151
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Parker CC, Sargos P, Sydes MR, Kneebone A, Vale C. Postoperative radiotherapy in prostate cancer - Authors' reply. Lancet 2021; 397:1624. [PMID: 33933204 DOI: 10.1016/s0140-6736(21)00268-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 01/24/2021] [Indexed: 01/05/2023]
Affiliation(s)
- Christopher C Parker
- Department of Oncology, Royal Marsden NHS Foundation Trust, Sutton, UK; Institute of Cancer Research, Sutton, UK
| | - Paul Sargos
- Department of Radiotherapy, Institut Bergonié, Bordeaux, France
| | - Matthew R Sydes
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, University College London, London WC1V 6LJ, UK.
| | - Andrew Kneebone
- Department Radiation Oncology, Royal North Shore Hospital, Sydney, NSW, Australia; University of Sydney, Sydney, NSW Australia
| | - Claire Vale
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, University College London, London WC1V 6LJ, UK
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152
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A framework for prospective, adaptive meta-analysis (FAME) of aggregate data from randomised trials. PLoS Med 2021; 18:e1003629. [PMID: 33956789 PMCID: PMC8115774 DOI: 10.1371/journal.pmed.1003629] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Revised: 05/12/2021] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND The vast majority of systematic reviews are planned retrospectively, once most eligible trials have completed and reported, and are based on aggregate data that can be extracted from publications. Prior knowledge of trial results can introduce bias into both review and meta-analysis methods, and the omission of unpublished data can lead to reporting biases. We present a collaborative framework for prospective, adaptive meta-analysis (FAME) of aggregate data to provide results that are less prone to bias. Also, with FAME, we monitor how evidence from trials is accumulating, to anticipate the earliest opportunity for a potentially definitive meta-analysis. METHODOLOGY We developed and piloted FAME alongside 4 systematic reviews in prostate cancer, which allowed us to refine the key principles. These are to: (1) start the systematic review process early, while trials are ongoing or yet to report; (2) liaise with trial investigators to develop a detailed picture of all eligible trials; (3) prospectively assess the earliest possible timing for reliable meta-analysis based on the accumulating aggregate data; (4) develop and register (or publish) the systematic review protocol before trials produce results and seek appropriate aggregate data; (5) interpret meta-analysis results taking account of both available and unavailable data; and (6) assess the value of updating the systematic review and meta-analysis. These principles are illustrated via a hypothetical review and their application to 3 published systematic reviews. CONCLUSIONS FAME can reduce the potential for bias, and produce more timely, thorough and reliable systematic reviews of aggregate data.
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153
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Chilukuri S, Murthy V. Adjuvant radiation for prostate cancer: too early to abandon? BJU Int 2021; 128:23-24. [PMID: 33834591 DOI: 10.1111/bju.15422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- Srinivas Chilukuri
- Department of Radiation Oncology, Apollo Proton Cancer Centre, Chennai, India
| | - Vedang Murthy
- Department of Radiation Oncology, ACTREC, Tata Memorial Centre, Mumbai, India
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154
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Zhou Z, Xie J, Ma S, Luo X, Liu J, Wang S, Chen Y, Yan J, Luo F. Construction of Smart Nanotheranostic Platform Bi-Ag@PVP: Multimodal CT/PA Imaging-Guided PDT/PTT for Cancer Therapy. ACS OMEGA 2021; 6:10723-10734. [PMID: 34056226 PMCID: PMC8153791 DOI: 10.1021/acsomega.1c00225] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 04/09/2021] [Indexed: 05/11/2023]
Abstract
High-efficiency nanotheranostic agents with multimodal imaging guidance have attracted considerable interest in the field of cancer therapy. Herein, novel silver-decorated bismuth-based heterostructured polyvinyl pyrrolidone nanoparticles (NPs) with good biocompatibility (Bi-Ag@PVP NPs) were synthesized for accurate theranostic treatment, which can integrate computed tomography (CT)/photoacoustic (PA) imaging and photodynamic therapy/photothermal therapy (PDT/PTT) into one platform. The Bi-Ag@PVP NPs can enhance light absorption and achieve a better photothermal effect than bismuth NPs. Moreover, after irradiation under an 808 nm laser, the Bi-Ag@PVP NPs can efficiently induce the generation of reactive oxygen species (ROS), thereby synergizing PDT/PTT to exert an efficient tumor ablation effect both in vitro and in vivo. Furthermore, Bi-Ag@PVP NPs can also be employed to perform enhanced CT/PA imaging because of their high X-ray absorption attenuation and enhanced photothermal conversion. Thus, they can be utilized as a highly effective CT/PA imaging-guided nanotheranostic agent. In addition, an excellent antibacterial effect was achieved. After irradiation under an 808 nm laser, the Bi-Ag@PVP NPs can destroy the integrity of Escherichia coli, thereby inhibiting E. coli growth, which can minimize the risk of infection during cancer therapy. In conclusion, our study provides a novel nanotheranostic platform that can achieve CT/PA-guided PDT/PTT synergistic therapy and have potential antibacterial properties. Thus, this work provides an effective strategy for further broad clinical application prospects.
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Affiliation(s)
- Zonglang Zhou
- The
174th Clinic College of People’s Liberation Army, Anhui Medical University, Hefei 230031, China
- The
73rd Army Hospital of the Chinese People’s Liberation Army, Xiamen 361003, China
| | - Jun Xie
- School
of Medicine, Xiamen University, Xiamen 361005, China
| | - Sihan Ma
- College
of Energy, Xiamen University, Xiamen 361005, China
| | - Xian Luo
- School
of Medicine, Xiamen University, Xiamen 361005, China
| | - Jiajing Liu
- School
of Medicine, Xiamen University, Xiamen 361005, China
| | - Shengyu Wang
- School
of Medicine, Xiamen University, Xiamen 361005, China
| | - Yuqiang Chen
- The
174th Clinic College of People’s Liberation Army, Anhui Medical University, Hefei 230031, China
- The
73rd Army Hospital of the Chinese People’s Liberation Army, Xiamen 361003, China
| | - Jianghua Yan
- School
of Medicine, Xiamen University, Xiamen 361005, China
| | - Fanghong Luo
- School
of Medicine, Xiamen University, Xiamen 361005, China
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155
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Klaassen Z, Scarpato KR, Ristau BT, Stratton KL, Porten SP, Smaldone MC, Chapin BF, Psutka SP. Research highlights of the 2020 society of urologic oncology young urologic oncologists' program. Urol Oncol 2021; 39:452-454. [PMID: 33858748 PMCID: PMC9647056 DOI: 10.1016/j.urolonc.2021.03.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 03/24/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Zachary Klaassen
- Division of Urology, Augusta University - Medical College of Georgia, Augusta, GA; Georgia Cancer Center, Augusta, GA.
| | | | | | - Kelly L Stratton
- Department of Urology, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Sima P Porten
- Department of Urology, Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA
| | - Marc C Smaldone
- Division of Urological Oncology, Fox Chase Cancer Center, Philadelphia, PA
| | - Brian F Chapin
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Sarah P Psutka
- Department of Urology, University of Washington, Seattle, WA
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156
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Knipper S, Ott S, Schlemmer HP, Grimm MO, Graefen M, Wiegel T. Options for Curative Treatment of Localized Prostate Cancer. DEUTSCHES ARZTEBLATT INTERNATIONAL 2021; 118:arztebl.m2021.0026. [PMID: 33549154 PMCID: PMC8572540 DOI: 10.3238/arztebl.m2021.0026] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 09/16/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND Prostate cancer is the most frequently occurring malignancy among men in Germany, with 60 000 new cases each year. Three of every four tumors are detected at an early, localized stage, when various curative treatment strategies are possible. METHODS A selective search of the literature in PubMed accompanied by consideration of guidelines from Germany and other countries. RESULTS Owing to the usually prolonged natural course of localized prostate cancer, local treatment is recommended for patients with a life expectancy of at least 10 years. The established treatments with curative intent are radical prostatectomy, percutaneous radiotherapy, and brachytherapy, with active surveillance as a further option for patients with low-risk disease. The eventual choice of treatment is determined by tumor stage, risk group, comorbidities, and patient preference. Conversations with the patient must cover not only the oncological outcome but also the potential adverse effects of the different treatment options. Depending on the procedure, urinary incontinence, erectile dysfunction, and inflammation of the bladder and/or rectum may be frequently occurring complications. CONCLUSION A number of curative and other treatments are available for patients with localized prostate cancer. The goal is to identify the appropriate option for each individual patient by means of detailed discussion.
