Health-related quality of life in men receiving prostate brachytherapy on RTOG 98-05

Redefining bladder neck dose in low-dose-rate prostate brachytherapy-Can we improve urinary toxicity without impacting disease control?

BACKGROUND

We sought to assess the impact of bladder neck dose (BND) on patient reported urinary toxicity, and feasibility of relative urethral sparing technique in prostate brachytherapy (PB).

METHODS AND MATERIALS

We retrospectively identified bladder neck as a point dose on post-implant CT scans in patients treated with 131Cs PB. Urinary symptoms were assessed through EPIC questionnaires. Patient cohorts were identified based on mean BND as a percentage of prescription dose with toxicity assessment at each time point.

RESULTS

In our cohort of 542 patients, BND was associated with clinically significant acute urinary symptoms and chronic symptoms, as patients receiving >70% of the prescription dose had significantly worse overall EPIC scores than patients receiving ≤70% of prescription dose. There was no difference in bDFS between patients receiving BND ≤70% (96% bDFS) and >70% (94% bDFS) at a median follow up of 57 months.

CONCLUSIONS

BND has a significant impact on both acute and chronic urinary symptoms, with reduced symptoms reported with BND <70% of prescription dose. With a median follow up of 4.7 years, excellent bDFS has thus far been achieved with relative urethral and bladder neck sparing. Utilizing this constraint should improve urinary symptoms without impacting disease control.

Treatment Regret, Mental and Physical Health Indicators of Psychosocial Well-Being among Prostate Cancer Survivors

Prostate cancer (PCa) patients and survivors are at high risk of mental health illness. Here, we examined the contribution of treatment regret, mental and physical health indicators to the social/family, emotional, functional and spiritual well-being of PCa survivors. The study assessed 367 men with a history of PCa residing in the Maritimes Canada who were surveyed between 2017 and 2021. The outcomes were social/family, emotional, functional and spiritual well-being (FACT-P,FACIT-Sp). Predictor variables included urinary, bowel and sexual function (UCLA-PCI), physical and mental health (SF-12), and treatment regret. Logistic regression analyses were controlled for age, income, and survivorship time. Poor social/family, emotional, functional and spiritual well-being was identified among 54.4%, 26.5%, 49.9% and 63.8% of the men in the sample. Men who reported treatment regret had 3.62, 5.58, or 4.63 higher odds of poor social/family, emotional, and functional well-being, respectively. Men with low household income had 3.77 times higher odds for poor social/well-being. Good mental health was a protective factor for poor social/family, emotional, functional, or spiritual well-being. Better physical and sexual health were protective factors for poor functional well-being. Seeking to promote PCa patients' autonomy in treatment decisions and recognizing this process' vulnerability in health care contexts is warranted.

Long-term outcomes of a prospective randomized trial of 131Cs/125I permanent prostate brachytherapy

PURPOSE

Iodine-125 (¹²⁵I) is the most commonly used isotope for prostate brachytherapy (BT). Cesium-131 (¹³¹Cs) has a higher dose rate and shorter dose delivery time resulting in decreased duration of acute urinary morbidity. Long-term data suggest excellent oncologic outcomes; it is not known how outcomes compare. A prospective randomized trial comparing the two isotopes was initiated.

MATERIALS AND METHODS

Patients with low- or intermediate-risk disease were treated with a BT in a single outpatient facility. Prescription dose was 144 Gy for ¹²⁵I and 115 Gy for ¹³¹Cs. Androgen deprivation or supplemental EBRT was not allowed. The primary study objective was comparison of the mean EPIC Urinary Domain Score. Secondary objective was biochemical relapse-free survival (BRFS) comparison. Time-to-event for all outcomes of interest was measured from implant date.

RESULTS

One hundred forty men were enrolled; 81.4% were low-risk and 18.6% were intermediate-risk. The median followup was 97 months. Urinary and sexual health-related quality of life did not differ between isotopes at any recorded time point. At 2 months after implantation, bowel health-related quality of life was worse with ¹²⁵I; however, this difference was lost at subsequent time points. The 9-year BRFS was 87.2% and 84.0% for the ¹²⁵I and ¹³¹Cs group, respectively (p = 0.897). There was no statistically significant difference in BRFS based on initial T stage, PSA, or Gleason score.

CONCLUSIONS

Short- and long-term urinary, sexual, and bowel quality of life, as well as long-term biochemical control were comparable between ¹²⁵I and ¹³¹Cs. This report therefore supports the continued use of ¹³¹Cs as an effective and comparable alternative isotope.

Risk of erectile dysfunction after modern radiotherapy for intact prostate cancer

BACKGROUND

Erectile dysfunction (ED) is a prevalent side effect of prostate cancer treatment. We hypothesized that the previously reported rates of ED may have improved with the advent of modern technology. The purpose of this project was to evaluate modern external beam radiotherapy and brachytherapy techniques to determine the incidence of radiotherapy (RT) induced ED.

METHODS

A systematic review of the literature published between January 2002 and December 2018 was performed to obtain patient reported rates of ED after definitive external beam radiotherapy, ultrafractionated stereotactic radiotherapy, and brachytherapy (BT) to the prostate in men who were potent prior to RT. Univariate and multivariate analyses of radiation dose, treatment strategy, and length of follow-up were analyzed to ascertain their relationship with RT-induced ED.

RESULTS

Of 890 articles reviewed, 24 met inclusion criteria, providing data from 2714 patients. Diminished erectile function status post RT was common and similar across all studies. The median increase in men reporting ED was 17%, 26%, 23%, and 23%, 3DCRT, IMRT, low dose rate BT, and SBRT, respectively, at 2-year median follow-up.

