Five-year prospective patient evaluation of bladder and bowel symptoms after dose-escalated radiotherapy for prostate cancer with the BeamCath® technique

Quality of life in men with metastatic prostate cancer in their final years before death - a retrospective analysis of prospective data

Background

Quality of Life (QoL) is the most important outcome for patients in palliative care along with symptom alleviation. Metastatic prostate cancer (mPC) is a life-threatening illness, and hence, a palliative care approach may be beneficial to this group. Over time, new life-prolonging treatments have been developed for men with mPC, but the possibility to prolong life should also be balanced against the men’s QoL, particularly because there are side effects involved with these treatments. The aim of this study was to evaluate QoL, functioning and symptoms in men with mPC during their final years before death.

Methods

This is a retrospective analysis of data from a long-term prospective study of men (n = 3885) with prostate cancer from two regions in Sweden. Validated questionnaires asking about participants’ QoL, functioning and symptoms were used to collect data. From the overall study, 190 men with mPC were identified. They were stratified into three groups, depending on the amount of time that had passed between the last questionnaire and their death; < 6 months, 6–18 months and > 18 months before death.

Results

Men with mPC generally rated their QoL poorly compared to established clinically significant threshold values. The group of men that were < 6 months before death rated their QoL, functioning and several symptoms significantly worse than the two other groups. Men that died after the year 2006 reported lower QoL and functioning and more pain and fatigue than those who died before 2006.

Conclusion

The results in this study indicate that men with mPC have unmet needs with regards to QoL and symptoms. A palliative care approach, alongside possible life-prolonging treatments, that focuses on QoL and symptom relief, may serve as an important frame to give the best support to these men in their final years of life.

Intensity-modulated radiation therapy from 70Gy to 80Gy in prostate cancer: six- year outcomes and predictors of late toxicity

Objective

To report grade ≥2 overall late rectal and urinary toxicities in patients (pts) with prostate cancer treated by intensity-modulated radiotherapy (IMRT) at 3 dose-levels. Identify predictors of radiation toxicity and report biochemical progression free survival (bPFS).

Methods

A total of 277 pts were treated with 70Gy (10.8%), 74Gy (63.9%) and 80 Gy (25.3%) using IMRT without pelvic irradiation were analyzed. Short or long-course androgen deprivation therapy (ADT) was allowed in 46.1% of pts. The toxicity was described using the Common Terminology Criteria for Adverse Events (CTCAE) v4.0 scale. Cox regression models addressed demographics, disease and dosimetry characteristics as potential predictors of late grade ≥2 toxicity after adjusting for other modifying factors.

Results

The median follow-up was 77 months (range 15; 150). There was no grade ≥4 toxicity. The 5-year cumulative rate of grade ≥2 late rectal and urinary toxicities was 6.3% (95% CI = 3.8%; 10.3%) and 25.3% (95% CI = 19.8%; 31.8%) respectively. In multivariate analysis, only the dose (80Gy vs 74 and 70Gy) was found to increase the risk of rectal toxicity (HR = 2.96 [1.07; 8.20]). For pts receiving 74 Gy, International Prostate Symptom Score (IPSS) at baseline ≥8 (HR = 2.40 [1.08; 5.35]) and dose ≥73Gy delivered in more than 2% of bladder (D2%) were found to be predictors of bladder toxicity (HR = 3.29 [1.36; 7.98]). The 5–year biochemical relapse free survival was 81.0% [74.5%; 86.0%] in the entire population, 97.5% [83.5%; 99.6%] in the low risk group, 84.9% [76.7%; 90.3%] in the intermediate risk group and 66.4% [51.8%; 77.4%] in the high-risk group. D’Amico low (HR = 0.09 [0.01; 0.69]) and intermediate risk groups (HR = 0.50 [0.28; 0.88]) as well as PSA nadir ≥0.2 ng/ml (HR = 1.79 [1.01; 3.21]) were predictive of biochemical relapse.

Conclusions

The rate of late rectal toxicity increased with higher doses, while Dmax ≥74Gy, D2% ≥ 73Gy for bladder wall and baseline IPSS ≥8 increased late urinary toxicity.

What is the mechanism effect that links social support to coping and psychological outcome within individuals affected by prostate cancer? Real time data collection using mobile technology

PURPOSE

Unmet support needs are prevalent in men affected by prostate cancer. Moreover, little is known about the optimal type of social support, or its mechanism effect between coping and emotional outcome in men affected by this disease to identify areas for clinical intervention. This study aimed to empirically test the propositions of social support theory in "real time" within individual men living with and beyond prostate cancer.

METHODS

Purposeful sub-sample from a larger prospective longitudinal study of prostate cancer survivors, took part in real time data collection using mobile technology. Self-reports were collected for 31 days prompted by an audio alarm 3 times per day (a total of 93 data entries) for each of the 12 case studies. Electronic data were analysed using time series analysis.

RESULTS

Majority of response rates were >90%. Men reported a lack of satisfaction with their support over time. Testing the propositions of social support theory "within individuals" over time demonstrated different results for main effect, moderation and mediation pathways that linked coping and social support to emotional outcome. For two men, negative effects of social support were identified. For six men the propositions of social support theory did not hold considering their within-person data.