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157
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Achard V, Panje CM, Engeler D, Zilli T, Putora PM. Localized and Locally Advanced Prostate Cancer: Treatment Options. Oncology 2021; 99:413-421. [PMID: 33784675 DOI: 10.1159/000513258] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 11/20/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND There are many treatment options for localized and locally advanced prostate cancer with radiotherapy and surgery representing the main local therapeutic strategies. SUMMARY Depending on the risk of disease recurrence, we can stratify patients into low-, intermediate- and high-risk groups, which will guide patients' treatment. For low-risk patients, active surveillance is an option. Brachytherapy is also an option for low- and intermediate-risk patients and can be used as a boost following external beam radiotherapy for high-risk patients. For intermediate- and high-risk patients, radical prostatectomy and radiotherapy should be considered. Moreover, in addition to radiotherapy, concomitant androgen deprivation therapy may be needed. Finally, after radical prostatectomy and depending on pathological, biological and clinical factors, radiotherapy ± androgen deprivation therapy can be proposed as an adjuvant or salvage treatment. Key Messages: With radiotherapy and surgery being well-established treatment options for localized prostate cancer patients with equally good overall survival rates, priority must be given to patients' choice concerning the logistics and the toxicity profile of each option.
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Affiliation(s)
- Vérane Achard
- Department of Radiation Oncology, Geneva University Hospital, Geneva, Switzerland.,Faculty of Medicine, Geneva University, Geneva, Switzerland
| | - Cédric Michael Panje
- Department of Radiation Oncology, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Daniel Engeler
- Department of Urology, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Thomas Zilli
- Department of Radiation Oncology, Geneva University Hospital, Geneva, Switzerland.,Faculty of Medicine, Geneva University, Geneva, Switzerland
| | - Paul Martin Putora
- Department of Radiation Oncology, Kantonsspital St. Gallen, St. Gallen, Switzerland.,Department of Radiation Oncology, University of Bern, Bern, Switzerland
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158
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Prognostic factors in postoperative radiotherapy for prostate cancer - tertiary center experience. Radiol Oncol 2021; 55:203-211. [PMID: 33768769 PMCID: PMC8042817 DOI: 10.2478/raon-2021-0017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 02/06/2021] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND The aim of the study was to analyse the prognostic factors in postoperative prostate cancer irradiation and develop a nomogram for disease-free survival (DFS). PATIENTS AND METHODS This retrospective study included 236 consecutive prostate cancer patients who had radical prostatectomy followed by radiotherapy (RT) at a single tertiary institution between 2009 and 2014. The main outcome was DFS analysed through uni- and multivariable analysis, Kaplan-Meier curves, log-rank testing, recursive partitioning analysis, and nomogram development. RESULTS The median follow up was 62.3 (interquartile range [IQR] 38.1-79) months. The independent clinical factors associated with increased risk of recurrence or progression in the multivariate analysis (MVA) were prostate-specific antigen (PSA) level before RT, pT3 characteristic, and local failure as salvage indication. The value of PSA nadir had a significant impact on the risk of biochemical failure. Biochemical control and DFS were significantly different depending on treatment indication (p < 0.0001). The recursive partitioning analysis highlighted the importance of the PSA level before RT, Gleason Grade Group, PSA nadir, and local failure as a treatment indication. Finally, the nomogram for DFS was developed and is available online at https://apps.konsta.com.pl/app/prostate-salvage-dfs/. CONCLUSIONS The Pre-RT PSA level, pT3 characteristic and local failure as salvage indication are pivotal prognostic factors associated with increased risk of recurrence or progression. The Gleason grade group of 4-5 and PSA nadir value allow for further risk stratification. The treatment outcomes in postoperative prostate cancer irradiation are significantly different depending on treatment indication. An online nomogram comprising of both pre-treatment and current data was developed allowing for visualization of changes in prognosis depending on clinical data.
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159
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Tannock IF, Ratain MJ, Goldstein DA, Lichter AS, Rosner GL, Saltz LB. Near-Equivalence: Generating Evidence to Support Alternative Cost-Effective Treatments. J Clin Oncol 2021; 39:950-955. [DOI: 10.1200/jco.20.02768] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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160
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Würnschimmel C, Tilki D. [Update for adjuvant versus early salvage radiotherapy after radical prostatectomy]. Urologe A 2021; 60:790-791. [PMID: 33725164 DOI: 10.1007/s00120-021-01501-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/22/2021] [Indexed: 11/28/2022]
Affiliation(s)
- C Würnschimmel
- Martini-Klinik, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - D Tilki
- Martini-Klinik, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland. .,Klinik für Urologie, Universitätsklinikum Hamburg-Eppendorf, Martinistraße 52, Gebäude Ost 46, 20246, Hamburg, Deutschland.
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161
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Segundo CGS, Couñago F, Gómez-Iturriaga A. Adjuvant versus early salvage radiotherapy for prostate cancer patients: Time to move on. Urol Oncol 2021; 39:351-356. [PMID: 34049780 DOI: 10.1016/j.urolonc.2021.02.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 02/07/2021] [Accepted: 02/10/2021] [Indexed: 10/21/2022]
Abstract
In the management of prostate cancer , few treatments have caused as much controversy as adjuvant radiotherapy (ART) after radical prostatectomy in high-risk patients In the present article, we assess the exclusion and inclusion criteria of the 6 randomised trials and 5-year biochemical relapse-free survival and overall survival rates in order to identify the patient subgroups most likely to benefit from ART. We also evaluate treatment-related toxicity and the indications for androgen deprivation therapy . The main aim of this analysis was to determine whether the available evidence, which previously appeared to support ART, now favours early salvage radiotherapy. If so, perhaps we can finally resolve the controversy surrounding the optimal timing of postoperative radiotherapy.
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Affiliation(s)
| | - Felipe Couñago
- Hospital Universitario Quirónsalud, Hospital La Luz, Universidad Europea de Madrid (UEM), Madrid, Spain
| | - Alfonso Gómez-Iturriaga
- Biocruces Health Research Institute, Cruces University Hospital, Basque Country University (UPV/EHU), Barakaldo, Bizkaia, Spain
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162
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Beck M, Ghadjar P, Mehrhof F, Zips D, Paulsen F, Wegener D, Burock S, Kaul D, Stromberger C, Nadobny J, Ott OJ, Fietkau R, Budach V, Wust P, Müller AC, Zschaeck S. Salvage-Radiation Therapy and Regional Hyperthermia for Biochemically Recurrent Prostate Cancer after Radical Prostatectomy (Results of the Planned Interim Analysis). Cancers (Basel) 2021; 13:cancers13051133. [PMID: 33800872 PMCID: PMC7961934 DOI: 10.3390/cancers13051133] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Revised: 03/01/2021] [Accepted: 03/04/2021] [Indexed: 11/18/2022] Open
Abstract
Simple Summary Several efforts like dose-escalated salvage radiation therapy and the use of androgen deprivation therapy aimed to improve the postoperative treatment in patients with biochemical recurrence of prostate cancer after prostatectomy. However, the oncological outcome is still not satisfactory. Hyperthermia is well-known to improve the efficacy of radiation therapy, whereas only limited data for postoperative therapy in prostate cancer are available. Thus, we conducted a prospective multicenter non-randomized Phase-II-Trial (HTProstate) investigating the implementation of combined salvage radiation therapy and regional hyperthermia in case of biochemical recurrence after prostatectomy with the aim to evaluate the safety, feasibility, and oncological outcome of this approach. The results of our planned interim analysis (n = 50) met the criteria of safety (only one patient with acute grade 3 hyperthermia-specific toxicity), showed feasibility of planned radiation and hyperthermia therapy, no significant changes in quality of life and promising short-term prostate-specific antigen response. Late toxicity and robust oncological outcome data will be reported after completion of the trial. Abstract Efforts to improve the outcome of prostate cancer (PC) patients after radical prostatectomy (RP) include adjuvant or salvage radiation therapy (SRT), but still up to 50% of patients develop a disease progression after radiotherapy (RT). Regional hyperthermia (HT) is well-known to improve tumor sensitivity to RT in several entities. Here we report on a planned interim analysis of tolerability and feasibility after recruitment of the first 50 patients of a trial combining SRT and HT. We conducted a prospective multicenter non-randomized Phase-II-Trial (HTProstate-NCT04159051) investigating the implementation of combined moderate-dose escalated SRT (70 Gy in 35 fractions) and locoregional deep HT (7–10 HT sessions). The primary endpoints were the rate of acute genitourinary (GU), gastrointestinal (GI), and HT-related toxicities, completed HT sessions (≥7), and SRT applications per protocol (≥95% of patients). The two-step design included a planned interim analysis for acute GU-, GI- and HT-specific toxicities to ensure patients’ safety. Between November 2016 and December 2019, 52 patients entered into the trial. After 50 patients completed therapy and three months of follow-up, we performed the planned interim analysis. 10% of patients developed acute grade 2 GU and 4% grade 2 GI toxicities. No grade ≥3 GU or GI toxicities occurred. HT-specific symptoms grade 2 and 3 were observed in 4% and 2% of all patients. Thus, the pre-specified criteria for safety and continuation of recruitment were met. Moreover, ≥7 HT treatments were applicable, indicating the combination of SRT + HT to be feasible. Evaluation of early QoL showed no significant changes. With its observed low rate of GU and GI toxicities, moderate and manageable rates of HT-specific symptoms, and good feasibility, the combined SRT + HT seems to be a promising treatment approach for biochemical recurrence after RP in PC patients.