CONCLUSION

ED is a common side effect of RT. Risk of post-RT ED is similar for both LDR brachytherapy and external beam RT with advanced prostate targeting and penile-bulb sparing techniques utilized in modern RT techniques.

Challenges in Reporting the Effect of Radiotherapy on Erectile Function

BACKGROUND

Erectile dysfunction (ED) is the most common side effect of prostate radiotherapy (RT), but reported rates over time and across modalities have varied widely.

AIM

To evaluate the published literature between 2002 and 2018 for high quality data utilizing prospectively gathered patient-reported ED, and to summarize the challenges in reporting of RT-induced ED (RIED).

METHODS

A PubMed search and literature review was performed to identify articles describing rates of ED before and after definitive external beam RT or brachytherapy without androgen deprivation.

OUTCOMES

Patient-reported ED, patient and treatment variables, and study follow-up constituted the main outcomes of this study.

RESULTS

24 articles were identified, reporting RIED rates between 17% and 90%. Variables contributing to this range included patient, treatment, and study characteristics known to impact ED reporting.

CLINICAL IMPLICATIONS

For future studies, we recommend the use of validated patient-reported questionnaires and reporting of baseline function and comorbidities, RT type and dose, and use of androgen deprivation therapy and erectile aids at the time of ED measurement. With sufficient follow-up to understand the late nature of RIED, these recommendations will improve comparison of results between studies and the applicability of results to patients undergoing pretreatment counseling regarding the risks of RIED.

STRENGTHS & LIMITATIONS

The literature search and formulation of results were based on a broad understanding of the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines and the literature, but because of the focus on data reporting, a comprehensive systematic review of all RIED literature was not performed.

CONCLUSION

Reported rates of ED after RT vary widely due to differences in patients' baseline reported erectile function, age, comorbidities, and characteristics of the treatment delivered. The methodology of ED measurement has significant impact on the applicability and comparability of results to other studies and clinical practice. Nukala V, Incrocci L, Hunt AA, et al. Challenges in Reporting the Effect of Radiotherapy on Erectile Function. J Sex Med 2020;17:1053-1059.

Comparison of multiparametric MRI-based and transrectal ultrasound-based preplans with intraoperative ultrasound-based planning for low dose rate interstitial prostate seed implantation

PURPOSE

Transrectal ultrasound images are routinely acquired for low dose rate (LDR) prostate brachytherapy dosimetric preplanning (pTRUS), although diagnostic multiparametric magnetic resonance imaging (mpMRI) may serve this purpose as well. We compared the predictive abilities of TRUS vs MRI relative to intraoperative TRUS (iTRUS) to assess the role of mpMRI in brachytherapy preplanning.

MATERIALS AND METHODS

Retrospective analysis was performed on 32 patients who underwent iTRUS-guided prostate LDR brachytherapy as either mono- or combination therapy. 56.3% had pTRUS-only volume studies and 43.7% had both 3T-mpMRI and pTRUS preplanning. MRI was used for preplanning and its image fusion with iTRUS was also used for intraoperative guidance of seed placement. Differences in gland volume, seed number, and activity and procedure time were examined, as well as the identification of lesions suspicious for tumor foci. Pearson correlation coefficient and Fisher's Z test were used to estimate associations between continuous measures.

RESULTS

There was good correlation of planning volumes between iTRUS and either pTRUS or MRI (r = 0.89, r = 0.77), not impacted by the addition of hormonal therapy (P = 0.65, P = 0.33). Both consistently predicted intraoperative seed number (r = 0.87, r = 0.86). MRI/TRUS fusion did not significantly increase surgical or anesthesia time (P = 0.10, P = 0.46). mpMRI revealed suspicious focal lesions in 11 of 14 cases not visible on pTRUS, that when correlated with histopathology, were incorporated into the plan.

CONCLUSIONS

Relative to pTRUS, MRI yielded reliable preplanning measures, supporting the role of MRI-only LDR treatment planning. mpMRI carries numerous diagnostic, staging and preplanning advantages that facilitate better patient selection and delivery of novel dose escalation and targeted therapy, with no additional surgical or anesthesia time. Prospective studies assessing its impact on treatment planning and delivery can serve to establish mpMRI as the standard of care in LDR prostate brachytherapy planning.

Patient-reported outcomes after treatment for clinically localized prostate cancer: A systematic review and meta-analysis

BACKGROUND

The aim of this systematic review is to assess the impact of primary treatments with curative intention in patients with localized prostate cancer, measured with Patient-Reported Outcomes (PROs), and to examine differences among modalities within treatments.

METHODS

We conducted a systematic literature search for January 2005-March 2017 following PRISMA guidelines, including longitudinal studies measuring disease-specific PROs in localized prostate cancer patients with a follow-up from pre- to post-treatment (≥1 year). Two reviewers independently extracted data and assessed risk of bias. The study is registered in PROSPERO: CRD42015019747.

RESULTS

Of 148 identified studies, 60 were included in the meta-analyses. At the 1st year, radical prostatectomy patients showed small urinary irritative-obstructive improvement (0.37SD 95%CI 0.30, 0.45), but large deterioration for sexual function and incontinence with high heterogeneity (I² = 77% and 93%). Moderate worsening in external radiotherapy patients for sexual function (-0.46SD 95%CI -0.55, -0.36), small urinary incontinence (-0.16SD 95%CI -0.23, -0.09) and bowel impairment (-0.31SD 95%CI -0.39, -0.23). Brachytherapy patients presented small deterioration in urinary incontinence (-0.29SD 95%CI -0.39, -0.19), irritative obstructive symptoms (-0.35SD 95%CI -0.47, -0.23), sexual function (-0.12SD 95%CI -0.24, -0.002), and bowel bother (-0.27SD 95%CI -0.42, -0.11). These patterns persisted up to the 5th year. High-intensity focused ultrasound and active surveillance only have results at 1st year, showing no statistically significant worsening.

