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Rajeev-Kumar G, Pitroda SP, Szmulewitz RZ, Skolarus T, Eggener SE, Liauw SL. Hormonal Therapy and Radiation Therapy in Prostate Cancer: 5-Year Outcomes From a Trial Evaluating Combined Androgen Blockade With 5-Alpha Reductase Inhibitors as an Alternative to Gonadotropin Releasing Hormone Agonists. Clin Genitourin Cancer 2024; 22:102103. [PMID: 38781786 DOI: 10.1016/j.clgc.2024.102103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Revised: 04/03/2024] [Accepted: 04/22/2024] [Indexed: 05/25/2024]
Abstract
BACKGROUND We previously reported that for men undergoing combined androgen deprivation therapy (ADT) and radiation therapy (RT) for prostate cancer, substitution of LHRH-agonists with 5-α- reductase inhibitors (5-ARIs) led to improved preservation of 6-month hormonal quality of life (hQOL). With longer term follow-up, we evaluated disease control. METHODS In this non-randomized trial, men with unfavorable intermediate or high-risk prostate cancer, aged ≥70 years or with Charlson Comorbidity Index ≥2, were treated with RT (78-79.2 Gy in 39-44 fractions) and either oral ADT (oADT; 5-ARI with antiandrogen) or standard of care ADT (SOC; leuprolide with antiandrogen) for up to 28 months. The primary endpoint was EPIC hQOL; secondary endpoints included biochemical control and survival as well as changes in cholesterol and hemoglobin levels. RESULTS Between 2011 and 2018, 70 men were enrolled (40 in oADT; 30 in SOC). Median follow-up was 65 months [IQR 36-94]. Five-year freedom from biochemical failure for oADT and SOC was 89% versus 86%, disease free survival was 62% versus 69%, cancer-specific survival was 100% versus 96%, and overall survival was 70% versus 81% (all P>.1). Testosterone (2 mo through 3 yr) and hemoglobin levels (2 mo through 2 yr) were higher, and cholesterol levels (1 yr) were lower in the oADT groups (all P < .05). CONCLUSIONS In this non-randomized study, men treated with combined RT and oADT had better preservation of hQOL and comparable 5-year disease outcomes to men treated with SOC. Eugonadal testosterone with this approach may yield measurable benefits in cholesterol and hemoglobin levels.
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Affiliation(s)
- Greeshma Rajeev-Kumar
- Department of Radiation and Cellular Oncology, University of Chicago, 5758 S. Maryland Ave, Chicago, IL 60637, USA
| | - Sean P Pitroda
- Department of Radiation and Cellular Oncology, University of Chicago, 5758 S. Maryland Ave, Chicago, IL 60637, USA
| | - Russell Z Szmulewitz
- Genitourinary Oncology Program, Department of Medicine, University of Chicago, 5841 S. Maryland Ave, Chicago, IL 60637, USA
| | - Ted Skolarus
- Department of Urology, University of Chicago, 5758 S. Maryland Ave, DCAM 2D, Chicago, IL 60637, USA
| | - Scott E Eggener
- Department of Urology, University of Chicago, 5758 S. Maryland Ave, DCAM 2D, Chicago, IL 60637, USA
| | - Stanley L Liauw
- Department of Radiation and Cellular Oncology, University of Chicago, 5758 S. Maryland Ave, Chicago, IL 60637, USA.
