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Gallagher L, Xiao J, Hsueh J, Shah S, Danner M, Zwart A, Ayoob M, Yung T, Simpson T, Fallick M, Kumar D, Leger P, Dawson NA, Suy S, Collins SP. Early biochemical outcomes following neoadjuvant/adjuvant relugolix with stereotactic body radiation therapy for intermediate to high risk prostate cancer. Front Oncol 2023; 13:1289249. [PMID: 37916156 PMCID: PMC10616590 DOI: 10.3389/fonc.2023.1289249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 10/02/2023] [Indexed: 11/03/2023] Open
Abstract
Introduction Injectable GnRH receptor agonists have been shown to improve cancer control when combined with radiotherapy. Prostate SBRT offers an abbreviated treatment course with comparable efficacy to conventionally fractionated radiotherapy. Relugolix is a new oral GnRH receptor antagonist which achieves rapid, sustained testosterone suppression. This prospective study sought to evaluate early testosterone suppression and PSA response following relugolix and SBRT for intermediate to high prostate cancer. Methods Relugolix was initiated at least 2 months prior to SBRT. Interventions to improve adherence were not utilized. PSA and total testosterone levels were obtained prior to and 1-4 months post SBRT. Profound castration was defined as serum testosterone ≤ 20 ng/dL. Early PSA nadir was defined as the lowest PSA value within 4 months of completion of SBRT. Per prior trials, we examined the percentage of patients who achieved PSA level of ≤ 0.5 ng/mL and ≤ 0.2 ng/mL during the first 4 months post SBRT. Results Between July 2021 and January 2023, 52 men were treated at Georgetown with relugolix (4-6 months) and SBRT (36.25-40 Gy in 5 fractions) per an institutional protocol (IRB 12-1775). Median age was 71 years. 26.9% of patients were African American and 28.8% were obese (BMI ≥30 kg/m2). The median pretreatment PSA was 9.1 ng/ml. 67% of patients were ≥ Grade Group 3. 44 patients were intermediate- and 8 were high-risk. Patients initiated relugolix at a median of 3.6 months prior to SBRT with a median duration of 6.2 total months. 92.3% of patients achieved profound castration during relugolix treatment. Poor drug adherence was observed in 2 patients. A third patient chose to discontinue relugolix due to side effects. By post-SBRT month 4, 87.2% and 74.4% of patients achieved PSA levels ≤ 0.5 ng/ml and ≤ 0.2 ng/ml, respectively. Discussion Relugolix combined with SBRT allows for high rates of profound castration with low early PSA nadirs. We observed a 96% testosterone suppresion rate without the utilization of scheduled cues/reminders. This finding supports the notion that patients with localized prostate cancer can consistently and successfully follow an oral ADT protocol without daily reminders. Given relugolix's potential benefits over injectable GnRH receptor agonists, its usage may be preferred in specific patient populations (fear of needles, prior cardiovascular events). Future studies should focus on boundaries to adherence in specific underserved populations.
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Affiliation(s)
- Lindsey Gallagher
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC, United States
| | - Jerry Xiao
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC, United States
| | - Jessica Hsueh
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC, United States
| | - Sarthak Shah
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC, United States
| | - Malika Danner
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC, United States
| | - Alan Zwart
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC, United States
| | - Marilyn Ayoob
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC, United States
| | - Thomas Yung
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC, United States
| | - Tiffany Simpson
- Department of Oncology, Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC, United States
| | - Mark Fallick
- Medical Science Department, Myovant Sciences, Inc, United States
| | - Deepak Kumar
- Biotechnology Research Institute, North Carolina Central University, Durham, NC, United States
| | - Paul Leger
- Department of Oncology, Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC, United States
| | - Nancy A. Dawson
- Department of Oncology, Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC, United States
| | - Simeng Suy
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC, United States
| | - Sean P. Collins
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC, United States
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Wondergem M, van der Zant FM, Broos WAM, Roeleveld TA, Donker R, Ten Oever D, Geenen RWF, Knol RJJ. 18F-DCFPyL PET/CT for primary staging in 160 high-risk prostate cancer patients; metastasis detection rate, influence on clinical management and preliminary results of treatment efficacy. Eur J Nucl Med Mol Imaging 2020; 48:521-531. [PMID: 32719916 DOI: 10.1007/s00259-020-04782-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Accepted: 03/19/2020] [Indexed: 12/20/2022]
Abstract
PURPOSE Prostate-specific membrane antigen (PSMA) PET/CT shows better diagnostic performance for detection of lymph node and bone metastases as compared to conventional imaging. Studies of PSMA PET/CT in primary staging comprise highly selected patient cohorts. This study evaluates 18F-DCFPyL PET/CT as first-line imaging modality for primary staging of high-risk prostate cancer. MATERIAL From February 2018 until April 2019, all patients with high-risk prostate cancer received 18F-DCFPyL PET/CT for staging of prostate cancer. Baseline characteristics, findings at 18F-DCFPyL PET/CT, number and type of required additional diagnostic procedures, findings at additional diagnostic procedures, and effects of therapy on PSA levels for all patients treated with curative intent were collected and evaluated. RESULTS One hundred-sixty patients were included in the study of which 90 (56%) had evidence of metastasized disease (N1, M1a, M1b and, M1c in 49%, 28%, 31%, and 3% respectively). Additional diagnostic imaging was needed in 2/160 patients (1%) because of equivocal findings on 18F-DCFPyL PET/CT. Eighty-one patients had evidence of PSMA-positive lymph node metastases, of whom 39 (48%) had no enlarged lymph nodes on CT; 18F-DCFPyL PET detected additional metastatic lymph nodes in 41/42 patients that had evidence of lymph node metastases on CT. 18F-DCFPyL PET altered patients' management in 17% of patients. CONCLUSION 18F-DCFPyL PET/CT can be used as first-line imaging modality for therapy selection in patients with primary high-risk prostate cancer, without need for further diagnostic imaging procedures in the majority of patients.
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Affiliation(s)
- M Wondergem
- Department of Nuclear Medicine, Noordwest Ziekenhuisgroep, Wilhelminalaan 12, 1815 JD, Alkmaar, The Netherlands.
