Cancer Research, London, UK
| | | | | | | | | | | | | | - Emma Hall
- The Institute of Cancer Research, London, UK
| | - David Dearnaley
- The Institute of Cancer Research, London, UK
- Royal Marsden NHS Foundation Trust, London, UK
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13
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Murray J, Griffin C, Gulliford S, Syndikus I, Staffurth J, Panades M, Scrase C, Parker C, Khoo V, Dean J, Mayles H, Mayles P, Thomas S, Naismith O, Baker A, Mossop H, Cruickshank C, Hall E, Dearnaley D. A randomised assessment of image guided radiotherapy within a phase 3 trial of conventional or hypofractionated high dose intensity modulated radiotherapy for prostate cancer. Radiother Oncol 2020; 142:62-71. [PMID: 31767473 PMCID: PMC7005673 DOI: 10.1016/j.radonc.2019.10.017] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Revised: 10/24/2019] [Accepted: 10/25/2019] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND PURPOSE Image-guided radiotherapy (IGRT) improves treatment set-up accuracy and provides the opportunity to reduce target volume margins. We introduced IGRT methods using standard (IGRT-S) or reduced (IGRT-R) margins in a randomised phase 2 substudy within CHHiP trial. We present a pre-planned analysis of the impact of IGRT on dosimetry and acute/late pelvic side effects using gastrointestinal and genitourinary clinician and patient-reported outcomes (PRO) and evaluate efficacy. MATERIALS AND METHODS CHHiP is a randomised phase 3, non-inferiority trial for men with localised prostate cancer. 3216 patients were randomly assigned to conventional (74 Gy in 2 Gy/fraction (f) daily) or moderate hypofractionation (60 or 57 Gy in 3 Gy/f daily) between October 2002 and June 2011. The IGRT substudy included a second randomisation assigning to no-IGRT, IGRT-S (standard CTV-PTV margins), or IGRT-R (reduced CTV-PTV margins). Primary substudy endpoint was late RTOG bowel and urinary toxicity at 2 years post-radiotherapy. RESULTS Between June 2010 to July 2011, 293 men were recruited from 16 centres. Median follow-up is 56.9(IQR 54.3-60.9) months. Rectal and bladder dose-volume and surface percentages were significantly lower in IGRT-R compared to IGRT-S group; (p < 0.0001). Cumulative proportion with RTOG grade ≥ 2 toxicity reported to 2 years for bowel was 8.3(95% CI 3.2-20.7)%, 8.3(4.7-14.6)% and 5.8(2.6-12.4)% and for urinary 8.4(3.2-20.8)%, 4.6(2.1-9.9)% and 3.9(1.5-9.9)% in no IGRT, IGRT-S and IGRT-R groups respectively. In an exploratory analysis, treatment efficacy appeared similar in all three groups. CONCLUSION Introduction of IGRT was feasible in a national randomised trial and IGRT-R produced dosimetric benefits. Overall side effect profiles were acceptable in all groups but lowest with IGRT and reduced margins. ISRCTN 97182923.
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Affiliation(s)
- Julia Murray
- The Institute of Cancer Research, London, UK; Royal Marsden NHS Foundation Trust, London, UK
| | | | - Sarah Gulliford
- The Institute of Cancer Research, London, UK; Department of Radiotherapy, University College London Hospitals NHS Foundation Trust, UK
| | | | | | | | | | - Chris Parker
- The Institute of Cancer Research, London, UK; Royal Marsden NHS Foundation Trust, London, UK
| | - Vincent Khoo
- The Institute of Cancer Research, London, UK; Royal Marsden NHS Foundation Trust, London, UK
| | - Jamie Dean
- The Institute of Cancer Research, London, UK
| | | | | | | | | | | | | | | | - Emma Hall
- The Institute of Cancer Research, London, UK
| | - David Dearnaley
- The Institute of Cancer Research, London, UK; Royal Marsden NHS Foundation Trust, London, UK.