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A Contemporary Report of Low-Dose-Rate Brachytherapy for Prostate Cancer Using MRI for Risk Stratification: Disease Outcomes and Patient-Reported Quality of Life. Cancers (Basel) 2023; 15:cancers15041336. [PMID: 36831677 PMCID: PMC9953871 DOI: 10.3390/cancers15041336] [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: 01/11/2023] [Revised: 02/08/2023] [Accepted: 02/11/2023] [Indexed: 02/22/2023] Open
Abstract
PURPOSE We examined a prospective consecutive cohort of low dose rate (LDR) brachytherapy for prostate cancer to evaluate the efficacy of monotherapy for unfavorable-intermediate risk (UIR) disease, and explore factors associated with toxicity and quality of life (QOL). METHODS 149 men with prostate cancer, including 114 staged with MRI, received Iodine-125 brachytherapy alone (144-145 Gy) or following external beam radiation therapy (110 Gy; EBRT). Patient-reported QOL was assessed by the Expanded Prostate Index Composite (EPIC) survey, and genitourinary (GU) and gastrointestinal (GI) toxicity were prospectively recorded (CTC v4.0). Global QOL scores were assessed for decline greater than the minimum clinically important difference (MCID). Univariate analysis (UVA) was performed, with 30-day post-implant dosimetry covariates stratified into quartiles. Median follow-up was 63 mo. RESULTS Men with NCCN low (n = 42) or favorable-intermediate risk (n = 37) disease were treated with brachytherapy alone, while most with high-risk disease had combined EBRT (n = 17 of 18). Men with UIR disease (n = 52) were selected for monotherapy (n = 42) based on clinical factors and MRI findings. Freedom from biochemical failure-7 yr was 98%. Of 37 men with MRI treated with monotherapy for UIR disease, all 36 men without extraprostatic extension were controlled. Late Grade 2+/3+ toxicity occurred in 55/3% for GU and 8/2% for GI, respectively. Fifty men were sexually active at baseline and had 2 yr sexual data; 37 (74%) remained active at 2 yr. Global scores for urinary incontinence (UC), urinary irritation/obstruction (UIO), bowel function, and sexual function (SF) showed decreases greater than the MCID (p < 0.05) in UC at 2 mo, UIO at 2 and 6 mo, and SF at 2-24 mo, and >5 yr. Analysis did not reveal any significant associations with any examined rectal or urethral dosimetry for late toxicity or QOL. CONCLUSION Disease outcomes and patient-reported QOL support LDR brachytherapy, including monotherapy for UIR disease.
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Onderdonk BE, Dorn PL, Martinez C, Arif F, Cloutier D, Antic T, Golden DW, Karrison T, Pitroda SP, Szmulewitz RZ, Liauw SL. A prospective clinical and transcriptomic feasibility study of oral-only hormonal therapy with radiation for unfavorable prostate cancer in men 70 years of age and older or with comorbidity. Cancer 2021; 127:2631-2640. [PMID: 33882144 DOI: 10.1002/cncr.33556] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 02/05/2021] [Accepted: 03/04/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND Androgen deprivation therapy (ADT) improves outcomes in unfavorable-risk prostate cancer (PCa) treated with radiation therapy (RT). It was hypothesized that replacing luteinizing hormone-releasing hormone (LHRH) agonists with a 5-α-reductase inhibitor (5-ARI) would improve hormonal health-related quality of life (HRQOL) without differentially suppressing androgen-responsive (AR) gene expression. METHODS Patients with localized unfavorable-risk PCa, aged ≥70 years or Charlson Comorbidity Index score ≥2 were treated with oral ADT (oADT), consisting of 4 months of bicalutamide, a 5-ARI, and RT at 78 Gy. The primary end point was Expanded Prostate Cancer Index Composite HRQOL at 6 months ≤30%, and improvement compared with a synchronous standard of care (SOC) cohort receiving 4 months of bicalutamide and long-term LHRH agonist with RT. RNA sequencing was performed from matched pre-/post-ADT prostate tumor biopsies in a subset of men. Differential gene and pathway expressional changes were examined using gene set enrichment. RESULTS Between 2011 and 2018, 40 and 30 men were enrolled in the oADT and SOC cohorts, respectively. Median follow-up was 40 months. Those with ≤30% decline in hormonal HRQOL at 6 months was 97% (oADT) and 93% (SOC). The average 6-month hormonal decline was 1% (oADT) versus 12% (SOC; P = .04). The 4-year freedom from biochemical failure was 88% (oADT) versus 81% (SOC; P = .48). RNA sequencing (n = 9) showed similar numbers of downregulated and upregulated genes between the treatment groups (fold-change = 2; false-discovery rate-adjusted P ≤ .05). Both treatments comparably decreased the expression of 20 genes in canonical androgen receptor signaling. CONCLUSIONS For men with PCa undergoing RT, oral versus standard ADT may improve 6-month QOL and appears to have a similar impact on androgen-responsive gene expression.
