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Corrao G, Marvaso G, Mastroleo F, Biffi A, Pellegrini G, Minari S, Vincini MG, Zaffaroni M, Zerini D, Volpe S, Gaito S, Mazzola GC, Bergamaschi L, Cattani F, Petralia G, Musi G, Ceci F, De Cobelli O, Orecchia R, Alterio D, Jereczek-Fossa BA. Photon vs proton hypofractionation in prostate cancer: A systematic review and meta-analysis. Radiother Oncol 2024; 195:110264. [PMID: 38561122 DOI: 10.1016/j.radonc.2024.110264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 03/21/2024] [Accepted: 03/24/2024] [Indexed: 04/04/2024]
Abstract
BACKGROUND High-level evidence on hypofractionated proton therapy (PT) for localized and locally advanced prostate cancer (PCa) patients is currently missing. The aim of this study is to provide a systematic literature review to compare the toxicity and effectiveness of curative radiotherapy with photon therapy (XRT) or PT in PCa. METHODS PubMed, Embase, and the Cochrane Library databases were systematically searched up to April 2022. Men with a diagnosis of PCa who underwent curative hypofractionated RT treatment (PT or XRT) were included. Risk of grade (G) ≥ 2 acute and late genitourinary (GU) OR gastrointestinal (GI) toxicity were the primary outcomes of interest. Secondary outcomes were five-year biochemical relapse-free survival (b-RFS), clinical relapse-free, distant metastasis-free, and prostate cancer-specific survival. Heterogeneity between study-specific estimates was assessed using Chi-square statistics and measured with the I2 index (heterogeneity measure across studies). RESULTS A total of 230 studies matched inclusion criteria and, due to overlapped populations, 160 were included in the present analysis. Significant lower rates of G ≥ 2 acute GI incidence (2 % vs 7 %) and improved 5-year biochemical relapse-free survival (95 % vs 91 %) were observed in the PT arm compared to XRT. PT benefits in 5-year biochemical relapse-free survival were maintained for the moderate hypofractionated arm (p-value 0.0122) and among patients in intermediate and low-risk classes (p-values < 0.0001 and 0.0368, respectively). No statistically relevant differences were found for the other considered outcomes. CONCLUSION The present study supports that PT is safe and effective for localized PCa treatment, however, more data from RCTs are needed to draw solid evidence in this setting and further effort must be made to identify the patient subgroups that could benefit the most from PT.
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Affiliation(s)
- Giulia Corrao
- Division of Radiation Oncology, European Institute of Oncology IRCCS, Milan, Italy; Department of Oncology and Hemato-oncology, University of Milan, Milan, Italy
| | - Giulia Marvaso
- Division of Radiation Oncology, European Institute of Oncology IRCCS, Milan, Italy; Department of Oncology and Hemato-oncology, University of Milan, Milan, Italy
| | - Federico Mastroleo
- Division of Radiation Oncology, European Institute of Oncology IRCCS, Milan, Italy; Department of Oncology and Hemato-oncology, University of Milan, Milan, Italy
| | - Annalisa Biffi
- National Centre of Healthcare Research and Pharmacoepidemiology, University of Milano-Bicocca, Milan, Italy; Unit of Biostatistics, Epidemiology and Public Health, Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy
| | - Giacomo Pellegrini
- National Centre of Healthcare Research and Pharmacoepidemiology, University of Milano-Bicocca, Milan, Italy; Unit of Biostatistics, Epidemiology and Public Health, Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy
| | - Samuele Minari
- National Centre of Healthcare Research and Pharmacoepidemiology, University of Milano-Bicocca, Milan, Italy
| | - Maria Giulia Vincini
- Division of Radiation Oncology, European Institute of Oncology IRCCS, Milan, Italy.
| | - Mattia Zaffaroni
- Division of Radiation Oncology, European Institute of Oncology IRCCS, Milan, Italy.
