Population-Based Referrals for Adjuvant Radiotherapy After Radical Prostatectomy in Men With Prostate Cancer: Impact of Randomized Trials

Adjuvant versus early salvage radiotherapy for prostate cancer patients: Time to move on

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.

Urologists' referral and radiation oncologists' treatment patterns regarding high-risk prostate cancer patients receiving radiotherapy within 6 months after radical prostatectomy: A prospective cohort analysis

INTRODUCTION

Previous studies have observed low rates of adjuvant radiotherapy after radical prostatectomy (RP) for high-risk prostate cancer patients. However, it is not clear the extent to which these low rates are driven by urologists' referral and radiation oncologists' treatment patterns.

METHOD

The Clinician-Led Improvement in Cancer Care (CLICC) implementation trial was conducted in nine public hospitals in New South Wales, Australia. Men who underwent RP for prostate cancer during 2013-2015 and had at least one high-risk pathological feature of extracapsular extension, seminal vesicle invasion and/or positive surgical margins were included in these analyses. Outcomes were as follows: (i) referral to a radiation oncologist within 4 months after RP ('referred'); (ii) commencement of radiotherapy within 6 months after RP among those who consulted a radiation oncologist ('radiotherapy after consultation').

RESULTS

Three hundred and twenty-five (30%) of 1071 patients were 'referred', and 74 (61%) of 121 patients received 'radiotherapy after consultation'. Overall, the probability of receiving radiotherapy within 6 months after RP was 15%. The probability of being 'referred' increased according to higher 5-year risk of cancer-recurrence (P < 0.001).

CONCLUSION

Only 30% of patients with high-risk features are referred to a radiation oncologist with the likelihood of referral being influenced by the perceived risk of cancer-recurrence as well as the urologist's institutional/personal preference. When patients are seen by a radiation oncologist, 61% receive radiotherapy within 6 months after RP with the likelihood of receiving radiotherapy not being heavily influenced by increasing risk of recurrence. This suggests many suitable patients would receive radiotherapy if referred and seen by a radiation oncologist.

Discord Among Radiation Oncologists and Urologists in the Postoperative Management of High-Risk Prostate Cancer

OBJECTIVE

To query specialty-specific differences regarding postoperative radiotherapy (RT) for high-risk prostate cancer.

MATERIALS AND METHODS

Electronic mail survey of radiation oncologists (ROs) and urologists. We sought to maximize absolute response number to capture contemporary practice ethos. The outcome of interest was association between response and specialty. Training level/expertise, practice setting, percentage of consultation caseload consisting of high-risk prostate cancer, and nationality were set as effect modifiers for multivariate logistic regression.

RESULTS

In total, 846 ROs and 407 urologists responded. ROs were more likely to prefer adjuvant radiotherapy (ART). ART or early salvage radiotherapy (SRT, with early SRT defined as that delivered at prostate-specific antigen<0.2), whereas urologists were more likely to prefer early or delayed SRT (P<0.0001). ROs were more likely to prefer lower PSA thresholds for initiating SRT (P<0.0001), and more likely to recommend ART in the setting of adverse pathologic features or node-positive disease (P<0.0001). Significantly more ROs would recommend concurrent androgen deprivation therapy or pelvic nodal RT in the setting of node-positive or Gleason score 8 to 10 disease (P<0.0001).

CONCLUSIONS

Specialty-specific differences were readily elucidated with respect to timing and indications for ART and SRT, as well as for indications for androgen deprivation therapy and nodal RT. These differences are likely to create a sense of dissonance for patients, which may in turn explain the underutilization of postoperative RT in general practice.

A multidisciplinary team-oriented intervention to increase guideline recommended care for high-risk prostate cancer: A stepped-wedge cluster randomised implementation trial

BACKGROUND

This study assessed whether a theoretically conceptualised tailored intervention centred on multidisciplinary teams (MDTs) increased clinician referral behaviours in line with clinical practice guideline recommendations.

METHODS

Nine hospital Sites in New South Wales (NSW), Australia with a urological MDT and involvement in a state-wide urological clinical network participated in this pragmatic stepped wedge, cluster randomised implementation trial. Intervention strategies included flagging of high-risk patients by pathologists, clinical leadership, education, and audit and feedback of individuals' and study Sites' practices. The primary outcome was the proportion of patients referred to radiation oncology within 4 months after prostatectomy. Secondary outcomes were proportion of patients discussed at a MDT meeting within 4 months after surgery; proportion of patients who consulted a radiation oncologist within 6 months; and the proportion who commenced radiotherapy within 6 months. Urologists' attitudes towards adjuvant radiotherapy were surveyed pre- and post-intervention. A process evaluation measured intervention fidelity, response to intervention components and contextual factors that impacted on implementation and sustainability.