| | - F M van der Zant
- Department of Nuclear Medicine, Noordwest Ziekenhuisgroep, Wilhelminalaan 12, 1815 JD, Alkmaar, The Netherlands
| | - W A M Broos
- Department of Nuclear Medicine, Noordwest Ziekenhuisgroep, Wilhelminalaan 12, 1815 JD, Alkmaar, The Netherlands
| | - T A Roeleveld
- Department of Urology, Noordwest Ziekenhuisgroep, Alkmaar, The Netherlands
| | - R Donker
- Department of Radiation Oncology, Noordwest Ziekenhuisgroep, Alkmaar, The Netherlands
| | - D Ten Oever
- Department of Oncology, Noordwest Ziekenhuisgroep, Alkmaar, The Netherlands
| | - R W F Geenen
- Department of Radiology, Noordwest Ziekenhuisgroep, Alkmaar, The Netherlands
| | - R J J Knol
- Department of Nuclear Medicine, Noordwest Ziekenhuisgroep, Wilhelminalaan 12, 1815 JD, Alkmaar, The Netherlands
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Wark L, Quon H, Ong A, Drachenberg D, Rangel-Pozzo A, Mai S. Long-Term Dynamics of Three Dimensional Telomere Profiles in Circulating Tumor Cells in High-Risk Prostate Cancer Patients Undergoing Androgen-Deprivation and Radiation Therapy. Cancers (Basel) 2019; 11:cancers11081165. [PMID: 31416141 PMCID: PMC6721586 DOI: 10.3390/cancers11081165] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Revised: 08/08/2019] [Accepted: 08/09/2019] [Indexed: 02/07/2023] Open
Abstract
Patient-specific assessment, disease monitoring, and the development of an accurate early surrogate of the therapeutic efficacy of locally advanced prostate cancer still remain a clinical challenge. Contrary to prostate biopsies, circulating tumor cell (CTC) collection from blood is a less-invasive method and has potential as a real-time liquid biopsy and as a surrogate marker for treatment efficacy. In this study, we used size-based filtration to isolate CTCs from the blood of 100 prostate cancer patients with high-risk localized disease. CTCs from five time points: +0, +2, +6, +12 and +24 months were analyzed. Consenting treatment-naïve patients with cT3, Gleason 8-10, or prostate-specific antigen > 20 ng/mL and non-metastatic prostate cancer were included. For all time points, we performed 3D telomere-specific quantitative fluorescence in situ hybridization on a minimum of thirty isolated CTCs. The patients were divided into five groups based on the changes of number of telomeres vs. telomere lengths over time and into three clusters based on all telomere parameters found on diagnosis. Group 2 was classified as non-respondent to treatment and the Cluster 3 presented more aggressive phenotype. Additionally, we compared our telomere results with the PSA levels for each patient at 6 months of ADT, at 6 months of completed RT, and at 36 months post-initial therapy. CTCs of patients with PSA levels above or equal to 0.1 ng/mL presented significant increases of nuclear volume, number of telomeres, and telomere aggregates. The 3D telomere analysis of CTCs identified disease heterogeneity among a clinically homogeneous group of patients, which suggests differences in therapeutic responses. Our finding suggests a new opportunity for better treatment monitoring of patients with localized high-risk prostate cancer.
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Affiliation(s)
- Landon Wark
- Cell Biology, Research Institute of Oncology and Hematology, University of Manitoba, CancerCare Manitoba, Winnipeg, MB R3E 0V9, Canada
| | - Harvey Quon
- Manitoba Prostate Center, Cancer Care Manitoba, Section of Urology, Department of Surgery, University of Manitoba, Winnipeg, MB R3E 0V9, Canada
| | - Aldrich Ong
- Manitoba Prostate Center, Cancer Care Manitoba, Section of Urology, Department of Surgery, University of Manitoba, Winnipeg, MB R3E 0V9, Canada
| | - Darrel Drachenberg
- Manitoba Prostate Center, Cancer Care Manitoba, Section of Urology, Department of Surgery, University of Manitoba, Winnipeg, MB R3E 0V9, Canada
| | - Aline Rangel-Pozzo
- Cell Biology, Research Institute of Oncology and Hematology, University of Manitoba, CancerCare Manitoba, Winnipeg, MB R3E 0V9, Canada.
| | - Sabine Mai
- Cell Biology, Research Institute of Oncology and Hematology, University of Manitoba, CancerCare Manitoba, Winnipeg, MB R3E 0V9, Canada.
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Hallemeier CL, Zhang P, Pisansky TM, Hanks GE, McGowan DG, Roach M, Zeitzer KL, Firat SY, Husain SM, D'Souza DP, Souhami L, Parliament MB, Rosenthal SA, Lukka HR, Rotman M, Horwitz EM, Miles EF, Paulus R, Sandler HM. Prostate-Specific Antigen After Neoadjuvant Androgen Suppression in Prostate Cancer Patients Receiving Short-Term Androgen Suppression and External Beam Radiation Therapy: Pooled Analysis of Four NRG Oncology Radiation Therapy Oncology Group Randomized Clinical Trials. Int J Radiat Oncol Biol Phys 2019; 104:1057-1065. [PMID: 30959123 DOI: 10.1016/j.ijrobp.2019.03.049] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Revised: 03/22/2019] [Accepted: 03/31/2019] [Indexed: 11/12/2022]
Abstract
PURPOSE To validate whether prostate-specific antigen (PSA) level after neoadjuvant androgen suppression (neoAS) is associated with long-term outcome after neoAS and external beam radiation therapy (RT) with concurrent short-term androgen suppression (AS) in patients with prostate cancer. METHODS AND MATERIALS This study included 2404 patients. The patients were treated with neoAS before RT and concurrent AS (without post-RT AS) and were pooled from NRG Oncology/RTOG trials 9202, 9408, 9413, and 9910. Multivariable models were used to test associations between the prespecified dichotomized post-neoAS, pre-RT PSA level (≤0.1 vs >0.1 ng/mL) groupings, and clinical outcomes. RESULTS The median follow-up for surviving patients was 9.4 years. The median post-neoAS, pre-RT PSA level was 0.3 ng/mL, with 32% of patients having levels ≤0.1 ng/mL. Race, Gleason score, tumor stage, node stage, pretreatment PSA level, and duration of neoAS were associated with the groups of patients with PSA levels ≤0.1 and >0.1 ng/mL. In univariate analyses, post-neoAS, pre-RT PSA level >0.1 ng/mL was associated with increased risks of biochemical failure (hazard ratio [HR], 2.04; P < .0001); local failure (HR, 2.51; P < .0001); distant metastases (HR, 1.73; P = .0006); cause-specific mortality (HR, 2.36; P < .0001); and all-cause mortality (HR, 1.24; P = .005). In multivariable models that also included baseline and treatment variables, post-neoAS, pre-RT PSA level >0.1 ng/mL was independently associated with increased risk of biochemical failure (HR, 2.00; P < .0001); local failure (HR, 2.33; P < .0001); and cause-specific mortality (HR, 1.75; P = .03). CONCLUSIONS Patients with a PSA level >0.1 ng/mL after neoAS and before the start of RT had less favorable clinical outcomes than patients whose PSA level was ≤0.1 ng/mL. The role of post-neoAS, pre-RT PSA level relative to PSA levels obtained along the continuum of medical care is not presently defined but could be tested in future clinical trials.
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Affiliation(s)
| | - Peixin Zhang
- NRG Oncology Statistics and Data Management Center, Philadelphia, Pennsylvania
| | | | | | | | - Mack Roach
- University of California, San Francisco, San Francisco, California
| | | | - Selim Y Firat
- Medical College of Wisconsin-Zablocki VA Medical Center, Milwaukee, Wisconsin
| | | | | | - Luis Souhami
- McGill University Health Centre, Montreal, Quebec, Canada
| | | | | | - Himanshu R Lukka
- McMaster University, Juravinski Cancer Center, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | | | | | - Edward F Miles
- Naval Medical Center Accruals Dartmouth Hitchcock Medical Center, Portsmouth, Virginia
| | - Rebecca Paulus
- NRG Oncology Statistics and Data Management Center, Philadelphia, Pennsylvania
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Dignam JJ, Hamstra DA, Lepor H, Grignon D, Brereton H, Currey A, Rosenthal S, Zeitzer KL, Venkatesan VM, Horwitz EM, Pisansky TM, Sandler HM. Time Interval to Biochemical Failure as a Surrogate End Point in Locally Advanced Prostate Cancer: Analysis of Randomized Trial NRG/RTOG 9202. J Clin Oncol 2018; 37:213-221. [PMID: 30526194 DOI: 10.1200/jco.18.00154] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND In prostate cancer, end points that reliably portend prognosis and treatment benefit (surrogate end points) can accelerate therapy development. Although surrogate end point candidates have been evaluated in the context of radiotherapy and short-term androgen deprivation (AD), potential surrogates under long-term (24 month) AD, a proven therapy in high-risk localized disease, have not been investigated. MATERIALS AND METHODS In the NRG/RTOG 9202 randomized trial (N = 1,520) of short-term AD (4 months) versus long-term AD (LTAD; 28 months), the time interval free of biochemical failure (IBF) was evaluated in relation to clinical end points of prostate cancer-specific survival (PCSS) and overall survival (OS). Survival modeling and landmark analysis methods were applied to evaluate LTAD benefit on IBF and clinical end points, association between IBF and clinical end points, and the mediating effect of IBF on LTAD clinical end point benefits. RESULTS LTAD was superior to short-term AD for both biochemical failure (BF) and the clinical end points. Men remaining free of BF for 3 years had relative risk reductions of 39% for OS and 73% for PCSS. Accounting for 3-year IBF status reduced the LTAD OS benefit from 12% (hazard ratio [HR], 0.88; 95% CI, 0.79 to 0.98) to 6% (HR, 0.94; 95% CI, 0.83 to 1.07). For PCSS, the LTAD benefit was reduced from 30% (HR, 0.70; 95% CI, 0.52 to 0.82) to 6% (HR, 0.94; 95% CI, 0.72 to 1.22). Among men with BF, by 3 years, 50% of subsequent deaths were attributed to prostate cancer, compared with 19% among men free of BF through 3 years. CONCLUSION The IBF satisfied surrogacy criteria and identified the benefit of LTAD on disease-specific survival and OS. The IBF may serve as a valid end point in clinical trials and may also aid in risk monitoring after initial treatment.
