1
|
Miyake M, Tanaka N, Asakawa I, Owari T, Hori S, Morizawa Y, Nakai Y, Inoue T, Anai S, Torimoto K, Hasegawa M, Fujii T, Konishi N, Fujimoto K. The impact of the definition of biochemical recurrence following salvage radiotherapy on outcomes and prognostication in patients with recurrent prostate cancer after radical prostatectomy: a comparative study of three definitions. Prostate Int 2018; 7:47-53. [PMID: 31384605 PMCID: PMC6664305 DOI: 10.1016/j.prnil.2018.04.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2018] [Revised: 03/30/2018] [Accepted: 04/26/2018] [Indexed: 10/28/2022] Open
Abstract
Purpose The clinical management and follow-up of patients with recurrent prostate cancer after salvage radiotherapy (SRT) has not yet been established, and no standardized definition of biochemical recurrence (BCR) after SRT exists. We compared the impact of applying three different definitions of BCR following SRT on patient outcomes and prognostication. Subjects Patients who received salvage androgen-deprivation therapy before the completion of SRT were excluded. The data of 118 men who had undergone salvage radiation as monotherapy for BCR after radical prostatectomy were reviewed. In all patients, SRT comprised irradiation to the prostatic bed (70 Gy) using three-dimensional conformal radiotherapy techniques. Treatment outcomes, including BCR-free survival and prognostic factors, were analyzed and compared among three definitions: The Nara, Radiation Therapy Oncology Group (RTOG) 9601, and GETUG-AFU 16 definitions. Results The BCR rate differed significantly among the applied definitions. Multivariate analyses identified the same four independent prognostic factors, including primary Gleason pattern 4 or 5, negative resection margin, prostate-specific antigen (PSA) level before SRT 0.5 or more, and PSA doubling time before SRT <6 months, using the RTOG 9601 and GETUG-AFU 16 definitions, whereas only two of the four factors were identified using the Nara definition. Although the results obtained using the RTOG 9601 and GETUG-AFU 16 definitions were similar, the prognostic value of the four factors differed. According to the RTOG 9601 definition of BCR, a negative resection margin on prostatectomy specimens and short PSA doubling time before SRT were associated with no subsequent response in PSA level. Conclusions The applied definition of BCR after SRT can influence the reported BCR-free rate and the potential prognostic factors. Establishment of the standardized definition is needed for the optimal management of patients with recurrent prostate cancer undergoing SRT.
Collapse
Affiliation(s)
- Makito Miyake
- Department of Urology, Nara Medical University, Kashihara, Nara 634-8522, Japan
| | - Nobumichi Tanaka
- Department of Urology, Nara Medical University, Kashihara, Nara 634-8522, Japan
| | - Isao Asakawa
- Department of Radiation Oncology, Nara Medical University, Kashihara, Nara 634-8522, Japan
| | - Takuya Owari
- Department of Urology, Nara Medical University, Kashihara, Nara 634-8522, Japan
| | - Shunta Hori
- Department of Urology, Nara Medical University, Kashihara, Nara 634-8522, Japan
| | - Yosuke Morizawa
- Department of Urology, Nara Medical University, Kashihara, Nara 634-8522, Japan
| | - Yasushi Nakai
- Department of Urology, Nara Medical University, Kashihara, Nara 634-8522, Japan
| | - Takeshi Inoue
- Department of Urology, Nara Medical University, Kashihara, Nara 634-8522, Japan
| | - Satoshi Anai
- Department of Urology, Nara Medical University, Kashihara, Nara 634-8522, Japan
| | - Kazumasa Torimoto
- Department of Urology, Nara Medical University, Kashihara, Nara 634-8522, Japan
| | - Masatoshi Hasegawa
- Department of Radiation Oncology, Nara Medical University, Kashihara, Nara 634-8522, Japan
| | - Tomomi Fujii
- Department of Diagnostic Pathology, Nara Medical University, Kashihara, Nara 634-8522, Japan
| | - Noboru Konishi
- Department of Pathology, Kouseikai Takai Hospital, Tenri, Nara 632-0006, Japan
| | - Kiyohide Fujimoto
- Department of Urology, Nara Medical University, Kashihara, Nara 634-8522, Japan
| |
Collapse
|
2
|
Ballare A, Di Salvo M, Loi G, Ferrari G, Beldì D, Krengli M. Conformal Radiotherapy of Clinically Localized Prostate Cancer: Analysis of Rectal and Urinary Toxicity and Correlation with Dose-Volume Parameters. TUMORI JOURNAL 2018; 95:160-8. [DOI: 10.1177/030089160909500206] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Aims and background Rectal and urinary toxicities are the principal limiting factors in delivering a high target dose to patients affected by prostate cancer. The verification of such toxicity is an important step before starting a dose-escalation program. The present observational study reports on the acute and late rectal and urinary toxicity in relation with dose-volume parameters in 104 patients with localized prostate cancer treated with 3-dimensional conformal radiation therapy. Methods and study design One hundred and four patients with stage T1b-T3b prostate cancer were treated with three-dimensional conformal radiation therapy to a total dose of 74 Gy, 2 Gy per fraction. Rigid dose constraints were applied for rectum and bladder. Acute and late rectal and urinary toxicities were analyzed also in relation to dose-volume histograms. Biochemical relapse-free survival was defined according to the American Society of Therapeutic Radiation Oncology (ASTRO) criteria and to the RTOG-ASTRO Phoenix Consensus Conference Recommendations using the Kaplan-Meier method. Results No grade 3 toxicity was observed. Acute and late grade 2 toxicity rates were 5.8% and 9.0% for rectum and 12.5% and 2.0% for bladder, respectively. Rectal V70 influenced the occurrence of late grade 2 toxicity. A relationship between acute and late urinary toxicity was also found. After a median follow-up of 30 months (range, 20–50), the actuarial overall and biochemical relapse-free survival rates were 84% and 77%, respectively, with a significant difference between low-intermediate and high-risk patients. Conclusions Conformal radiotherapy to the dose of 74 Gy was administered with good compliance. The incidence of acute and late toxicity was relatively low in accord with our dose constraints. Rectal V70 proved to be a reliable prognosticator of late toxicity. Overall survival and biochemical relapse-free survival rates were more favorable for low and intermediate-risk and significantly less favorable for high-risk patients.
