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Meynard C, Huertas A, Dariane C, Toublanc S, Dubourg Q, Urien S, Timsit MO, Méjean A, Thiounn N, Giraud P. Tumor burden and location as prognostic factors in patients treated by iodine seed implant brachytherapy for localized prostate cancers. Radiat Oncol 2019; 15:1. [PMID: 31892338 PMCID: PMC6938614 DOI: 10.1186/s13014-019-1449-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Accepted: 12/18/2019] [Indexed: 02/07/2023] Open
Abstract
Background Iodine seed implant brachytherapy is indicated for low risk and selected favorable intermediate risk prostate cancers. A percentage of positive biopsies > 50% is usually considered as a contra-indication, and the tumor location could also influence the treatment efficacy. We studied the association of the percentage of positive biopsy cores, and tumor location, with progression-free survival. Methods Among the 382 patients treated at our center by permanent implant iodine seed brachytherapy for a localized prostate cancer between 2006 and 2013, 282 had accessible detailed pathology reports, a minimum follow-up of 6 months, and were included. Progression was defined as a biochemical, local, nodal, or distant metastatic relapse. We studied cancer location on biopsies (base, midgland or apex of the prostate) and percentage of positive biopsy cores, as well as potential confounders (pre-treatment PSA, tumor stage, Gleason score, risk group according to D’Amico’s classification modified by Zumsteg, adjunction of androgen deprivation therapy, and dosimetric data). Results Most patients (197; 69.9%) had a low risk, 67 (23.8%) a favorable intermediate risk, 16 (5.7%) an unfavorable intermediate risk, and 1 (0.3%) a high-risk prostate cancer. An involvement of the apex was found for 131 patients (46,5%), of the midgland for 149 (52,8%), and of the base for 145 (51,4%). The median percentage of positive biopsy cores was 17% [3–75%]. The median follow-up was 64 months [12–140]. Twenty patients (7%) progressed: 4 progressions (20%) were biochemical only, 7 (35%) were prostatic or seminal, 6 (30%) were nodal, and 3 (15%) were metastatic. The median time to failure was 39.5 months [9–108]. There were more Gleason scores ≥7 among patients who progressed (40% vs 19%; p = 0.042). None of the studied covariates (including tumor location, and percentage of positive biopsy cores), were significantly associated with progression-free survival. The risk group showed a trend towards an association (p = 0.055). Conclusions Brachytherapy is an efficient treatment (5-year control rate of 93%) for patients carefully selected with classical criteria. The percentage and location of positive biopsies were not significantly associated with progression-free survival. A Gleason score ≥ 7 was more frequent in case of progression.
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Affiliation(s)
- Claire Meynard
- Hôpital Européen Georges Pompidou, 20 rue Leblanc, 75015, Paris, France.
| | - Andres Huertas
- Hôpital Européen Georges Pompidou, 20 rue Leblanc, 75015, Paris, France
| | - Charles Dariane
- Hôpital Européen Georges Pompidou, 20 rue Leblanc, 75015, Paris, France
| | - Sandra Toublanc
- Hôpital Européen Georges Pompidou, 20 rue Leblanc, 75015, Paris, France
| | - Quentin Dubourg
- Hôpital Européen Georges Pompidou, 20 rue Leblanc, 75015, Paris, France
| | - Saik Urien
- Unité de Recherche Clinique, Hôpital Tarnier, 89 rue d'Assas, 75006, Paris, France
| | | | - Arnaud Méjean
- Hôpital Européen Georges Pompidou, 20 rue Leblanc, 75015, Paris, France
| | - Nicolas Thiounn
- Hôpital Européen Georges Pompidou, 20 rue Leblanc, 75015, Paris, France
| | - Philippe Giraud
- Hôpital Européen Georges Pompidou, 20 rue Leblanc, 75015, Paris, France
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Ruiz-Cordero R, Gupta A, Pinto A, Jorda M. Cost-containment protocols for prostate core needle biopsies: hypothetical scenarios to reduce procedural costs. Prostate Int 2018; 7:15-18. [PMID: 30937293 PMCID: PMC6424682 DOI: 10.1016/j.prnil.2018.02.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Accepted: 02/05/2018] [Indexed: 11/20/2022] Open
Abstract
Background In recent years, anatomic pathology laboratories have been struck by new revenue policies secondary to the Affordable Care Act. In particular, modifications to compensation for processing prostatic core needle biopsies (PCNBs) have led to important reimbursement cuts. Herein, we explore a hypothetical reduction in the costs for the processing of PCNBs using three simple, hypothetical methods while maintaining high-standard patient care. Materials and methods We determined the number of blocks and slides used per case on all PCNBs performed at our institution from August 2013 to September 2014 and calculated the total procedural cost for each case and for the total number of cases processed during the study period based on a published estimated procedural cost. We then estimated the procedural cost of three different