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Affiliation(s)
- James J Dignam
- 1 NRG Oncology Statistics and Data Management Center, University of Chicago, Chicago, IL
| | | | | | | | | | - Adam Currey
- 6 Medical College of Wisconsin, Milwaukee, WI
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Abstract
Clinical research into clinically-localized prostate cancer (PC) is a highly challenging environment. The protracted durations and large numbers required to achieve survival endpoints have placed much pressure on validating early surrogate endpoints. Further confounding is the predominance of deaths from causes other than PC. The analysis of multiple randomized clinical trials in early PC has shown MFS to be a robust surrogate for OS, using a contemporary analytic framework that identify patient-level and trial-level associations. This could potentially save around one year of trial follow-up in some therapies. Identification of a similarly robust surrogate at a substantially earlier timepoint remains a major challenge. Multiple biochemical indices based on PSA have been proposed in the literature, but all remain to be validated at the trial-level. Operationally, many of these indices have inherent biases such as immortal-time bias (ITB) and interval censoring that potentially weakens associations and the individual- or trial-level. The complexity of a failure definition can also impact the reliability of the derived outcomes. Confounding issues such as the impact of comorbidities leading to non-cancer deaths have been largely dealt with by their exclusion using cancer-specific endpoints and advanced statistical methods, while issues such as PSA "bounce" and recovery from androgen deprivation therapy remain important to account for in cohorts treated with radiotherapy. Several potential surrogate endpoints based on serum prostate-specific antigen (PSA) levels show promising associations with PC-specific and overall survival (OS) in individual studies. Further large collaborative projects will continue to refine potential indices with these issues in mind, and explore the objective of an early surrogate of OS.
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Affiliation(s)
- Scott Williams
- Division of Radiation Oncology and Cancer Imaging, Peter MacCallum Cancer Centre and University of Melbourne, Melbourne, Australia
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7
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Bryant AK, D'Amico AV, Nguyen PL, Einck JP, Kane CJ, McKay RR, Simpson DR, Mundt AJ, Murphy JD, Rose BS. Three-month posttreatment prostate-specific antigen level as a biomarker of treatment response in patients with intermediate-risk or high-risk prostate cancer treated with androgen deprivation therapy and radiotherapy. Cancer 2018; 124:2939-2947. [PMID: 29727915 DOI: 10.1002/cncr.31400] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2017] [Revised: 01/31/2018] [Accepted: 03/25/2018] [Indexed: 11/09/2022]
Abstract
BACKGROUND Prostate-specific antigen (PSA) measurement after definitive radiotherapy (RT) and androgen deprivation therapy for localized prostate cancer has been proposed as an early prognostic biomarker. In the current study, the authors investigated the association between 3-month post-RT PSA level and biochemical progression-free survival (bPFS), prostate cancer-specific survival (PCSS), and overall survival (OS). METHODS A total of 5783 patients with intermediate-risk or high-risk localized prostate cancer who were diagnosed between 2000 and 2015 and treated with RT and androgen deprivation therapy were identified from Veterans Affairs data. Patients were divided into groups based on 3-month post-RT PSA values: <0.10 ng/mL, 0.10 to 0.49 ng/mL, and ≥0.50 ng/mL. The effect of the 3-month PSA group on bPFS, PCSS, and OS was evaluated in multivariable Cox models adjusting for potential confounders. RESULTS There were 2651 patients with intermediate-risk and 3132 with high-risk disease; approximately 11% had a 3-month PSA level of ≥0.50 ng/mL. A higher 3-month PSA level was found to be strongly associated with each outcome; compared with patients in the group with a 3-month PSA value <0.10 ng/mL, the authors noted greater hazards for the patients with a 3-month PSA value ≥0.50 ng/mL (hazard ratio for bPFS: 5.23; PCSS: 3.97; and OS: 1.50 [P<.001 for all]) and the patients with a 3-month PSA value of 0.10 to 0.49 ng/mL (hazard ratio for bPFS: 2.41 [P<.001]; PCSS: 2.29 [P<.001]; and OS: 1.21 [P = .003]). When analyzed separately, the 3-month PSA level was found to be predictive of OS in the high-risk group (P<.001) but not the intermediate-risk group (P = .21). CONCLUSIONS The 3-month post-RT PSA level appears to be a strong prognostic biomarker for bPFS, PCSS, and OS in patients with intermediate-risk and high-risk prostate cancer, particularly those with high-risk disease. The 3-month PSA measurement may augment clinical decision making and holds promise as a potential surrogate endpoint in clinical trials. Cancer 2018;124:2939-47. © 2018 American Cancer Society.
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Affiliation(s)
- Alex K Bryant
- Department of Radiation Medicine and Applied Sciences, University of California at San Diego, San Diego, California
| | - Anthony V D'Amico
- Department of Radiation Oncology, Brigham and Women's Hospital, Boston, Massachusetts.,Department of Radiation Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Paul L Nguyen
- Department of Radiation Oncology, Brigham and Women's Hospital, Boston, Massachusetts.,Department of Radiation Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - John P Einck
- Department of Radiation Medicine and Applied Sciences, University of California at San Diego, San Diego, California
| | - Christopher J Kane
- Department of Urology, University of California at San Diego, San Diego, California
| | - Rana R McKay
- Division of Hematology-Oncology, Department of Internal Medicine, University of California at San Diego, San Diego, California
| | - Daniel R Simpson
- Department of Radiation Medicine and Applied Sciences, University of California at San Diego, San Diego, California.,Clinical and Translational Research Institute, University of California at San Diego, San Diego, California
| | - Arno J Mundt
- Department of Radiation Medicine and Applied Sciences, University of California at San Diego, San Diego, California
| | - James D Murphy
- Department of Radiation Medicine and Applied Sciences, University of California at San Diego, San Diego, California.,Clinical and Translational Research Institute, University of California at San Diego, San Diego, California
| | - Brent S Rose
- Department of Radiation Medicine and Applied Sciences, University of California at San Diego, San Diego, California.,Clinical and Translational Research Institute, University of California at San Diego, San Diego, California
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Böhmer D, Wirth M, Miller K, Budach V, Heidenreich A, Wiegel T. Radiotherapy and Hormone Treatment in Prostate Cancer. DEUTSCHES ARZTEBLATT INTERNATIONAL 2018; 113:235-41. [PMID: 27146591 DOI: 10.3238/arztebl.2016.0235] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/12/2015] [Revised: 01/20/2016] [Accepted: 01/20/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND Prostate cancer has the highest incidence of any type of cancer in Germany; an estimated 67 000 new diagnoses of prostate cancer will be made in 2016. In the current German S3 guideline for the treatment of prostate cancer, radiotherapy-sometimes in combination with androgen deprivation therapy (ADT)-is one of the two recommended options for treatment with curative intent (the other is radical prostatectomy). There have been many publications on this subject, yet it is still often unclear in routine practice how ADT should be administered, and for how long. METHODS This review is based on publications retrieved by a selective literature search, with special attention to controlled trials. RESULTS For low risk patients, radiotherapy without ADT is indicated (evidence level 1). Patients with localized prostate cancer and an intermediate risk benefit from radiotherapy combined with a four-to-six-month course of ADT. In this situation, a higher radiation dose might be an effective substitute for ADT (evidence level 1-2). For patients at high risk, radiotherapy combined with long-term hormonal treatment is the standard therapy, as it significantly improves all oncological end points (evidence level 1). For example, in the largest randomized and controlled trial, this form of treatment reduced cancer-specific mortality from 19% to 9% . Higher radiation doses of 66-74 Gy and longer ADT can improve local control at the cost of increased urethral toxicity. CONCLUSION Androgen deprivation combined with external beam radiotherapy is a curative standard option for patients with prostate cancer who are at high risk of recurrence. The modern radiotherapeutic techniques that are now available, such as intensity-modulated radiotherapy, enable a further improvement of the risk/benefit ratio.