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Affiliation(s)
- Marcus Beck
- Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Radiation Oncology, 13353 Berlin, Germany; (P.G.); (F.M.); (D.K.); (C.S.); (J.N.); (V.B.); (P.W.); (S.Z.)
- Correspondence: ; Tel.: +49-30-450-627-343; Fax: +49-30-450-7527343
| | - Pirus Ghadjar
- Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Radiation Oncology, 13353 Berlin, Germany; (P.G.); (F.M.); (D.K.); (C.S.); (J.N.); (V.B.); (P.W.); (S.Z.)
| | - Felix Mehrhof
- Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Radiation Oncology, 13353 Berlin, Germany; (P.G.); (F.M.); (D.K.); (C.S.); (J.N.); (V.B.); (P.W.); (S.Z.)
| | - Daniel Zips
- Department of Radiation Oncology, University Hospital Eberhard-Karls-University Tübingen, 72076 Tübingen, Germany; (D.Z.); (F.P.); (D.W.); (A.-C.M.)
| | - Frank Paulsen
- Department of Radiation Oncology, University Hospital Eberhard-Karls-University Tübingen, 72076 Tübingen, Germany; (D.Z.); (F.P.); (D.W.); (A.-C.M.)
| | - Daniel Wegener
- Department of Radiation Oncology, University Hospital Eberhard-Karls-University Tübingen, 72076 Tübingen, Germany; (D.Z.); (F.P.); (D.W.); (A.-C.M.)
| | - Susen Burock
- Charité Comprehensive Cancer Center, Charité Universitätsmedizin Berlin, 10117 Berlin, Germany;
| | - David Kaul
- Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Radiation Oncology, 13353 Berlin, Germany; (P.G.); (F.M.); (D.K.); (C.S.); (J.N.); (V.B.); (P.W.); (S.Z.)
| | - Carmen Stromberger
- Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Radiation Oncology, 13353 Berlin, Germany; (P.G.); (F.M.); (D.K.); (C.S.); (J.N.); (V.B.); (P.W.); (S.Z.)
| | - Jacek Nadobny
- Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Radiation Oncology, 13353 Berlin, Germany; (P.G.); (F.M.); (D.K.); (C.S.); (J.N.); (V.B.); (P.W.); (S.Z.)
| | - Oliver J. Ott
- Department of Radiation Oncology, Universitätsklinikum Erlangen, 91054 Erlangen, Germany; (O.J.O.); (R.F.)
| | - Rainer Fietkau
- Department of Radiation Oncology, Universitätsklinikum Erlangen, 91054 Erlangen, Germany; (O.J.O.); (R.F.)
| | - Volker Budach
- Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Radiation Oncology, 13353 Berlin, Germany; (P.G.); (F.M.); (D.K.); (C.S.); (J.N.); (V.B.); (P.W.); (S.Z.)
| | - Peter Wust
- Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Radiation Oncology, 13353 Berlin, Germany; (P.G.); (F.M.); (D.K.); (C.S.); (J.N.); (V.B.); (P.W.); (S.Z.)
| | - Arndt-Christian Müller
- Department of Radiation Oncology, University Hospital Eberhard-Karls-University Tübingen, 72076 Tübingen, Germany; (D.Z.); (F.P.); (D.W.); (A.-C.M.)
| | - Sebastian Zschaeck
- Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Radiation Oncology, 13353 Berlin, Germany; (P.G.); (F.M.); (D.K.); (C.S.); (J.N.); (V.B.); (P.W.); (S.Z.)
- Berlin Institute of Health, 10117 Berlin, Germany
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163
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164
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López Campos F, Sancho Pardo G, Maldonado Pijoan X, Zilli T, Couñago Lorenzo F, Hervás Morón A. Is hypofractionation acceptable for prostate bed radiotherapy? Urol Oncol 2021; 39:346-350. [PMID: 34049781 DOI: 10.1016/j.urolonc.2021.02.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 02/02/2021] [Indexed: 11/15/2022]
Abstract
Approximately 30% of patients who undergo radical prostatectomy for prostate cancer develop disease progression. The only potentially curative treatment in these patients is postoperative radiotherapy with or without hormonotherapy. One of the standards of care in nonsurgical patients is hypofractionated radiotherapy. However, the current evidence based is insufficient to define the optimal dose and fractionation schedule for postoperative radiotherapy. In this context, the aim of this editorial is to assess the main efficacy and toxicity data for postoperative hypofractionated radiotherapy and discuss the potential to implement this fractionation in routine clinical practice.
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Affiliation(s)
| | - Gemma Sancho Pardo
- Radiation Oncology Department. Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | | | - Thomas Zilli
- Radiation Oncology Department. Geneva University Hospital, Geneva, Switzerland
| | - Felipe Couñago Lorenzo
- Radiation Oncology Department. Hospital Universitario Quirónsalud Madrid, Madrid, Spain.
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165
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Görtz M, Hohenfellner M. Re: Adjuvant Radiotherapy Versus Early Salvage Radiotherapy Following Radical Prostatectomy (TROG 08.03/ANZUP RAVES): A Randomised, Controlled, Phase 3, Non-inferiority Trial. Eur Urol 2021; 79:893-894. [PMID: 33608153 DOI: 10.1016/j.eururo.2021.02.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 02/05/2021] [Indexed: 10/22/2022]
Affiliation(s)
- Magdalena Görtz
- Department of Urology, University Hospital Heidelberg, Heidelberg, Germany.