Collapse
Affiliation(s)
- Andrea Ballare
- Radiotherapy, University of Piemonte Orientale Amedeo Avogadro and Hospital Maggiore della Carità, Novara, Italy
| | - Maurizio Di Salvo
- Radiotherapy, University of Piemonte Orientale Amedeo Avogadro and Hospital Maggiore della Carità, Novara, Italy
| | - Gianfranco Loi
- Medical Physics, Hospital Maggiore della Carità, Novara, Italy
| | - Gianmarco Ferrari
- Radiotherapy, University of Piemonte Orientale Amedeo Avogadro and Hospital Maggiore della Carità, Novara, Italy
| | - Debora Beldì
- Radiotherapy, University of Piemonte Orientale Amedeo Avogadro and Hospital Maggiore della Carità, Novara, Italy
| | - Marco Krengli
- Radiotherapy, University of Piemonte Orientale Amedeo Avogadro and Hospital Maggiore della Carità, Novara, Italy
| |
Collapse
|
3
|
Parameters predicting for prostate specific antigen response rates at one year post low-dose-rate intraoperative prostate brachytherapy. J Contemp Brachytherapy 2017; 9:99-105. [PMID: 28533796 PMCID: PMC5437084 DOI: 10.5114/jcb.2017.67198] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Accepted: 03/04/2017] [Indexed: 11/17/2022] Open
Abstract
Purpose To develop a model for prostate specific antigen (PSA) values at one year among patients treated with intraoperatively planned 125I prostate brachytherapy (IOPB). Material and methods Four hundred and deven patients treated with IOPB for prostate adenocarcinoma were divided into four groups: those with PSA values ≥ 3 ng/ml; < 3 and ≥ 2; < 2 and ≥ 1 or PSA < 1 between 10.5 and 14.5 months post implantation (1yPSA). Ordinal regression analysis was then performed between patient, tumor, and treatment characteristics. 1yPSA values were also compared with toxicity outcomes. Results Median 1yPSA was 0.77 (0.04-17.36). Thirty-two patients (8%) had a PSA ≥ 3; 35 (9%) had PSA < 3, ≥ 2; 87 (21%) had PSA < 2, ≥ 1, and most patients 254 (62%) had PSA < 1. PSA response was independent of gland volume, Gleason score, clinical stage, seed activity, V90, V200, D90, or number of needles and seeds used. Older patients had significantly lower 1yPSA; median ages 65.1 (46.5-81.0), 62.1 (50.4-79.5), 60.5 (47.1-80.3), and 58.1 (45.1-74.2) years for each of the 1yPSA groups respectively (p < 0.001). Also, both implant V150 (p < 0.001) and initial PSA values (p = 0.04) were predictive of 1yPSA values. There was no correlation between 1yPSA values and toxicity encountered. Conclusions PSA response at 1 year post IOPB appears to be dependent on patient age, initial PSA, and implant V150. Our results provide reassurance that parameters other than biochemical failure influence 1yPSA values.
Collapse
|
4
|
Payne H, Khan A, Chowdhury S, Davda R. Hormone therapy for radiorecurrent prostate cancer. World J Urol 2012; 31:1333-8. [DOI: 10.1007/s00345-012-0952-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2012] [Accepted: 09/10/2012] [Indexed: 11/30/2022] Open
|
5
|
Arvold ND, Chen MH, Moul JW, Moran BJ, Dosoretz DE, Bañez LL, Katin MJ, Braccioforte MH, D'Amico AV. Risk of death from prostate cancer after radical prostatectomy or brachytherapy in men with low or intermediate risk disease. J Urol 2011; 186:91-6. [PMID: 21571341 DOI: 10.1016/j.juro.2011.03.003] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2010] [Indexed: 01/10/2023]
Abstract
PURPOSE Radical prostatectomy and brachytherapy are widely used treatments for favorable risk prostate cancer. We estimated the risk of prostate cancer specific mortality following radical prostatectomy or brachytherapy in men with low or intermediate risk prostate cancer using prospectively collected data. MATERIALS AND METHODS The study cohort comprised 5,760 men with low risk prostate cancer (prostate specific antigen 10 ng/ml or less, clinical category T1c or 2a and Gleason score 6 or less), and 3,079 with intermediate risk prostate cancer (prostate specific antigen 10 to 20 ng/ml, clinical category T2b or T2c, or Gleason score 7). Competing risks multivariable regression was performed to assess the risk of prostate cancer specific mortality after radical prostatectomy or brachytherapy, adjusting for age, year of treatment, cardiovascular comorbidity and known prostate cancer prognostic factors. RESULTS After a median followup of 4.2 years (IQR 2.0-7.4) for low risk and 4.8 years (IQR 2.2-8.1) for intermediate risk men, there was no significant difference in the risk of prostate cancer specific mortality among low risk (adjusted hazard ratio 1.62, 95% CI 0.59-4.45, p = 0.35) or intermediate risk men (AHR 2.30, 95% CI 0.95-5.58, p = 0.07) treated with brachytherapy compared with radical prostatectomy. The only factor associated with an increased risk of prostate cancer specific mortality (AHR 1.05, 95% CI 1.01-1.10, p = 0.03) was increasing age at treatment in intermediate risk men. CONCLUSIONS The risk of prostate cancer specific mortality in men with low or intermediate risk prostate cancer was not significantly different following radical prostatectomy vs brachytherapy.
Collapse
Affiliation(s)
- Nils D Arvold
- Harvard Radiation Oncology Program, Harvard Medical School, Boston, Massachusetts, USA.
| | | | | | | | | | | | | | | | | |
Collapse
|
6
|
Radiothérapie de rattrapage pour récidive biochimique après prostatectomie : comparaison entre les définitions de récidive biochimique de l’Astro et de Phoenix. Cancer Radiother 2009; 13:267-75. [DOI: 10.1016/j.canrad.2009.02.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2008] [Revised: 02/15/2009] [Accepted: 02/22/2009] [Indexed: 11/19/2022]
|
7
|
Salvage HIFU for recurrent prostate cancer after radiotherapy. Prostate Cancer Prostatic Dis 2008; 12:124-9. [DOI: 10.1038/pcan.2008.53] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
|
8
|
Ishikawa H, Tsuji H, Kamada T, Hirasawa N, Yanagi T, Mizoe JE, Akakura K, Suzuki H, Shimazaki J, Nakano T, Tsujii H. Adverse Effects of Androgen Deprivation Therapy on Persistent Genitourinary Complications After Carbon Ion Radiotherapy for Prostate Cancer. Int J Radiat Oncol Biol Phys 2008; 72:78-84. [DOI: 10.1016/j.ijrobp.2007.12.044] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2007] [Revised: 11/27/2007] [Accepted: 12/13/2007] [Indexed: 11/29/2022]
|
9
|
Kershaw LE, Logue JP, Hutchinson CE, Clarke NW, Buckley DL. Late tissue effects following radiotherapy and neoadjuvant hormone therapy of the prostate measured with quantitative magnetic resonance imaging. Radiother Oncol 2008; 88:127-34. [DOI: 10.1016/j.radonc.2008.02.018] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2007] [Revised: 02/15/2008] [Accepted: 02/15/2008] [Indexed: 11/28/2022]
|
10
|
Ramalingam M, Lau W, Tan T, Fook S, Ngoi F, Cheng C. Asians with localized prostate cancer treated with 3-dimensional conformal radiation therapy and adjuvant hormonal therapy: comparing Phoenix and American Society of Therapeutic Radiology and Oncology (ASTRO) definitions in an Asian population. Urology 2008; 71:506-10. [PMID: 18342198 DOI: 10.1016/j.urology.2007.09.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2007] [Revised: 07/28/2007] [Accepted: 09/13/2007] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Conformal radiotherapy with adjuvant androgen suppression is used in our center to treat localized prostate cancer. We compare Phoenix as an alternative to American Society of Therapeutic Radiology and Oncology (ASTRO) for defining biochemical failure. Our primary aim was to assess the Phoenix and ASTRO definitions of biochemical failure in a population of mainly Asian men with early localized prostate cancer treated with conformal radiotherapy with and without androgen ablation. METHODS We retrospectively analyzed 141 patients who were treated for T1/T2 cancer of the prostate in our center from January 1997 to June 2002 with a mean duration of follow-up of 62 months. Outcomes were analyzed by using both Phoenix and ASTRO definitions of biochemical failure as well as clinical failure. RESULTS The Phoenix definition of biochemical failure was superior as measured by sensitivity, specificity, positive and negative predictive values, accuracy, and a greater concordance with clinical outcome as measured by Kappa analysis. CONCLUSIONS The ASTRO definition helped to standardize reporting of biochemical failures post-radiotherapy but inadequacies have been identified especially when adjuvant hormone therapy has been given. The Phoenix definition has been noted to be a more accurate and precise description of biochemical failure in international series, and we find this to be true in our Asian population as well.