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Affiliation(s)
- Benjamin E Onderdonk
- Department of Radiation and Cellular Oncology, University of Chicago Medicine, Chicago, Illinois
| | - Paige L Dorn
- Rose Medical Center Radiation Oncology, Denver, Colorado
| | - Carlos Martinez
- Department of Radiation and Cellular Oncology, University of Chicago Medicine, Chicago, Illinois
| | - Fauzia Arif
- Department of Radiation and Cellular Oncology, University of Chicago Medicine, Chicago, Illinois
| | - Denise Cloutier
- Department of Radiation and Cellular Oncology, University of Chicago Medicine, Chicago, Illinois
| | - Tatjana Antic
- Department of Pathology, University of Chicago Medicine, Chicago, Illinois
| | - Daniel W Golden
- Department of Radiation and Cellular Oncology, University of Chicago Medicine, Chicago, Illinois
| | - Theodore Karrison
- Department of Biostatistics, University of Chicago Medicine, Chicago, Illinois
| | - Sean P Pitroda
- Department of Radiation and Cellular Oncology, University of Chicago Medicine, Chicago, Illinois
| | | | - Stanley L Liauw
- Department of Radiation and Cellular Oncology, University of Chicago Medicine, Chicago, Illinois
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Roberts C, Paterson C. An Exploration of the Rs of Radiobiology in Prostate Cancer. Semin Oncol Nurs 2020; 36:151054. [PMID: 32669231 DOI: 10.1016/j.soncn.2020.151054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To explore the four Rs of radiobiology (Repair, Reoxygenation, Reassortment, and Repopulation) as a means to understand the effects of ionising radiation on biological tissue and subsequently as the basis for conventional fractionated treatment schedules. These radiobiological principles will form a rationale for combined regimens in prostate cancer treatment involving androgen deprivation therapy and radiation therapy and the associated toxicities of this approach will be discussed. DATA SOURCES Electronic databases including CINAHL, MEDLINE, Scopus, professional websites, books and grey literature were searched using Google Scholar. CONCLUSION It is important for nurses to understand the four Rs of radiobiology to grasp the effects of ionising radiation on biological tissue as the basis for conventional fractionated treatment schedules in prostate cancer. Men can experience a sequalae of physical and psychological side effects of treatment that can negatively impact quality of life. IMPLICATIONS FOR NURSING PRACTICE Men can experience a range of unmet supportive care needs particularly related to informational, sexual, and psychological needs. For men affected by prostate cancer opting for radiation therapy (+/-) androgen deprivation therapy, nurses should ask targeted questions based on the Common Terminology Criteria for Adverse Events related to urinary and bowel function, potency and fatigue, and sexual health. We also recommend the use of holistic needs assessments to tailor self-management care plans. Evidence-based self-management advice should be provided in response to each man's unique needs.
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Affiliation(s)
- C Roberts
- Faculty of Health, University of Canberra, Canberra ACT, Australia; Prehabilitation, Activity, Cancer, Exercise and Survivorship (PACES) Research group, University of Canberra, Canberra ACT, Australia; School of Nursing, Midwifery and Public Health, University of Canberra, ACT, Australia.
| | - C Paterson
- Faculty of Health, University of Canberra, Canberra ACT, Australia; Prehabilitation, Activity, Cancer, Exercise and Survivorship (PACES) Research group, University of Canberra, Canberra ACT, Australia; School of Nursing, Midwifery and Public Health, University of Canberra, ACT, Australia; ACT Synergy Nursing and Midwifery Research Centre, Canberra Hospital, ACT, Australia
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Kauffmann G, Arif F, Patel P, Oto A, Liauw SL. Pretreatment multiparametric MRI is independently associated with biochemical outcome in men treated with radiation therapy for prostate cancer. Urol Oncol 2018; 36:471.e11-471.e18. [PMID: 30122344 DOI: 10.1016/j.urolonc.2018.07.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Revised: 06/28/2018] [Accepted: 07/10/2018] [Indexed: 10/28/2022]
Abstract
PURPOSE The purpose of this study was to investigate the utility of pre-treatment multiparametric magnetic resonance imaging (mpMRI) in a modern cohort of intermediate and high-risk prostate cancer patients treated with primary radiotherapy. METHODS AND MATERIALS One hundred twenty three men with National Comprehensive Cancer Network (NCCN) intermediate or high-risk prostate cancer were treated with primary EBRT and/or brachytherapy and had evaluable pre-treatment mpMRI with endorectal coil. Images were assessed for the presence of radiographic extraprostatic extension (rEPE), seminal vesicle invasion (rSVI), lymph node involvement (LNI), sextant involvement, and largest axial tumor diameter. Imaging characteristics were analyzed along with clinical risk factors against freedom from biochemical failure (FFBF). Median follow-up time was 50 months. RESULTS Fourteen (11%) men developed biochemical failure. The 5-year FFBF was 94% in intermediate-risk patients and 82% in high-risk patients (p < 0.01). mpMRI findings including rEPE (29% vs. 66%, p < 0.01), rSVI (6% vs. 25%, p < 0.01), LNI (1% vs. 30%, p < 0.01), and largest axial tumor size> 15 mm (27% vs. 48%, p = 0.02) were identified in men with intermediate vs. high risk prostate cancer, respectively. mpMRI features associated with 5-y FFBF biochemical failure on univariate analysis included rEPE (80% vs 98%), rSVI (55% vs. 96%), LNI (65% vs. 93%), and largest axial tumor size >15mm (81% vs. 94%, all p < 0.01). Men without any high risk MRI finding had a 5-y FFBF of 100% vs. 81% (p < 0.01). Adverse imaging features (HR 8.9, p < 0.01) were independently associated with biochemical failure in a bivariate model analyzed alongside clinical risk category (HR 3.2, p = 0.04). CONCLUSIONS Pre-treatment mpMRI findings are strongly associated with biochemical outcomes in a modern cohort of intermediate and high-risk patients treated with primary radiotherapy. mpMRI may aid risk stratification beyond clinical risk factors in men treated with radiation therapy; further study is warranted to better understand how mpMRI can be used to individualize therapy.