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166
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Sargos P, Leduc N, Giraud N, Gandaglia G, Roumiguié M, Ploussard G, Rozet F, Soulié M, Mathieu R, Artus PM, Niazi T, Vinh-Hung V, Beauval JB. Deep Neural Networks Outperform the CAPRA Score in Predicting Biochemical Recurrence After Prostatectomy. Front Oncol 2021; 10:607923. [PMID: 33643910 PMCID: PMC7906005 DOI: 10.3389/fonc.2020.607923] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Accepted: 12/14/2020] [Indexed: 01/16/2023] Open
Abstract
Background Use of predictive models for the prediction of biochemical recurrence (BCR) is gaining attention for prostate cancer (PCa). Specifically, BCR occurs in approximately 20–40% of patients five years after radical prostatectomy (RP) and the ability to predict BCR may help clinicians to make better treatment decisions. We aim to investigate the accuracy of CAPRA score compared to others models in predicting the 3-year BCR of PCa patients. Material and Methods A total of 5043 men who underwent RP were analyzed retrospectively. The accuracy of CAPRA score, Cox regression analysis, logistic regression, K-nearest neighbor (KNN), random forest (RF) and a densely connected feed-forward neural network (DNN) classifier were compared in terms of 3-year BCR predictive value. The area under the receiver operating characteristic curve was mainly used to assess the performance of the predictive models in predicting the 3 years BCR of PCa patients. Pre-operative data such as PSA level, Gleason grade, and T stage were included in the multivariate analysis. To measure potential improvements to the model performance due to additional data, each model was trained once more with an additional set of post-operative surgical data from definitive pathology. Results Using the CAPRA score variables, DNN predictive model showed the highest AUC value of 0.7 comparing to the CAPRA score, logistic regression, KNN, RF, and cox regression with 0.63, 0.63, 0.55, 0.64, and 0.64, respectively. After including the post-operative variables to the model, the AUC values based on KNN, RF, and cox regression and DNN were improved to 0.77, 0.74, 0.75, and 0.84, respectively. Conclusions Our results showed that the DNN has the potential to predict the 3-year BCR and outperformed the CAPRA score and other predictive models.
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Affiliation(s)
- Paul Sargos
- Department of Radiation Oncology, Institut Bergonié, Bordeaux, France
| | - Nicolas Leduc
- Department of Radiation Oncology, Institut Bergonié, Bordeaux, France
| | - Nicolas Giraud
- Division of Radiation Oncology, Department of Oncology, McGill University, Montreal, QC, Canada
| | - Giorgio Gandaglia
- Division of Oncology, Unit of Urology, Urological Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy
| | | | | | - Francois Rozet
- Department of Urology, Institut Mutualiste Montsouris, Paris, France
| | - Michel Soulié
- Department of Urology, CHU de Toulouse, Toulouse, France
| | | | | | - Tamim Niazi
- Division of Radiation Oncology, Department of Oncology, McGill University, Montreal, QC, Canada
| | - Vincent Vinh-Hung
- Department of Radiation Oncology, Hôpital Clarac, CHU de la Martinique, Fort-de-France, France
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Young S, Liu W, Zukotynski K, Bauman G. Prostate-specific membrane antigen targeted PET/CT for recurrent prostate cancer: a clinician's guide. Expert Rev Anticancer Ther 2021; 21:641-655. [PMID: 33476253 DOI: 10.1080/14737140.2021.1878883] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
INTRODUCTION PSMA-targeted PET/CT is a 'Next Generation Imaging' technique with superior sensitivity and specificity for detecting recurrent prostate cancer compared with conventional imaging, allowing more accurate staging and re-staging. AREAS COVERED This article reviews the role of PSMA-targeted PET/CT in clinical management of men with recurrent prostate cancer. EXPERT OPINION Through enhanced spatial characterization of recurrent prostate cancer, PSMA-targeted PET/CT has shown significant impact on management decisions. In particular, by identifying men with recurrence confined to the prostate or pelvic nodes, PSMA-targeted PET/CT enables selective deployment of localized salvage therapies for management of biochemical failure after primary treatment with prostatectomy or radiotherapy. In oligometastatic disease, PSMA-targeted PET/CT may improve patient selection and treatment accuracy for metastasis-directed therapy and early phase II studies show encouraging results in delaying the need for systemic therapy. Further, quantitative PSMA-targeted PET/CT for monitoring response and therapeutic PSMA-targeted radiopharmaceuticals are emerging as encouraging treatment options in the setting of castrate-resistant disease.
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Affiliation(s)
- Sympascho Young
- Department of Radiation Oncology, London Regional Cancer Program, London Health Sciences Centre, London, Ontario, Canada
| | - Wei Liu
- Department of Radiation Oncology, London Regional Cancer Program, London Health Sciences Centre, London, Ontario, Canada
| | | | - Glenn Bauman
- Department of Radiation Oncology, London Regional Cancer Program, London Health Sciences Centre, London, Ontario, Canada
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168
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Vogel MME, Dewes S, Sage EK, Devecka M, Gschwend JE, Schiller K, Combs SE. Patterns of care for prostate cancer radiotherapy-results from a survey among German-speaking radiation oncologists. Strahlenther Onkol 2021; 197:962-970. [PMID: 33506347 PMCID: PMC8547211 DOI: 10.1007/s00066-020-01738-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 12/09/2020] [Indexed: 12/16/2022]
Abstract
Background Emerging moderately hypofractionated and ultra-hypofractionated schemes for radiotherapy (RT) of prostate cancer (PC) have resulted in various treatment options. The aim of this survey was to evaluate recent patterns of care of German-speaking radiation oncologists for RT of PC. Methods We developed an online survey which we distributed via e‑mail to all registered members of the German Society of Radiation Oncology (DEGRO). The survey was completed by 109 participants between March 3 and April 3, 2020. For evaluation of radiation dose, we used the equivalent dose at fractionation of 2 Gy with α/β = 1.5 Gy, equivalent dose (EQD2 [1.5 Gy]). Results Median EQD2(1.5 Gy) for definitive RT of the prostate is 77.60 Gy (range: 64.49–84.00) with median single doses (SD) of 2.00 Gy (range: 1.80–3.00), while for postoperative RT of the prostate bed, median EQD2(1.5 Gy) is 66.00 Gy (range: 60.00–74.00) with median SD of 2.00 Gy (range: 1.80–2.00). For definitive RT, the pelvic lymph nodes (LNs) are treated in case of suspect findings in imaging (82.6%) and/or according to risk formulas/tables (78.0%). In the postoperative setting, 78.9% use imaging and 78.0% use the postoperative tumor stage for LN irradiation. In the definitive and postoperative situation, LNs are irradiated with a median EQD2(1.5 Gy) of 47.52 Gy with a range of 42.43–66.00 and 41.76–62.79, respectively. Conclusion German-speaking radiation oncologists’ patterns of care for patients with PC are mainly in line with the published data and treatment recommendation guidelines. However, dose prescription is highly heterogenous for RT of the prostate/prostate bed, while the dose to the pelvic LNs is mainly consistent. Supplementary Information The online version of this article (10.1007/s00066-020-01738-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Marco M. E. Vogel
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich (TUM), Ismaninger Straße 22, 81675 Munich, Germany
- Institute for Radiation Medicine (IRM), Department of Radiation Sciences (DRS), Helmholtz Zentrum München, Neuherberg, Germany
| | - Sabrina Dewes
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich (TUM), Ismaninger Straße 22, 81675 Munich, Germany
| | - Eva K. Sage
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich (TUM), Ismaninger Straße 22, 81675 Munich, Germany
| | - Michal Devecka
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich (TUM), Ismaninger Straße 22, 81675 Munich, Germany
| | - Jürgen E. Gschwend
- Department of Urology, Klinikum rechts der Isar, Technical University of Munich (TUM), Munich, Germany
| | - Kilian Schiller
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich (TUM), Ismaninger Straße 22, 81675 Munich, Germany
| | - Stephanie E. Combs
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich (TUM), Ismaninger Straße 22, 81675 Munich, Germany
- Institute for Radiation Medicine (IRM), Department of Radiation Sciences (DRS), Helmholtz Zentrum München, Neuherberg, Germany
- Partner Site Munich, Deutsches Konsortium für Translationale Krebsforschung (DKTK), Munich, Germany
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169
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Valero J, Montero A, Hernando O, Izquierdo M, Sánchez E, García-Aranda M, López M, Ciérvide R, Martí J, Álvarez B, Alonso R, Chen-Zhao X, Fernández-Letón P, Rubio C. Moderate hypofractionated post-prostatectomy radiation therapy is feasible and well tolerated: experience from a single tertiary cancer centre. Clin Transl Oncol 2021; 23:1452-1462. [PMID: 33433839 DOI: 10.1007/s12094-020-02543-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 12/14/2020] [Indexed: 12/24/2022]
Abstract
PURPOSE Conventional post-prostatectomy radiation therapy comprises 6.5-8 weeks of treatment, therefore, hypofractionated and shortened schemes arouse increasing interest. We describe our experience regarding feasibility and clinical outcome of a post-prostatectomy moderate hypofractionated image-guided radiotherapy schedule MATERIALS AND METHODS: From Oct 2015-Mar 2020, 113 patients, median age of 62 years-old (range 45-76) and prostate adenocarcinoma of low risk (30%), intermediate risk (49%) and high risk (21%) were included for adjuvant (34%) or salvage radiation therapy (66%) after radical prostatectomy (RP). All patients underwent radiotherapy with image-guided IMRT/VMAT to a total dose of 62.5 Gy in 2.5 Gy/fraction in 25 fractions. Sixteen patients (14%) received concomitant androgen deprivation therapy. RESULTS With a median follow-up of 29 months (range 3-60 months) all patients but three are alive. Eleven patients (10%) developed exclusive biochemical relapse while 19 patients (17%) presented macroscopically visible relapse: prostatectomy bed in two patients (2%), pelvic lymph nodes in 13 patients (11.5%) and distant metastases in four patients (4%). The 3 years actuarial rates for OS, bFRS, and DMFS were 99.1, 91.1 and 91.2%, respectively. Acute and late tolerance was satisfactory. Maximal acute genitourinary (AGU) toxicity was G2 in 8% of patients; maximal acute gastrointestinal (AGI) toxicity was G2 in 3.5% of patients; maximal late genitourinary (LGU) toxicity was G3 in 1% of patients and maximal late gastrointestinal (LGI) toxicity was G2 in 2% of patients. There were no cases of severe acute or late toxicity. No relationship was found between acute or late GI/GU adverse effects and dosimetric parameters, age, presence of comorbidities or concomitant treatments. CONCLUSIONS Hypofractionated radiotherapy (62.5 Gy in 25 2.5 Gy fractions) is feasible and well tolerated with low complication rates allowing for a moderate dose-escalation that offers encouraging clinical results for biochemical control and survival in patients with prostate cancer after radical prostatectomy.