CONCLUSIONS

No remarkable differences in PRO appeared between modalities within each treatment. Nowadays, available evidence supports brachytherapy as possible alternative to radical prostatectomy for patients seeking an attempted curative treatment limiting the risk for urinary incontinence and sexual dysfunction.

Prostate cancer Ki-67 (MIB-1) expression, perineural invasion, and gleason score as biopsy-based predictors of prostate cancer mortality: the Mayo model

OBJECTIVE

To determine the role of cellular proliferation and other biopsy-based features in the prediction of prostate cancer mortality.

PATIENTS AND METHODS

Between 1993 and 2012, our institution has performed quantitation of prostate cancer DNA ploidy and Ki-67 (MIB-1) on most prostate cancer needle biopsy specimens. The outcomes of 451 consecutive patients with biopsy-proven cancer treated by radical prostatectomy between January 24, 1995, and December 29, 1998, without neoadjuvant hormonal therapy were assessed. Clinical and biopsy information obtained before radical prostatectomy was placed in multivariate Cox proportional hazards regression models to predict local or systemic progression and cancer-specific death. Predictive ability was evaluated using a concordance index.

RESULTS

With a median follow-up of 12.9 years, 46 patients experienced local or systemic progression, and 18 patients died of prostate cancer. On multivariate analysis, the biopsy features of Ki-67 expression, perineural invasion, and Gleason score were associated with local or systemic progression. Ki-67 expression, perineural invasion, and Gleason score were associated with cancer-specific death with a concordance index of 0.892. After adjusting for perineural invasion and Gleason score, each 1% increase in Ki-67 expression was associated with a 12% increased risk of cancer-specific death (P<.001). Ki-67 expression alone was a strong predictor of cancer-specific outcomes and improved the predictive ability of currently used algorithms.

CONCLUSION

This study documents that long-term prostate cancer outcomes are best estimated with a combination of Gleason score, perineural invasion, and Ki-67 expression. Given its low cost, rapid assessment, and strong predictive power, we believe that adding Ki-67 expression to perineural invasion and Gleason score at biopsy should be considered a standard by which all new biomarkers are compared before introducing them into clinical practice.

Early quality of life outcomes in patients with prostate cancer managed by high-dose-rate brachytherapy as monotherapy

OBJECTIVES

To evaluate the early quality of life outcomes in prostate cancer patients managed by high-dose-rate brachytherapy as monotherapy.

METHODS

A total of 51 patients with cT1c-T3aN0M0 prostate cancer treated between July 2007 and January 2010 were included in this study. The average age was 69 years, and the average initial serum prostate-specific antigen was 10.98 ng/mL. A total of 25, 18 and eight patients were considered to be low, intermediate and high risk, respectively. All patients received one implant of Ir-192 and seven fractions of 6.5 Gy within 3.5 days for a total prescribed dose of 45.5 Gy. For high-risk prostate cancer, neoadjuvant androgen deprivation therapy was carried out for at least 6 months, and continued after high-dose-rate brachytherapy. Quality of life outcomes were measured by using the International Prostate Symptom Score, the Functional Assessment of Cancer Therapy-Prostate and the International Index of Erectile Function Questionnaire. The oncological outcome was assessed by serum prostate-specific antigen and diagnostic imaging. Adverse events were also recorded.

RESULTS

The Functional Assessment of Cancer Therapy-Prostate scores decreased for a few months after high-dose-rate brachytherapy, and recovered to pretreatment condition thereafter. The International Prostate Symptom Score significantly increased 2 weeks after treatment for each of its items and their sum, and it returned to baseline after 12 weeks. Sexual function decreased at 2 and 4 weeks, and recovered after 12 weeks. Severe complications were rare. Within a median follow up of 17.2 months, two patients showed a prostate-specific antigen recurrence.

CONCLUSIONS

High-dose-rate brachytherapy for prostate cancer is a feasible treatment modality with acceptable toxicity and only a limited impact on the quality of life.

A survey of current clinical practice in permanent and temporary prostate brachytherapy: 2010 update

PURPOSE

To help establish patterns of care and standards of care of interstitial permanent low-dose-rate (LDR) and temporary high-dose-rate brachytherapy for prostate cancer and to compare the results with a similar 1998 American Brachytherapy Society (ABS) survey.

METHODS AND MATERIALS

A comprehensive questionnaire intended to survey specific details of current clinical brachytherapy practice was provided to the participants of the seventh ABS Prostate Brachytherapy School. Responses were tabulated and descriptive statistics are reported.

RESULTS

Sixty-five brachytherapy practitioners responded to the survey. Eighty-nine percent (89%) of respondents performed LDR and 49% perform high-dose-rate brachytherapy. The median number of years of experience for LDR brachytherapists increased from 5 to 10 years over the course of the 12 years since the preceding survey. Compared with the first ABS, a smaller proportion of respondents received formal brachytherapy residency training (43% vs. 56%) or formal "hands-on" brachytherapy training (15% vs. 63%). There has been a marked decline in the utilization of the Mick applicator (Mick Radio-Nuclear Instruments, Inc., Mount Vernon, NY, USA) (60% vs. 28%) and an increase in the use of stranded seeds (40% vs. 11%). Compliance with postimplant dosimetry was higher in the 2010 survey.

