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Swensen S, Liao JJ, Chen JJ, Kim K, Ma TM, Weg ES. The expanding role of radiation oncology across the prostate cancer continuum. Abdom Radiol (NY) 2024; 49:2693-2705. [PMID: 38900319 DOI: 10.1007/s00261-024-04408-3] [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: 03/31/2024] [Revised: 05/23/2024] [Accepted: 05/24/2024] [Indexed: 06/21/2024]
Abstract
Radiotherapy is used in the treatment of prostate cancer in a variety of disease states with significant reliance on imaging to guide clinical decision-making and radiation delivery. In the definitive setting, the choice of radiotherapy treatment modality, dose, and fractionation for localized prostate cancer is determined by the patient's initial risk stratification and other clinical considerations. Radiation is also an option as salvage therapy in patients with locoregionally recurrent disease after prior definitive radiation or surgery. In recent years, the role of radiation has expanded for patients with metastatic disease, including prostate-directed radiotherapy in de novo low volume metastatic disease, metastasis-directed therapy for oligorecurrent disease, and palliative management of symptomatic metastases in the advanced setting. Here we review the expanding role of radiation in the treatment of prostate cancer in the definitive, locoregionally recurrent, and metastatic settings, as well as highlight the role of imaging in clinical reasoning, radiation planning, and treatment delivery.
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Affiliation(s)
- Sasha Swensen
- Department of Radiation Oncology, University of Washington, Fred Hutchinson Cancer Center, 1959 NE Pacific St, Seattle, WA, 98195, USA
| | - Jay J Liao
- Department of Radiation Oncology, University of Washington, Fred Hutchinson Cancer Center, 1959 NE Pacific St, Seattle, WA, 98195, USA
| | - Jonathan J Chen
- Department of Radiation Oncology, University of Washington, Fred Hutchinson Cancer Center, 1959 NE Pacific St, Seattle, WA, 98195, USA
| | - Katherine Kim
- Department of Radiation Oncology, University of Washington, Fred Hutchinson Cancer Center, 1959 NE Pacific St, Seattle, WA, 98195, USA
| | - Ting Martin Ma
- Department of Radiation Oncology, University of Washington, Fred Hutchinson Cancer Center, 1959 NE Pacific St, Seattle, WA, 98195, USA
| | - Emily S Weg
- Department of Radiation Oncology, University of Washington, Fred Hutchinson Cancer Center, 1959 NE Pacific St, Seattle, WA, 98195, USA.
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2
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Slevin F, Zattoni F, Checcucci E, Cumberbatch MGK, Nacchia A, Cornford P, Briers E, De Meerleer G, De Santis M, Eberli D, Gandaglia G, Gillessen S, Grivas N, Liew M, Linares Espinós EE, Oldenburg J, Oprea-Lager DE, Ploussard G, Rouvière O, Schoots IG, Smith EJ, Stranne J, Tilki D, Smith CT, Van Den Bergh RCN, Van Oort IM, Wiegel T, Yuan CY, Van den Broeck T, Henry AM. A Systematic Review of the Efficacy and Toxicity of Brachytherapy Boost Combined with External Beam Radiotherapy for Nonmetastatic Prostate Cancer. Eur Urol Oncol 2024; 7:677-696. [PMID: 38151440 DOI: 10.1016/j.euo.2023.11.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Revised: 11/14/2023] [Accepted: 11/28/2023] [Indexed: 12/29/2023]
Abstract
CONTEXT The optimum use of brachytherapy (BT) combined with external beam radiotherapy (EBRT) for localised/locally advanced prostate cancer (PCa) remains uncertain. OBJECTIVE To perform a systematic review to determine the benefits and harms of EBRT-BT. EVIDENCE ACQUISITION Ovid MEDLINE, Embase, and EBM Reviews-Cochrane Central Register of Controlled Trials databases were systematically searched for studies published between January 1, 2000 and June 7, 2022, according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. Eligible studies compared low- or high-dose-rate EBRT-BT against EBRT ± androgen deprivation therapy (ADT) and/or radical prostatectomy (RP) ± postoperative radiotherapy (RP ± EBRT). The main outcomes were biochemical progression-free survival (bPFS), severe late genitourinary (GU)/gastrointestinal toxicity, metastasis-free survival (MFS), cancer-specific survival (CSS), and overall survival (OS), at/beyond 5 yr. Risk of bias was assessed and confounding assessment was performed. A meta-analysis was performed for randomised controlled trials (RCTs). EVIDENCE SYNTHESIS Seventy-three studies were included (two RCTs, seven prospective studies, and 64 retrospective studies). Most studies included participants with intermediate-or high-risk PCa. Most studies, including both RCTs, used ADT with EBRT-BT. Generally, EBRT-BT was associated with improved bPFS compared with EBRT, but similar MFS, CSS, and OS. A meta-analysis of the two RCTs showed superior bPFS with EBRT-BT (estimated fixed-effect hazard ratio [HR] 0.54 [95% confidence interval {CI} 0.40-0.72], p < 0.001), with absolute improvements in bPFS at 5-6 yr of 4.9-16%. However, no difference was seen for MFS (HR 0.84 [95% CI 0.53-1.28], p = 0.4) or OS (HR 0.87 [95% CI 0.63-1.19], p = 0.4). Fewer studies examined RP ± EBRT. There is an increased risk of severe late GU toxicity, especially with low-dose-rate EBRT-BT, with some evidence of increased prevalence of severe GU toxicity at 5-6 yr of 6.4-7% across the two RCTs. CONCLUSIONS EBRT-BT can be considered for unfavourable intermediate/high-risk localised/locally advanced PCa in patients with good urinary function, although the strength of this recommendation based on the European Association of Urology guideline methodology is weak given that it is based on improvements in biochemical control. PATIENT SUMMARY We found good evidence that radiotherapy combined with brachytherapy keeps prostate cancer controlled for longer, but it could lead to worse urinary side effects than radiotherapy without brachytherapy, and its impact on cancer spread and patient survival is less clear.