| | - Dario Zerini
- Division of Radiation Oncology, European Institute of Oncology IRCCS, Milan, Italy
| | - Stefania Volpe
- Division of Radiation Oncology, European Institute of Oncology IRCCS, Milan, Italy; Department of Oncology and Hemato-oncology, University of Milan, Milan, Italy
| | - Simona Gaito
- Proton Clinical Outcomes Unit, The Christie NHS Proton Beam Therapy Centre, Manchester, UK; Division of Clinical Cancer Science, School of Medical Sciences, The University of Manchester, Manchester, UK
| | | | - Luca Bergamaschi
- Division of Radiation Oncology, European Institute of Oncology IRCCS, Milan, Italy
| | - Federica Cattani
- Unit of Medical Physics, European Institute of Oncology IRCCS, Milan, Italy
| | - Giuseppe Petralia
- Department of Oncology and Hemato-oncology, University of Milan, Milan, Italy; Division of Radiology, IEO European Institute of Oncology IRCCS, Milan, Italy
| | - Gennaro Musi
- Division of Urology, European Institute of Oncology IRCCS, Milan, Italy
| | - Francesco Ceci
- Department of Oncology and Hemato-oncology, University of Milan, Milan, Italy; Division of Nuclear Medicine and Theranostics, IEO European Institute of Oncology, IRCCS, Milan, Italy
| | - Ottavio De Cobelli
- Department of Oncology and Hemato-oncology, University of Milan, Milan, Italy; Division of Urology, European Institute of Oncology IRCCS, Milan, Italy
| | - Roberto Orecchia
- Scientific Directorate, European Institute of Oncology IRCCS, Milan, Italy
| | - Daniela Alterio
- Division of Radiation Oncology, European Institute of Oncology IRCCS, Milan, Italy
| | - Barbara Alicja Jereczek-Fossa
- Division of Radiation Oncology, European Institute of Oncology IRCCS, Milan, Italy; Department of Oncology and Hemato-oncology, University of Milan, Milan, Italy
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Lischalk JW, Akerman M, Repka MC, Sanchez A, Mendez C, Santos VF, Carpenter T, Wise D, Corcoran A, Lepor H, Katz A, Haas JA. High-risk prostate cancer treated with a stereotactic body radiation therapy boost following pelvic nodal irradiation. Front Oncol 2024; 14:1325200. [PMID: 38410097 PMCID: PMC10895712 DOI: 10.3389/fonc.2024.1325200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 01/08/2024] [Indexed: 02/28/2024] Open
Abstract
Purpose Modern literature has demonstrated improvements in long-term biochemical outcomes with the use of prophylactic pelvic nodal irradiation followed by a brachytherapy boost in the management of high-risk prostate cancer. However, this comes at the cost of increased treatment-related toxicity. In this study, we explore the outcomes of the largest cohort to date, which uses a stereotactic body radiation therapy (SBRT) boost following pelvic nodal radiation for exclusively high-risk prostate cancer. Methods and materials A large institutional database was interrogated to identify all patients with high-risk clinical node-negative prostate cancer treated with conventionally fractionated radiotherapy to the pelvis followed by a robotic SBRT boost to the prostate and seminal vesicles. The boost was uniformly delivered over three fractions. Toxicity was measured using the Common Terminology Criteria for Adverse Events (CTCAE) version 5.0. Oncologic outcomes were assessed using the Kaplan-Meier method. Cox proportional hazard models were created to evaluate associations between pretreatment characteristics and clinical outcomes. Results A total of 440 patients with a median age of 71 years were treated, the majority of whom were diagnosed with a grade group 4 or 5 disease. Pelvic nodal irradiation was delivered at a total dose of 4,500 cGy in 25 fractions, followed by a three-fraction SBRT boost. With an early median follow-up of 2.5 years, the crude incidence of grade 2+ genitourinary (GU) and gastrointestinal (GI) toxicity was 13% and 11%, respectively. Multivariate analysis revealed grade 2+ GU toxicity was associated with older age and a higher American Joint Committee on Cancer (AJCC) stage. Multivariate analysis revealed overall survival was associated with patient age and posttreatment prostate-specific antigen (PSA) nadir. Conclusion Utilization of an SBRT boost following pelvic nodal irradiation in the treatment of high-risk prostate cancer is oncologically effective with early follow-up and yields minimal high-grade toxicity. We demonstrate a 5-year freedom from biochemical recurrence (FFBCR) of over 83% with correspondingly limited grade 3+ GU and GI toxicity measured at 3.6% and 1.6%, respectively. Long-term follow-up is required to evaluate oncologic outcomes and late toxicity.