CONCLUSION

This innovative study is one of the first, to demonstrate the acceptability of e-health technology in an ageing population of men affected by prostate cancer. Collectively, the case series provided mixed support for the propositions of social support theory, and demonstrates that "one size does not fit all".

Prospective assessment of urinary, gastrointestinal and sexual symptoms before, during and after image-guided volumetric modulated arc therapy for prostate cancer

OBJECTIVE

The aim of this study was to prospectively assess the development of 24 urinary, gastrointestinal and sexual symptoms in patients with prostate cancer (PCa) during and after image-guided volumetric modulated arc therapy (IG-VMAT).

MATERIAL AND METHODS

A total of 87 patients with PCa participated in this study. The patients were asked to complete a modified version of the Prostate Cancer Symptom Scale (PCSS) questionnaire before radiotherapy (RT) (baseline), at the start of RT, at the end of RT and 1 year after RT. Changes in symptoms at the start of RT, at the end of RT and 1 year after RT compared to baseline were analysed by a mixed model analysis of repeated measurements with the following covariates: age, comorbidity, smoking and androgen deprivation therapy (ADT).

RESULTS

All urinary problems except for haematuria increased significantly at the end of RT compared to baseline. One year after RT, there was no longer any difference compared to baseline for any of the urinary symptoms. All gastrointestinal symptoms except for nausea increased significantly at the end of RT. One year after RT, patients also reported slightly higher degrees of stool frequency, bowel leakage, planning of toilet visits, flatulence, mucus, gastrointestinal bleeding and impact of gastrointestinal bother on daily activities compared to baseline. All sexual symptoms increased significantly at all times compared to baseline. The use of ADT was associated with worse sexual symptoms.

CONCLUSIONS

IG-VMAT is a safe treatment for PCa, with few and mild changes in urinary and gastrointestinal symptoms 1 year after RT compared to baseline. Sexual symptoms deteriorated both during and after RT. The use of ADT was associated with worse sexual symptoms.

Improvement in toxicity in high risk prostate cancer patients treated with image-guided intensity-modulated radiotherapy compared to 3D conformal radiotherapy without daily image guidance

BACKGROUND

Image-guided radiotherapy (IGRT) facilitates the delivery of a very precise radiation dose. In this study we compare the toxicity and biochemical progression-free survival between patients treated with daily image-guided intensity-modulated radiotherapy (IG-IMRT) and 3D conformal radiotherapy (3DCRT) without daily image guidance for high risk prostate cancer (PCa).

METHODS

A total of 503 high risk PCa patients treated with radiotherapy (RT) and endocrine treatment between 2000 and 2010 were retrospectively reviewed. 115 patients were treated with 3DCRT, and 388 patients were treated with IG-IMRT. 3DCRT patients were treated to 76 Gy and without daily image guidance and with 1-2 cm PTV margins. IG-IMRT patients were treated to 78 Gy based on daily image guidance of fiducial markers, and the PTV margins were 5-7 mm. Furthermore, the dose-volume constraints to both the rectum and bladder were changed with the introduction of IG-IMRT.

RESULTS

The 2-year actuarial likelihood of developing grade > = 2 GI toxicity following RT was 57.3% in 3DCRT patients and 5.8% in IG-IMRT patients (p < 0.001). For GU toxicity the numbers were 41.8% and 29.7%, respectively (p = 0.011). On multivariate analysis, 3DCRT was associated with a significantly increased risk of developing grade > = 2 GI toxicity compared to IG-IMRT (p < 0.001, HR = 11.59 [CI: 6.67-20.14]). 3DCRT was also associated with an increased risk of developing GU toxicity compared to IG-IMRT.The 3-year actuarial biochemical progression-free survival probability was 86.0% for 3DCRT and 90.3% for IG-IMRT (p = 0.386). On multivariate analysis there was no difference in biochemical progression-free survival between 3DCRT and IG-IMRT.

CONCLUSION

The difference in toxicity can be attributed to the combination of the IMRT technique with reduced dose to organs-at-risk, daily image guidance and margin reduction.

Change in prostate volume during extreme hypo-fractionation analysed with MRI

BACKGROUND

Hypo-fractionated external beam radiotherapy with narrow CTV-PTV margins is increasingly applied for prostate cancer. This demands a precise target definition and knowledge on target location and extension during treatment. It is unclear how increase in fraction size affects changes in prostate volume during treatment. Our aim was to study prostate volume changes during extreme hypo-fractionation (7 × 6.1 Gy) by using sequential MRIs.

METHODS

Twenty patients treated with extreme hypo-fractionation were recruited from an on-going prospective randomized phase III trial. An MRI scan was done before start of treatment, at mid treatment and at the end of radiotherapy. The prostate was delineated at each MRI and the volume and maximum extension in left-right, anterior-posterior and cranial-caudal directions were measured.