Collapse
Affiliation(s)
- Mohan Ramalingam
- Department of Urology and Radiation Oncology, Singapore General Hospital and National Cancer Centre, Singapore.
| | | | | | | | | | | |
Collapse
|
11
|
Nielsen ME, Makarov DV, Humphreys E, Mangold L, Partin AW, Walsh PC. Is it possible to compare PSA recurrence-free survival after surgery and radiotherapy using revised ASTRO criterion--"nadir + 2"? Urology 2008; 72:389-93; discussion 394-5. [PMID: 18279937 DOI: 10.1016/j.urology.2007.10.053] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2007] [Revised: 09/24/2007] [Accepted: 10/25/2007] [Indexed: 12/01/2022]
Abstract
OBJECTIVES The new American Society for Therapeutic Radiology and Oncology/Radiation Therapy Oncology Group consensus definition of biochemical failure after radiotherapy for prostate cancer is defined as a prostate-specific antigen level at or greater than the absolute nadir PSA level plus 2 ng/mL. Because this definition inevitably will be used to compare cancer control rates after radiotherapy to those after surgery, this study examined the effect of this comparison. METHODS We reviewed the data from 2570 men who had undergone radical prostatectomy from 1985 to 2004. Biochemical failure was defined as any measurable PSA level of 0.2 ng/mL or greater. We evaluated how the nadir+2 definition affected the failure rate when applied to this series. RESULTS The actuarial 5, 10, and 15-year biochemical recurrence-free survival probability with failure defined as a PSA level of 0.2 ng/mL or more and a PSA level of 2 ng/mL or more was 88.6%, 81.2%, and 78.1% and 94.6%, 89.4%, and 84.3%, respectively (P <0.0001). The median time to biochemical progression was 2.8 years for the greater than 0.2 ng/mL definition and 7.9 years for the 2 ng/mL or more definition. The nadir+2 definition systematically overestimated the biochemical recurrence-free survival, even after stratifying patients into standard prognostic risk groups, especially in men who developed local recurrence. CONCLUSIONS When applied to a mature series of surgically treated patients with localized prostate cancer, the American Society for Therapeutic Radiology and Oncology "nadir+2" definition resulted in a systematic delay in the determination of biochemical failure. Because patients in this series who experienced a detectable PSA level took more than 5 years to progress to a PSA level of 2 ng/mL or greater, the 5-year biochemical control rates with the definition of 0.2 ng/mL or more should be compared with the 10-year biochemical control rates using the nadir+2 definition.
Collapse
Affiliation(s)
- Matthew E Nielsen
- James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland 21287-2101, USA.
| | | | | | | | | | | |
Collapse
|
12
|
Schmid HP, Keuler FU, Altwein JE. Rising prostate-specific antigen after primary treatment of prostate cancer: sequential hormone manipulation. Urol Int 2007; 79:95-104. [PMID: 17851276 DOI: 10.1159/000106320] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To evaluate systematically the current endocrine treatment options for patients with biochemical recurrence after radical prostatectomy or radiation therapy for localized prostate cancer. METHODS Literature search of PubMed documented publications and abstracts from international meetings. Key items included timing and type of salvage hormone therapy, length of its application and handling of side effects. RESULTS The majority of patients with isolated prostate-specific antigen (PSA) relapse are not candidates for salvage treatment with curative intent. The PSA threshold that triggers initiation of hormonal therapy is debatable and should be based also on pretreatment risk assessment. Intermittent androgen suppression is an emerging concept to circumvent the unresolved controversy of early versus deferred endocrine therapy. Since the tumor load at time of recurrence is low, peripheral androgen blockade with an antiandrogen and a 5alpha-reductase inhibitor is an acceptable first choice. In case of progression, addition of a LHRH analogue would be the next step. Antiandrogen withdrawal and second-line antiandrogens are clinically of limited value. CONCLUSIONS Biochemical-only progression after definitive treatment in curative intent is different from objective or even symptomatic relapse and allows for sequential hormonal therapy with a variety of compounds.
Collapse
|
13
|
Dudderidge T, Payne H, Emberton M. An algorithm for managing the failure of external beam radiotherapy in prostate cancer. BJU Int 2007; 100:518-27. [PMID: 17573894 DOI: 10.1111/j.1464-410x.2007.06999.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To present a management algorithm for men with prostate cancer recurring after external beam radiotherapy (EBRT), based on a review of published reports, to assist clinicians in identifying men who are suitable for salvage therapy and to help them to decide which type of salvage treatment is most likely to confer the desired outcome with the minimum of harm. METHODS Men with radiorecurrent prostate cancer require special consideration; they tend to be older, have more comorbidity and have worse disease than their contemporaries having primary treatment. Salvage treatment is compromised by the irradiated pelvis, resulting in increased treatment toxicity. Using the Pubmed database and reference lists of key articles, we identified studies relating to the management of radiorecurrent prostate cancer; the findings were incorporated into a management algorithm and summary table of treatments. RESULTS The American Society for Therapeutic Radiology and Oncology criteria, which define biochemical failure has now been superseded by the Phoenix definition (nadir prostate-specific antigen [PSA] plus 2 ng/mL). Biochemical follow-up after EBRT should be 3-monthly until the PSA level has reached a stable nadir after withdrawing androgen suppression. Contrast-enhanced dynamic magnetic resonance imaging (MRI) is an accurate tool and can be used for both the diagnosis and staging of patients with prostate cancer, in conjunction with prostate biopsies. Prostate biopsies should only be considered >2 years after EBRT to avoid false-positive results. In addition to MRI, high-risk cases being considered for salvage therapy should be considered for laparoscopic lymph-node dissection to exclude micrometastases. Deferred androgen suppression, laparoscopic or open radical prostatectomy, cryotherapy and high-intensity focused ultrasound all seem reasonable salvage treatment approaches. CONCLUSION Through improved methods of detection, including frequent PSA measurements, modern imaging and carefully obtained biopsies, those with radiorecurrent disease can be identified before their disease has spread. Rigorous staging will exclude those with micrometastases. The minimally invasive salvage therapies seem to offer an advantage over salvage surgery to patients in whom the benefits and harms are so finely balanced.
Collapse
Affiliation(s)
- Tim Dudderidge
- University College London Hospitals NHS Foundation Trust, and Institute of Urology, Division of Surgical and Interventional Sciences, University College London, London, UK.
| | | | | |
Collapse
|
14
|
Kupelian PA, Willoughby TR, Reddy CA, Klein EA, Mahadevan A. Hypofractionated Intensity-Modulated Radiotherapy (70 Gy at 2.5 Gy Per Fraction) for Localized Prostate Cancer: Cleveland Clinic Experience. Int J Radiat Oncol Biol Phys 2007; 68:1424-30. [PMID: 17544601 DOI: 10.1016/j.ijrobp.2007.01.067] [Citation(s) in RCA: 260] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2006] [Revised: 01/25/2007] [Accepted: 01/27/2007] [Indexed: 10/23/2022]
Abstract
PURPOSE To study the outcomes in patients treated for localized prostate cancer with 70 Gy delivered at 2.5-Gy/fraction within 5 weeks. METHODS AND MATERIALS The study sample included all 770 consecutive patients with localized prostate cancer treated with hypofractionated intensity-modulated radiotherapy at the Cleveland Clinic between 1998 and 2005. The median follow-up was 45 months (maximum, 86). Both the American Society for Therapeutic Radiology and Oncology (ASTRO) biochemical failure definition and the alternate nadir + 2 ng/mL definition were used. RESULTS The overall 5-year ASTRO biochemical relapse-free survival rate was 82% (95% confidence interval, 79-85%), and the 5-year nadir + 2 ng/mL rate was 83% (95% confidence interval, 79-86%). For patients with low-risk, intermediate-risk, and high-risk disease, the 5-year ASTRO rate was 95%, 85%, and 68%, respectively. The 5-year nadir + 2 ng/mL rate for patients with low-, intermediate-, and high-risk disease was 94%, 83%, and 72%, respectively. The Radiation Therapy Oncology Group acute rectal toxicity scores were 0 in 51%, 1 in 40%, and 2 in 9% of patients. The acute urinary toxicity scores were 0 in 33%, 1 in 48%, 2 in 18%, and 3 in 1% of patients. The late rectal toxicity scores were 0 in 89.6%, 1 in 5.9%, 2 in 3.1%, 3 in 1.3%, and 4 in 0.1% (1 patient). The late urinary toxicity scores were 0 in 90.5%, 1 in 4.3%, 2 in 5.1%, and 3 in 0.1% (1 patient). CONCLUSION The outcomes after high-dose hypofractionation were acceptable in the entire cohort of patients treated with the schedule of 70 at 2.5 Gy/fraction.