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Affiliation(s)
- J Valero
- Department of Radiation Oncology, Hospital Universitario HM Sanchinarro, HM Hospitales, c/Oña 10, 28050, Madrid, Spain
| | - A Montero
- Department of Radiation Oncology, Hospital Universitario HM Sanchinarro, HM Hospitales, c/Oña 10, 28050, Madrid, Spain.
| | - O Hernando
- Department of Radiation Oncology, Hospital Universitario HM Sanchinarro, HM Hospitales, c/Oña 10, 28050, Madrid, Spain
| | - M Izquierdo
- Department of Radiation Oncology, Hospital Universitario HM Sanchinarro, HM Hospitales, c/Oña 10, 28050, Madrid, Spain
| | - E Sánchez
- Department of Radiation Oncology, Hospital Universitario HM Sanchinarro, HM Hospitales, c/Oña 10, 28050, Madrid, Spain
| | - M García-Aranda
- Department of Radiation Oncology, Hospital Universitario HM Sanchinarro, HM Hospitales, c/Oña 10, 28050, Madrid, Spain
| | - M López
- Department of Radiation Oncology, Hospital Universitario HM Sanchinarro, HM Hospitales, c/Oña 10, 28050, Madrid, Spain
| | - R Ciérvide
- Department of Radiation Oncology, Hospital Universitario HM Sanchinarro, HM Hospitales, c/Oña 10, 28050, Madrid, Spain
| | - J Martí
- Department of Medical Physics, HM Hospitales, Madrid, Spain
| | - B Álvarez
- Department of Radiation Oncology, Hospital Universitario HM Sanchinarro, HM Hospitales, c/Oña 10, 28050, Madrid, Spain
| | - R Alonso
- Department of Radiation Oncology, Hospital Universitario HM Sanchinarro, HM Hospitales, c/Oña 10, 28050, Madrid, Spain
| | - X Chen-Zhao
- Department of Radiation Oncology, Hospital Universitario HM Sanchinarro, HM Hospitales, c/Oña 10, 28050, Madrid, Spain
| | | | - C Rubio
- Department of Radiation Oncology, Hospital Universitario HM Sanchinarro, HM Hospitales, c/Oña 10, 28050, Madrid, Spain
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Pignot G, Sargos P. [Adjuvant radiotherapy after radical cystectomy for muscle-invasive bladder cancer]. Prog Urol 2020; 31:158-168. [PMID: 33358467 DOI: 10.1016/j.purol.2020.12.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 12/02/2020] [Accepted: 12/04/2020] [Indexed: 11/17/2022]
Abstract
OBJECTIVES Locoregional relapse (LRR) after cystectomy is a common early event associated with poor prognosis. The role of radiotherapy as an adjunct to radical cystectomy is not well-defined. The aim of this critical literature review is to provide an overview of the elements in favor of adjuvant radiation for patients treated for muscle-invasive bladder cancer. MATERIAL AND METHODS An exhaustive review of the literature was carried out using the Pubmed search tool with the following keywords: "radiotherapy" [Mesh], "adjuvant" [Mesh], "local recurrence" [Mesh], "Bladder cancer" [Mesh]. RESULTS Several recent publications have led to the development of a nomogram that predicts the risk of LRR, in order to identify patients for which adjuvant radiotherapy could be beneficial. Several randomized trials seem to suggest a benefit of radiotherapy, in particular when combined with chemotherapy, in terms of reducing LRR, and may even improve overall survival, with good safety profile. However, there are many biases and the interest of adjuvant radiotherapy in urothelial carcinomas remains debated. CONCLUSION Prospective trials evaluating adjuvant radiotherapy with current techniques should be undertaken.
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Affiliation(s)
- G Pignot
- Service de chirurgie oncologique 2, institut Paoli-Calmettes, Marseille, France.
| | - P Sargos
- Département de radiothérapie, institut Bergonié, Bordeaux, France
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171
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Hypofractionated Radiation Therapy to the Prostate Bed With Intensity-Modulated Radiation Therapy (IMRT): A Phase 2 Trial. Int J Radiat Oncol Biol Phys 2020; 109:1263-1270. [PMID: 33346091 DOI: 10.1016/j.ijrobp.2020.12.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 12/10/2020] [Accepted: 12/13/2020] [Indexed: 11/23/2022]
Abstract
PURPOSE Postoperative radiation therapy (RT) is a common therapy used for patients with prostate cancer. Although clinical trials have established the safety and efficacy of hypofractionation as a primary therapy, there are limited data in a postoperative setting. We conducted a prospective trial to evaluate the safety and feasibility of postoperative hypofractionated RT to the prostate bed. METHODS AND MATERIALS In this phase 2 trial, patients submitted to radical prostatectomy were treated with hypofractionated RT to the prostate bed (adjuvant or salvage). The prescribed dose was 51 Gy in 15 fractions (3.4 Gy per fraction), using intensity modulated and image guided radiation therapy techniques. The primary endpoint was the rate of acute genitourinary (GU) grade ≥2 toxicity. Secondary endpoints included acute gastrointestinal (GI) and late GU/GI toxicities, biochemical failure-free survival (BFFS), metastasis-free survival, cancer-specific survival, overall survival, and health-related quality of life. RESULTS Of 64 enrolled patients, 61 received radiation therapy (57 salvage and 4 adjuvant radiation therapy). After a median follow-up of 16 months, 11.5% of patients experienced acute grade ≥2 GU symptoms and 13.1% experienced acute grade ≥2 GI symptoms. The late grade ≥2 GU toxicity rate was 8.2%, and 1 patient (1.6%) developed both acute and late grade 3 GU toxicity. The late grade ≥2 GI toxicity rate was 11.5%, and no grade 3 GI adverse events were reported. The short follow-up limits our ability to perform a robust oncologic endpoint assessment; however, the 2-year BFFS, use of subsequent salvage therapy, and the development of metastasis were 95.1%, 0%, and 0%, respectively. CONCLUSIONS Hypofractionated RT to the prostate bed in 15 treatments was safe, with an acceptable GU and GI toxicity profile. Further study in large, randomized trials is warranted.