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Affiliation(s)
- Dirk Böhmer
- Department of Radiation Oncology and Radiotherapy, Charité-Universitätsmedizin Berlin, Department of Urology, University Hospital Carl Gustav Carus, Dresden, Department of Urology, Charité Universitätsmedizin, Berlin, Department of Urology, Uniklinik RWTH Aachen, Department of Radiation Oncology, University Hospital Ulm
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9
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Posttreatment Prostate-Specific Antigen 6 Months After Radiation With Androgen Deprivation Therapy Predicts for Distant Metastasis–Free Survival and Prostate Cancer–Specific Mortality. Int J Radiat Oncol Biol Phys 2016; 96:617-23. [DOI: 10.1016/j.ijrobp.2016.07.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Revised: 06/16/2016] [Accepted: 07/11/2016] [Indexed: 11/19/2022]
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10
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Lee SH, Kim HJ, Kim WC. Prostate-specific antigen kinetics following hypofractionated stereotactic body radiotherapy versus conventionally fractionated external beam radiotherapy for low- and intermediate-risk prostate cancer. Asia Pac J Clin Oncol 2016; 12:388-395. [DOI: 10.1111/ajco.12566] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Revised: 03/23/2016] [Accepted: 04/17/2016] [Indexed: 12/01/2022]
Affiliation(s)
- Seok Ho Lee
- Department of Radiation Oncology; Gachon University Gill Medical Center; Inchon South Korea
| | - Hun Jung Kim
- Department of Radiation Oncology, Inha University Hospital; Inha University of Medicine; Inchon South Korea
| | - Woo Chul Kim
- Department of Radiation Oncology, Inha University Hospital; Inha University of Medicine; Inchon South Korea
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11
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Kim HJ, Phak JH, Kim WC. Hypofractionated stereotactic body radiotherapy in low- and intermediate-risk prostate carcinoma. Radiat Oncol J 2016; 34:260-264. [PMID: 27306777 PMCID: PMC5207371 DOI: 10.3857/roj.2015.01571] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Revised: 12/15/2015] [Accepted: 12/22/2015] [Indexed: 01/17/2023] Open
Abstract
Purpose Stereotactic body radiotherapy (SBRT) takes advantage of low α/β ratio of prostate cancer to deliver a large dose in few fractions. We examined clinical outcomes of SBRT using CyberKnife for the treatment of low- and intermediate-risk prostate cancer. Materials and Methods This study was based on a retrospective analysis of the 33 patients treated with SBRT using CyberKnife for localized prostate cancer (27.3% in low-risk and 72.7% in intermediate-risk). Total dose of 36.25 Gy in 5 fractions of 7.25 Gy were administered. The acute and late toxicities were recorded using the Radiation Therapy Oncology Group scale. Prostate-specific antigen (PSA) response was monitored. Results Thirty-three patients with a median 51 months (range, 6 to 71 months) follow-up were analyzed. There was no biochemical failure. Median PSA nadir was 0.27 ng/mL at median 33 months and PSA bounce occurred in 30.3% (n = 10) of patients at median at median 10.5 months after SBRT. No grade 3 acute toxicity was noted. The 18.2% of the patients had acute grade 2 genitourinary (GU) toxicities and 21.2% had acute grade 2 gastrointestinal (GI) toxicities. After follow-up of 2 months, most complications had returned to baseline. There was no grade 3 late GU and GI toxicity. Conclusion Our experience with SBRT using CyberKnife in low- and intermediate-risk prostate cancer demonstrates favorable efficacy and toxicity. Further studies with more patients and longer follow-up duration are required.
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Affiliation(s)
- Hun Jung Kim
- Department of Radiation Oncology, Inha University Hospital, Inha University School of Medicine, Incheon, Korea
| | - Jeong Hoon Phak
- Department of Radiation Oncology, Inha University Hospital, Inha University School of Medicine, Incheon, Korea
| | - Woo Chul Kim
- Department of Radiation Oncology, Inha University Hospital, Inha University School of Medicine, Incheon, Korea
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Kim HJ, Phak JH, Kim WC. Prostate-specific antigen kinetics following hypofractionated stereotactic body radiotherapy boost and whole pelvic radiotherapy for intermediate- and high-risk prostate cancer. Asia Pac J Clin Oncol 2016; 13:21-27. [DOI: 10.1111/ajco.12472] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Revised: 01/08/2016] [Accepted: 01/17/2016] [Indexed: 11/28/2022]
Affiliation(s)
- Hun Jung Kim
- Department of Radiation Oncology; Inha University Hospital; Inha University of Medicine; Inchon Korea
| | - Jeong Hoon Phak
- Department of Radiation Oncology; Inha University Hospital; Inha University of Medicine; Inchon Korea
| | - Woo Chul Kim
- Department of Radiation Oncology; Inha University Hospital; Inha University of Medicine; Inchon Korea
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Phak JH, Kim HJ, Kim WC. Prostate-specific antigen kinetics following hypofractionated stereotactic body radiotherapy boost as post-external beam radiotherapy versus conventionally fractionated external beam radiotherapy for localized prostate cancer. Prostate Int 2015; 4:25-9. [PMID: 27014661 PMCID: PMC4789329 DOI: 10.1016/j.prnil.2015.12.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Revised: 11/12/2015] [Accepted: 11/30/2015] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Stereotactic body radiotherapy (SBRT) has emerged as an effective treatment for localized prostate cancer. The purpose of this study was to compare the prostate-specific antigen (PSA) kinetics between conventionally fractionated external beam radiotherapy (CF-EBRT) and SBRT boost after whole pelvis EBRT (WP-EBRT) in localized prostate cancer. METHODS A total of 77 patients with localized prostate cancer [T-stage, T1-T3; Gleason score (GS) 5-9; PSA < 20 ng/mL] were enrolled. A total of 35 patients were treated with SBRT boost (21 Gy in 3 fractions) after WP-EBRT and 42 patients were treated with CF-EBRT (45 Gy WP-EBRT and boost of 25.2-30.6 Gy in 1.8-Gy fractions). PSA nadir and rate of change in PSA (slope) were calculated and compared. RESULTS With a median follow-up of 52.4 months (range, 14-74 months), the median PSA nadir and slope for SBRT boost were 0.29 ng/mL and -0.506, -0.235, -0.129, and -0.092 ng/mL/mo, respectively, for durations of 1 year, 2 years, 3 years, and 4 years postradiotherapy. Similarly, for CF-EBRT, the median PSA nadir and slopes were 0.39 ng/mL and -0.720 ng/mL/mo, -0.204 ng/mL/mo, -0.121 ng/mL/mo, and -0.067 ng/mL/mo, respectively. The slope of CF-EBRT was significantly different with a greater median rate of change for 1 year postradiotherapy than that of SBRT boost (P = 0.018). Contrastively, the slopes of SBRT boost for durations of 2 years, 3 years, and 4 years tended to be continuously greater than that of CF-EBRT. The significantly lower PSA nadir was observed in SBRT boost (median nadir 0.29 ng/mL) compared with CF-EBRT (median nadir 0.35 ng/mL, P = 0.025). Five-year biochemical failure (BCF) free survival was 94.3% for SBRT boost and 78.6% for CF-EBRT (P = 0.012). CONCLUSION Patients treated with SBRT boost after WP-EBRT experienced a lower PSA nadir and there tended to be a continuously greater rate of decline of PSA for durations of 2 years, 3 years, and 4 years than with CF-EBRT. The improved PSA kinetics of SBRT boost over CF-EBRT led to favorable BCF free survival.