CONCLUSION

This survey does suggest an evolution in the practice of LDR brachytherapy since 1998 and aids in identifying aspects that require further progress or investigation. ABS guidelines and other practice recommendations appear to impact the practice of brachytherapy.

Suppressive Effects of Eviprostat, a Phytotherapeutic Agent, on Lower Urinary Tract Symptoms in Prostate Cancer Patients Treated with Brachytherapy

OBJECTIVES

Eviprostat is an anti-oxidant, anti-inflammatory phytotherapeutic agent that is commonly used to treat lower urinary tract symptoms (LUTS) in benign prostatic hyperplasia in Japan and Germany. Prostate cancer patients treated with brachytherapy generally have complaints of LUTS for several months postoperatively.

METHODS

We investigated the protective effects of Eviprostat against the development of LUTS in 37 patients, who had received (125) I prostate brachytherapy as monotherapy. These patients were divided into two groups, an Eviprostat-treated group (n = 18) and an untreated control (n = 19), whose background had no significant difference. The group treated with Eviprostat was prophylactically medicated from 3 weeks preoperatively until 3 months postoperatively. Symptom scores and quality of life for urination were evaluated according to the International Prostate Symptom Score (IPSS) and Expanded Prostate Cancer Index Composite (EPIC) on preoperative day 1, and postoperative months 1, 3 and 6.

RESULTS

Both the scores of IPSS and the levels of quality of life in EPIC were significantly worse at 1 month postoperatively compared to the pretreatment baseline, and thereafter progressively improved in both groups. Eviprostat-treated patients showed significantly better recovery compared to Eviprostat-untreated control at 6 months postoperatively, with respect to urinary summary score, urinary function and urinary irritation/obstruction subscales in EPIC. Moreover, the feeling of incomplete emptying in IPSS and the urinary irritation/obstruction subscale in EPIC were significantly improved at 3 months postoperatively compared to the peak impairment at 1 month in the Eviprostat-treated group.

CONCLUSIONS

It is possible that Eviprostat has the potential to ameliorate postoperative LUTS caused by brachytherapy.

Long-term results of a phase II trial of ultrasound-guided radioactive implantation of the prostate for definitive management of localized adenocarcinoma of the prostate (RTOG 98-05)

PURPOSE

To evaluate the long-term effectiveness of transrectal ultrasound-guided permanent radioactive I125 implantation of the prostate for organ confined adenocarcinoma of the prostate compared with historical data of prostatectomy and external beam radiotherapy within a cooperative group setting.

METHODS AND MATERIALS

Patients accrued to this study had histologically confirmed, locally confined adenocarcinoma of the prostate clinical stage T1b, T1c, or T2a; no nodal or metastatic disease; prostate-specific antigen level of ≤10 ng/ml; and a Gleason score of ≤6. All patients underwent transrectal ultrasound-guided radioactive I125 seed implantation into the prostate. The prescribed dose was 145 Gy to the prostate planning target volume.

RESULTS

A total of 101 patients from 27 institutions were accrued to this protocol; by design, no single institution accrued more than 8 patients. There were 94 eligible patients. The median follow up was 8.1 years (range, 0.1-9.2 years). After 8 years, 8 patients had protocol-defined biochemical (prostate-specific antigen) failure (cumulative incidence, 8.0%); 5 patients had local failure (cumulative incidence, 5.5%); and 1 patient had distant failure (cumulative incidence, 1.1%; this patient also had biochemical failure and died of causes not related to prostate cancer). The 8-year overall survival rate was 88%. At last follow-up, no patient had died of prostate cancer or related toxicities. Three patients had maximum late toxicities of Grade 3, all of which were genitourinary. No Grade 4 or 5 toxicities were observed.

CONCLUSIONS

The long-term results of this clinical trial have demonstrated that this kind of trial can be successfully completed through the RTOG and that results in terms of biochemical failure and toxicity compare very favorably with other brachytherapy published series as well as surgical and external beam radiotherapy series. In addition, the prospective, multicenter design highlights the probable generalizability of the outcomes.

A review of low-dose-rate prostate brachytherapy--techniques and outcomes

Prostate cancer is the most common male cancer in the United States and the second leading cause of male cancer death. The main therapeutic modalities for the treatment of prostate cancer are surgery, external beam radiation therapy, hormonal therapy, and brachytherapy. In recent years, brachytherapy has been increasingly utilized for the treatment of early-stage prostate cancer. Technological advances, including improvements in imaging, planning, and postimplant quality assessment by dosimetry have led to widespread use of brachytherapy. Outcomes for prostate brachytherapy have been shown to be equivalent, in selected patients, to those of other treatment modalities for prostate cancer, including radical prostatectomy and external beam radiation therapy. Further, prostate brachytherapy has quality-of-life benefits in comparison to these other treatment modalities, particularly in the domain of sexual function. This paper describes the history of low-dose rate brachytherapy; current techniques for brachytherapy implantation and postoperative dosimetric evaluation; recent outcomes studies; recent quality-of-life analyses; and current and future prostate brachytherapy developments, including open clinical trials. As research in prostate brachytherapy continues, it is likely that this modality will play an increasingly important role in the treatment of early-stage prostate cancer patients in the future.

Sexual function after stereotactic body radiotherapy for prostate cancer: results of a prospective clinical trial

PURPOSE

To study the sexual quality of life for prostate cancer patients after stereotactic body radiotherapy (SBRT).