Collapse
Affiliation(s)
- Patrick A Kupelian
- Department of Radiation Oncology, M.D. Anderson Cancer Center Orlando, Orlando, FL 32806, USA.
| | | | | | | | | |
Collapse
|
15
|
Chin JL, Ng CK, Touma NJ, Pus NJ, Hardie R, Abdelhady M, Rodrigues G, Radwan J, Venkatesan V, Moussa M, Downey DB, Bauman G. Randomized trial comparing cryoablation and external beam radiotherapy for T2C-T3B prostate cancer. Prostate Cancer Prostatic Dis 2007; 11:40-5. [PMID: 17579613 DOI: 10.1038/sj.pcan.4500988] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The objective was to evaluate the relative efficacy of cryoablation (CRYO) versus external beam radiation (EBRT) for clinically locally advanced prostate cancer in a randomized clinical trial. Patients with histologically proven, clinically staged as T2C, T3A or T3B disease were randomized with 6 months of perioperative hormone therapy to one of the two procedures. Owing largely to a shift in practice to longer term adjuvant hormonal therapy and higher doses of radiation for T3 disease, only 64 out of the planned 150 patients were accrued. Twenty-one of 33 (64%) in the CRYO group and 14 of 31 (45%) in the EBRT-treated group who had met the ASTRO definition of failure were also classified as treatment failure. The mean biochemical disease-free survival (bDFS) was 41 months for the EBRT group compared to 28 months for the CRYO group. The 4-year bDFS for EBRT and CRYO groups were 47 and 13%, respectively. Disease-specific survival (DSS) and overall survival (OS) for both groups were very similar. Serious complications were uncommon in either group. EBRT patients exhibited gastrointestinal (GI) adverse effects more frequently. Taking into account the relative deficiency in numbers and the original trial design, this prospective randomized trial indicated that the results of CRYO were less favorable compared to those of EBRT, and was suboptimal primary therapy in locally advanced prostate cancer.
Collapse
Affiliation(s)
- J L Chin
- Division of Urology, Department of Surgery, London Health Sciences Centre, University of Western Ontario, London, Ontario, Canada.
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
16
|
Kaufman DS, McDougal WS, Zietman AL, Young RH. Case records of the Massachusetts General Hospital. Case 18-2007. A 54-year-old man with early-stage prostate cancer. N Engl J Med 2007; 356:2515-20. [PMID: 17568033 DOI: 10.1056/nejmcpc079012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Donald S Kaufman
- Department of Hematology-Oncology, Massachusetts General Hospital, USA
| | | | | | | |
Collapse
|
17
|
Ellis RJ, Zhou H, Kim EY, Fu P, Kaminsky DA, Sodee B, Colussi V, Vance WZ, Spirnak JP, Kim C, Resnick MI. Biochemical disease-free survival rates following definitive low-dose-rate prostate brachytherapy with dose escalation to biologic target volumes identified with SPECT/CT capromab pendetide. Brachytherapy 2007; 6:16-25. [PMID: 17284381 DOI: 10.1016/j.brachy.2006.11.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2006] [Revised: 11/01/2006] [Accepted: 11/03/2006] [Indexed: 10/23/2022]
Abstract
PURPOSE To report biochemical disease-free survival (bDFS) after conformal brachytherapy with dose escalation to biological target volumes (BTVs) identified by Capromab Pendetide with single photon emission computed tomography and computed tomography image fusion (SPECT/CT). METHODS AND MATERIALS Two hundred thirty-nine (T1c-T3b NxM0) consecutive patients were evaluated by SPECT/CT before treatment. Intraprostatic SPECT/CT BTVs were identified and targeted for 150% dose escalation during brachytherapy seed implant (SI). Patients received either SI alone (n = 150) or external beam radiation therapy (EBRT) plus SI boost (EBRT+SI) (n = 89), with (n = 50) and without (n = 189) neoadjuvant hormone ablation therapy. Risk factors (RF) (prostate-specific antigen [PSA] >10 ng/mL, Stage > or = T2b, and Gleason grade > or = 7) defined risk group (RG) categories [none, 1, and > or = 2 RF define low, intermediate, and high RG] for bDFS calculations using four failure criteria: American Society for Therapeutic Radiology and Oncology (ASTRO) consensus definition, PSA >1.0 ng/mL (PSA >1), PSA >0.5 ng/mL after nadir (PSA >0.5), and PSA nadir+2 ng/mL rise in PSA clinical nadir (CN+2). Median followup was 47.2 months (range, 24.8-96.1). RESULTS Seven-year actuarial bDFS rates were 88.0%, 82.1%, 80.4%, and 79.9% using the ASTRO, PSA >1, PSA >0.5, and CN+2 failure criteria, respectively. ASTRO-defined bDFS rates were 96.0%, 87.0%, and 72.5% for low, intermediate, and high RG's. CONCLUSION The data presented here demonstrate the feasibility of performing SPECT/CT BTV dose escalation in a mature series.
Collapse
Affiliation(s)
- Rodney J Ellis
- Department of Radiation Oncology, Aultman Hospital, Canton, OH, USA.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
18
|
Williams SG, Taylor JMG, Liu N, Tra Y, Duchesne GM, Kestin LL, Martinez A, Pratt GR, Sandler H. Use of Individual Fraction Size Data from 3756 Patients to Directly Determine the α/β Ratio of Prostate Cancer. Int J Radiat Oncol Biol Phys 2007; 68:24-33. [PMID: 17448868 DOI: 10.1016/j.ijrobp.2006.12.036] [Citation(s) in RCA: 137] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2006] [Revised: 09/28/2006] [Accepted: 12/12/2006] [Indexed: 11/15/2022]
Abstract
PURPOSE To examine the effect of fraction size and total dose of radiation on recurrence of localized prostate cancer. METHODS AND MATERIALS A total of 3756 patients treated with radiation monotherapy at three institutions were analyzed, including 185 high-dose-rate brachytherapy (HDRB) boost patients. The 5th to 95th centiles of external beam radiotherapy (EBRT) fraction sizes and doses were 1.8 to 2.86 Gy, and 57.4 to 77.4 Gy, respectively, and HDRB fractional doses were between 5.5 and 12 Gy, totaling 147 unique fractionation schedules. Failure was defined by one biochemical (nadir + 2 ng/ml) and two advanced disease endpoints. The alpha/beta ratios were estimated via a proportional hazards model stratified by risk severity and institution. RESULTS The alpha/beta ratio using biochemical recurrence was 3.7 Gy (95% confidence interval [95% CI], 1.1, infinity Gy) for EBRT-only cases and 2.6 Gy (95% CI, 0.9, 4.8 Gy) after the addition of HDRB data. This estimate was highly dependent on an HDRB homogeneity correction factor (120% HDRB dose increase; alpha/beta ratio 4.5 Gy, 95% CI 1.6, 8.7 Gy). A 5-Gy increase in total dose reduced the hazard of failure by 16% (95% CI 11, 21%, p < 0.0001), and had more impact as follow-up matured (p < 0.0003). The clinically advanced endpoints concurred with the biochemical failure results, albeit with less precision. CONCLUSIONS This study supports the concept that the alpha/beta ratio of prostate cancer is low, although considerable uncertainty remains in the estimated value. Outcome data from EBRT studies using substantially higher doses per fraction are needed to show increased precision in these estimates.