RESULTS

There was a significant increase in mean prostate volume (14%) at mid treatment as compared to baseline. The prostate volume remained enlarged (9%) at the end of radiotherapy. Prostate swelling was most pronounced in the anterior-posterior and cranial-caudal directions.

CONCLUSIONS

Extreme hypo-fractionation induced a significant prostate swelling during treatment that was still present at the time of last treatment fraction. Our results indicate that prostate swelling is an important factor to take into account when applying treatment margins during short extreme hypo-fractionation, and that tight margins should be applied with caution.

Quality of life for members of Swedish Prostate Cancer Patient Associations

Prostate Cancer Patient Associations (PCPAs) have become common. The aim of this study was to evaluate the quality of life of patients belonging to PCPAs. Members of 10 PCPAs in Sweden with prostate cancer completed 2 quality of life questionnaires (Quality-of-Life Questionnaire [QLQ-C30] and Prostate Cancer Symptom Scale). Of 2,028 members, 1,301 (64%) responded to the survey. Sixty percent of the members felt "healthy," and 38% were "free from the cancer." Ninety-five percent scored >80 on the physical function scale compared with 44% on the overall quality of life/health scale. The most severe symptom was sleeping disturbances (mean = 29). Seventeen percent scored "Quite a bit/Much" tiredness. More than 50% did not report any bladder or bowel problems. Fifty percent had "Much" sexual problems, and almost 80% did not have sufficient erection. Those reported as being "disease free" scored higher on the functioning scales than those with "metastatic disease." Those with an experience of a "metastatic disease" had more symptoms than those with less advanced disease. This is the first descriptive study of quality of life in members of Swedish PCPAs with prostate cancer. These findings show that it is possible to gain valid data to further study the situation of patients living with prostate cancer by collecting data from PCPAs.

15-year prospective follow-up of patient-reported outcomes of late bowel toxicity after external beam radiotherapy for localized prostate cancer. A comparison with age-matched controls

We have previously described patient-reported outcomes of late side effects induced by conventional external beam radiotherapy (EBRT), 4 and 8 years after treatment, in 181 patients with localized prostate cancer compared with 141 age-matched controls. In the present study, we compare bowel side effects 15 years after EBRT with the same controls, and with the results of our previous 4-year and 8-year follow-ups. Of the 181 patients and 141 controls at the 4-year follow-up, 45 patients (25%) and 79 controls (56%) were still alive at the 15-year follow-up. Bowel symptoms were assessed using the symptom-specific questionnaire Prostate Cancer Symptom Scale (PCSS), which was sent to these 45 patients and 79 age-matched controls with a mean follow-up time of 15 years (162-197 months) after EBRT. The answer frequency was 64% in the patient group and 52% in the control group. The mean age was 78 years in both groups. At the 15-year follow-up, 39% of the patients and 84% of the controls reported no bowel problems (p < 0.001), while 16% of the patients and 0% of the controls reported "Quite a few/many" problems with mucus in the stools (p < 0.001). "Quite a bit/much" stool leakage was reported by 20% of the patients at the 15-year follow-up, in comparison to 4% of the patients at the 4-year follow-up (ns). The proportion of patients reporting late bowel symptoms was unchanged 15 years after EBRT in comparison to the 4-year follow-up. Increased bowel symptoms were seen in patients in comparison to the age-matched controls.

Accuracy of image-guided radiotherapy of prostate cancer based on the BeamCath® urethral catheter technique

BACKGROUND AND PURPOSE

To examine the accuracy of the BeamCath urethral catheter technique for prostate localization during radiotherapy.

MATERIALS AND METHODS

Sixty-four patients were CT scanned twice with the BeamCath catheter, and once without the catheter. The catheter contains radiopaque fiducial markers for prostate visualization on setup images. It is held in place by a balloon inflated with air in the bladder. The repeated CT scans were co-registered and the relative shifts of the BeamCath isocenter fiducial, the prostate center-of-mass, and external skin markers were evaluated. The displacement of the BeamCath isocenter fiducial relative to its position at the planning CT scan was also determined on setup films for 53 consecutive patients (222 setup films).

RESULTS

The standard deviation (SD) of the prostate movement relative to the BeamCath isocenter fiducial was 0.9 mm in the left-right (LR), 2.8 mm in the cranial-caudal (CC), and 1.6 mm in the anteroposterior (AP) directions, respectively. When the balloon radius differed more than 1mm between the CT scans (14 of 64 cases) the SD in the CC direction increased to 4.5 mm. The SD of the prostate movement relative to the pelvic bone was 0.6 mm (LR), 2.4 mm (CC), and 2.8 mm (AP), while the prostate movement relative to external skin markers was considerably larger. Removal of the catheter resulted in a mean cranial prostate movement of 1.5mm relative to the pelvic bone. Caudal catheter displacements of 7-30 mm were observed in 5% of the setup films. In these cases, recatherization was necessary to obtain reliable prostate localization.

CONCLUSIONS

The BeamCath catheter technique markedly improved prostate localization in all directions when compared with skin markers. In the AP direction, the BeamCath technique was also superior to the use of bony structures. However, in the CC direction the catheter position was very vulnerable to changes in the balloon volume.