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14
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Naismith O, Mayles H, Bidmead M, Clark CH, Gulliford S, Hassan S, Khoo V, Roberts K, South C, Hall E, Dearnaley D. Radiotherapy Quality Assurance for the CHHiP Trial: Conventional Versus Hypofractionated High-Dose Intensity-Modulated Radiotherapy in Prostate Cancer. Clin Oncol (R Coll Radiol) 2019; 31:611-620. [PMID: 31201110 DOI: 10.1016/j.clon.2019.05.009] [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] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Revised: 04/01/2019] [Accepted: 04/12/2019] [Indexed: 10/26/2022]
Abstract
AIMS The CHHiP trial investigated the use of moderate hypofractionation for the treatment of localised prostate cancer using intensity-modulated radiotherapy (IMRT). A radiotherapy quality assurance programme was developed to assess compliance with treatment protocol and to audit treatment planning and dosimetry of IMRT. This paper considers the outcome and effectiveness of the programme. MATERIALS AND METHODS Quality assurance exercises included a pre-trial process document and planning benchmark cases, prospective case reviews and a dosimetry site visit on-trial and a post-trial feedback questionnaire. RESULTS In total, 41 centres completed the quality assurance programme (37 UK, four international) between 2005 and 2010. Centres used either forward-planned (field-in-field single phase) or inverse-planned IMRT (25 versus 17). For pre-trial quality assurance exercises, 7/41 (17%) centres had minor deviations in their radiotherapy processes; 45/82 (55%) benchmark plans had minor variations and 17/82 (21%) had major variations. One hundred prospective case reviews were completed for 38 centres. Seventy-one per cent required changes to clinical outlining pre-treatment (primarily prostate apex and base, seminal vesicles and penile bulb). Errors in treatment planning were reduced relative to pre-trial quality assurance results (49% minor and 6% major variations). Dosimetry audits were conducted for 32 centres. Ion chamber dose point measurements were within ±2.5% in the planning target volume and ±8% in the rectum. 28/36 films for combined fields passed gamma criterion 3%/3 mm and 11/15 of IMRT fluence film sets passed gamma criterion 4%/4 mm using a 98% tolerance. Post-trial feedback showed that trial participation was beneficial in evolving clinical practice and that the quality assurance programme helped some centres to implement and audit prostate IMRT. CONCLUSION Overall, quality assurance results were satisfactory and the CHHiP quality assurance programme contributed to the success of the trial by auditing radiotherapy treatment planning and protocol compliance. Quality assurance supported the introduction of IMRT in UK centres, giving additional confidence and external review of IMRT where it was a newly adopted technique.
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Affiliation(s)
- O Naismith
- Royal Marsden NHS Foundation Trust, London, UK.
| | - H Mayles
- Clatterbridge Cancer Centre, Bebington, Wirral, UK
| | - M Bidmead
- Royal Marsden NHS Foundation Trust, London, UK
| | - C H Clark
- Royal Surrey County Hospital, Guildford, UK
| | - S Gulliford
- The Institute of Cancer Research, London, UK
| | - S Hassan
- The Institute of Cancer Research, London, UK
| | - V Khoo
- Royal Marsden NHS Foundation Trust, London, UK; The Institute of Cancer Research, London, UK
| | - K Roberts
- Royal Marsden NHS Foundation Trust, London, UK
| | - C South
- Royal Surrey County Hospital, Guildford, UK
| | - E Hall
- The Institute of Cancer Research, London, UK
| | - D Dearnaley
- Royal Marsden NHS Foundation Trust, London, UK; The Institute of Cancer Research, London, UK
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Morrison K, Naismith O, van As N. Variability Analysis of Clinical Target Volume Outlining for Prostate Stereotactic Body Radiotherapy within the Multicentre PACE Trial. Clin Oncol (R Coll Radiol) 2019. [DOI: 10.1016/j.clon.2018.11.012] [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: 11/28/2022]