METHODS AND MATERIALS

Using the Expanded Prostate Cancer Index Composite (EPIC)-validated quality-of-life questionnaire, the sexual function of 32 consecutive patients who received prostate SBRT in a prospective Phase II clinical trial were analyzed at baseline, and at median times of 4, 12, 20, and 50 months after treatment. SBRT consisted of 36.25 Gy in five fractions of 7.25 Gy using the Cyberknife. No androgen deprivation therapy was given. The use of erectile dysfunction (ED) medications was monitored. A comprehensive literature review for radiotherapy-alone modalities based on patient self-reported questionnaires served as historical comparison.

RESULTS

Median age at treatment was 67.5 years, and median follow-up was 35.5 months (minimum 12 months). The mean EPIC sexual domain summary score, sexual function score, and sexual bother score decreased by 45%, 49%, and 25% respectively at 50 months follow-up. These differences reached clinical relevance by 20 months after treatment. Baseline ED rate was 38% and increased to 71% after treatment (p = 0.024). Use of ED medications was 3% at baseline and progressed to 25%. For patients aged <70 years at follow-up, 60% maintained satisfactory erectile function after treatment compared with only 12% aged ≥70 years (p = 0.008). Penile bulb dose was not associated with ED.

CONCLUSIONS

The rates of ED after treatment appear comparable to those reported for other modalities of radiotherapy. Given the modest size of this study and the uncertainties in the physiology of radiotherapy-related ED, these results merit further investigations.

Predictors of response to sildenafil citrate following radiation therapy for prostate cancer

INTRODUCTION

Phosphodiesterase type 5 inhibitor (PDE5) use is a treatment strategy for prostate cancer patients with post-radiation therapy (RT) erectile dysfunction (ED).

AIM

To define the predictors of sildenafil response in men treated with RT for prostate cancer.

MAIN OUTCOME MEASURES

International Index of Erectile Function (IIEF).

METHODS

Patients were enrolled prospectively if they met the following criteria: (i) either a three-dimensional conformal external beam (EBRT) or brachytherapy (BT) with or without androgen deprivation (AD) for prostate cancer; (ii) self-reported ability to have sexual intercourse prior to RT; (iii) experienced onset of ED following RT; (iv) candidates for sildenafil citrate use; (v) followed-up periodically; and (vi) completed the IIEF at least 12 months after RT. Failure to respond to sildenafil was defined as IIEF-erectile function (EF) domain score of <22.

RESULTS

One hundred fifty-two patients met all the criteria: 110 in the EBRT group and 42 in the BT group. Mean age was 62 years. The mean follow-up was 38 months. Mean radiation dose for EBRT was 78 Gy and for BT was 101 Gy. Thirty-five patients received AD, 25% of EBRT, and 62% of BT patients. Sixty-one percent of the patients receiving AD had exposure only pre-RT, whereas 39% had pre- and post-RT AD exposure. The mean duration of AD was 4.6 months. Post-RT IIEF-EF domain score at >24 months was 17. Successful response to sildenafil occurred in 68% of men at 12 months after RT, 50% at 24 months, and 36% at 36 months. On multivariable analysis, predictors of failure to respond to sildenafil were: older age, longer time after RT, AD > 4 months duration, and RT dose > 85 Gy. Modality of radiation delivery was not predictive of sildenafil failure.

CONCLUSIONS

A steady decrease in sildenafil response was seen with increasing duration after RT. Several factors were predictive of sildenafil failure.

Comparison between Real-time Intra-operative Ultrasound-based Dosimetry and CT-based Dosimetry for Prostate Brachytherapy Using Cesium-131

The purpose of this study was to evaluate the correlation between real-time intra-operative ultrasound-based dosimetry (USD) and day 0 post-implant CT dosimetry (CTD) 131 Cs permanent prostate brachytherapy. Fifty-two consecutive patients who underwent prostate brachytherapy with 131 Cs were evaluated. Real time operating room planning was performed using VariSeed 7.1 software. Post-needle placement prostate volume was used for real-time planning. Targets for dosimetry were D90 >110%, V100 >90%, V150 <50%, and V200 <20%. The CT scan for post-operative dosimetry was obtained on day 0. The mean values for USD, CTD, and the linear correlation, respectively, were, for D90: 114.0%, 105.61%, and 0.15; for V100: 95.1%, 91.6%, and 0.22; for V150: 51.5%, 46.4%, and 0.40; and for V200: 15.8%, 17.9%, and 0.42. The differences between the mean values for USD and CTD for D90 (p<0.01), V100 (p<0.01), and V150 (p<0.05) were statistically significant. For D90, 30.8% of patients had a >15% difference between USD and CTD and 51.9% of patients had a >10% difference between these values. In contrast, the USD and CTD for V100 were within 5% in 55.8% of patients and within 10% in 86.5% of patients. This study demonstrates a correlation between the mean intra-operative USD and post-implant day 0 CTD values only for V200. Significant variation in D90, V150, and V200 values existed for individual patients between USD and CTD. These results suggest that real-time intra-operative USD does not serve as a surrogate for post-operative CTD, and that post-operative CTD is still necessary.

Sexuality and sexual function in long-term survivors of cervical cancer

OBJECTIVES

The study reported here assesses sexuality and sexual functioning among women treated for invasive cervical cancer over broad portions of the life cycle. Hysterectomy and oophorectomy, two widespread interventions in invasive cervical cancer, have potentially important effects on a woman's self-image and sexuality.