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Affiliation(s)
- Jonathan W. Lischalk
- Department of Radiation Oncology, Perlmutter Cancer Center at New York University Langone Hospital - Long Island, New York, NY, United States
| | - Meredith Akerman
- Division of Health Services Research, New York University Long Island School of Medicine, New York University Langone Health, Mineola, NY, United States
| | - Michael C. Repka
- Department of Radiation Oncology, University of North Carolina School of Medicine, Chapel Hill, NC, United States
| | - Astrid Sanchez
- Department of Radiation Oncology, Perlmutter Cancer Center at New York University Langone Hospital - Long Island, New York, NY, United States
| | - Christopher Mendez
- Department of Radiation Oncology, Perlmutter Cancer Center at New York University Langone Hospital - Long Island, New York, NY, United States
| | - Vianca F. Santos
- Department of Radiation Oncology, Perlmutter Cancer Center at New York University Langone Hospital - Long Island, New York, NY, United States
| | - Todd Carpenter
- Department of Radiation Oncology, Perlmutter Cancer Center at New York University Langone Hospital - Long Island, New York, NY, United States
| | - David Wise
- Department of Medical Oncology, Perlmutter Cancer Center at New York University Langone Health - Manhattan, New York, NY, United States
| | - Anthony Corcoran
- Department of Urology, Perlmutter Cancer Center at New York University Langone Hospital - Long Island, New York, NY, United States
| | - Herbert Lepor
- Department of Urology, Perlmutter Cancer Center at New York University Grossman School of Medicine, New York, NY, United States
| | - Aaron Katz
- Department of Urology, Perlmutter Cancer Center at New York University Langone Hospital - Long Island, New York, NY, United States
| | - Jonathan A. Haas
- Department of Radiation Oncology, Perlmutter Cancer Center at New York University Langone Hospital - Long Island, New York, NY, United States
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Alger E, Minchom A, Lee Aiyegbusi O, Schipper M, Yap C. Statistical methods and data visualisation of patient-reported outcomes in early phase dose-finding oncology trials: a methodological review. EClinicalMedicine 2023; 64:102228. [PMID: 37781154 PMCID: PMC10541462 DOI: 10.1016/j.eclinm.2023.102228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 08/25/2023] [Accepted: 09/05/2023] [Indexed: 10/03/2023] Open
Abstract
Background Traditionally, within dose-finding clinical trials, treatment toxicity and tolerability are assessed by clinicians. Research has shown that clinician reporting may have inadequate inter-rater reliability, poor correlation with patient reported outcomes, and under capture the true toxicity burden. The introduction of patient-reported outcomes (PROs), where the patient can assess their own symptomatic adverse events or quality of life, has potential to complement current practice to aid dose optimisation. There are no international recommendations offering guidance for the inclusion of PROs in dose-finding trial design and analysis. Our review aimed to identify and describe current statistical methods and data visualisation techniques employed to analyse and visualise PRO data in published early phase dose-finding oncology trials (DFOTs). Methods DFOTs published from June 2016-December 2022, which presented PRO analysis methods, were included in this methodological review. We extracted 35 eligible papers indexed in PubMed. Study characteristics extracted included: PRO objectives, PRO measures, statistical analysis and visualisation techniques, and whether the PRO was involved in interim and final dose selection decisions. Findings Most papers (30, 85.7%) did not include clear PRO objectives. 20 (57.1%) papers used inferential statistical techniques to analyse PROs, including survival analysis and mixed-effect models. One trial used PROs to classify a clinicians' assessed dose-limiting toxicities (DLTs). Three (8.6%) trials used PROs to confirm the tolerability of the recommended dose. 25 trial reports visually presented PRO data within a figure or table within their publication, of which 12 papers presented PRO score longitudinally. Interpretation This review highlighted that the statistical methods and reporting of PRO analysis in DFOTs are often poorly described and inconsistent. Many trials had PRO objectives which were not clearly described, making it challenging to evaluate the appropriateness of the statistical techniques used. Drawing conclusions based on DFOTs which are not powered for PROs may be misleading. With no guidance and standardisation of analysis methods for PROs in early phase DFOTs, it is challenging to compare study findings across trials. Therefore, there is a crucial need to establish international guidance to enhance statistical methods and graphical presentation for PRO analysis in the dose-finding setting. Funding EA has been supported to undertake this work as part of a PhD studentship from the Institute of Cancer Research within the MRC/NIHR Trials Methodology Research Partnership. AM is supported by the National Institute for Health Research (NIHR) Biomedical Research Centre at the Royal Marsden NHS Foundation Trust, the Institute of Cancer Research and Imperial College.