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Dearnaley D, Syndikus I, Mossop H, Khoo V, Birtle A, Bloomfield D, Graham J, Kirkbride P, Logue J, Malik Z, Money-Kyrle J, O'Sullivan JM, Panades M, Parker C, Patterson H, Scrase C, Staffurth J, Stockdale A, Tremlett J, Bidmead M, Mayles H, Naismith O, South C, Gao A, Cruickshank C, Hassan S, Pugh J, Griffin C, Hall E. Conventional versus hypofractionated high-dose intensity-modulated radiotherapy for prostate cancer: 5-year outcomes of the randomised, non-inferiority, phase 3 CHHiP trial. Lancet Oncol 2016; 17:1047-1060. [PMID: 27339115 PMCID: PMC4961874 DOI: 10.1016/s1470-2045(16)30102-4] [Citation(s) in RCA: 819] [Impact Index Per Article: 102.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Revised: 04/19/2016] [Accepted: 04/21/2016] [Indexed: 01/20/2023]
Abstract
BACKGROUND Prostate cancer might have high radiation-fraction sensitivity that would give a therapeutic advantage to hypofractionated treatment. We present a pre-planned analysis of the efficacy and side-effects of a randomised trial comparing conventional and hypofractionated radiotherapy after 5 years follow-up. METHODS CHHiP is a randomised, phase 3, non-inferiority trial that recruited men with localised prostate cancer (pT1b-T3aN0M0). Patients were randomly assigned (1:1:1) to conventional (74 Gy delivered in 37 fractions over 7·4 weeks) or one of two hypofractionated schedules (60 Gy in 20 fractions over 4 weeks or 57 Gy in 19 fractions over 3·8 weeks) all delivered with intensity-modulated techniques. Most patients were given radiotherapy with 3-6 months of neoadjuvant and concurrent androgen suppression. Randomisation was by computer-generated random permuted blocks, stratified by National Comprehensive Cancer Network (NCCN) risk group and radiotherapy treatment centre, and treatment allocation was not masked. The primary endpoint was time to biochemical or clinical failure; the critical hazard ratio (HR) for non-inferiority was 1·208. Analysis was by intention to treat. Long-term follow-up continues. The CHHiP trial is registered as an International Standard Randomised Controlled Trial, number ISRCTN97182923. FINDINGS Between Oct 18, 2002, and June 17, 2011, 3216 men were enrolled from 71 centres and randomly assigned (74 Gy group, 1065 patients; 60 Gy group, 1074 patients; 57 Gy group, 1077 patients). Median follow-up was 62·4 months (IQR 53·9-77·0). The proportion of patients who were biochemical or clinical failure free at 5 years was 88·3% (95% CI 86·0-90·2) in the 74 Gy group, 90·6% (88·5-92·3) in the 60 Gy group, and 85·9% (83·4-88·0) in the 57 Gy group. 60 Gy was non-inferior to 74 Gy (HR 0·84 [90% CI 0·68-1·03], pNI=0·0018) but non-inferiority could not be claimed for 57 Gy compared with 74 Gy (HR 1·20 [0·99-1·46], pNI=0·48). Long-term side-effects were similar in the hypofractionated groups compared with the conventional group. There were no significant differences in either the proportion or cumulative incidence of side-effects 5 years after treatment using three clinician-reported as well as patient-reported outcome measures. The estimated cumulative 5 year incidence of Radiation Therapy Oncology Group (RTOG) grade 2 or worse bowel and bladder adverse events was 13·7% (111 events) and 9·1% (66 events) in the 74 Gy group, 11·9% (105 events) and 11·7% (88 events) in the 60 Gy group, 11·3% (95 events) and 6·6% (57 events) in the 57 Gy group, respectively. No treatment-related deaths were reported. INTERPRETATION Hypofractionated radiotherapy using 60 Gy in 20 fractions is non-inferior to conventional fractionation using 74 Gy in 37 fractions and is recommended as a new standard of care for external-beam radiotherapy of localised prostate cancer. FUNDING Cancer Research UK, Department of Health, and the National Institute for Health Research Cancer Research Network.