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Affiliation(s)
- Greg Kauffmann
- Department of Radiation and Cellular Oncology, University of Chicago, Chicago, IL
| | - Fauzia Arif
- Department of Radiation and Cellular Oncology, University of Chicago, Chicago, IL
| | - Pritesh Patel
- Department of Radiology, University of Chicago, Chicago, IL
| | - Aytek Oto
- Department of Radiology, University of Chicago, Chicago, IL
| | - Stanley L Liauw
- Department of Radiation and Cellular Oncology, University of Chicago, Chicago, IL.
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Nguyen C, Lairson DR, Swartz MD, Du XL. Racial, Socioeconomic, and Geographic Disparities in the Receipt, Timing to Initiation, and Duration of Adjuvant Androgen Deprivation Therapy in Men with Prostate Cancer. J Racial Ethn Health Disparities 2018; 6:133-142. [PMID: 29959759 DOI: 10.1007/s40615-018-0508-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Revised: 06/12/2018] [Accepted: 06/19/2018] [Indexed: 12/30/2022]
Abstract
OBJECTIVE This retrospective cohort study aims to examine the receipt, timing to initiation, and duration of androgen deprivation therapy (ADT) in men with prostate cancer by race/ethnicity, socioeconomic status, and geographic location. METHODS The study population are patients from Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database, who were 66 years or older and newly diagnosed with stage III and IV prostate cancer in 1992-2009 and underwent radiation therapy, where ADT was proven to be highly beneficial and its use was considered as most appropriate (n = 12,170). We use logistic regression to examine the receipt of ADT and linear regression to study factors associated with time to ADT initiation while controlling for baseline characteristics. RESULTS Overall, 77% of eligible patients received at least one form of ADT in combination with radiation therapy, of which 12% underwent orchiectomy and the rest received ADT, and 77.2% of non-Hispanic white and 80.7% of Hispanic patients received ADT compared to 73.8% of non-Hispanic black. After adjustment for demographic and tumor characteristics, black men and men of other races are less likely to receive ADT compared to white counterparts (OR = 0.64 and 0.74, respectively). The median time from cancer diagnosis to ADT initiation is 2 months. Once initiated, men received a median of seven drug injections. After controlling for covariates, race/ethnicity and geographic location (SEER areas) are associated with early initiation of therapy. White, Hispanic men and men living in the South initiate ADT earlier. CONCLUSION Significant racial disparities exist in the receipt and use of this highly beneficial therapy, and there are geographic variations in the utilization of this therapy.
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Affiliation(s)
- Chi Nguyen
- Department of Epidemiology, Human Genetics, and Environmental Science, University of Texas School of Public Health, University of Texas Health Science Center in Houston, 1200 Pressler Street, RAS-E631, Houston, TX, 77030, USA
| | - David R Lairson
- Department of Management Policy and Community Health, School of Public Health, University of Texas Health Science Center in Houston, Houston, TX, 77030, USA
| | - Michael D Swartz
- Department of Biostatistics and Data Science, School of Public Health, University of Texas Health Science Center in Houston, Houston, TX, 77030, USA
| | - Xianglin L Du
- Department of Epidemiology, Human Genetics, and Environmental Science, University of Texas School of Public Health, University of Texas Health Science Center in Houston, 1200 Pressler Street, RAS-E631, Houston, TX, 77030, USA.
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