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172
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Lu K, Yu M, Chen Y. Non-coding RNAs regulating androgen receptor signaling pathways in prostate cancer. Clin Chim Acta 2020; 513:57-63. [PMID: 33309734 DOI: 10.1016/j.cca.2020.11.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 11/24/2020] [Accepted: 11/30/2020] [Indexed: 12/24/2022]
Abstract
Prostate cancer (PCa) is one of the most common malignancies for men worldwide, and abnormal activation of the androgen receptor (AR) signaling plays an important role in the progression of PCa. However, in the androgen deprivation therapy (ADT), AR signaling inevitably recovered, as a result, exploring novel regulating mechanisms is of great importance. Recently, non-coding RNAs (ncRNAs), including microRNAs, long non-coding RNAs, circular RNAs, could be involved in the progression of PCa, and participate in the regulatory network of AR signaling in a variety of ways. This will help to identify novel molecular mechanisms to promote the development of PCa and find new potential therapeutic targets. In this review, we provide a synopsis of the latest research relating to ncRNAs and associated AR signaling in PCa.
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Affiliation(s)
- Ke Lu
- Department of Urology, Changshu Second People's Hospital, Yangzhou University Fifth Clinical Medical College, Changshu, China
| | - Muyuan Yu
- Department of Urology, Changshu Second People's Hospital, Yangzhou University Fifth Clinical Medical College, Changshu, China
| | - Yongchang Chen
- Department of Urology, Changshu Second People's Hospital, Yangzhou University Fifth Clinical Medical College, Changshu, China.
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173
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Labidi M, Hennequin C, Quéro L. [Early salvage radiotherapy in prostate cancer: A future standard treatment?]. Bull Cancer 2020; 108:40-42. [PMID: 33280838 DOI: 10.1016/j.bulcan.2020.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 11/05/2020] [Indexed: 10/22/2022]
Affiliation(s)
- Mouna Labidi
- AP-HP, hôpital Saint Louis, service de cancérologie-radiothérapie, Paris, France
| | - Christophe Hennequin
- AP-HP, hôpital Saint Louis, service de cancérologie-radiothérapie, Paris, France; Université de Paris, Paris, France
| | - Laurent Quéro
- AP-HP, hôpital Saint Louis, service de cancérologie-radiothérapie, Paris, France; Université de Paris, Paris, France.
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174
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Re: Adjuvant Radiotherapy Versus Early Salvage Radiotherapy plus Short-term Androgen Deprivation Therapy in Men with Localised Prostate Cancer After Radical Prostatectomy (GETUG-AFU 17): A Randomised, Phase 3 Trial. Eur Urol 2020; 79:555-556. [PMID: 33279305 DOI: 10.1016/j.eururo.2020.11.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 11/19/2020] [Indexed: 11/20/2022]
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175
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Tilki D, D'Amico AV. Timing of radiotherapy after radical prostatectomy. Lancet 2020; 396:1374-1375. [PMID: 33002430 DOI: 10.1016/s0140-6736(20)31957-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 09/03/2020] [Indexed: 10/23/2022]
Affiliation(s)
- Derya Tilki
- Martini-Klinik Prostate Cancer Center and Department of Urology, University Hospital Hamburg-Eppendorf, 20246 Hamburg, Germany.
| | - Anthony V D'Amico
- Brigham and Women's Hospital and Dana Farber Cancer Institute, Department of Radiation Oncology, Boston, MA, USA
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176
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Vale CL, Fisher D, Kneebone A, Parker C, Pearse M, Richaud P, Sargos P, Sydes MR, Brawley C, Brihoum M, Brown C, Chabaud S, Cook A, Forcat S, Fraser-Browne C, Latorzeff I, Parmar MKB, Tierney JF. Adjuvant or early salvage radiotherapy for the treatment of localised and locally advanced prostate cancer: a prospectively planned systematic review and meta-analysis of aggregate data. Lancet 2020; 396:1422-1431. [PMID: 33002431 PMCID: PMC7611137 DOI: 10.1016/s0140-6736(20)31952-8] [Citation(s) in RCA: 216] [Impact Index Per Article: 54.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 07/13/2020] [Accepted: 07/27/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND It is unclear whether adjuvant or early salvage radiotherapy following radical prostatectomy is more appropriate for men who present with localised or locally advanced prostate cancer. We aimed to prospectively plan a systematic review of randomised controlled trials (RCTs) comparing these radiotherapy approaches. METHODS We used a prospective framework for adaptive meta-analysis (FAME), starting the review process while eligible trials were ongoing. RCTs were eligible if they aimed to compare immediate adjuvant radiotherapy versus early salvage radiotherapy, following radical prostatectomy in men (age ≥18 years) with intermediate-risk or high-risk, localised or locally advanced prostate cancer. We searched trial registers and conference proceedings until July 8, 2020, to identify eligible RCTs. By establishing the ARTISTIC collaboration with relevant trialists, we were able to anticipate when eligible trial results would emerge, and we developed and registered a protocol with PROSPERO before knowledge of the trial results (CRD42019132669). We used a harmonised definition of event-free survival, as the time from randomisation until the first evidence of either biochemical progression (prostate-specific antigen [PSA] ≥0·4 ng/mL and rising after completion of any postoperative radiotherapy), clinical or radiological progression, initiation of a non-trial treatment, death from prostate cancer, or a PSA level of at least 2·0 ng/mL at any time after randomisation. We predicted when we would have sufficient power to assess whether adjuvant radiotherapy was superior to early salvage radiotherapy. Investigators supplied results for event-free survival, both overall and within predefined patient subgroups. Hazard ratios (HRs) for the effects of radiotherapy timing on event-free survival and subgroup interactions were combined using fixed-effect meta-analysis. FINDINGS We identified three eligible trials and were able to obtain updated results for event-free survival for 2153 patients recruited between November, 2007, and December, 2016. Median follow-up ranged from 60 months to 78 months, with a maximum follow-up of 132 months. 1075 patients were randomly assigned to receive adjuvant radiotherapy and 1078 to a policy of early salvage radiotherapy, of whom 421 (39·1%) had commenced treatment at the time of analysis. Patient characteristics were balanced within trials and overall. Median age was similar between trials at 64 or 65 years (with IQRs ranging from 59 to 68 years) across the three trials and most patients (1671 [77·6%]) had a Gleason score of 7. All trials were assessed as having low risk of bias. Based on 270 events, the meta-analysis showed no evidence that event-free survival was improved with adjuvant radiotherapy compared with early salvage radiotherapy (HR 0·95, 95% CI 0·75-1·21; p=0·70), with only a 1 percentage point (95% CI -2 to 3) change in 5-year event-free survival (89% vs 88%). Results were consistent across trials (heterogeneity p=0·18; I2=42%). INTERPRETATION This collaborative and prospectively designed systematic review and meta-analysis suggests that adjuvant radiotherapy does not improve event-free survival in men with localised or locally advanced prostate cancer. Until data on long-term outcomes are available, early salvage treatment would seem the preferable treatment policy as it offers the opportunity to spare many men radiotherapy and its associated side-effects. FUNDING UK Medical Research Council.