Collapse
Affiliation(s)
- Scott G Williams
- Division of Radiation Oncology, Peter MacCallum Cancer Centre, University of Melbourne, Melbourne, Victoria, Australia.
| | | | | | | | | | | | | | | | | |
Collapse
|
19
|
Schostak M, Krause H, Miller K, Schrader M, Kempkensteffen C, Kollermann J. Does the molecular staging in pelvic lymph nodes improve the detection of relevant prostate cancer metastases? An assessment after 6 years. BJU Int 2007; 99:1409-14. [PMID: 17428244 DOI: 10.1111/j.1464-410x.2007.06861.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To assess the course of cancer-free survival and thus determine how reliably reverse transcriptase-polymerase chain reaction (RT-PCR) can detect prostate-specific antigen (PSA)-expressing cells, as patients with untreated lymph node-positive prostate cancer tend to have a poor prognosis, whereas those treated with radical prostatectomy (RP) and immediate adjuvant hormonal therapy show excellent local disease control and a disease-free survival comparable with that of patients with negative lymph nodes, but the detection of micrometastatic disease in pelvic lymph nodes remains a major challenge. PATIENTS AND METHODS Quantitative RT-PCR was used to detect PSA mRNA expression in total RNA of 457 pelvic lymph nodes from 70 patients who had RP (53 patients) or laparoscopic lymphadenectomy (17) at our clinic in 1999/2000. For this purpose, alternate sections of lymph node tissue were either snap-frozen for later RNA isolation or examined by standard histopathological methods. Clinicopathological data, adjuvant treatments and follow-up data were recorded for all patients. RESULTS After January 2006 (6-year observation period), 13 patients had no follow-up data, while 27 had biochemical (PSA) recurrence or other evidence of clinical progression (two died from prostate cancer), and 30 had no signs of recurrence. Compared to the 'reference' standard (histopathology), the PCR method had a sensitivity of 83% and a specificity of 66%. The method had a positive predictive value of 52% and a negative predictive value of 57%. CONCLUSION Considered alone, pelvic lymph node PSA RT-PCR does not predict the clinical course better than a histopathological assessment of lymph nodes. However, it also identifies some patients with negative histology who later show progression. When added to the pathological classification, PSA RT-PCR improves the detection rate of primary lymphatic dissemination.
Collapse
Affiliation(s)
- Martin Schostak
- Department of Urology, Charité- Campus Benjamin Franklin, Universitätsmedizin Berlin, Germany.
| | | | | | | | | | | |
Collapse
|
20
|
Eade TN, Hanlon AL, Horwitz EM, Buyyounouski MK, Hanks GE, Pollack A. What dose of external-beam radiation is high enough for prostate cancer? Int J Radiat Oncol Biol Phys 2007; 68:682-9. [PMID: 17398026 PMCID: PMC2770596 DOI: 10.1016/j.ijrobp.2007.01.008] [Citation(s) in RCA: 126] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2006] [Revised: 01/03/2007] [Accepted: 01/03/2007] [Indexed: 10/23/2022]
Abstract
PURPOSE To quantify the radiotherapy dose-response of prostate cancer, adjusted for prognostic factors in a mature cohort of men treated relatively uniformly at a single institution. PATIENTS AND METHODS The study cohort consisted of 1,530 men treated with three-dimensional conformal external-beam radiotherapy between 1989 and 2002. Patients were divided into four isocenter dose groups: <70 Gy (n = 43), 70-74.9 Gy (n = 552), 75-79.9 Gy (n = 568), and > or =80 Gy (n = 367). The primary endpoints were freedom from biochemical failure (FFBF), defined by American Society for Therapeutic Radiology and Oncology (ASTRO) and Phoenix (nadir + 2.0 ng/mL) criteria, and freedom from distant metastases (FFDM). Multivariate analyses were performed and adjusted Kaplan-Meier estimates were calculated. Logit regression dose-response functions were determined at 5 and 8 years for FFBF and at 5 and 10 years for FFDM. RESULTS Radiotherapy dose was significant in multivariate analyses for FFBF (ASTRO and Phoenix) and FFDM. Adjusted 5-year estimates of ASTRO FFBF for the four dose groups were 60%, 68%, 76%, and 84%. Adjusted 5-year Phoenix FFBFs for the four dose groups were 70%, 81%, 83%, and 89%. Adjusted 5-year and 10-year estimates of FFDM for the four dose groups were 96% and 93%, 97% and 93%, 99% and 95%, and 98% and 96%. Dose-response functions showed an increasing benefit for doses > or =80 Gy. CONCLUSIONS Doses of > or =80 Gy are recommended for most men with prostate cancer. The ASTRO definition of biochemical failure does not accurately estimate the effects of radiotherapy at 5 years because of backdating, compared to the Phoenix definition, which is less sensitive to follow-up and more reproducible over time.
Collapse
Affiliation(s)
- Thomas N. Eade
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA
| | | | - Eric M. Horwitz
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA
| | | | - Gerald E. Hanks
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA
| | - Alan Pollack
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA
| |
Collapse
|
21
|
Cookson MS, Aus G, Burnett AL, Canby-Hagino ED, D'Amico AV, Dmochowski RR, Eton DT, Forman JD, Goldenberg SL, Hernandez J, Higano CS, Kraus SR, Moul JW, Tangen C, Thrasher JB, Thompson I. Variation in the Definition of Biochemical Recurrence in Patients Treated for Localized Prostate Cancer: The American Urological Association Prostate Guidelines for Localized Prostate Cancer Update Panel Report and Recommendations for a Standard in the Reporting of Surgical Outcomes. J Urol 2007; 177:540-5. [PMID: 17222629 DOI: 10.1016/j.juro.2006.10.097] [Citation(s) in RCA: 594] [Impact Index Per Article: 34.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2006] [Indexed: 10/23/2022]
Abstract
PURPOSE The American Urological Association Prostate Guideline Update Panel was charged with updating the Guidelines for Clinically Localized Prostate Cancer. In assessing outcomes with treatment, it became apparent that a highly variable number of definitions exist with respect to biochemical recurrence. Herein, we review the variability in published definitions of biochemical recurrence and make recommendations directed toward improving this terminology by recommending a standard definition in patients treated with radical prostatectomy. MATERIALS AND METHODS Four PubMed literature searches were performed between May 2001 and April, 2004 and covered articles published from 1991 through early 2004. The search terms included the MeSH major headings of prostate cancer and prostatic neoplasm. All potentially relevant articles were retrieved and a more detailed screen for relevance was performed. An article was considered relevant if it reported treatment outcomes of patients with clinical T1 or T2N0M0 prostate cancer. Data extractors recorded the definition of biochemical recurrence and definitions were then collapsed into categories representing the same criteria. The results of biochemical failure were subcategorized by initial treatment. RESULTS Of 13,800 citations, a total of 436 articles were selected. Among these, a total of 145 articles contained 53 different definitions of biochemical recurrence for those treated with radical prostatectomy. Of these, the most common definition (35) was a prostate specific antigen of >0.2 ng/mL or a slight variation thereof. In addition, a total of 208 articles reported 99 different definitions of biochemical failure among those treated with radiation therapy. Of these, the American Society for Therapeutic Radiology and Oncology definition (70) and/or a variation thereof was the most commonly reported. In total, 166 different definitions of biochemical failure were identified. Following radical prostatectomy, the Panel recommends defining biochemical recurrence as an initial serum prostate specific antigen of > or =0.2 ng/mL, with a second confirmatory level of prostate specific antigen of >0.2 ng/mL. The Panel recommends the use of the American Society for Therapeutic Radiology and Oncology criteria for patients treated with radiation therapy and acknowledges that these criteria will soon be updated although not yet published. CONCLUSIONS A high degree of variability in the definition of biochemical recurrence exists following treatment for localized prostate cancer. Strict definitions for biochemical recurrence are necessary to identify men at risk for disease progression and to allow meaningful comparisons among patients treated similarly. The Panel acknowledges the American Society for Therapeutic Radiology and Oncology criteria and future modifications thereof for those receiving radiation therapy and recommends the newly developed American Urological Association criteria for those treated with radical prostatectomy. The purpose for the establishment of this standard is for data reporting purposes and for comparison of similarly treated patients. It is not intended to represent a threshold value for which to initiate treatment. The Panel acknowledges that the clinical decision to initiate treatment will be dependent on multiple factors including patient and physician interaction rather than a specific prostate specific antigen threshold value.