RESULTS

Records for 1071 high-risk post-RP patients operated on by 37 urologists were reviewed: 505 control-phase; and 407 intervention-phase. The proportion of patients discussed at a MDT meeting increased from 17% in the control-phase to 59% in the intervention-phase (adjusted RR = 4.32; 95% CI [2.40 to 7.75]; p < 0·001). After adjustment, there was no significant difference in referral to radiation oncology (intervention 32% vs control 30%; adjusted RR = 1.06; 95% CI [0.74 to 1.51]; p = 0.879). Sites with the largest relative increases in the percentage of patients discussed also tended to have greater increases in referral (p = 0·001). In the intervention phase, urologists failed to provide referrals to more than half of patients whom the MDT had recommended for referral (78 of 140; 56%).

CONCLUSIONS

The intervention resulted in significantly more patients being discussed by a MDT. However, the recommendations from MDTs were not uniformly recorded or followed. Although practice varied markedly between MDTs, the intervention did not result in a significant overall change in referral rates, probably reflecting a lack of change in urologists' attitudes. Our results suggest that interventions focused on structures and processes that enable health system-level change, rather than those focused on individual-level change, are likely to have the greatest effect.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12611001251910 ). Registered 6 December 2011.

Use of the Electronic Medical Record to Facilitate Intervention for Patients With Rising Prostate-Specific Antigen Values After Radical Prostatectomy: A Feasibility Study

PURPOSE

Salvage radiotherapy (SRT) is the standard of care offered when postprostatectomy prostate-specific antigen (PSA) levels are ≥ 0.2 ng/mL. However, emerging evidence suggests that early SRT (ie, SRT delivered at PSA values < 0.2 ng/mL, but generally ≥ 0.05 ng/mL) improves oncologic outcomes. We evaluated the feasibility of improving referral rates for discussion of early SRT by using a dynamic registry that identifies through the electronic medical record patients with rising postprostatectomy PSA levels.

METHODS

We developed an iteratively updated registry that identifies patients who fall within two postoperative PSA strata: ≥ 0.05 to < 0.1 ng/mL and ≥ 0.1 to < 0.2 ng/mL. We compared referral rates to radiation oncology during a 3-year period before use of this registry with those during a 1-year period after promotion of the registry in multidisciplinary tumor board settings.

RESULTS

Before promotion of the registry, referral rates for patients with PSA values ≥ 0.05 to < 0.1 ng/mL and ≥ 0.1 to < 0.2 ng/mL were 35% and 65%, respectively. After promotion of the registry, referral rates within each stratum increased significantly to 82% and 94%, respectively ( P < .05 for both by Fisher's exact test). The overall rate of referral for patients with PSA values ≥ 0.05 to < 0.2 ng/mL rose from 48% to 90% ( P < .001).

CONCLUSION

The creation of a registry of patients with rising postprostatectomy PSA values can facilitate increased referral rates for early SRT without burdening providers with a clinical support tool embedded within the EMR itself. This is true even in the case of already high baseline rates of referral for early SRT. The changes reported herein most likely reflect a Hawthorne effect wherein the ability to track referrals rather than a direct function of the registry influenced practice patterns. Nonetheless, the registry provided an integral framework to allow for tracking.

Quality of Radiation Therapy Referral and Utilisation Post-prostatectomy: A Population-based Study of Time Trends

AIMS

Adjuvant radiotherapy post-prostatectomy has been shown to benefit patients with adverse pathology. It remains unclear whether salvage radiotherapy confers equivalent outcomes. Practice guidelines recommend referral to radiation oncology within 6 months after prostatectomy to discuss adjuvant and salvage radiotherapy. The study objectives were to assess, at a population level: (i) post-prostatectomy referral patterns for radiotherapy; (ii) adjuvant and salvage radiotherapy utilisation; and (iii) time trends in relation to clinical trials and guidelines. These findings provide indications of access to quality care.

MATERIALS AND METHODS

This was a retrospective cohort study. Electronic radiotherapy consultation and treatment records were linked to the population-based Ontario Cancer Registry. The population included prostate cancer cases treated with prostatectomy in Ontario between 2003 and 2012. Radiotherapy referral and treatment rates over time were analysed using the chi-squared trend test.