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Affiliation(s)
- Emily Alger
- Clinical Trial and Statistics Unit, Institute of Cancer Research, London, UK
| | - Anna Minchom
- Drug Development Unit, Royal Marsden/Institute of Cancer Research, London, UK
| | - Olalekan Lee Aiyegbusi
- Centre for Patient Reported Outcomes Research, Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, UK
- National Institute for Health and Care Research (NIHR) Birmingham Biomedical Research Centre, University of Birmingham, Birmingham, UK
| | - Matthew Schipper
- Departments of Radiation Oncology and Biostatistics, University of Michigan, Ann Arbor, MI, USA
| | - Christina Yap
- Clinical Trial and Statistics Unit, Institute of Cancer Research, London, UK
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Pasquier D, Nickers P, Peiffert D, Maingon P, Pommier P, Lacornerie T, Tresch E, Barthoulot M, Lartigau E. A Multicenter Phase 2 Study of Ultrahypofractionated Stereotactic Boost After External Beam Radiotherapy in Intermediate-risk Prostate Carcinoma: A Very Long-term Analysis of the CKNO-PRO Trial. EUR UROL SUPPL 2023; 54:80-87. [PMID: 37545850 PMCID: PMC10403693 DOI: 10.1016/j.euros.2023.06.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/08/2023] [Indexed: 08/08/2023] Open
Abstract
Background Genitourinary (GU) or gastrointestinal (GI) complications and tumor relapse can occur in the long term after radiotherapy for prostate cancer. Objective To assess the late tolerance and relapse-free survival (RFS) in patients undergoing hypofractionated stereotactic boost therapy after external beam radiotherapy (EBRT) for intermediate-risk prostate cancer. Design setting and participants Seventy-six patients with intermediate-risk prostate carcinoma between August 2010 and April 2013 were included. The first course delivered a dose of 46 Gy by conventional fractionation; the second course was a boost of 18 Gy (3 × 6 Gy) within 10 d. Outcome measurements and statistical analysis GU and GI toxicities were evaluated as the primary outcomes. The secondary outcomes were overall survival and RFS. The cumulative incidence of toxicity was calculated using a competing-risk approach. Overall survival and RFS were estimated using the Kaplan-Meier method. Results and limitations The median follow-up period was 88 mo (range, 81-99 mo). Sixty (79%) patients were treated with the CyberKnife and 16 (21%) using a linear accelerator. The cumulative incidences of GU and GI grade ≥2 toxicities at 120 mo were 1.4% (95% confidence interval [CI]: 0.1-6.6%) and 11.0% (95% CI: 5.1-19.4%), respectively. The overall survival and RFS rates at 8 yr were 89.1% (95% CI: 77-95%) and 76.9% (95% CI: 63.1-86.1), respectively. Conclusions A very long follow-up showed low GU and GI toxicities after a hypofractionated stereotactic boost after EBRT for intermediate-risk prostate cancer. Dose escalation of the boost delivered by hypofractionated radiation therapy appears safe for use in future trials. Patient summary We found low toxicity and good survival rates after a short and high-precision boost after external beam radiotherapy for intermediate-risk prostate cancer, with a long-term follow-up of 88 mo. This long-term treatment is safe and should be considered in future trials.