METHODS

The investigation focused on women aged 29-69 with histories of invasive cervical cancer (n = 179) from the Connecticut Tumor Registry, 6-29 years postdiagnosis. Logistic regression analysis was used to assess the relative impact of time since cervical cancer diagnosis and treatment received, adjusting for age and social and economic background. Sexuality, sexual function, and potential correlates were assessed using the Sexual Adjustment Scale, the MOS-36, and the Center for Epidemiological Studies-Depression Scale (CES-D).

RESULTS

Strong majorities of women in the study indicated that they were sexually active (81.1%) and both desired (81.4%) and enjoyed (90.9%) sexual activity. Neither time since cervical cancer diagnosis nor age significantly affected sexuality or sexual function. Women with hysterectomies (with or without oophorectomy) less often reported lack of interest in (odds ratio [OR] 0.36, p < 0.05) and lack of desire for (OR 0.26, p < 0.05) sexual activity than women who had not had hysterectomies. Among women with hysterectomies, those with oophorectomies had a greater risk (OR 21.1, p < 0.05) of not enjoying sex but did not differ otherwise from those without oophorectomies.

CONCLUSIONS

These findings suggest that cervical cancer survivors generally have a positive attitude toward sexuality and engage in satisfying sexual activity.

Focal cryosurgery followed by penile rehabilitation as primary treatment for localized prostate cancer: initial results

The study reported here was undertaken to assess medium short-term efficacy of focal cryoablation as primary therapy for localized prostate cancer and to determine the rate of morbidity in patients who undergo this treatment. Patients were treated with focal cryoablation with argon cryoprobes under ultrasonographic visualization with temperature monitoring. Men who were potent at the time of intervention were encouraged to use a vacuum erectile dysfunction device on a regular basis after treatment. Incontinence was defined as any urine leakage regardless of the number of pads worn (if any). Potency was defined as the ability to achieve an erection sufficient to complete intercourse with or without oral pharmaceuticals. Biochemical failure was defined as 3 successive rises in serum prostate-specific antigen (PSA) concentration. A total of 60 consecutive patients were treated. Mean patient age was 69.0 years; mean PSA was 7.2 ng/mL, median Gleason score was 6, and median stage was T1c. Before treatment was initiated, all patients were continent and 72.7% were potent. Mean follow-up for the entire population was 15.2+/-7.4 months. Of those patients who were continent before receiving treatment, 3.6% were incontinent at 6 months, but none used any absorbent pads. At last follow-up, 80.4% of patients were biochemically disease free; mean time to failure was 3.5 months among those for whom treatment failed. The positive biopsy rate after first treatment was 23.3%, and mean time to failure was 12.0 months. Of those who underwent a second focal cryoablation procedure after positive biopsy, 66% were subsequently cancer free. All patients who were potent after the first cryoablation procedure regained their potency after the second cryoablation procedure. Focal cryoablation combined with penile rehabilitation as primary treatment for localized prostate cancer is a minimally morbid procedure with acceptable morbidity and the potential for retreatment of a patient if cancer is subsequently detected. Further study is warranted.

A comparison of acute and chronic toxicity for men with low-risk prostate cancer treated with intensity-modulated radiation therapy or (125)I permanent implant

PURPOSE

To compare the toxicity and biochemical outcomes of intensity-modulated radiation therapy (IMRT) and (125)I transperineal permanent prostate seed implant ((125)I) for patients with low-risk prostate cancer.

METHODS AND MATERIALS

Between 1998 and 2004, a total of 374 low-risk patients (prostate-specific antigen < 10 ng/ml, T1c-T2b, Gleason score of 6 or less, and no neoadjuvant hormones) were treated at Fox Chase Cancer Center (216 IMRT and 158 (125)I patients). Median follow-up was 43 months for IMRT and 48 months for (125)I. The IMRT prescription dose ranged from 74-78 Gy, and (125)I prescription was 145 Gy. Acute and late gastrointestinal (GI) and genitourinary (GU) toxicity was recorded by using a modified Radiation Therapy Oncology Group scale. Freedom from biochemical failure was defined by using the Phoenix definition (prostate-specific antigen nadir + 2.0 ng/ml).

RESULTS

Patients treated by using IMRT were more likely to be older and have a higher baseline American Urological Association symptom index score, history of previous transurethral resection of the prostate, and larger prostate volumes. On multivariate analysis, IMRT was an independent predictor of lower acute and late Grade 2 or higher GU toxicity and late Grade 2 or higher GI toxicity. Three-year actuarial estimates of late Grade 2 or higher toxicity were 2.4% for GI and 3.5% for GU by using IMRT compared with 7.7% for GI and 19.2% for GU for (125)I, respectively. Four-year actuarial estimates of freedom from biochemical failure were 99.5% for IMRT and 93.5% for (125)I (p = 0.09).

CONCLUSIONS

The IMRT and (125)I produce similar outcomes, although IMRT appears to have less acute and late toxicity.

A prospective analysis of long-term quality of life after permanent I-125 brachytherapy for localised prostate cancer

BACKGROUND AND PURPOSE

To prospectively evaluate long-term urinary, bowel and sexual function after I-125 brachytherapy for localised prostate cancer using patient administered validated Quality of Life (QoL) instruments.

MATERIALS AND METHODS

Between March 1995 and March 2004, 673 men underwent brachytherapy and recorded urinary symptoms prospectively using the International Prostate Symptom Score (IPSS). In addition, in a subgroup of 116 patients, the Expanded Prostate Cancer Index Composite (EPIC) was used to record QoL information on urinary, bowel and sexual function before treatment and at regular time intervals for at least two years.