proposed hypothetical scenarios that consisted in reducing the number of blocks used per case. A Student t test was used to assess the difference between real and hypothetical costs. Results A total of 4,406 paraffin blocks were used to process 363 PCNBs with a total annual procedural cost of $26,303. By implementing any of the hypothetical scenarios, the annual procedural cost was significantly reduced; the reduction could potentially be as low as $8,978 (P < 0.0001). Conclusions This study illustrates three hypothetical alternatives that could dramatically reduce the procedural costs of PCNBs while maintaining high-quality care. Implementation of these scenarios at a global scale could potentially have an impact on health-care cost in the USA of several millions of dollars per year.
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Affiliation(s)
- Roberto Ruiz-Cordero
- Department of Pathology, University of Miami Miller School of Medicine and Jackson Memorial Hospital, Miami, FL 33136, USA
| | - Alia Gupta
- Department of Pathology, University of Miami Miller School of Medicine and Jackson Memorial Hospital, Miami, FL 33136, USA
| | - Andre Pinto
- Department of Pathology, University of Miami Miller School of Medicine and Jackson Memorial Hospital, Miami, FL 33136, USA
| | - Merce Jorda
- Department of Pathology, University of Miami Miller School of Medicine and Jackson Memorial Hospital, Miami, FL 33136, USA
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Raymond E, O'Callaghan ME, Campbell J, Vincent AD, Beckmann K, Roder D, Evans S, McNeil J, Millar J, Zalcberg J, Borg M, Moretti K. An appraisal of analytical tools used in predicting clinical outcomes following radiation therapy treatment of men with prostate cancer: a systematic review. Radiat Oncol 2017; 12:56. [PMID: 28327203 PMCID: PMC5359887 DOI: 10.1186/s13014-017-0786-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Accepted: 02/22/2017] [Indexed: 11/10/2022] Open
Abstract
Background Prostate cancer can be treated with several different modalities, including radiation treatment. Various prognostic tools have been developed to aid decision making by providing estimates of the probability of different outcomes. Such tools have been demonstrated to have better prognostic accuracy than clinical judgment alone. Methods A systematic review was undertaken to identify papers relating to the prediction of clinical outcomes (biochemical failure, metastasis, survival) in patients with prostate cancer who received radiation treatment, with the particular aim of identifying whether published tools are adequately developed, validated, and provide accurate predictions. PubMed and EMBASE were searched from July 2007. Title and abstract screening, full text review, and critical appraisal were conducted by two reviewers. A review protocol was published in advance of commencing literature searches. Results The search strategy resulted in 165 potential articles, of which 72 were selected for full text review and 47 ultimately included. These papers described 66 models which were newly developed and 31 which were external validations of already published predictive tools. The included studies represented a total of 60,457 patients, recruited between 1984 and 2009. Sixty five percent of models were not externally validated, 57% did not report accuracy and 31% included variables which are not readily accessible in existing datasets. Most models (72, 74%) related to external beam radiation therapy with the remainder relating to brachytherapy (alone or in combination with external beam radiation therapy). Conclusions A large number of prognostic models (97) have been described in the recent literature, representing a rapid increase since previous reviews (17 papers, 1966–2007). Most models described were not validated and a third utilised variables which are not readily accessible in existing data collections. Where validation had occurred, it was often limited to data taken from single institutes in the US. While validated and accurate models are available to predict prostate cancer specific mortality following external beam radiation therapy, there is a scarcity of such tools relating to brachytherapy. This review provides an accessible catalogue of predictive tools for current use and which should be prioritised for future validation. Electronic supplementary material The online version of this article (doi:10.1186/s13014-017-0786-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Elspeth Raymond
- South Australian Prostate Cancer Clinical Outcomes Collaborative (SA-PCCOC), Adelaide, Australia
| | - Michael E O'Callaghan
- South Australian Prostate Cancer Clinical Outcomes Collaborative (SA-PCCOC), Adelaide, Australia. .,Freemasons Foundation Centre for Men's Health, University of Adelaide, Adelaide, Australia. .,SA Health, Repatriation General Hospital, Urology Unit, Daws Road, Daw Park, 5041, SA, Australia. .,Flinders Centre for Innovation in Cancer, Bedford Park, Australia.