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Affiliation(s)
- Claire L Vale
- MRC Clinical Trials Unit, University College London, London, UK.
| | - David Fisher
- MRC Clinical Trials Unit, University College London, London, UK
| | | | - Christopher Parker
- Royal Marsden NHS Foundation Trust and Institute of Cancer Research, Sutton, UK
| | | | | | | | - Matthew R Sydes
- MRC Clinical Trials Unit, University College London, London, UK
| | | | | | - Chris Brown
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, NSW, Australia
| | | | - Adrian Cook
- MRC Clinical Trials Unit, University College London, London, UK
| | - Silvia Forcat
- MRC Clinical Trials Unit, University College London, London, UK
| | | | | | | | - Jayne F Tierney
- MRC Clinical Trials Unit, University College London, London, UK
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177
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Parker CC, Clarke NW, Cook AD, Kynaston HG, Petersen PM, Catton C, Cross W, Logue J, Parulekar W, Payne H, Persad R, Pickering H, Saad F, Anderson J, Bahl A, Bottomley D, Brasso K, Chahal R, Cooke PW, Eddy B, Gibbs S, Goh C, Gujral S, Heath C, Henderson A, Jaganathan R, Jakobsen H, James ND, Kanaga Sundaram S, Lees K, Lester J, Lindberg H, Money-Kyrle J, Morris S, O'Sullivan J, Ostler P, Owen L, Patel P, Pope A, Popert R, Raman R, Røder MA, Sayers I, Simms M, Wilson J, Zarkar A, Parmar MKB, Sydes MR. Timing of radiotherapy after radical prostatectomy (RADICALS-RT): a randomised, controlled phase 3 trial. Lancet 2020; 396:1413-1421. [PMID: 33002429 DOI: 10.1016/s0140-6736(20)31553-1] [Citation(s) in RCA: 222] [Impact Index Per Article: 55.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 05/26/2020] [Accepted: 06/12/2020] [Indexed: 12/30/2022]
Abstract
BACKGROUND The optimal timing of radiotherapy after radical prostatectomy for prostate cancer is uncertain. We aimed to compare the efficacy and safety of adjuvant radiotherapy versus an observation policy with salvage radiotherapy for prostate-specific antigen (PSA) biochemical progression. METHODS We did a randomised controlled trial enrolling patients with at least one risk factor (pathological T-stage 3 or 4, Gleason score of 7-10, positive margins, or preoperative PSA ≥10 ng/mL) for biochemical progression after radical prostatectomy (RADICALS-RT). The study took place in trial-accredited centres in Canada, Denmark, Ireland, and the UK. Patients were randomly assigned in a 1:1 ratio to adjuvant radiotherapy or an observation policy with salvage radiotherapy for PSA biochemical progression (PSA ≥0·1 ng/mL or three consecutive rises). Masking was not deemed feasible. Stratification factors were Gleason score, margin status, planned radiotherapy schedule (52·5 Gy in 20 fractions or 66 Gy in 33 fractions), and centre. The primary outcome measure was freedom from distant metastases, designed with 80% power to detect an improvement from 90% with salvage radiotherapy (control) to 95% at 10 years with adjuvant radiotherapy. We report on biochemical progression-free survival, freedom from non-protocol hormone therapy, safety, and patient-reported outcomes. Standard survival analysis methods were used. A hazard ratio (HR) of less than 1 favoured adjuvant radiotherapy. This study is registered with ClinicalTrials.gov, NCT00541047. FINDINGS Between Nov 22, 2007, and Dec 30, 2016, 1396 patients were randomly assigned, 699 (50%) to salvage radiotherapy and 697 (50%) to adjuvant radiotherapy. Allocated groups were balanced with a median age of 65 years (IQR 60-68). Median follow-up was 4·9 years (IQR 3·0-6·1). 649 (93%) of 697 participants in the adjuvant radiotherapy group reported radiotherapy within 6 months; 228 (33%) of 699 in the salvage radiotherapy group reported radiotherapy within 8 years after randomisation. With 169 events, 5-year biochemical progression-free survival was 85% for those in the adjuvant radiotherapy group and 88% for those in the salvage radiotherapy group (HR 1·10, 95% CI 0·81-1·49; p=0·56). Freedom from non-protocol hormone therapy at 5 years was 93% for those in the adjuvant radiotherapy group versus 92% for those in the salvage radiotherapy group (HR 0·88, 95% CI 0·58-1·33; p=0·53). Self-reported urinary incontinence was worse at 1 year for those in the adjuvant radiotherapy group (mean score 4·8 vs 4·0; p=0·0023). Grade 3-4 urethral stricture within 2 years was reported in 6% of individuals in the adjuvant radiotherapy group versus 4% in the salvage radiotherapy group (p=0·020). INTERPRETATION These initial results do not support routine administration of adjuvant radiotherapy after radical prostatectomy. Adjuvant radiotherapy increases the risk of urinary morbidity. An observation policy with salvage radiotherapy for PSA biochemical progression should be the current standard after radical prostatectomy. FUNDING Cancer Research UK, MRC Clinical Trials Unit, and Canadian Cancer Society.
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Affiliation(s)
- Christopher C Parker
- Department of Oncology, Royal Marsden NHS Foundation Trust, Sutton, UK; Institute of Cancer Research, Sutton, UK
| | - Noel W Clarke
- Department of Oncology, Genito-Urinary Cancer Research Group, The Christie Hospital, Manchester, UK; Department of Surgery, The Christie Hospital, Manchester, UK; Department of Urology, Salford Royal Hospitals, Manchester, UK
| | - Adrian D Cook
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, UCL, London, UK
| | - Howard G Kynaston
- Department of Urology, Cardiff University School of Medicine, Cardiff University, Cardiff, UK
| | - Peter Meidahl Petersen
- Department of Oncology, Copenhagen Prostate Cancer Center, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Charles Catton
- Department of Radiation Oncology, Princess Margaret Hospital, University Health Network, Toronto, ON, Canada
| | - William Cross
- Department Of Urology, St James's University Hospital, Leeds, UK
| | - John Logue
- Department of Oncology, The Christie Hospital, Manchester, UK
| | - Wendy Parulekar
- Department of Oncology, Canadian Cancer Trials Group, Queen's University, Kingston, ON, Canada
| | - Heather Payne
- Department of Oncology, University College London Hospitals, London, UK
| | - Rajendra Persad
- Department of Urology, Bristol Urological Institute, North Bristol Hospitals, Bristol, UK
| | - Holly Pickering
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, UCL, London, UK
| | - Fred Saad
- Department of Urology, Centre Hospitalier de l'Université de Montreal, Montreal, QC, Canada
| | - Juliette Anderson
- Department of Oncology, Mid Yorkshire Hospitals NHS Trust, Wakefield, UK
| | - Amit Bahl
- Department of Oncology, Bristol Cancer Institute, University Hospitals Bristol, Bristol, UK
| | | | - Klaus Brasso
- Department of Urology, Copenhagen Prostate Cancer Center, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Rohit Chahal
- Department of Urology, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Peter W Cooke
- Department of Urology, The Royal Wolverhampton NHS Trust, Wolverhampton, UK
| | - Ben Eddy
- Department of Urology, East Kent Hospitals University Foundation Trust, Canterbury, UK
| | - Stephanie Gibbs
- Department of Oncology, Barking, Havering and Redbridge University Hospitals NHS Trust, Romford, UK
| | - Chee Goh
- Department of Oncology, Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK
| | - Sandeep Gujral
- Department of Urology, Barking, Havering and Redbridge University Hospitals NHS Trust, Romford, UK
| | - Catherine Heath
- Department of Clinical Oncology, University Hospital Southampton, Southampton, UK
| | - Alastair Henderson
- Department of Urology, Maidstone and Tunbridge Wells NHS Trust, Maidstone, UK
| | - Ramasamy Jaganathan
- Department of Urology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Henrik Jakobsen
- Department of Urology, Herlev University Hospital, Herlev, Denmark
| | - Nicholas D James
- Institute of Cancer Research, London, UK; Department of Oncology, Royal Marsden NHS Foundation Trust, London, UK
| | | | - Kathryn Lees
- Kent Oncology Centre, Maidstone Hospital, Kent, UK
| | - Jason Lester
- Department of Oncology, South West Wales Cancer Centre, Swansea, UK
| | | | - Julian Money-Kyrle
- Department of Oncology, Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK
| | - Stephen Morris
- Department of Clinical Oncology, Guys Hospital, London, UK
| | - Joe O'Sullivan
- Department of Clinical Oncology, Belfast Health and Social Care Trust, Belfast, UK
| | | | - Lisa Owen
- Department of Oncology, Leeds Cancer Centre, St James's University Hospital, Leeds, UK
| | - Prashant Patel
- Department of Urology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Alvan Pope
- Department of Urology, Hillingdon Hospital, Middlesex, UK; Mount Vernon Hospital, Northwood, UK; Mount Vernon Cancer Centre, Northwood, UK
| | | | - Rakesh Raman
- Department of Clinical Oncology, Kent Oncology Centre, Canterbury, UK
| | - Martin Andreas Røder
- Department of Urology, Copenhagen Prostate Cancer Center, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Ian Sayers
- Department of Oncology, The Royal Wolverhampton NHS Trust, Wolverhampton, UK
| | - Matthew Simms
- Department of Urology, Hull University Hospitals NHS Trust, Hull, UK
| | - Jim Wilson
- Department of Urology, Anuerin Bevan University Health Board, Newport, UK
| | - Anjali Zarkar
- Department of Oncology, University Hospital Birmingham, Birmingham, UK
| | - Mahesh K B Parmar
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, UCL, London, UK
| | - Matthew R Sydes
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, UCL, London, UK.