Collapse
Affiliation(s)
- Michael S Cookson
- Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, TN 37232, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
22
|
Berg A, Berner A, Lilleby W, Bruland ØS, Fosså SD, Nesland JM, Kvalheim G. Impact of disseminated tumor cells in bone marrow at diagnosis in patients with nonmetastatic prostate cancer treated by definitive radiotherapy. Int J Cancer 2007; 120:1603-9. [PMID: 17230512 DOI: 10.1002/ijc.22488] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
The purpose of this study was to explore whether detection of disseminated tumor cells (DTCs) in bone marrow (BM) of nonmetastatic prostate cancer (PC) was associated with other clinical or histopathological factors at diagnoses or clinical outcome subsequent to definitive radiotherapy (RT). We evaluated BM aspirates from 272 cT(1-4)pN(0)M(0) PC patients by immunocytochemistry employing anticytokeratin antibodies (AE1/AE3). BM-status was compared with clinical and histopathological parameters. Long-term clinical outcome was assessed in 131 of the patients who all had completed definitive RT with or without androgen deprivation (AD), initiating treatment >5 years before cut-off date June 1, 2005. They had at least 1 unfavorable prognostic feature defined as cT(3-4) or Gleason score (GS) >or= 7B or PSA >or= 10 microg/l. Overall death, cause-specific death, distant metastases (DM) as first clinical relapse, local failure as first clinical relapse and biochemical failure were defined as end-points. DTCs were detected in 18% of the patients and were associated with increasing GS (p = 0.04) and percentage of Gleason pattern 4/5 (p = 0.04). The 7-year cumulative risk of DM was 21% for BM-positive patients vs. 6% for BM-negative patients (p = 0.07). In patients receiving RT without AD (n = 75), the 7-year cumulative risk of DM for BM-positive patients was 28% vs. 9% for BM-negative patients (p = 0.03). BM-status did not have impact on other end-points. In conclusion our study shows that presence of DTCs in BM at diagnosis was associated with the histological differentiation of the primary tumor and an increased risk of developing distant metastases after RT.
Collapse
Affiliation(s)
- Arne Berg
- Faculty of Medicine, University of Oslo, Norway.
| | | | | | | | | | | | | |
Collapse
|
23
|
Fitch DL, McGrath S, Martinez AA, Vicini FA, Kestin LL. Unification of a common biochemical failure definition for prostate cancer treated with brachytherapy or external beam radiotherapy with or without androgen deprivation. Int J Radiat Oncol Biol Phys 2006; 66:1430-9. [PMID: 16765527 DOI: 10.1016/j.ijrobp.2006.03.024] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2005] [Revised: 03/02/2006] [Accepted: 03/14/2006] [Indexed: 11/28/2022]
Abstract
PURPOSE Minimal data are available regarding selection of an optimal biochemical failure (BF) definition for patients treated with brachytherapy, external beam radiotherapy (EBRT), and combinations of these treatments with or without androgen deprivation (AD). We retrospectively analyzed our institution's experience treating localized prostate cancer in an attempt to determine a BF definition that could be applied for these various treatment modalities. METHODS AND MATERIALS A total of 2376 patients with clinical stage T1-T3 N0 M0 prostate cancer were treated with conventional dose (median, 66.6 Gy) EBRT (n = 1201), high-dose (median, 75.6 Gy) adaptive radiation therapy (n = 465), EBRT + high-dose-rate brachytherapy boost (n = 416), or brachytherapy alone (n = 294) between 1987 and 2003. A total of 496 patients (21%) received neoadjuvant AD with radiation therapy. There were 21924 posttreatment prostate-specific antigen (PSA) measurements. Multiple BF definitions were tested for their sensitivity, specificity, positive predictive value (+PV), and negative PV (-PV) in predicting subsequent clinical failure (CF) (any local failure or distant metastasis), overall survival (OS), and cause-specific survival (CSS). Median follow-up was 4.5 years. The date of BF was the date BF criteria were met (e.g., date of third rise). RESULTS A total of 290 patients (12%) experienced CF at a median interval of 3.6 years (range, 0.2-15.2 years). The 5- and 10-year CF rates were 12% and 26%, respectively. Three consecutive rises yielded a 46% sensitivity and 84% specificity for predicting CF. The 10-year CF for those 475 patients who experienced three rises (BF) was 37% vs. 17% for those patients who did not meet these criteria (biochemically controlled [BC]). For all patients, the following definitions were superior to three rises for predicting CF for both +PV, and -PV: n + 1 (> or =1 ng/mL above nadir), n + 2, n + 3, threshold 2 (any PSA > or =2.0 ng/mL at or after nadir), threshold 3, threshold 4, and threshold 5. For the subset of patients treated with EBRT alone, the n + k definitions and threshold k definitions maintained superior predictive capacity. However, the threshold k definitions seemed to maintain a slightly greater separation in 10-year CF rates (43% for BF vs. 13% for BC = 30% difference for threshold 3). Surprisingly, all definitions generally had better predictive capacity for those patients who received brachytherapy or neoadjuvant AD vs. EBRT alone. The endpoints appeared similar for n + 1 vs. threshold 3 and n + 2 vs. threshold 4 in EBRT alone patients, but for brachytherapy or neoadjuvant AD patients, there were similarities for n + 2 vs. threshold 3 and n + 3 vs. threshold 4. This may be a reflection of the lower nadir levels in patients receiving AD (median <0.1 ng/mL vs. 0.2 ng/mL for brachytherapy vs. 0.8 ng/mL for EBRT alone, p < 0.01). When examining CF correlation for the various classes of BF definitions, the threshold k definitions clearly demonstrated the greatest area under the receiver operating characteristic curve, followed by the n + k definitions. For OS, the threshold k definitions again demonstrated the greatest area under the curve, followed by definitions based on specific nadir cutoffs (nadir > or =k ng/mL). CONCLUSIONS Biochemical failure definitions applying a PSA threshold at or after the nadir (e.g., threshold 3) demonstrated the highest association with CF, OS, and CSS for all assessed treatment modalities. Definitions incorporating a PSA increase above the nadir value (e.g., nadir + 2 ng/mL) were also superior for all modalities. In general, BF definitions have greater predictive capacity for clinical outcome with brachytherapy or neoadjuvant AD than EBRT alone, possibly because of less "noise" from production of background PSA.