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Affiliation(s)
- David Dearnaley
- The Institute of Cancer Research, London, UK; Royal Marsden NHS Foundation Trust, London, UK.
| | | | | | - Vincent Khoo
- The Institute of Cancer Research, London, UK; Royal Marsden NHS Foundation Trust, London, UK
| | - Alison Birtle
- Rosemere Cancer Centre, Royal Preston Hospital, Preston, UK
| | | | - John Graham
- Beacon Centre, Musgrove Park Hospital, Taunton, UK
| | - Peter Kirkbride
- Sheffield Teaching Hospitals Foundation Trust, Sheffield, UK
| | | | | | | | | | | | - Chris Parker
- The Institute of Cancer Research, London, UK; Royal Marsden NHS Foundation Trust, London, UK
| | | | | | | | | | - Jean Tremlett
- Brighton and Sussex University Hospitals, Brighton, UK
| | | | | | | | | | - Annie Gao
- The Institute of Cancer Research, London, UK; Royal Marsden NHS Foundation Trust, London, UK
| | | | | | - Julia Pugh
- The Institute of Cancer Research, London, UK
| | | | - Emma Hall
- The Institute of Cancer Research, London, UK
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Dearnaley D, Syndikus I, Mossop H, Birtle A, Bloomfield D, Cruickshank C, Graham J, Hassan S, Khoo V, Logue J, Mayles H, Money-Kyrle J, Naismith O, Panades M, Patterson H, Scrase C, Staffurth J, Tremlett J, Griffin C, Hall E. 8LBA 5 year outcomes of a phase III randomised trial of conventional or hypofractionated high dose intensity modulated radiotherapy for prostate cancer (CRUK/06/016): report from the CHHiP Trial Investigators Group. Eur J Cancer 2015. [DOI: 10.1016/s0959-8049(16)31932-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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18
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Harris VA, Staffurth J, Naismith O, Esmail A, Gulliford S, Khoo V, Lewis R, Littler J, McNair H, Sadoyze A, Scrase C, Sohaib A, Syndikus I, Zarkar A, Hall E, Dearnaley D. Consensus Guidelines and Contouring Atlas for Pelvic Node Delineation in Prostate and Pelvic Node Intensity Modulated Radiation Therapy. Int J Radiat Oncol Biol Phys 2015; 92:874-83. [PMID: 26104940 DOI: 10.1016/j.ijrobp.2015.03.021] [Citation(s) in RCA: 75] [Impact Index Per Article: 8.3] [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: 12/16/2014] [Revised: 03/19/2015] [Accepted: 03/20/2015] [Indexed: 12/29/2022]
Abstract
PURPOSE The purpose of this study was to establish reproducible guidelines for delineating the clinical target volume (CTV) of the pelvic lymph nodes (LN) by combining the freehand Royal Marsden Hospital (RMH) and Radiation Therapy Oncology Group (RTOG) vascular expansion techniques. METHODS AND MATERIALS Seven patients with prostate cancer underwent standard planning computed tomography scanning. Four different CTVs (RMH, RTOG, modified RTOG, and Prostate and pelvIs Versus prOsTate Alone treatment for Locally advanced prostate cancer [PIVOTAL] trial) were created for each patient, and 6 different bowel expansion margins (BEM) were created to assess bowel avoidance by the CTV. The resulting CTVs were compared visually and by using Jaccard conformity indices. The volume of overlap between bowel and planning target volume (PTV) was measured to aid selection of an appropriate BEM to enable maximal LN yet minimal normal tissue coverage. RESULTS In total, 84 nodal contours were evaluated. LN coverage was similar in all groups, with all of the vascular-expansion techniques (RTOG, modified RTOG, and PIVOTAL), resulting in larger CTVs than that of the RMH technique (mean volumes: 287.3 cm(3), 326.7 cm(3), 310.3 cm(3), and 256.7 cm(3), respectively). Mean volumes of bowel within the modified RTOG PTV were 19.5 cm(3) (with 0 mm BEM), 17.4 cm(3) (1-mm BEM), 10.8 cm(3) (2-mm BEM), 6.9 cm(3) (3-mm BEM), 5.0 cm(3) (4-mm BEM), and 1.4 cm(3) (5-mm BEM) in comparison with an overlap of 9.2 cm(3) seen using the RMH technique. Evaluation of conformity between LN-CTVs from each technique revealed similar volumes and coverage. CONCLUSIONS Vascular expansion techniques result in larger LN-CTVs than the freehand RMH technique. Because the RMH technique is supported by phase 1 and 2 trial safety data, we proposed modifications to the RTOG technique, including the addition of a 3-mm BEM, which resulted in LN-CTV coverage similar to that of the RMH technique, with reduction in bowel and planning target volume overlap. On the basis of these findings, recommended guidelines including a detailed pelvic LN contouring atlas have been produced and implemented in the PIVOTAL trial.