RESULTS

Initially, there was a sharp rise in urinary symptoms which was most marked within the first three months. Scores then resolved slowly and returned to within one or two units of pre-treatment level at one year. Subsequently, there was no significant deterioration in urinary symptoms up to nine years following brachytherapy. Few had significant bowel symptoms. Sexual function deteriorated initially and then improved but failed to return to pre-treatment levels by two years. Patients requiring neo-adjuvant hormones experienced significantly more dysfunction.

CONCLUSIONS

After an initial period of mild to moderate urinary symptoms prostate brachytherapy is well tolerated with relatively little deterioration in long-term quality of life. Long-term reduction in sexual function may be seen particularly in those requiring hormones.

Rectal morbidity after permanent prostate brachytherapy with dose escalation to biologic target volumes identified by SPECT/CT fusion

PURPOSE

To evaluate rectal morbidity after dose escalation to biologic target volumes identified by capromab pendetide (ProstaScint) single-photon emission tomography images coregistered with computed tomography (SPECT/CT).

METHODS AND MATERIALS

Two hundred thirty-nine consecutive patients diagnosed with T1c-T3b NxM0 adenocarcinoma of the prostate were treated with brachytherapy seed implant (SI) dose escalation to SPECT/CT-identified biologic target volumes, from February 1997 through December 2002. Patients received SI (n=150) or external beam radiation therapy plus SI (n=89). Rectal morbidity was evaluated by clinician scoring using the modified Radiation Therapy Oncology Group criteria. The median followup was 47.2 (range 24.8-96.1) months.

RESULTS

The rate of acute Grades I and II toxicity was 29.9% and 3.7%, respectively, and chronic Grade I toxicity was 15.4%, 12.4%, 2.3%, and 1.8% at 1, 2, 3, and 4 years postimplant, respectively. Chronic Grade II toxicities were 1.8%, 1.9%, 1.5%, and 0.9% at 1, 2, 3, and 4 years, respectively. No Grade III rectal toxicity was reported. Chronic Grade IV rectal toxicity was 0.5% and 0.6% at 1.5 and 2.5 years, respectively. Ninety-six percent of patients reported freedom from all rectal toxicity after 3 years.

CONCLUSIONS

Dose intensification to occult tumor targets without increasing rectal toxicity may be achieved using SPECT/CT ProstaScint. Additional research to define the role of molecular imaging in prostate cancer is warranted.

Early use of a phosphodiesterase inhibitor after brachytherapy restores and preserves erectile function

OBJECTIVE

To investigate whether the early use of phosphodiesterase inhibitors (PDEIs) after brachytherapy (BT) is associated with better erectile function, as of men potent before BT 38-70% have erectile dysfunction afterward.

PATIENTS AND METHODS

We evaluated a prospectively created database of 2500 patients who had had BT at our institution since 1992. We measured baseline age, cancer stage, Gleason grade, prostate specific antigen (PSA) level at diagnosis, implant type, use of neoadjuvant and adjuvant hormonal suppression therapy, use of external beam radiotherapy in conjunction with interstitial therapy, and follow-up PSA levels. Men were stratified by their use of PDEIs at <1 year (early group) or >1 year after implantation (late group). We excluded all men who did not have baseline Sexual Health Inventory for Men (SHIM) scores and at least one follow-up SHIM score; the latter were obtained at 6-month intervals after BT. Data were analysed using the Mann-Whitney U-test.

RESULTS

In all, 210 men met the inclusion criteria; 85 began using PDEIs within a year of BT, and 125 started after a year. The mean time to PDEI use was 191 days in the early and 595 days in the late group. The median age was 62 years in the early and 63 years in the late group (P = 0.02). Baseline Gleason scores did not differ, nor did PSA levels between the groups. Of men in the early group, 48% received neoadjuvant and/or adjuvant hormonal suppression therapy, vs half of men in the late group. Baseline SHIM scores were not significantly different, nor were scores at the first two follow-up assessments, but the scores at 18-36 months after BT were significantly different.

CONCLUSION

The early use of PDEIs after BT is associated with a significant improvement in and maintenance of erectile function compared with late use. Men undergoing BT should be encouraged to use PDEIs early after implantation, to preserve erectile function.

Patient and Treatment Factors Associated With Complications After Prostate Brachytherapy

Purpose

To assess the prevalence and predictors of complications after prostate brachytherapy in a population-based sample of older men.

Patients and Methods

We analyzed claims for Medicare-enrolled men older than age 65 years living in Surveillance, Epidemiology, and End Results (SEER) surveillance areas diagnosed with prostate cancer from 1991 to 1999 who underwent brachytherapy as initial treatment.

Results

There were 5,621 men who had brachytherapy with at least 2 years of follow-up. A complication diagnosis or invasive procedure occurred in 54.5% of men within 2 years, with 14.1% undergoing an invasive procedure. Urinary, bowel, and erectile morbidity rates were 33.8%, 21.0%, and 16.7%, respectively, and invasive procedure rates were 10.3%, 0.8%, and 4.0%, respectively. On multivariable analysis, combined urinary diagnoses and invasive procedures (obstruction, incontinence, bleeding, fistula) were associated with older age (P < .01), nonwhite race (odds ratio [OR], 1.30; P = .01), low income (OR, 1.74; P < .01), external-beam radiotherapy (EBRT; OR, 0.85; P = .01), androgen deprivation (OR, 1.31; P < .01), later year of brachytherapy (OR, 1.03/yr; P = .02), higher Charlson comorbidity score (P < .01), and prior transurethral resection of the prostate (OR, 1.65; P < .01). Bowel morbidity (bleeding/proctitis, injury) was associated with older age (P = .04), EBRT (OR, 1.46; P < .01), later year (OR, 1.04/yr; P < .01), higher Charlson score (P = .01), and inflammatory bowel disease (OR, 2.60; P < .01). Erectile morbidity was associated with younger age (P < .01), nonwhite race (OR, 1.37; P < .01), AD (OR, 1.18; P = .04), and later year (OR, 1.08/yr; P < .01). Invasive procedure rates declined with later year of brachytherapy (OR, 0.93/yr; P < .01).