Collapse
Affiliation(s)
- Dwight L Fitch
- Department of Radiation Oncology, William Beaumont Hospital, Royal Oak, MI 48073, USA
| | | | | | | | | |
Collapse
|
24
|
Ray ME, Levy LB, Horwitz EM, Kupelian PA, Martinez AA, Michalski JM, Pisansky TM, Zelefsky MJ, Zietman AL, Kuban DA. Nadir prostate-specific antigen within 12 months after radiotherapy predicts biochemical and distant failure. Urology 2006; 68:1257-62. [PMID: 17141830 DOI: 10.1016/j.urology.2006.08.1056] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2006] [Revised: 05/19/2006] [Accepted: 08/11/2006] [Indexed: 11/23/2022]
Abstract
OBJECTIVES To determine whether nadir prostate-specific antigen (PSA) levels within 12 months (nadir PSA12) after completion of radiotherapy (RT) can be used as an early marker of recurrence risk. METHODS A total of 4839 patients were treated with RT and without hormonal therapy from 1986 to 1995 for Stage T1-T2 prostate cancer at nine institutions. Of these 4839 patients, 4833, with a median follow-up of 6.3 years, met the criteria for analysis. The study endpoints included freedom from PSA failure, initiation of androgen deprivation, or documented local or distant failure (PSA-DFS); freedom from clinically apparent distant metastasis (DMFS); and overall survival (OS). RESULTS Patients with a nadir PSA12 of 2.0 ng/mL or less had an 8-year PSA-DFS, DMFS, and OS rate of 55%, 95%, and 73%, respectively, compared with 40%, 88%, and 69%, respectively, for patients with a nadir PSA12 of more than 2.0 ng/mL. Multivariate analysis confirmed that a nadir PSA12 of greater than 2 ng/mL was an independent predictor of PSA-DFS, DMFS, and OS. Classification and regression tree analysis identified the nadir PSA12 levels after RT associated with PSA-DFS, DMFS, and OS. Nadir PSA12, combined with the pretreatment PSA level, identified patients at particularly high risk of distant metastasis. CONCLUSIONS The results of this large, multi-institutional study have demonstrated that nadir PSA12 is predictive of clinical outcomes for patients with localized prostate cancer after RT. A high pretreatment PSA level and high nadir PSA12 will identify patients at particularly high risk who might benefit from early adjuvant therapy.
Collapse
Affiliation(s)
- Michael E Ray
- Department of Radiation Oncology, University of Michigan Medical Center, Ann Arbor, Michigan 48109-0010, USA.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
25
|
Altwein JE, Ebert T. Das Lokalrezidiv des Prostatakarzinoms: Hormontherapie. Urologe A 2006; 45:1276, 1278-82. [PMID: 16998661 DOI: 10.1007/s00120-006-1201-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND The majority of patients receive HT after biochemical progression despite primary therapy of prostate cancer with curative intent. It is difficult to differentiate at a low rise in PSA level, e.g., <or=1 ng/ml, between local or systemic recurrence. MATERIAL AND METHODS The PSA doubling time (DT) is the most reliable surrogate parameter to decide if HT should be initiated. In practice, however, the trigger PSA is used instead. The latter is closely related to the timing of HT. A high PSA is a contraindication for local salvage therapy. Intermittent HT is apparently as effective as continuous HT and shortens the time of HT exposure. RESULTS Traditional HT employs a LHRH agonist, however, the side effect profile is a disadvantage due to the long duration of this treatment, e.g., sarcopenia, osteopenia, or even cognitive impairment. The alternative is nontraditional HT: nonsteroidal antiandrogen (AA) alone such as bicalutamide 150 mg or peripheral androgen blockade (AA plus 5alpha-reductase inhibitor). CONCLUSION Even after a long duration of the latter HT the side effects are less pronounced (gynecomastia) and treatable. Particularly in patients with high-risk primary tumors [Gleason score 7(4+3)-10 or an initially high PSA], nontraditional HT may be followed by secondary HT.
Collapse
Affiliation(s)
- J E Altwein
- Urologische Abteilung, Krankenhaus Barmherzige Brüder, Akademisches Lehrkrankenhaus, Technische Universität, Romanstrasse 93, 80639, München, Germany.
| | | |
Collapse
|
26
|
Kupelian PA, Mahadevan A, Reddy CA, Reuther AM, Klein EA. Use of different definitions of biochemical failure after external beam radiotherapy changes conclusions about relative treatment efficacy for localized prostate cancer. Urology 2006; 68:593-8. [PMID: 16979731 DOI: 10.1016/j.urology.2006.03.075] [Citation(s) in RCA: 86] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2005] [Revised: 03/06/2006] [Accepted: 03/31/2006] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To report biochemical relapse-free survival (bRFS) after radiotherapy (RT) for localized prostate cancer with two separate failure definitions and compare the results with those after radical prostatectomy (RP). METHODS The study sample comprised 2516 patients with a median follow-up of 78 months. Biochemical relapse after RT was defined as either the American Society for Therapeutic Radiology Oncology definition (definition A [DefA]) or a prostate-specific antigen elevation of more than 2 ng/mL greater than the nadir prostate-specific antigen level (definition N [DefN]). Failure after RP was defined as a prostate-specific antigen level greater than 0.2 ng/mL. RESULTS Compared with DefA, DefN resulted in a 13% greater bRFS rate at 5 years and a 12% lower bRFS rate at 10 years. On multivariate analysis, the treatment modality (RP versus RT) was a significant predictor of bRFS using DefA in favor of RP (P <0.001), but was not with DefN (P = 0.87). Higher radiation doses were independently associated with a better outcome with either definition. CONCLUSIONS Compared with DefA, DefN resulted in better outcomes for up to 7 years after RT, but worse outcomes thereafter. The use of DefA versus DefN resulted in opposite conclusions about the relative efficacies of RT and RP, with DefN suggesting RT is equivalent to RP and DefA that it is worse than RP. Different definitions of biochemical failure after RT can result in differences in the conclusions about treatment efficacy in men with localized prostate cancer, thereby potentially affecting clinical decisions.
Collapse
Affiliation(s)
- Patrick A Kupelian
- Department of Radiation Oncology, M.D. Anderson Cancer Center Orlando, Orlando, Florida 32806, USA.
| | | | | | | | | |
Collapse
|
27
|
Hennequin C, Quero L, Soudi H, Sergent G, Maylin C. Radiothérapie conformationnelle du cancer de la prostate : technique et résultats. ACTA ACUST UNITED AC 2006; 40:233-40. [PMID: 16970066 DOI: 10.1016/j.anuro.2006.03.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
A number of retrospective and prospective studies have demonstrated that radiotherapy of prostate cancer must be actually conformal. Three-dimensional (3D) treatment planning consists in an as accurate as possible definition of target-volume, usually by CT-scan, and design of radiation fields shaped to this target-volume. Several steps are required, each step being important for the overall quality of the treatment. Conformal radiotherapy is better tolerated than conventional irradiation, with significantly less rectal toxicity. It allows dose-escalation up to 80 Gy. It is now possible to go beyond this dose with intensity-modulated radiotherapy. The benefit of these high doses was demonstrated by some large retrospective studies and some prospective dose-escalation trials. Several randomized trials are in progress, preliminary results of two of them have been published, both showing an improvement in disease control with the higher doses. The advantage of higher doses is clearly evident for patients in the intermediate prognostic group, but is still discussed for patients with a low risk tumour or treated in combination with hormone therapy. Late proctitis is the main toxicity of these high doses. Some volume constraints have been defined during the last years and will allow a decrease of the rate of rectal toxicity. Because of these technological improvements, results of radiation therapy are now similar to those of surgery: no direct comparison with a randomized trial is available, but large comparative studies show that long-term disease control are identical with both techniques. Radiation therapy must be proposed to all patients with a prostate carcinoma as an alternative to surgery.