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Affiliation(s)
- Victoria A Harris
- Academic Urology Unit, Institute of Cancer Research and Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - John Staffurth
- Institute of Cancer and Genetics, School of Medicine, Cardiff University, Cardiff, Wales, United Kingdom
| | - Olivia Naismith
- Joint Department of Physics, Institute of Cancer Research, and Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Alikhan Esmail
- Ipswich Hospital NHS Foundation Trust, Ipswich, United Kingdom
| | - Sarah Gulliford
- Joint Department of Physics, Institute of Cancer Research, and Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Vincent Khoo
- Academic Urology Unit, Institute of Cancer Research and Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Rebecca Lewis
- Clinical Trials and Statistics Unit, Institute of Cancer Research, London, United Kingdom
| | - John Littler
- Clatterbridge Cancer Centre, Liverpool, United Kingdom
| | - Helen McNair
- Department of Radiotherapy, The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Azmat Sadoyze
- Beatson West of Scotland Cancer Centre, Scotland, Glasgow, United Kingdom
| | | | - Aslam Sohaib
- Department of Radiology, The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | | | - Anjali Zarkar
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Emma Hall
- Clinical Trials and Statistics Unit, Institute of Cancer Research, London, United Kingdom
| | - David Dearnaley
- Academic Urology Unit, Institute of Cancer Research and Royal Marsden NHS Foundation Trust, London, United Kingdom.
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Dearnaley D, Griffin C, Syndikus I, Scrase C, Thomas S, Naismith O, Mayles P, Staffurth J, Hall E, N behalf of TMG O. OC-0154: IGRT for prostate cancer ñ results from the CHHiP IGRT phase II sub-study. Radiother Oncol 2014. [DOI: 10.1016/s0167-8140(15)30259-0] [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: 11/17/2022]
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Wells E, Tsang Y, Bernstein D, Naismith O, Miles E, Clark C. PO-0877 STREAMLINING UK IMRT CREDENTIALING: IMRT PLAN COMPLEXITY HIERARCHY. Radiother Oncol 2012. [DOI: 10.1016/s0167-8140(12)71210-0] [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: 12/01/2022]
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Dearnaley D, Syndikus I, Sumo G, Bidmead M, Bloomfield D, Clark C, Gao A, Hassan S, Horwich A, Huddart R, Khoo V, Kirkbride P, Mayles H, Mayles P, Naismith O, Parker C, Patterson H, Russell M, Scrase C, South C, Staffurth J, Hall E. Conventional versus hypofractionated high-dose intensity-modulated radiotherapy for prostate cancer: preliminary safety results from the CHHiP randomised controlled trial. Lancet Oncol 2012; 13:43-54. [PMID: 22169269 DOI: 10.1016/s1470-2045(11)70293-5] [Citation(s) in RCA: 223] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND Prostate cancer might have high radiation-fraction sensitivity, implying a therapeutic advantage of hypofractionated treatment. We present a pre-planned preliminary safety analysis of side-effects in stages 1 and 2 of a randomised trial comparing standard and hypofractionated radiotherapy. METHODS We did a multicentre, randomised study and recruited men with localised prostate cancer between Oct 18, 2002, and Aug 12, 2006, at 11 UK centres. Patients were randomly assigned in a 1:1:1 ratio to receive conventional or hypofractionated high-dose intensity-modulated radiotherapy, and