RESULTS

Over the study period, 30 447 prostate cancer patients received prostatectomy. The proportion seen by radiation oncology within 6 months after prostatectomy doubled from 10.7% in 2003-2004 to 21.7% in 2011-2012 (P < 0.0001 for trend), with the largest annual percentage difference in 2009-2011 (3.4%). Among 4641 patients seen within 6 months, adjuvant radiotherapy rates remained at 51.0% ± 3.0%. Contemporaneous with radiation oncology referral trends, overall adjuvant radiotherapy use increased from 6.2% in 2003-2004 to 11.0% in 2011-2012 (P < 0.001), while salvage radiotherapy remained at 8.4% ± 0.4%. Consequently, the total proportion receiving radiotherapy within 24 months increased from 14.1% in 2003-2004 to 17.7% in 2009-2010 (P < 0.0001).

CONCLUSIONS

There was an increase in access to early radiation oncology referral post-prostatectomy and adjuvant radiotherapy in Ontario between 2003 and 2012, following guideline publication.

Risk stratification system and pattern of relapse in patients treated with adjuvant radiotherapy after radical prostatectomy

PURPOSE

To retrospectively evaluate the role of adjuvant radiotherapy (ART) as monotherapy in a cohort of prostate cancer patients with undetectable prostate-specific antigen (PSA) after surgery and to propose a risk stratification system.

METHODS

Between 2003 and 2010, 174 consecutive patients were treated with ART (median dose 71 Gy) at a single institution. Subsequently, we assigned a score of 1 to the following risk factors (RF): T stage ≥3b, presurgical PSA ≥10 ng/mL, pathologic Gleason score (GS) ≥4 + 3, and positive surgical margin (R1). The scores were then summed to stratify the population into low risk (LR), intermediate risk (IR), and high risk (HR).

RESULTS

Median follow-up was 61 months (range 4-105). Five-year biochemical relapse-free survival (bRFS), clinical relapse-free survival (cRFS), and overall survival (OS) were respectively 93%, 97.1%, and 98.6%. On univariate analyses, GS was the only variable related to bRFS (p = 0.04) and to cRFS (p = 0.05). Any variable was related to OS. Kaplan-Meier analysis showed that HR patients (3-4 RF) had a worse bRFS (p = 0.02) compared to LR patients (0 RF or R1 as single RF); IR patients (1-2 RF) had a lower bRFS compared to LR patients (p = 0.06). Patients with R1 as single RF have the same bRFS as patients with 0 RF (p = 0.6) and are considered as LR patients.

CONCLUSIONS

Adjuvant radiotherapy leads to excellent bRFS and cRFS rates at 5 years (93.3% and 97.1%, respectively) in our population. Patients with multiple RF are at higher risk of bRFS. Patients with R1 as single RF have bRFS rates comparable to patients without any RF.

Management of prostate cancer patients following radiation therapy after radical surgery referred from urology to radiation oncology departments in Spain

PURPOSE

To define usual clinical management of prostate cancer (PCa) patients following postoperative radiation therapy (RT) (adjuvant or salvage) and its evolution over time in radiation oncology (RO) departments in Spain.

METHODS

An epidemiological, cross-sectional, multicentre study was conducted. 567 PCa patients that had undergone radical prostatectomy (RP) and received postoperative RT between February and December of both 2006 and 2011 participated in the study. In patients from 2006, health-related quality of life (HRQoL) was assessed using the EPIC questionnaire. Investigators completed a specific survey on two clinical cases of adjuvant and salvage RT.

RESULTS

70.6 % of patients received salvage RT versus 29.4 % who received adjuvant RT; no significant differences were found in terms of frequency for each procedure between both the years. Regarding the survey, a positive surgical margin was the main criteria used in adjuvant RT decision making. In terms of salvage RT scenario, 85.7 % of the investigators stated that adjuvant RT should have been offered instead, 81.4 % of the investigators agreed on a PSA score >0.2 ng/mL as the main criteria for identifying biochemical recurrence after RP, and 67.4 % of investigators did not consider any PSA score for ruling out salvage RT treatment.

CONCLUSIONS

Most patients are referred to RO departments to receive salvage RT. Despite the publication of three IA evidence level randomized clinical trials, the patterns for using adjuvant and salvage RT did not change from 2006 to 2011, although patients' profile did. A consensus regarding postoperative RT indications should be reached in order to correct this controversial situation.