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Affiliation(s)
- David Pasquier
- Academic Department of Radiation Oncology, Centre Oscar Lambret, Lille, France
- Univ. Lille, &, CNRS, Centrale Lille, UMR 9189 - CRIStAL, Lille, France
| | - Philippe Nickers
- Academic Department of Radiation Oncology, Centre Oscar Lambret, Lille, France
| | - Didier Peiffert
- Institut de Cancérologie de Lorraine-Alexis Vautrin, Nancy, France
| | | | - Pascal Pommier
- Department of Radiation Oncology, Centre Leon Berard, Lyon, France
| | | | | | - Maël Barthoulot
- Department of Biostatistics, Centre Oscar Lambret, Lille, France
| | - Eric Lartigau
- Academic Department of Radiation Oncology, Centre Oscar Lambret, Lille, France
- Univ. Lille, &, CNRS, Centrale Lille, UMR 9189 - CRIStAL, Lille, France
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Wegener E, Samuels J, Sidhom M, Trada Y, Sridharan S, Dickson S, McLeod N, Martin JM. Virtual HDR Boost for Prostate Cancer: Rebooting a Classic Treatment Using Modern Tech. Cancers (Basel) 2023; 15:cancers15072018. [PMID: 37046680 PMCID: PMC10093761 DOI: 10.3390/cancers15072018] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 03/23/2023] [Accepted: 03/27/2023] [Indexed: 03/31/2023] Open
Abstract
Prostate cancer (PC) is the most common malignancy in men. Internal radiotherapy (brachytherapy) has been used to treat PC successfully for over a century. In particular, there is level-one evidence of the benefits of using brachytherapy to escalate the dose of radiotherapy compared with standard external beam radiotherapy approaches. However, the use of PC brachytherapy is declining, despite strong evidence for its improved cancer outcomes. A method using external beam radiotherapy known as virtual high-dose-rate brachytherapy boost (vHDRB) aims to noninvasively mimic a brachytherapy boost radiation dose plan. In this review, we consider the evidence supporting brachytherapy boosts for PC and the continuing evolution of vHDRB approaches, culminating in the current generation of clinical trials, which will help define the role of this emerging modality.
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Affiliation(s)
- Eric Wegener
- School of Medicine and Public Health, The University of Newcastle, Callaghan, NSW 2308, Australia
- Department of Radiation Oncology, Calvary Mater Newcastle Hospital, Waratah, NSW 2298, Australia
- GenesisCare, Maitland, NSW 2323, Australia
- GenesisCare, Gateshead, NSW 2290, Australia
- Correspondence:
| | - Justin Samuels
- Department of Radiation Oncology, Calvary Mater Newcastle Hospital, Waratah, NSW 2298, Australia
| | - Mark Sidhom
- Department of Radiation Oncology, Liverpool Hospital, Liverpool, NSW 2170, Australia
| | - Yuvnik Trada
- Department of Radiation Oncology, Calvary Mater Newcastle Hospital, Waratah, NSW 2298, Australia
| | - Swetha Sridharan
- Department of Radiation Oncology, Calvary Mater Newcastle Hospital, Waratah, NSW 2298, Australia
- GenesisCare, Gateshead, NSW 2290, Australia
| | - Samuel Dickson
- Department of Radiation Oncology, Calvary Mater Newcastle Hospital, Waratah, NSW 2298, Australia
| | - Nicholas McLeod
- Department of Urology, John Hunter Hospital, Newcastle, NSW 2305, Australia
| | - Jarad M. Martin
- School of Medicine and Public Health, The University of Newcastle, Callaghan, NSW 2308, Australia
- Department of Radiation Oncology, Calvary Mater Newcastle Hospital, Waratah, NSW 2298, Australia
- GenesisCare, Maitland, NSW 2323, Australia
- GenesisCare, Gateshead, NSW 2290, Australia
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Real-world utilisation of brachytherapy boost and patient-reported functional outcomes in men who had external beam radiation therapy for prostate cancer in Australia. Clin Transl Radiat Oncol 2022; 37:19-24. [PMID: 36052020 PMCID: PMC9424260 DOI: 10.1016/j.ctro.2022.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 08/12/2022] [Accepted: 08/16/2022] [Indexed: 11/20/2022] Open
Abstract
Background and purpose We aimed to evaluate utilisation of brachytherapy (BT) boost in men who had external beam radiation therapy (EBRT) for prostate cancer, and to compare patient-reported functional outcomes (PRO) following each approach in a population-based setting in Australia. Materials and methods This is a population-based cohort of men with localised prostate cancer enrolled in the Victorian Prostate Cancer Outcomes Registry, who had EBRT between 2015 and 2020. Primary outcomes were proportion who had BT-boost, and PRO (assessed using the EPIC-26 questionnaires) 12 months post-treatment. Multivariable logistic regressions were used to evaluate factors associated with BT-boost, and linear regressions were used to estimate differences in EPIC-26 domain scores between EBRT alone and EBRT + BT. Results Of the 1,626 men in the study, 88 (5.4 %) had BT-boost. Factors independently associated with BT-boost were younger age, higher socioeconomic status, and treatment in public institutions. 1,555 men completed EPIC-26 questionnaires. No statistically or clinically significant differences in EPIC-26 urinary, sexual and bowel functional domain scores were observed between men who had EBRT + BT vs EBRT alone, with adjusted mean differences in urinary incontinence, urinary irritative/ obstruction, sexual, and bowel domain of 1.28 (95 %CI = -3.23 to 5.79), -2.87 (95 %CI = -6.46 to 0.73), 0.49 (95 %CI = -4.78 to 5.76), and 2.89 (95 %CI = -0.83 to 6.61) respectively. Conclusion 1-in-20 men who had EBRT for prostate cancer had BT-boost. This is the first time that PRO following EBRT+/-BT is reported at a population-based level in Australia, with no evidence to suggest worse PRO with addition of BT-boost 12 months post-treatment.