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Salvage radiotherapy: a new standard of care. Nat Rev Urol 2020; 17:657. [PMID: 33077912 DOI: 10.1038/s41585-020-00392-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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179
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Kneebone A, Fraser-Browne C, Duchesne GM, Fisher R, Frydenberg M, Herschtal A, Williams SG, Brown C, Delprado W, Haworth A, Joseph DJ, Martin JM, Matthews JHL, Millar JL, Sidhom M, Spry N, Tang CI, Turner S, Wiltshire KL, Woo HH, Davis ID, Lim TS, Pearse M. Adjuvant radiotherapy versus early salvage radiotherapy following radical prostatectomy (TROG 08.03/ANZUP RAVES): a randomised, controlled, phase 3, non-inferiority trial. Lancet Oncol 2020; 21:1331-1340. [PMID: 33002437 DOI: 10.1016/s1470-2045(20)30456-3] [Citation(s) in RCA: 205] [Impact Index Per Article: 51.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 06/18/2020] [Accepted: 06/22/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND Adjuvant radiotherapy has been shown to halve the risk of biochemical progression for patients with high-risk disease after radical prostatectomy. Early salvage radiotherapy could result in similar biochemical control with lower treatment toxicity. We aimed to compare biochemical progression between patients given adjuvant radiotherapy and those given salvage radiotherapy. METHODS We did a phase 3, randomised, controlled, non-inferiority trial across 32 oncology centres in Australia and New Zealand. Eligible patients were aged at least 18 years and had undergone a radical prostatectomy for adenocarcinoma of the prostate with pathological staging showing high-risk features defined as positive surgical margins, extraprostatic extension, or seminal vesicle invasion; had an Eastern Cooperative Oncology Group performance status of 0-1, and had a postoperative prostate-specific antigen (PSA) concentration of 0·10 ng/mL or less. Patients were randomly assigned (1:1) using a minimisation technique via an internet-based, independently generated allocation to either adjuvant radiotherapy within 6 months of radical prostatectomy or early salvage radiotherapy triggered by a PSA of 0·20 ng/mL or more. Allocation sequence was concealed from investigators and patients, but treatment assignment for individual randomisations was not masked. Patients were stratified by radiotherapy centre, preoperative PSA, Gleason score, surgical margin status, and seminal vesicle invasion status. Radiotherapy in both groups was 64 Gy in 32 fractions to the prostate bed without androgen deprivation therapy with real-time review of plan quality on all cases before treatment. The primary endpoint was freedom from biochemical progression. Salvage radiotherapy would be deemed non-inferior to adjuvant radiotherapy if freedom from biochemical progression at 5 years was within 10% of that for adjuvant radiotherapy with a hazard ratio (HR) for salvage radiotherapy versus adjuvant radiotherapy of 1·48. The primary analysis was done on an intention-to-treat basis. This study is registered with ClinicalTrials.gov, NCT00860652. FINDINGS Between March 27, 2009, and Dec 31, 2015, 333 patients were randomly assigned (166 to adjuvant radiotherapy; 167 to salvage radiotherapy). Median follow-up was 6·1 years (IQR 4·3-7·5). An independent data monitoring committee recommended premature closure of enrolment because of unexpectedly low event rates. 84 (50%) patients in the salvage radiotherapy group had radiotherapy triggered by a PSA of 0·20 ng/mL or more. 5-year freedom from biochemical progression was 86% (95% CI 81-92) in the adjuvant radiotherapy group versus 87% (82-93) in the salvage radiotherapy group (stratified HR 1·12, 95% CI 0·65-1·90; pnon-inferiority=0·15). The grade 2 or worse genitourinary toxicity rate was lower in the salvage radiotherapy group (90 [54%] of 167) than in the adjuvant radiotherapy group (116 [70%] of 166). The grade 2 or worse gastrointestinal toxicity rate was similar between the salvage radiotherapy group (16 [10%]) and the adjuvant radiotherapy group (24 [14%]). INTERPRETATION Salvage radiotherapy did not meet trial specified criteria for non-inferiority. However, these data support the use of salvage radiotherapy as it results in similar biochemical control to adjuvant radiotherapy, spares around half of men from pelvic radiation, and is associated with significantly lower genitourinary toxicity. FUNDING New Zealand Health Research Council, Australian National Health Medical Research Council, Cancer Council Victoria, Cancer Council NSW, Auckland Hospital Charitable Trust, Trans-Tasman Radiation Oncology Group Seed Funding, Cancer Research Trust New Zealand, Royal Australian and New Zealand College of Radiologists, Cancer Institute NSW, Prostate Cancer Foundation Australia, and Cancer Australia.
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Affiliation(s)
- Andrew Kneebone
- Department of Radiation Oncology, Royal North Shore Hospital, Sydney, NSW, Australia; Sydney Medical School, University of Sydney, Sydney, NSW, Australia.
| | | | - Gillian M Duchesne
- University of Melbourne, Melbourne, VIC, Australia; Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Richard Fisher
- Centre for Biostatistics and Clinical Trials, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Mark Frydenberg
- Monash University, Melbourne, VIC, Australia; Cabrini Medical Centre, Melbourne, VIC, Australia
| | - Alan Herschtal
- Centre for Biostatistics and Clinical Trials, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Scott G Williams
- University of Melbourne, Melbourne, VIC, Australia; Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Chris Brown
- National Health and Medical Research Council, Clinical Trials Centre, University of Sydney, Camperdown, NSW, Australia
| | - Warick Delprado
- Douglass Hanly Moir Pathology, Sydney, NSW, Australia; University of Notre Dame Australia, Sydney, NSW, Australia; Macquarie University, Sydney, NSW, Australia
| | - Annette Haworth
- School of Physics, University of Sydney, Sydney, NSW, Australia
| | - David J Joseph
- University of Western Australia, Perth, WA, Australia; Edith Cowan University, Perth, WA, Australia; Genesis Cancer Care, Perth, WA, Australia; 5D Clinics, Perth, WA, Australia
| | - Jarad M Martin
- Calvary Mater Newcastle Hospital, Newcastle, NSW, Australia; School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia
| | | | - Jeremy L Millar
- Monash University, Melbourne, VIC, Australia; Alfred Health Radiation Oncology, Melbourne, VIC, Australia
| | - Mark Sidhom
- Cancer Therapy Centre, Liverpool Hospital, Sydney, NSW, Australia; University of New South Wales, Sydney, NSW, Australia
| | - Nigel Spry
- Edith Cowan University, Perth, WA, Australia; Sir Charles Gairdner Hospital, Perth, WA, Australia; Genesis Cancer Care, Perth, WA, Australia
| | - Colin I Tang
- Edith Cowan University, Perth, WA, Australia; Sir Charles Gairdner Hospital, Perth, WA, Australia
| | - Sandra Turner
- Sydney Medical School, University of Sydney, Sydney, NSW, Australia; Crown Princess Mary Cancer Centre, Westmead, NSW, Australia
| | - Kirsty L Wiltshire
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Henry H Woo
- Sydney Medical School, University of Sydney, Sydney, NSW, Australia; Department of Urology, Sydney Adventist Hospital, Wahroonga, NSW Australia
| | - Ian D Davis
- Monash University, Melbourne, VIC, Australia; ANZUP Cancer Trials Group, Sydney, NSW, Australia; Eastern Health, Melbourne, VIC, Australia
| | - Tee S Lim
- Genesis Cancer Care, Perth, WA, Australia; Curtin Medical School, Curtin University, Perth, WA, Australia
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