| | - Jared Campbell
- Joanna Briggs Institute, University of Adelaide, Adelaide, Australia
| | - Andrew D Vincent
- South Australian Prostate Cancer Clinical Outcomes Collaborative (SA-PCCOC), Adelaide, Australia.,Freemasons Foundation Centre for Men's Health, University of Adelaide, Adelaide, Australia
| | - Kerri Beckmann
- South Australian Prostate Cancer Clinical Outcomes Collaborative (SA-PCCOC), Adelaide, Australia.,Centre for Population Health Research, University of South Australia, Adelaide, Australia
| | - David Roder
- Centre for Population Health Research, University of South Australia, Adelaide, Australia
| | - Sue Evans
- Epidemiology & Preventative Medicine, Monash University, Clayton, Australia
| | - John McNeil
- Epidemiology & Preventative Medicine, Monash University, Clayton, Australia
| | - Jeremy Millar
- Radiation Oncology, Alfred Health, Melbourne, Australia
| | - John Zalcberg
- Epidemiology & Preventative Medicine, Monash University, Clayton, Australia.,School of Public Health and Preventive Medicine, Monash University, Clayton, Australia
| | - Martin Borg
- Adelaide Radiotherapy Centre, Adelaide, Australia
| | - Kim Moretti
- South Australian Prostate Cancer Clinical Outcomes Collaborative (SA-PCCOC), Adelaide, Australia.,Freemasons Foundation Centre for Men's Health, University of Adelaide, Adelaide, Australia.,Centre for Population Health Research, University of South Australia, Adelaide, Australia.,Joanna Briggs Institute, University of Adelaide, Adelaide, Australia.,Discipline of Surgery, University of Adelaide, Adelaide, Australia
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Stratification of brachytherapy-treated intermediate-risk prostate cancer patients into favorable and unfavorable cohorts. J Contemp Brachytherapy 2015; 7:430-6. [PMID: 26816337 PMCID: PMC4716130 DOI: 10.5114/jcb.2015.56763] [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: 10/27/2015] [Accepted: 12/18/2015] [Indexed: 01/11/2023] Open
Abstract
Purpose To evaluate biochemical failure (BF) and prostate cancer specific mortality (PCSM) in intermediate-risk (IR) brachytherapy patients stratified into favorable and unfavorable cohorts, and to compare those outcomes to patients with low (LR) and high-risk (HR) disease. Material and methods From March 1995 till February 2012, 2,502 consecutive patients underwent permanent interstitial brachytherapy for clinically localized prostate cancer. Patients were stratified into risk groups as per the NCCN guidelines with further stratification of the intermediate risk cohort into unfavorable (primary Gleason pattern 4, ≥ 50% positive biopsies or ≥ 2 IR features) and favorable cohorts. Median follow-up was 8.5 years. The brachytherapy prescription dose was prescribed to the prostate gland with generous periprostatic margins. Biochemical failure was defined as a PSA > 0.40 ng/ml after nadir. Patients with metastatic prostate cancer or non-metastatic castrate resistant disease who died of any cause were classified as dead of prostate cancer. Multiple parameters were evaluated for effect on outcomes. Results Fifteen year BF for LR, favorable IR, unfavorable IR, and HR were 1.4%, 2.2%, 7.1%, and 11.1% (p < 0.001), respectively. At 15 years, PCSM for LR, favorable IR, unfavorable IR, and HR was 0.3%, 0.6%, 2.2% and 4.6% (p < 0.001), respectively. In multivariate analysis, BF was best predicted by risk group, pre-implant PSA, percent positive biopsies, prostate volume, and ADT duration, while PCSM was most closely related to risk group, percent positive biopsies and prostate volume. Conclusions Patients with favorable IR disease have biochemical and PCSM outcomes comparable to those of patients with LR disease. Although unfavorable IR has greater than a 3-fold increased risk of BF and PCSM when compared to favorable IR, the outcomes remain superior to those men with HR disease.