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Affiliation(s)
- Jeong Hoon Phak
- Department of Radiation Oncology, Inha University Hospital, Inha University of Medicine, Inchon, South Korea
| | - Hun Jung Kim
- Department of Radiation Oncology, Inha University Hospital, Inha University of Medicine, Inchon, South Korea
| | - Woo Chul Kim
- Department of Radiation Oncology, Inha University Hospital, Inha University of Medicine, Inchon, South Korea
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Prostate-specific antigen kinetics after stereotactic body radiotherapy as monotherapy or boost after whole pelvic radiotherapy for localized prostate cancer. Prostate Int 2015; 3:118-22. [PMID: 26779457 PMCID: PMC4685203 DOI: 10.1016/j.prnil.2015.09.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2015] [Revised: 09/18/2015] [Accepted: 09/23/2015] [Indexed: 01/17/2023] Open
Abstract
Purpose Stereotactic body radiotherapy (SBRT) has emerged as an effective treatment for localized prostate cancer. However, prostate-specific antigen (PSA) kinetics after SBRT has not been well characterized. The purpose of the current study is to assess the kinetics of PSA for low- and intermediate-risk prostate cancer patients treated with SBRT using Cyberknife as both monotherapy and boost after whole pelvic radiotherapy (WPRT) in the absence of androgen deprivation therapy. Methods A total of 61 patients with low- and intermediated-risk prostate cancer treated with SBRT as monotherapy (36.25 Gy in 5 fractions in 32 patients) and SBRT (21 Gy in 3 fractions in 29 patients) boost combined with WPRT (45 Gy in 25 fractions). Patients were excluded if they failed therapy by the Phoenix definition or had androgen deprivation therapy. PSA nadir and rate of change in PSA over time (slope) were calculated and compared. Results With a median follow-up of 52.4 months (range, 14–74 months), for SBRT monotherapy, the median PSA nadir was 0.31 ng/mL (range, 0.04–1.15 ng/mL) and slopes were –0.41 ng/mL/mo, –0.17 ng/mL/mo, –0.12 ng/mL/mo, and –0.09 ng/mL/mo, respectively, for durations of 1 year, 2 years, 3 years, and 4 years postradiotherapy. Similarly, for SBRT boost after WPRT, the median PSA nadir was 0.34 ng/mL (range, 0.04–1.44 ng/mL) and slopes were –0.53 ng/mL/mo, –0.25 ng/mL/mo, –0.14 ng/mL/mo, and –0.09 ng/mL/mo, respectively. The median nadir and slopes of SBRT monotherapy did not differ significantly from those of SBRT boost after WPRT. Benign PSA bounces were common in 30.4% of all cohorts, and the median time to PSA bounce was 12 months (range, 6–25 months). Conclusions In this report of low- and intermediate-risk prostate cancer patients, an initial period of rapid PSA decline was followed by a slow decline, which resulted in a lower PSA nadir. The PSA kinetics of SBRT monotherapy appears to be comparable to those achieved with SBRT boost with WPRT.
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Cho E, Mostaghel EA, Russell KJ, Liao JJ, Konodi MA, Kurland BF, Marck BT, Matsumoto AM, Dalkin BL, Montgomery RB. External beam radiation therapy and abiraterone in men with localized prostate cancer: safety and effect on tissue androgens. Int J Radiat Oncol Biol Phys 2015; 92:236-43. [PMID: 25772183 PMCID: PMC4459893 DOI: 10.1016/j.ijrobp.2015.01.020] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2014] [Revised: 01/11/2015] [Accepted: 01/13/2015] [Indexed: 12/13/2022]
Abstract
PURPOSE Optimizing androgen suppression may provide better control of localized prostate cancer (PCa). Numerous trials have supported the benefit of combining androgen deprivation therapy with definitive radiation therapy in men with locally advanced or high-grade disease. Addition of abiraterone to luteinizing hormone-releasing hormone agonist (LHRHa) with radiation has not been reported. We examined the safety of this combination as well as its impact on androgen suppression. METHODS AND MATERIALS A prospective, phase 2 study was conducted in men with localized PCa treated with 6 months of neoadjuvant and concurrent abiraterone with LHRHa and radiation. Duration of adjuvant LHRHa was at the discretion of the treating clinician. Prostate biopsy assays were obtained prior to the start of therapy and prior to radiation. Sera and tissue androgen levels were measured by liquid chromatography-tandem mass spectrometry. RESULTS A total of 22 men with intermediate- (n=3) and high-risk PCa (n=19) received study therapy. Sixteen men completed the intended course of abiraterone, and 19 men completed planned radiation to 77.4 to 81 Gy. Radiation to pelvic nodes was administered in 20 men. The following grade 3 toxicities were reported: lymphopenia (14 patients), fatigue (1 patient), transaminitis (2 patients), hypertension (2 patients), and hypokalemia (1 patient). There were no grade 4 toxicities. All 21 men who complied with at least 3 months of abiraterone therapy had a preradiation prostate-specific antigen (PSA) concentration nadir of <0.3 ng/mL. Median levels of tissue androgen downstream of CYP17A were significantly suppressed after treatment with abiraterone, and upstream steroids were increased. At median follow-up of 21 months (range: 3-37 months), only 1 patient (who had discontinued abiraterone at 3 months) had biochemical relapse. CONCLUSIONS Addition of abiraterone to LHRHa with radiation is safe and achieves effective prostatic androgen suppression. Preliminary analysis of the clinical data is also promising, with excellent PSA nadir and no relapse to date in this high-risk population.