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Leung E, Gladwish AP, Davidson M, Taggar A, Velker V, Barnes E, Mendez L, Donovan E, Gien LT, Covens A, Vicus D, Kupets R, MacKay H, Han K, Cheung P, Zhang L, Loblaw A, D’Souza DP. Quality-of-Life Outcomes and Toxic Effects Among Patients With Cancers of the Uterus Treated With Stereotactic Pelvic Adjuvant Radiation Therapy: The SPARTACUS Phase 1/2 Nonrandomized Controlled Trial. JAMA Oncol 2022; 8:1-9. [PMID: 35420695 PMCID: PMC9011178 DOI: 10.1001/jamaoncol.2022.0362] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
IMPORTANCE Adjuvant radiation plays an important role in reducing locoregional recurrence in patients with uterine cancer. Although hypofractionated radiotherapy may benefit health care systems and the global community while decreasing treatment burden for patients traveling for daily radiotherapy, it has not been studied prospectively nor in randomized trials for treatment of uterine cancers, and the associated toxic effects and patient quality of life are unknown. OBJECTIVE To evaluate acute genitourinary and bowel toxic effects and patient-reported outcomes following stereotactic hypofractionated adjuvant radiation to the pelvis for treatment of uterine cancer. DESIGN, SETTING, AND PARTICIPANTS The Stereotactic Pelvic Adjuvant Radiation Therapy in Cancers of the Uterus (SPARTACUS) phase 1/2 nonrandomized controlled trial of patients accrued between May 2019 and August 2021 was conducted as a multicenter trial at 2 cancer centers in Ontario, Canada. In total, 61 patients with uterine cancer stages I through III after surgery entered the study. INTERVENTIONS Stereotactic adjuvant pelvic radiation to a dose of 30 Gy in 5 fractions administered every other day or once weekly. MAIN OUTCOMES AND MEASURES Assessments of toxic effects and patient-reported quality of life (European Organisation for Research and Treatment of Cancer Quality of Life Questionnaires C30 and endometrial EN24) were collected at baseline, fractions 3 and 5, and at 6 weeks and 3 months of follow-up. Descriptive analysis was conducted, calculating means, SDs, medians, IQRs, and ranges for continuous variables and proportions for categorical variables. Univariate generalized linear mixed models were generated for repeated measurements on the quality-of-life scales. RESULTS A total of 61 patients were enrolled (median age, 66 years; range, 51-88 years). Tumor histologic results included 39 endometrioid adenocarcinoma, 15 serous or clear cell, 3 carcinosarcoma, and 4 dedifferentiated. Sixteen patients received sequential chemotherapy, and 9 received additional vault brachytherapy. Median follow-up was 9 months (IQR, 3-15 months). Of 61 patients, worst acute gastrointestinal tract toxic effects of grade 1 were observed in 33 patients (54%) and of grade 2 in 8 patients (13%). For genitourinary worst toxic effects, grade 1 was observed in 25 patients (41%) and grade 2 in 2 patients (3%). One patient (1.6%) had an acute grade 3 gastrointestinal tract toxic effect of diarrhea at fraction 5 that resolved at follow-up. Only patient-reported diarrhea scores were both clinically (scores ≥10) and statistically significantly worse at fraction 5 (mean [SD] score, 35.76 [26.34]) compared with baseline (mean [SD] score, 6.56 [13.36]; P < .001), but this symptom improved at follow-up. CONCLUSIONS AND RELEVANCE Results of this phase 1/2 nonrandomized controlled trial suggest that stereotactic hypofractionated radiation was well tolerated at short-term follow-up for treatment of uterine cancer. Longer follow-up and future randomized studies are needed to further evaluate this treatment. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04866394.