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Merrick GS, Wallner KE, Galbreath RW, Butler WM, Adamovich E. Is supplemental external beam radiation therapy essential to maximize brachytherapy outcomes in patients with unfavorable intermediate-risk disease? Brachytherapy 2015; 15:79-84. [PMID: 26525214 DOI: 10.1016/j.brachy.2015.09.011] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Revised: 09/21/2015] [Accepted: 09/28/2015] [Indexed: 10/22/2022]
Abstract
PURPOSE To evaluate whether supplemental external beam radiotherapy (EBRT) is essential to maximize Pd-103 brachytherapy outcomes in patients with unfavorable intermediate-risk (IR) disease. METHODS AND MATERIALS A total of 630 patients were assessed from two prospective randomized brachytherapy trials evaluating the role of supplemental EBRT in patients with higher risk features. Patients were stratified into unfavorable IR (primary Gleason pattern 4, ≥50% positive biopsies, or ≥2 IR features), favorable IR, and high-risk (HR) cohorts. Median follow-up was 7.5 years. The brachytherapy prescription dose was prescribed to the prostate gland with generous periprostatic margins. Biochemical failure (BF) was defined as a prostate-specific antigen >0.40 ng/mL after nadir. Patients with metastatic prostate cancer or nonmetastatic castrate-resistant disease who died of any cause were classified as dead of prostate cancer. Multiple parameters were evaluated for effect on outcomes. RESULTS The 10-year BF for favorable IR, unfavorable IR, and HR was 1.7%, 6.6%, and 15.5% (p < 0.001). At 10 years, prostate cancer-specific mortality (PCSM) and overall mortality (OM) were 0% and 20.4%, 2.1% and 23.2%, and 4.3% and 42.4% for favorable IR, unfavorable IR, and HR. Although unfavorable IR patients had a greater incidence of BF, PCSM, and OM when compared with favorable IR, neither the addition nor dose of supplemental EBRT influenced outcome. CONCLUSIONS Outcomes for favorable IR were superior to those with unfavorable IR. Within the confines of this study, neither the addition nor dose of supplemental EBRT influenced BF, PCSM, or OM in patients with IR disease.
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Affiliation(s)
- Gregory S Merrick
- Department of Radiation Oncology, Schiffler Cancer Center, Wheeling Jesuit University, Wheeling, WV; Department of Urology, Wheeling Hospital, Wheeling, WV.