all were given with 3-6 months of neoadjuvant androgen suppression. Computer-generated random permuted blocks were used, with risk of seminal vesicle involvement and radiotherapy-treatment centre as stratification factors. The conventional schedule was 37 fractions of 2 Gy to a total of 74 Gy. The two hypofractionated schedules involved 3 Gy treatments given in either 20 fractions to a total of 60 Gy, or 19 fractions to a total of 57 Gy. The primary endpoint was proportion of patients with grade 2 or worse toxicity at 2 years on the Radiation Therapy Oncology Group (RTOG) scale. The primary analysis included all patients who had received at least one fraction of radiotherapy and completed a 2 year assessment. Treatment allocation was not masked and clinicians were not blinded. Stage 3 of this trial completed the planned recruitment in June, 2011. This study is registered, number ISRCTN97182923. FINDINGS 153 men recruited to stages 1 and 2 were randomly assigned to receive conventional treatment of 74 Gy, 153 to receive 60 Gy, and 151 to receive 57 Gy. With 50·5 months median follow-up (IQR 43·5-61·3), six (4·3%; 95% CI 1·6-9·2) of 138 men in the 74 Gy group had bowel toxicity of grade 2 or worse on the RTOG scale at 2 years, as did five (3·6%; 1·2-8·3) of 137 men in the 60 Gy group, and two (1·4%; 0·2-5·0) of 143 men in the 57 Gy group. For bladder toxicities, three (2·2%; 0·5-6·2) of 138 men, three (2·2%; 0·5-6·3) of 137, and none (0·0%; 97·5% CI 0·0-2·6) of 143 had scores of grade 2 or worse on the RTOG scale at 2 years. INTERPRETATION Hypofractionated high-dose radiotherapy seems equally well tolerated as conventionally fractionated treatment at 2 years. FUNDING Stage 1 was funded by the Academic Radiotherapy Unit, Cancer Research UK programme grant; stage 2 was funded by the Department of Health and Cancer Research UK.
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Naismith O, Dearnaley D, Hall E. 1575 poster A SURVEY OF THE BENEFITS TO RT PROCESSES AND TECHNIQUES OF PARTICIPATING IN THE CHHIP TRIAL. Radiother Oncol 2011. [DOI: 10.1016/s0167-8140(11)71697-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Dearnaley D, Naismith O, Sumo G. 1573 poster A DOSIMETRY COMPARISON OF FORWARD- AND INVERSE-PLANNED IMRT FOR PROSTATE CANCER IN THE CHHIP TRIAL. Radiother Oncol 2011. [DOI: 10.1016/s0167-8140(11)71695-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Ciurlionis L, Tsang Y, Miles E, Naismith O, Clark C, Wells E, Aird E. 395 poster A REVIEW OF IMRT CREDENTIALING FOR CLINICAL TRIALS IN THE UK. Radiother Oncol 2011. [DOI: 10.1016/s0167-8140(11)70517-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Baker A, Naismith O, Mayles P, Mayles H, McNair H, Bidmead M, Miles E, Dearnaley D. 1577 poster A UK-WIDE QUALITY ASSURANCE PROGRAMME FOR AN IMAGE-GUIDED RADIOTHERAPY PROSTATE TRIAL. Radiother Oncol 2011. [DOI: 10.1016/s0167-8140(11)71699-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [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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South C, Khoo V, Naismith O, Norman A, Dearnaley D. A Comparison of Treatment Planning Techniques Used in Two Randomised UK External Beam Radiotherapy Trials for Localised Prostate Cancer. Clin Oncol (R Coll Radiol) 2008; 20:15-21. [DOI: 10.1016/j.clon.2007.10.012] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2007] [Revised: 09/30/2007] [Accepted: 10/31/2007] [Indexed: 10/22/2022]
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