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Affiliation(s)
- Eric Leung
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Odette Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Adam P. Gladwish
- Department of Radiation Oncology, Royal Victoria Hospital, University of Toronto, Barrie, Ontario, Canada
| | - Melanie Davidson
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Odette Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Amandeep Taggar
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Odette Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Vikram Velker
- Division of Radiation Oncology, Department of Oncology, London Health Sciences Centre, Western University, London, Ontario, Canada
| | - Elizabeth Barnes
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Odette Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Lucas Mendez
- Division of Radiation Oncology, Department of Oncology, London Health Sciences Centre, Western University, London, Ontario, Canada
| | - Elysia Donovan
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Odette Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Lilian T. Gien
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Centre, Odette Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Allan Covens
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Centre, Odette Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Danielle Vicus
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Centre, Odette Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Rachel Kupets
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Centre, Odette Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Helen MacKay
- Divison of Medical Oncology and Hematology, Sunnybrook Health Sciences Centre, Odette Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Kathy Han
- Department of Radiation Oncology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Patrick Cheung
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Liying Zhang
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Odette Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Andrew Loblaw
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Odette Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - David P. D’Souza
- Division of Radiation Oncology, Department of Oncology, London Health Sciences Centre, Western University, London, Ontario, Canada
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8
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Remick JS, Sabouri P, Zhu M, Bentzen SM, Sun K, Kwok Y, Kaiser A. Simulation of an HDR "Boost" with Stereotactic Proton versus Photon Therapy in Prostate Cancer: A Dosimetric Feasibility Study. Int J Part Ther 2021; 7:11-23. [PMID: 33604412 PMCID: PMC7886266 DOI: 10.14338/ijpt-20-00029.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 08/19/2020] [Indexed: 11/21/2022] Open
Abstract
Purpose/Objectives To compare the dose escalation potential of stereotactic body proton therapy (SBPT) versus stereotactic body photon therapy (SBXT) using high-dose rate prostate brachytherapy (HDR-B) dose-prescription metrics. Patients and Methods Twenty-five patients previously treated with radiation for prostate cancer were identified and stratified by prostate size (≤ 50cc; n = 13, > 50cc; n = 12). Initial CT simulation scans were re-planned using SBXT and SBPT modalities using a prescription dose of 19Gy in 2 fractions. Target coverage goals were designed to mimic the dose distributions of HDR-B and maximized to the upper limit constraint for the rectum and urethra. Dosimetric parameters between SBPT and SBXT were compared using the signed-rank test and again after stratification for prostate size (≤ 50cm3 and >50cm3) using the Wilcoxon rank test. Results Prostate volume receiving 100% of the dose (V100) was significantly greater for SBXT (99%) versus SBPT (96%) (P ≤ 0.01), whereas the median V125 (82% vs. 73%, P < 0.01) and V200 (12% vs. 2%, P < 0.01) was significantly greater for SBPT compared to SBXT. Median V150 was 49% for both cohorts (P = 0.92). V125 and V200 were significantly correlated with prostate size. For prostates > 50cm3, V200 was significantly greater with SBPT compared to SBXT (14.5% vs. 1%, P = 0.005), but not for prostates 50cm3 (9% vs 4%, P = 0.11). Median dose to 2cm3 of the bladder neck was significantly lower with SBPT versus SBXT (9.6 Gy vs. 14 Gy, P < 0.01). Conclusion SBPT and SBXT can be used to simulate an HDR-B boost for locally advanced prostate cancer. SBPT demonstrated greater dose escalation potential than SBXT. These results are relevant for future trial design, particularly in patients with high risk prostate cancer who are not amenable to brachytherapy.