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Affiliation(s)
- Eunpi Cho
- University of Washington School of Medicine, Seattle, Washington; Fred Hutchinson Cancer Research Center, Seattle, Washington
| | | | | | - Jay J Liao
- University of Washington School of Medicine, Seattle, Washington
| | - Mark A Konodi
- University of Washington School of Medicine, Seattle, Washington
| | | | - Brett T Marck
- Veterans Affairs Puget Sound Health Care System, Seattle, Washington
| | - Alvin M Matsumoto
- University of Washington School of Medicine, Seattle, Washington; Veterans Affairs Puget Sound Health Care System, Seattle, Washington
| | - Bruce L Dalkin
- University of Washington School of Medicine, Seattle, Washington
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Morris LM, Izard MA, Wan WY. Does prostate-specific antigen nadir predict longer-term outcomes of prostate cancer after neoadjuvant and adjuvant androgen deprivation therapy in conjunction with brachytherapy? Brachytherapy 2014; 14:322-8. [PMID: 25487524 DOI: 10.1016/j.brachy.2014.11.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2014] [Revised: 11/01/2014] [Accepted: 11/05/2014] [Indexed: 11/26/2022]
Abstract
PURPOSE To evaluate whether nadir prostate-specific antigen (nPSA), time to nPSA (TnPSA), and nPSA 3-years post-treatment are prognostic for prostate cancer (PC) in patients treated with temporary brachytherapy plus external beam radiation therapy (EBRT) and hormonal manipulation. METHODS AND MATERIALS We retrospectively analyzed our database of 253 patients with Stage T1-T3 N0M0 PC who underwent brachytherapy with temporary brachytherapy plus EBRT. All patients received neoadjuvant androgen deprivation for a median of 6 months. Treatment consisted of three pulses of pseudo pulsed-dose-rate brachytherapy to a median dose of 18Gy with 50.4Gy in 28 fractions of EBRT. Treatment took place between December 1999 and March 2006. RESULTS At a median of 6-years followup, nPSA value was a predictor of biochemical control. Rising nPSA categories of <0.01, 0.01-<0.05, 0.05-≤0.1, 0.1-≤ 1.0, or >1.0 ng/mL correlated with a deteriorating 5-year biochemical control (nBED) by the Phoenix definition of 100%, 90.0%, 82.5%, 64.3%, and 10%, respectively. A highly statistically significant relationship between nPSA value and subsequent clinical failure is also demonstrated. The relationship between TnPSA and nBED was strongly significant (p<0.0001), with a significantly longer nPSA for patients who had Phoenix nBED. A PSA of <1.5 ng/mL achieved 3-year post radiation therapy was prognostic for biochemical and clinical disease control (p<0.0001). CONCLUSION The nPSA, TnPSA, and reaching a PSA cutoff level of <1.5 ng/mL at 3 years post-treatment can provide useful prognostic information on long-term biochemical and clinical control of PC in patients treated with pseudo PDR, EBRT, and hormone manipulation.
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Affiliation(s)
- Lucinda May Morris
- Crown Princess Mary Cancer Centre, Westmead Hospital, Sydney, Australia.
| | - Michael Anthony Izard
- Department of Radiotherapy, Mater Hospital, North Sydney, New South Wales, Australia
| | - Wai-Yin Wan
- Department of Biostatistics, University of Sydney, New South Wales, Australia
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Lamb DS, Greig L, Russell GL, Nacey JN, Broome K, Studd R, Delahunt B, Iupati D, Jain M, Rooney C, Murray J, Lamb PJ, Bethwaite PB. Patterns of failure after iodine-125 seed implantation for prostate cancer. Radiother Oncol 2014; 112:68-71. [PMID: 25082097 DOI: 10.1016/j.radonc.2014.07.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2013] [Revised: 06/25/2014] [Accepted: 07/10/2014] [Indexed: 01/11/2023]
Abstract
PURPOSE To determine the site of relapse when biochemical failure (BF) occurs after iodine-125 seed implantation for prostate cancer. MATERIALS AND METHODS From 2001-2009, 500 men underwent implantation in Wellington, New Zealand. Men who sustained BF were placed on relapse guidelines that delayed restaging and intervention until the prostate-specific antigen (PSA) was ⩾20 ng/mL. RESULTS Most implants (86%) had a prostate D90 of ⩾90%, and multivariate analysis showed that this parameter was not a variable that affected the risk of BF. Of 21 BFs that occurred, the site of failure was discovered to be local in one case and distant in nine cases. Restaging failed to identify the site of relapse in two cases. In nine cases the trigger for restaging had not been reached. CONCLUSIONS If post-implant dosimetry is generally within the optimal range, distant rather than local failure appears to be the main cause of BF. Hormone treatment is therefore the most commonly indicated secondary treatment intervention (STI). Delaying the start of STI prevents the unnecessary treatment of men who undergo PSA 'bounce' and have PSA dynamics initially mimicking those of BF.
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Affiliation(s)
- David S Lamb
- Prostate Cancer Trials Unit, Department of Pathology and Molecular Medicine, University of Otago, Wellington, New Zealand; Radiation Oncology, Southern Cross Hospital, Wellington, New Zealand.
| | - Lynne Greig
- Medical Physics, Southern Cross Hospital, Wellington, New Zealand
| | | | - John N Nacey
- Prostate Cancer Trials Unit, Department of Pathology and Molecular Medicine, University of Otago, Wellington, New Zealand; Urology, Southern Cross Hospital, Wellington, New Zealand
| | - Kim Broome
- Omahu Urology Clinic, Hawkes Bay, New Zealand
| | - Rod Studd
- Urology, Southern Cross Hospital, Wellington, New Zealand
| | - Brett Delahunt
- Prostate Cancer Trials Unit, Department of Pathology and Molecular Medicine, University of Otago, Wellington, New Zealand
| | - Douglas Iupati
- Radiation Oncology, Southern Cross Hospital, Wellington, New Zealand
| | - Mohua Jain
- Anesthetics, Southern Cross Hospital, Wellington, New Zealand
| | - Colin Rooney
- Medical Physics, Southern Cross Hospital, Wellington, New Zealand
| | - Judy Murray
- Prostate Cancer Trials Unit, Department of Pathology and Molecular Medicine, University of Otago, Wellington, New Zealand
| | - Peter J Lamb
- Prostate Cancer Trials Unit, Department of Pathology and Molecular Medicine, University of Otago, Wellington, New Zealand
| | - Peter B Bethwaite
- Prostate Cancer Trials Unit, Department of Pathology and Molecular Medicine, University of Otago, Wellington, New Zealand
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Combining prostate-specific antigen nadir and time to nadir allows for early identification of patients at highest risk for development of metastasis and death following salvage radiation therapy. Pract Radiat Oncol 2014; 4:99-107. [DOI: 10.1016/j.prro.2013.05.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2013] [Revised: 05/17/2013] [Accepted: 05/29/2013] [Indexed: 11/22/2022]
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Böhmer D. Strahlentherapie des fortgeschrittenen und rezidivierenden Prostatakarzinoms. Urologe A 2012; 51:1759-69; quiz 1770-1. [DOI: 10.1007/s00120-012-3030-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Denham JW, Wilcox C, Lamb DS, Spry NA, Duchesne G, Atkinson C, Matthews J, Turner S, Kenny L, Tai KH, Gogna NK, Ebert M, Delahunt B, McElduff P, Joseph D. Rectal and urinary dysfunction in the TROG 03.04 RADAR trial for locally advanced prostate cancer. Radiother Oncol 2012; 105:184-92. [DOI: 10.1016/j.radonc.2012.09.018] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2012] [Revised: 09/20/2012] [Accepted: 09/29/2012] [Indexed: 01/03/2023]
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Chen RC, Rosenman JG, Hoffman LG, Chiu WK, Wang AZ, Pruthi RS, Wallen EM, Crane JM, Kim WY, Rathmell WK, Godley PA, Whang YE. Phase I study of concurrent weekly docetaxel, high-dose intensity-modulated radiation therapy (IMRT) and androgen-deprivation therapy (ADT) for high-risk prostate cancer. BJU Int 2012; 110:E721-6. [PMID: 23016517 DOI: 10.1111/j.1464-410x.2012.11536.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