Conclusion

Morbidity after prostate brachytherapy was common, though invasive procedures were required infrequently. Invasive procedures for complications declined during the 1990s, suggesting technical improvement with experience.

Prospective evaluation of quality of life after interstitial brachytherapy for localized prostate cancer

PURPOSE

Permanent interstitial brachytherapy (IB) has become an increasingly appealing therapeutic option for localized prostate cancer (LPC) among physicians and patients because it involves short hospitalization and treatment and its postulated low degree of toxicity may reduce its impact on the patients' quality of life (QoL). The aim of this prospective study was to assess the impact of IB on the QoL of patients with LPC.

METHODS AND MATERIALS

A validated self-completed questionnaire was administered to the patients before and after IB and then at yearly intervals. The items allowed the identification of seven subscales exploring physical well-being (PHY), physical autonomy (POW), psychological well-being (PSY), relational life (REL), urinary function (URI), rectal function (REC), and sexual function (SEX).

RESULTS

The assessment of the QoL of 147 patients treated between May 2000 and February 2005 revealed no relevant differences in the PHY scale scores 1 month after IB or later, and the same was true of the POW, PSY, and REL scales. Urinary function significantly worsened after IB and returned to pretreatment levels only after 3 years; the impact of the treatment on the URI scale was greater in the patients with good baseline urinary function than in those presenting more urinary symptoms before IB. Rectal and sexual functions were significantly worse only at the post-IB evaluation.

CONCLUSIONS

The results of the present study confirm that the impact of IB on the patients' QoL is low despite its transient negative effects on some function, and extend existing knowledge concerning QoL after IB.

The abbreviated comprehensive geriatric assessment (aCGA) for use in the older cancer patient as a prescreen: scoring and interpretation

The abbreviated CGA (aCGA) can be used as a prescreening assessment to identify patients who would most benefit from the complete CGA.

OBJECTIVE

To develop cutpoints for scoring the aCGA that are consistent with existing limitations as revealed by the full CGA.

DESIGN/SETTING

A retrospective chart review of patients at the H. Lee Moffitt Cancer Center.

PARTICIPANTS

Over 500 charts between 1995 and 2001 were reviewed on cancer patients 70 and over.

MEASUREMENTS

Each of the four domains: functional status (activities of daily living (ADL), instrumental activities of daily living (IADL), depression, using the geriatric depression scale (GDS), and cognition using the mini-mental state examination (MMSE)) are scored separately.

RESULTS

For the depression domain, a score of 2 or more toward depression indicates that the entire GDS be administered. For the MMSE, a score of 6 or lower indicates necessity of the entire MMSE. For the ADL/IADL, any deficit on either scale (needs assistance or complete assistance) requires further clinical evaluation using the entire instruments.

CONCLUSIONS

These guidelines provide the clinician with parameters to target patients most likely to benefit from more intensive geriatric evaluation.

Association of neoadjuvant hormonal therapy with adverse health-related quality of life after permanent iodine-125 brachytherapy for localized prostate cancer

OBJECTIVES

To characterize the influence of neoadjuvant hormonal therapy (NHT) on health-related quality of life after permanent iodine-125 brachytherapy (BT) for prostate cancer.

METHODS

A cross-sectional survey using the Expanded Prostate Cancer Index Composite health-related quality-of-life instrument was administered to 134 consecutive patients a median of 29 months after BT. A separate group of 111 patients with comparable demographic characteristics without any prior treatment for prostate cancer rendered the baseline information (control group). The scores and symptom rates were compared. The effect of NHT was tested for independence in a multivariate analysis.

RESULTS

In contrast to patients who received NHT, prostatic edema was hardly detectable 30 days after implantation in patients who received BT alone (comparing median preimplant and postimplant volumes), resulting in a greater dose to the prostate and anterior rectal wall. However, compared with the control group and the patients who received BT alone, the addition of NHT to BT led to lower health-related quality-of-life scores in all domains. Score differences of more than 10 points with a statistical significance were found for the urinary bother, sexual function/bother, and hormonal function/bother domains. Apart from the sexual function scores (patient age shown to be the crucial factor), the influence of NHT remained independent on multivariate analysis.

CONCLUSIONS

The results stress the need for well-considered administration of NHT before BT and the need for reporting the use of NHT in studies dealing with BT-related toxicity.

Estimating the risk of long-term erectile, urinary and bowel symptoms resulting from prostate cancer treatment

Reports on long-term complications resulting from treatment for localized prostate cancer are very inconsistent. In order to estimate the risks of long-term erectile dysfunction, urine symptoms and bowel symptoms following prostatectomy (RP), external conventional or conformal beam radiation (ERT or CRT) and brachytherapy (BRT), 98 papers from the PubMed and Cochrane Clinical Trial databases were selected, reviewed and critically evaluated. The majority of papers were institution-based retrospective and prospective follow-up studies; only two of these studies measured the risk of developing more than one treatment complication. Due to differences in study designs and populations, it is difficult to directly compare studies and not meaningful to calculate summary estimates. In addition to focusing on randomized clinical trials and well-designed population based studies, future research should adopt standardized methodologies and should measure the risk of developing more than one treatment complication.