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Affiliation(s)
- Jill S Remick
- Department of Radiation Oncology, University of Maryland Medical Center, Baltimore, MD, USA
| | - Pouya Sabouri
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Mingyao Zhu
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA.,Department of Radiation Oncology, Emory University, Atlanta, GA, USA
| | - Søren M Bentzen
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Kai Sun
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Young Kwok
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Adeel Kaiser
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA.,Department of Radiation Oncology, Miami Cancer Institute, Miami, FL, USA
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Den RB, Greenspan J, Doyle LA, Harrison AS, Peng C, Williams NL, Lallas CD, Trabulsi EJ, Gomella LG, Hurwitz MD, Leiby B, Dicker AP. A phase IB clinical trial of 15 Gy HDR brachytherapy followed by hypofractionated/SBRT in the management of intermediate-risk prostate cancer. Brachytherapy 2020; 19:282-289. [PMID: 32217038 DOI: 10.1016/j.brachy.2020.02.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 01/28/2020] [Accepted: 02/03/2020] [Indexed: 02/07/2023]
Abstract
PURPOSE High dose-rate (HDR) brachytherapy is commonly administered as a boost to external beam radiation therapy (EBRT). Our purpose was to compare toxicity with increasingly hypofractionated EBRT in combination with a single 15 Gy HDR boost for men with intermediate-risk prostate cancer. METHODS AND MATERIALS Forty-two men were enrolled on this phase IB clinical trial to one of three EBRT dose cohorts: 10 fractions, seven fractions, or five fractions. Patients were followed prospectively for safety, efficacy, and health-related quality of life (Expanded Prostate Index Composite). Efficacy was assessed biochemically using the Phoenix definition. RESULTS With a median follow up of 36 months, the biochemical disease-free survival was 95.5%. One man developed metastatic disease at 5 years. There was no significant minimally important difference in EPIC PRO for either urinary, bowel, or sexual domains. There was one acute Grade 3 GI and GU toxicity, but no late Grade 3 GU or GI toxicities. CONCLUSION Fifteen gray HDR brachytherapy followed by a five fraction SBRT approach results in high disease control rates and low toxicity similar to previously reported HDR protocols with significant improvement in patient convenience and resource savings. While mature results with longer follow up are awaited, this treatment approach may be considered a safe and effective option for men with intermediate-risk disease.
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Affiliation(s)
- Robert B Den
- Department of Radiation Oncology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA.
| | - Jacob Greenspan
- Department of Radiation Oncology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA
| | - Laura A Doyle
- Department of Radiation Oncology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA
| | - Amy S Harrison
- Department of Radiation Oncology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA
| | - Cheng Peng
- Department of Radiation Oncology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA
| | - Noelle L Williams
- Southeast Radiation Oncology Group, Levine Cancer Institute, Charlotte, NC
| | - Costas D Lallas
- Department of Urology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA
| | - Edouard J Trabulsi
- Department of Urology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA
| | - Leonard G Gomella
- Department of Urology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA
| | - Mark D Hurwitz
- Department of Radiation Oncology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA
| | - Benjamin Leiby
- Division of Biostatistics, Department of Pharmacology and Experimental Therapeutics, Thomas Jefferson University, Philadelphia, PA
| | - Adam P Dicker
- Department of Radiation Oncology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA
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10
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[Moderate or extreme hypofractionation and localized prostate cancer: The times are changing]. Cancer Radiother 2019; 23:503-509. [PMID: 31471253 DOI: 10.1016/j.canrad.2019.07.139] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Revised: 07/08/2019] [Accepted: 07/09/2019] [Indexed: 02/07/2023]
Abstract
There are many treatment options for localized prostate cancers, including active surveillance, brachytherapy, external beam radiotherapy, and radical prostatectomy. Quality of life remains a primary objective in the absence of superiority of one strategy over another in terms of specific survival with similar long-term biochemical control rates. Despite a significant decrease in digestive and urinary toxicities thanks to IMRT and IGRT, external radiotherapy remains a treatment that lasts approximately 2 months or 1.5 months, when combined with a brachytherapy boost. Given the specific radiosensitivity of this tumor, several randomized studies have shown that a hypofractionated scheme is not inferior in terms of biochemical control and toxicities, allowing to divide the number of fractions by a factor 2 to 8. Given that SBRT becomes a validated therapeutic option for a selected population of patients with localized prostate cancer, extreme hypofractionation is becoming a strong challenger of conventional external radiotherapy or brachytherapy.
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