| | - Kent E Wallner
- Department of Radiation Oncology, Puget Sound Healthcare Corporation, Group Health Cooperative, University of Washington, Seattle, WA
| | - Robert W Galbreath
- Department of Radiation Oncology, Schiffler Cancer Center, Wheeling Jesuit University, Wheeling, WV; Ohio Univeristy Eastern, St. Clairsville, OH
| | - Wayne M Butler
- Department of Radiation Oncology, Schiffler Cancer Center, Wheeling Jesuit University, Wheeling, WV
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Hill J, Hackett C, Sloboda R, Menon G, Singhal S, Pervez N, Pedersen J, Yee D, Murtha A, Amanie J, Usmani N. Does location of prostate cancer by sextant biopsies predict for relapse after (125)I seed implant brachytherapy? Brachytherapy 2015; 14:788-94. [PMID: 26249125 DOI: 10.1016/j.brachy.2015.07.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Revised: 07/07/2015] [Accepted: 07/07/2015] [Indexed: 12/29/2022]
Abstract
PURPOSE To report on the importance of cancer location from diagnostic prostate biopsies in predicting biochemical relapse for patients treated with (125)I seed implant brachytherapy as monotherapy for favorable risk disease; specifically, to assess the clinical significance of potentially underdosing the base region of the prostate gland. METHODS AND MATERIALS Of 1145 consecutive patients, 846 had pretreatment biopsies allowing for sextant analysis and consequent evaluation of biochemical failure tendencies. Biochemical failure was defined as a posttreatment rise in the nadir prostate-specific antigen (PSA) by at least 2 ng/mL. Patient and tumor characteristics, dosimetry, the use of hormone therapy, source strength, and postimplant PSA kinetics were analyzed between sextant subgroups. RESULTS Sixty-two patients (7.3%) with sextant pathology had biochemical failure. There was no significant difference between the failure locations. There were 528 patients (62.4%) with some element of base involvement (BI), and 318 patients (37.6%) with no evidence of BI. Of the 62 patients with biochemical failure, 42 (67.7%) showed BI on biopsy and 20 (32.3%) had no BI. The 10-year relapse-free survival rate is 88.2% (95% confidence interval: 84.3%, 92.2%) and 92.0% (95% confidence interval: 88.4%, 95.8%) for the BI and no BI groups, respectively (p = 0.17). The mean D90 delivered to the base, midgland, and apex was 140.8 (±21.8) Gy, 170.8 (±22.5) Gy, and 177.9 (±29.5) Gy, respectively, for all patients. CONCLUSIONS There are no significantly worse outcomes for patients treated with an (125)I seed implant for favorable risk prostate cancer with some element of BI, despite lower doses of radiation delivered to the base region.
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Affiliation(s)
- Jesse Hill
- Department of Oncology, Faculty of Medicine and Dentistry, Division of Radiation Oncology, Cross Cancer Institute, Edmonton, Alberta, Canada; Department of Oncology, University of Alberta, Edmonton, Alberta, Canada.
| | - Cian Hackett
- Department of Oncology, Faculty of Medicine and Dentistry, Division of Radiation Oncology, Cross Cancer Institute, Edmonton, Alberta, Canada; Department of Oncology, University of Alberta, Edmonton, Alberta, Canada
| | - Ron Sloboda
- Department of Oncology, University of Alberta, Edmonton, Alberta, Canada; Department of Oncology, Faculty of Medicine and Dentistry, Division of Medical Physics, Cross Cancer Institute, Edmonton, Alberta, Canada
| | - Geetha Menon
- Department of Oncology, University of Alberta, Edmonton, Alberta, Canada; Department of Oncology, Faculty of Medicine and Dentistry, Division of Medical Physics, Cross Cancer Institute, Edmonton, Alberta, Canada
| | - Sandeep Singhal
- Department of Oncology, University of Alberta, Edmonton, Alberta, Canada
| | - Nadeem Pervez
- Radiotherapy Department, Tawam Hospital In Affiliation With John Hopkins Medicine, Al Ain, Abu Dhabi, UAE
| | - John Pedersen
- Department of Oncology, Faculty of Medicine and Dentistry, Division of Radiation Oncology, Cross Cancer Institute, Edmonton, Alberta, Canada; Department of Oncology, University of Alberta, Edmonton, Alberta, Canada
| | - Don Yee
- Department of Oncology, Faculty of Medicine and Dentistry, Division of Radiation Oncology, Cross Cancer Institute, Edmonton, Alberta, Canada; Department of Oncology, University of Alberta, Edmonton, Alberta, Canada
| | - Albert Murtha
- Department of Oncology, Faculty of Medicine and Dentistry, Division of Radiation Oncology, Cross Cancer Institute, Edmonton, Alberta, Canada; Department of Oncology, University of Alberta, Edmonton, Alberta, Canada
| | - John Amanie
- Department of Oncology, Faculty of Medicine and Dentistry, Division of Radiation Oncology, Cross Cancer Institute, Edmonton, Alberta, Canada; Department of Oncology, University of Alberta, Edmonton, Alberta, Canada
| | - Nawaid Usmani
- Department of Oncology, Faculty of Medicine and Dentistry, Division of Radiation Oncology, Cross Cancer Institute, Edmonton, Alberta, Canada; Department of Oncology, University of Alberta, Edmonton, Alberta, Canada
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