UNLABELLED Study Type - Therapy (phase 1) Level of Evidence 2a What's known on the subject? and What does the study add? High-risk and locally advanced prostate cancers are difficult to cure with the standard regimen of radiation therapy (RT) with concurrent androgen-deprivation therapy (ADT). Multiple studies have explored the addition of docetaxel chemotherapy in attempt to improve patient outcomes. Prior Phase I studies have shown that docetaxel 20 mg/m(2) is a safe dose, when given concurrently with 70 Gy of radiation. But current standard RT for prostate cancer uses higher doses, and it is unclear if concurrent chemotherapy is safe with modern RT. This is a Phase I study that explored the addition of concurrent docetaxel chemotherapy to modern RT (intensity-modulated RT to 78 Gy) plus ADT. The study showed that weekly docetaxel at 20 mg/m(2) is safe with modern RT. At a median follow-up of 2.2 years, biochemical progression-free survival was 94%. This triple-therapy regimen is safe and promising for further evaluation in prospective trials. OBJECTIVE • To evaluate in a phase I trial, the feasibility of adding concurrent weekly docetaxel chemotherapy to high-dose intensity modulated radiation therapy (IMRT) and androgen-deprivation therapy (ADT) for treatment of high-risk prostate cancer. PATIENTS AND METHODS • Patients with high-risk prostate cancer were treated with a luteinising hormone-releasing hormone agonist (starting 2-3 months before IMRT and lasting 2 years), IMRT of 78 Gy to the prostate and seminal vesicles, and weekly docetaxel during RT. • All patients had computed tomography and bone scans to exclude metastatic disease. • A standard 3 + 3 design was used for docetaxel dose escalation. Successive patients were treated on dose levels of 10, 15, and 20 mg/m(2) of weekly docetaxel. RESULTS • In all, 18 patients participated in the study: 15 (83%) had Gleason 8-10 disease; the other three had either clinical T3 disease and/or a prostate-specific antigen (PSA) level of >20 ng/mL. • Grade 3 diarrhoea (a defined dose-limiting toxicity, DLT) occurred in one patient in each of the first two dose levels. However, when the cohorts were expanded, no further DLT was seen. • Weekly docetaxel at 20 mg/m(2) (dose level 3) was successfully given without DLT. • No patient had grade 4 or 5 toxicity. • At a median follow-up of 2.2 years, all patients achieved a PSA nadir of <1 ng/mL, including 13 patients who had an undetectable PSA level. The 2-year biochemical progression-free survival was 94%. CONCLUSION • A dose of 20 mg/m(2) of weekly docetaxel given concurrently with high-dose IMRT and ADT appears safe for further study in patients with high-risk prostate cancer.
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Affiliation(s)
- Ronald C Chen
- Department of Radiation Oncology, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599-7295, USA
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Stereotactic body radiation therapy for the primary treatment of localized prostate cancer. ACTA ACUST UNITED AC 2012; 2:63-70. [PMID: 23504305 PMCID: PMC3594824 DOI: 10.1007/s13566-012-0067-2] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2012] [Accepted: 08/30/2012] [Indexed: 01/26/2023]
Abstract
Objective The low alpha/beta ratio of prostate cancer suggests that hypofractionated schemes of dose-escalated radiotherapy should be advantageous. We report our experience using stereotactic body radiation therapy (SBRT) for the primary treatment of prostate cancer to assess efficacy and toxicity. Methods From 2007 to 2010, 70 patients (51 % low risk, 31 % intermediate risk, and 17 % high risk) with localized prostate cancer were treated with SBRT using the CyberKnife system. One-third of patients received androgen deprivation therapy. Doses of 37.5 Gy (n = 29), 36.25 Gy (n = 36), and 35 Gy (n = 5) were administered in five fractions and analyzed as high dose (37.5 Gy) vs. low dose (36.25 and 35 Gy). Results At a median 27 and 37 months follow-up, the low and high dose groups' median PSA nadir to date was 0.3 and 0.2 ng/ml, respectively. The 3-year freedom from biochemical failure (FFBF) was 100 %, 95.0 % and 77.1 % for the low-, intermediate- and high-risk patients. A dose response was observed in intermediate- and high-risk patients with 72 % vs. 100 % 3-year FFBF for the low and high dose groups, respectively (p = 0.0363). Grade III genitourinary toxicities included 4 % acute and 3 % late (all high dose). Potency was preserved in 83 % of hormone naïve patients. Conclusion CyberKnife dose escalated SBRT for low-, intermediate- and high-risk prostate cancer exhibits favorable efficacy with acceptable toxicity.
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McGivern U, Mitchell DM, McDowell C, O'Hare J, Corey G, O'Sullivan JM. Neoadjuvant Hormone Therapy for Radical Prostate Radiotherapy: Bicalutamide Monotherapy vs. Luteinizing Hormone–Releasing Hormone Agonist Monotherapy: A Single-Institution Matched-Pair Analysis. Clin Genitourin Cancer 2012; 10:190-5. [DOI: 10.1016/j.clgc.2012.04.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2011] [Revised: 03/30/2012] [Accepted: 04/13/2012] [Indexed: 10/28/2022]
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Current world literature. Curr Opin Endocrinol Diabetes Obes 2012; 19:233-47. [PMID: 22531108 DOI: 10.1097/med.0b013e3283542fb3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Tseng YD, Chen MH, Beard CJ, Martin NE, Orio PF, Loffredo M, Renshaw AA, Choueiri TK, Hu JC, Kantoff PW, D'Amico AV, Nguyen PL. Posttreatment Prostate Specific Antigen Nadir Predicts Prostate Cancer Specific and All Cause Mortality. J Urol 2012; 187:2068-73. [DOI: 10.1016/j.juro.2012.01.073] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2011] [Indexed: 11/26/2022]
Affiliation(s)
| | - Ming-Hui Chen
- Department of Statistics, University of Connecticut, Storrs, Connecticut
| | - Clair J. Beard
- Department of Radiation Oncology, Dana Farber Cancer Institute and Brigham and Women's Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Neil E. Martin
- Department of Radiation Oncology, Dana Farber Cancer Institute and Brigham and Women's Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Peter F. Orio
- Department of Radiation Oncology, Dana Farber Cancer Institute and Brigham and Women's Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Marian Loffredo
- Department of Radiation Oncology, Dana Farber Cancer Institute and Brigham and Women's Hospital, Boston, Massachusetts
| | | | - Toni K. Choueiri
- Department of Medical Oncology, Dana Farber Cancer Institute and Brigham and Women's Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Jim C. Hu
- Department of Urology, Dana Farber Cancer Institute and Brigham and Women's Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Philip W. Kantoff
- Department of Medical Oncology, Dana Farber Cancer Institute and Brigham and Women's Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Anthony V. D'Amico
- Department of Radiation Oncology, Dana Farber Cancer Institute and Brigham and Women's Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Paul L. Nguyen
- Department of Radiation Oncology, Dana Farber Cancer Institute and Brigham and Women's Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
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Surrogate endpoints for prostate cancer-specific mortality after radiotherapy and androgen suppression therapy in men with localised or locally advanced prostate cancer: an analysis of two randomised trials. Lancet Oncol 2012; 13:189-95. [DOI: 10.1016/s1470-2045(11)70295-9] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Katz AJ, Santoro M, Ashley R, Diblasio F. Stereotactic Body Radiation Therapy for Low- and Low-Intermediate-Risk Prostate Cancer: Is there a Dose Effect? Front Oncol 2011; 1:49. [PMID: 22655249 PMCID: PMC3356012 DOI: 10.3389/fonc.2011.00049] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2011] [Accepted: 11/15/2011] [Indexed: 11/29/2022] Open
Abstract
This study examines the efficacy and toxicity of two stereotactic body radiation therapy (SBRT) dose regimens for treatment of early prostate cancer. Forty-one patients treated with 35 Gy were matched with 41 patients treated with 36.25 Gy. Both patient groups received SBRT in five fractions over five consecutive days using the CyberKnife. Each group had 37 low-risk patients and 4 intermediate-risk patients. No statistically significant differences were present for age, prostate volume, PSA, Gleason score, stage, or risk between the groups. The dose was prescribed to the 83–87% isodose line to cover the prostate and a 5-mm margin all around, except 3 mm posteriorly. The overall median follow-up is 51 months (range, 45–58 months) with a median 54 and 48 months follow-up for the 35 and 36.25-Gy dose groups, respectively. One biochemical failure occurred in each group yielding a 97.5% freedom from biochemical failure. The PSA response has been favorable for all patients with a mean PSA of 0.1 ng/ml at 4-years. Overall toxicity has been mild with 5% late grade 2 rectal toxicity in both dose groups. Late grade 1 urinary toxicity was equivalent between groups; grade 2 urinary toxicity was 5% (2/41 patients) and 10% (4/41 patients) in the 35-Gy and 36.25-Gy dose groups (p = 0.6969), respectively. Overall, the highly favorable PSA response, limited biochemical failures, limited toxicity, and limited impact on quality of life in these low- to low-intermediate-risk patients are supportive of excellent long-term results for CyberKnife delivered SBRT.