Collapse
Affiliation(s)
- C Hennequin
- Service de cancérologie-radiothérapie, Hôpital Saint-Louis, 1, avenue Claude-Vellefaux, 75010 Paris, France.
| | | | | | | | | |
Collapse
|
28
|
Hammerer PG, Kattan MW, Mottet N, Prayer-Galetti T. Using prostate-specific antigen screening and nomograms to assess risk and predict outcomes in the management of prostate cancer. BJU Int 2006; 98:11-9. [PMID: 16566811 DOI: 10.1111/j.1464-410x.2006.06177.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
We review the role of prostate-specific antigen (PSA) and the importance of patient education in the management of prostate cancer, based on discussions held at a European symposium on managing prostate cancer. Although PSA is the most widely used serum marker for detecting prostate cancer and for monitoring treatment responses, its use as a diagnostic marker is controversial due to concerns of over-diagnosis and low specificity. PSA isoforms, as well as PSA doubling time, might improve the specificity for earlier prostate cancer detection and can be used as surrogate markers for treatment efficacy. Patients can differ considerably in the importance they place on health-related quality of life aspects and fear of cancer progression. Consequently, there needs to be active, educated discussion of risk and outcomes between physicians and patients. Risk assessment tools, e.g. validated nomograms, enable clinicians to improve their decision analysis and form the basis for subsequent discussion of treatment options between the physician and patient, thereby enabling informed consent and appropriate decision-making.
Collapse
Affiliation(s)
- Peter G Hammerer
- Department of Urology, Academic Hospital, Braunschweig, Germany.
| | | | | | | |
Collapse
|
29
|
Abstract
The quoted incidence of biochemical recurrence (BCR) after localized treatment varies significantly and depends on numerous well-known prognostic factors; however, it likely occurs in at least 30%-40% of patients who receive localized treatment. Because the clinical significance of BCR is often unclear, and depends in many cases on unknown factors, it is difficult to select the best treatment and determine when best to institute that therapy. This review examines some of the issues associated with BCR and attempts to shed some light on this common but controversial clinical scenario. Some treatment strategies discussed in this article include salvage radiotherapy after radical prostatectomy, salvage therapy after radiotherapy, and hormonal therapy.
Collapse
Affiliation(s)
- Christopher L Amling
- Division of Urology, University of Alabama, South Birmingham, AL 35294-3411, USA.
| |
Collapse
|
30
|
Tward JD, Lee CM, Pappas LM, Szabo A, Gaffney DK, Shrieve DC. Survival of men with clinically localized prostate cancer treated with prostatectomy, brachytherapy, or no definitive treatment. Cancer 2006; 107:2392-400. [PMID: 17041884 DOI: 10.1002/cncr.22261] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND The optimal treatment for men with early stage prostate cancer remains undefined. Survival of such patients after surgery, brachytherapy, or no definitive therapy was investigated specifically to determine the impact of age at diagnosis. METHODS In all, 60,290 men diagnosed with organ-confined, low and moderate grade prostate cancer between 1988 and 2002 were retrospectively identified from centers participating in the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) Program. Prostate cancer-specific mortality (PCSM) and any-cause mortality (ACM) were determined. Outcomes for patients treated by brachytherapy, surgery, or receiving no definitive treatment were compared using the Wilcoxon test, stratified by T-stage and grade, and using multivariate analysis. RESULTS The median follow-up time was 46 months (range, 0-189 months). For men under age 60 at diagnosis, PCSM at 10 years was 1.3%, 0.5%, and 3.7% for surgery, brachytherapy, and no definitive therapy, respectively. For men age 60 and older the PCSM was 3.8%, 5.3%, and 8.4%, respectively. On univariate and multivariate analysis, surgery and brachytherapy resulted in statistically equivalent PCSM and ACM, and both had a significantly lower PCSM and ACM versus no definitive therapy. CONCLUSIONS A better survival was observed in men treated with a definitive therapy. The magnitude of the benefit on PCSM or ACM was similar for both definitive therapies irrespective of age.
Collapse
Affiliation(s)
- Jonathan D Tward
- Department of Radiation Oncology, Huntsman Cancer Hospital, University of Utah, Salt Lake City, Utah 84112, USA.
| | | | | | | | | | | |
Collapse
|
31
|
Kupelian PA, Thakkar VV, Khuntia D, Reddy CA, Klein EA, Mahadevan A. Hypofractionated intensity-modulated radiotherapy (70 gy at 2.5 Gy per fraction) for localized prostate cancer: long-term outcomes. Int J Radiat Oncol Biol Phys 2005; 63:1463-8. [PMID: 16169683 DOI: 10.1016/j.ijrobp.2005.05.054] [Citation(s) in RCA: 154] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2005] [Revised: 05/13/2005] [Accepted: 05/16/2005] [Indexed: 01/27/2023]
Abstract
PURPOSE To analyze the long-term relapse-free survival and toxicity rates in patients treated with hypofractionated intensity-modulated radiotherapy. METHODS AND MATERIALS The study sample includes the first 100 consecutive localized prostate cancer patients treated to 70.0 Gy at 2.5 Gy per fraction. The median follow-up was 66 months (range, 3 to 75 months). Biochemical failure was the study endpoint, using both the ASTRO definition (A-bRFS) and the alternate "nadir + 2 ng/mL" definition (N-bRFS). RTOG scores were used to assess toxicity. RESULTS The 5-year A-bRFS and N-bRFS rates were 85% (95%CI, 78-93%) and 88% (95%CI, 82-95%) for all cases, respectively. For low, intermediate and high-risk disease, the 5-year A-bRFS rates were 97%, 88%, and 70%. The corresponding 5-year N-bRFS rates were 97%, 93%, and 75%, respectively. The acute rectal toxicity scores were 0 in 20, 1 in 61, and 2 in 19 patients. The acute urinary toxicity scores were 0 in 9, 1 in 76, and 2 in 15 patients. The late rectal toxicity scores were 0 in 71, 1 in 19, 2 in 7, and 3 in 3 patients. The actuarial late Grade 3 rectal toxicity rate at 5 years was 3%. A number of the toxicities observed either resolved spontaneously or were corrected. At last follow-up, the rate of combined Grades 2 and 3 late rectal toxicity at 5 years was only 5%. The late urinary toxicity scores were 0 in 75, 1 in 13, 2 in 11, and 3 in 1 patients. The actuarial late Grade 3 urinary toxicity rate at 5 years was 1%. CONCLUSION With a median follow-up of 66 months, the long-term results after high-dose hypofractionation are excellent. Late toxicity, urinary and rectal, has been limited. High-dose hypofractionation is an alternative dose escalation method in the treatment of localized prostate cancer.
Collapse
Affiliation(s)
- Patrick A Kupelian
- Department of Radiation Oncology, M.D. Anderson Cancer Center Orlando, Orlando, FL 32806, USA.
| | | | | | | | | | | |
Collapse
|