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Affiliation(s)
- Alan J Katz
- Flushing Radiation Oncology Flushing, NY, USA
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Ko EC, Stone NN, Stock RG. PSA nadir of <0.5 ng/mL following brachytherapy for early-stage prostate adenocarcinoma is associated with freedom from prostate-specific antigen failure. Int J Radiat Oncol Biol Phys 2011; 83:600-7. [PMID: 21985944 DOI: 10.1016/j.ijrobp.2011.07.009] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2011] [Revised: 06/23/2011] [Accepted: 07/09/2011] [Indexed: 11/16/2022]
Abstract
PURPOSE Because limited information exists regarding whether the rate or magnitude of PSA decline following brachytherapy predicts long-term clinical outcomes, we evaluated whether achieving a prostate-specific antigen (PSA) nadir (nPSA) <0.5 ng/mL following brachytherapy is associated with decreased PSA failure and/or distant metastasis. METHODS AND MATERIALS We retrospectively analyzed our database of early-stage prostate adenocarcinoma patients who underwent brachytherapy, excluding those receiving androgen-deprivation therapy and those with <2 years follow-up. Median and mean pretreatment PSA were 6 ng/mL and 7.16 ng/mL, respectively. By clinical stage, 775 were low risk (≤ T2a), 126 were intermediate risk (T2b), and 20 were high risk (>T2b). By Gleason score, 840 were low risk (≤ 6), 71 were intermediate risk (7), and 10 were high risk (>7). Patients were treated with brachytherapy only (I-125, n = 779, or Pd-103, n = 47), or brachytherapy + external-beam radiation therapy (n = 95). Median follow-up was 6.3 years. We noted whether nPSA <0.5 ng/mL was achieved and the time to achieve this nadir and tested for associations with pretreatment risk factors. We also determined whether this PSA endpoint was associated with decreased PSA failure or distant metastasis. RESULTS Absence of high-risk factors in clinical stage (≤ T2b), Gleason score (≤ 7), and pretreatment PSA (≤ 20 ng/mL) was significantly associated with achieving nPSA <0.5 ng/mL. By Kaplan-Meier analysis, patients achieving nPSA <0.5 ng/mL had significantly higher long-term freedom from biochemical failure (FFBF) than nonresponders (5-year FFBF: 95.2 ± 0.8% vs. 71.5 ± 6.7%; p < 0.0005). Among responders, those who achieved nPSA <0.5 ng/mL in ≤ 5 years had higher FFBF than those requiring >5 years (5-year FFBF: 96.7 ± 0.7% vs. 80.8 ± 4.6%; p < 0.0005). On multivariate analysis, patients who achieved nPSA <0.5 ng/mL in ≤ 5 years had significantly higher FFBF than other patients. CONCLUSIONS Pretreatment risk factors (clinical tumor stage, Gleason score, pretreatment PSA) strongly predict for patients achieving nPSA <0.5 ng/mL following brachytherapy, and this cohort had significantly higher long-term FFBF.
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Affiliation(s)
- Eric C Ko
- Department of Radiation Oncology, Mount Sinai Medical Center, New York, NY 10029, USA.
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Early choline levels from 3-tesla MR spectroscopy after exclusive radiation therapy in patients with clinically localized prostate cancer are predictive of plasmatic levels of PSA at 1 year. Int J Radiat Oncol Biol Phys 2011; 81:e407-13. [PMID: 21605949 DOI: 10.1016/j.ijrobp.2011.03.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2010] [Revised: 02/08/2011] [Accepted: 03/09/2011] [Indexed: 11/21/2022]
Abstract
PURPOSE To investigate the time course response of prostate metabolism to irradiation using magnetic resonance spectroscopy (MRS) at 3-month intervals and its impact on biochemical control. METHODS AND MATERIALS Between January 2008 and April 2010, 24 patients with localized prostate cancer were prospectively enrolled in the Evaluation of the Response to Irradiation with MR Spectroscopy (ERIS) trial. All the patients had been treated with intensity-modulated radiation therapy with or without long-term adjuvant hormonal therapy (LTHT) and underwent 3-T MRS and prostate-specific antigen (PSA) assays at baseline and every 3 months thereafter up to 12 months. RESULTS After radiation, the mean normalized citrate level (citrate/water) decreased significantly over time, both in the peripheral zone (PZ) (p = 0.0034) and in the entire prostate (p = 0.0008), whereas no significant change was observed in mean normalized choline levels (choline/water) in the PZ (p = 0.84) and in the entire prostate (p = 0.95). At 6 months after radiation, the mean choline level was significantly lower in the PZ for patients with a PSA value of ≤0.5 ng/mL at 12 months (4.9 ± 1.7 vs. 7.1 ± 1.5, p = 0.0378). Similar results were observed at 12 months in the PZ (6.2 ± 2.3 vs. 11.4 ± 4.1, p = 0.0117 for choline level and 3.4 ± 0.7 vs. 16.1 ± 6.1, p = 0.0054 for citrate level) and also in the entire prostate (6.2 ± 1.9 vs. 10.4 ± 3.2, p = 0.014 for choline level and 3.0 ± 0.8 vs. 13.3 ± 4.7, p = 0.0054 for citrate level). For patients receiving LTHT, there was no correlation between choline or citrate levels and PSA value, either at baseline or at follow-up. CONCLUSIONS Low normalized choline in the PZ, 6 months after radiation, predicts which patients attained a PSA ≤0.5 ng/mL at 1 year. Further analyses with longer follow-up times are warranted to determine whether or not these new biomarkers can conclusively predict the early radiation response and the clinical outcome for patients with or without LTHT.
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Mazeron JJ. Compte-rendu de la 29e réunion de l’European Society for Therapeutic Radiology and Oncology (ESTRO). Barcelone (Espagne), 12–16 septembre 2010. Cancer Radiother 2011; 15:154-60. [DOI: 10.1016/j.canrad.2011.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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A methodology for the analysis of PSA response signatures. Radiother Oncol 2011; 98:198-202. [DOI: 10.1016/j.radonc.2010.11.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2010] [Revised: 10/07/2010] [Accepted: 11/07/2010] [Indexed: 11/20/2022]
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