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Affiliation(s)
- Finbar Slevin
- University of Leeds, Leeds, UK; Leeds Cancer Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK.
| | - Fabio Zattoni
- Department Surgery, Oncology and Gastroenterology, Urologic Unit, University of Padova, Padova, Italy
| | - Enrico Checcucci
- Division of Urology, Department of Oncology, School of Medicine, San Luigi Hospital, University of Turin, Turin, Italy
| | | | | | - Philip Cornford
- Department of Urology, Liverpool University Hospitals NHS Trust, Liverpool, UK
| | | | - Gert De Meerleer
- Department of Radiotherapy, University Hospitals Leuven, Leuven, Belgium
| | - Maria De Santis
- Department of Urology, Charité Universitätsmedizin, Berlin, Germany; Department of Urology, Medical University of Vienna, Vienna, Austria
| | - Daniel Eberli
- Department of Urology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | | | - Silke Gillessen
- Oncology Institute of Southern Switzerland, EOC, Bellinzona, Switzerland; Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland
| | - Nikolaos Grivas
- Department of Urology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Matthew Liew
- Department of Urology, Wrightington, Wigan and Leigh NHS Foundation Trust, Wigan, UK
| | | | - Jan Oldenburg
- Department of Oncology, Akershus University Hospital, Lørenskog, Norway; Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Daniela E Oprea-Lager
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | | | - Olivier Rouvière
- Hospices Civils de Lyon, Department of Urinary and Vascular Imaging, Hôpital Edouard Herriot, Lyon, France
| | - Ivo G Schoots
- Department of Radiology & Nuclear Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Emma Jane Smith
- European Association of Urology Guidelines Office, Arnhem, The Netherlands
| | - Johan Stranne
- Department of Urology, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden; Department of Urology, Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Sweden
| | - Derya Tilki
- Martini-Klinik Prostate Cancer Center, University Hospital Hamburg Eppendorf, Hamburg, Germany; Department of Urology, University Hospital Hamburg-Eppendorf, Hamburg, Germany; Department of Urology, Koc University Hospital, Istanbul, Turkey
| | - Catrin Tudur Smith
- Department of Health Data Science, University of Liverpool, Liverpool, UK
| | | | - Inge M Van Oort
- Radboud University Medical Center, Department of Urology, Radboud Institute for Molecular Life Sciences, Nijmegen, The Netherlands
| | | | - Cathy Y Yuan
- Department of Medicine, Health Science Centre, McMaster University, Hamilton, Ontario, Canada
| | | | - Ann M Henry
- University of Leeds, Leeds, UK; Leeds Cancer Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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3
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Cornford P, van den Bergh RCN, Briers E, Van den Broeck T, Brunckhorst O, Darraugh J, Eberli D, De Meerleer G, De Santis M, Farolfi A, Gandaglia G, Gillessen S, Grivas N, Henry AM, Lardas M, van Leenders GJLH, Liew M, Linares Espinos E, Oldenburg J, van Oort IM, Oprea-Lager DE, Ploussard G, Roberts MJ, Rouvière O, Schoots IG, Schouten N, Smith EJ, Stranne J, Wiegel T, Willemse PPM, Tilki D. EAU-EANM-ESTRO-ESUR-ISUP-SIOG Guidelines on Prostate Cancer-2024 Update. Part I: Screening, Diagnosis, and Local Treatment with Curative Intent. Eur Urol 2024; 86:148-163. [PMID: 38614820 DOI: 10.1016/j.eururo.2024.03.027] [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: 03/02/2024] [Revised: 03/14/2024] [Accepted: 03/27/2024] [Indexed: 04/15/2024]
Abstract
BACKGROUND AND OBJECTIVE The European Association of Urology (EAU)-European Association of Nuclear Medicine (EANM)-European Society for Radiotherapy and Oncology (ESTRO)-European Society of Urogenital Radiology (ESUR)-International Society of Urological Pathology (ISUP)-International Society of Geriatric Oncology (SIOG) guidelines provide recommendations for the management of clinically localised prostate cancer (PCa). This paper aims to present a summary of the 2024 version of the EAU-EANM-ESTRO-ESUR-ISUP-SIOG guidelines on the screening, diagnosis, and treatment of clinically localised PCa. METHODS The panel performed a literature review of all new data published in English, covering the time frame between May 2020 and 2023. The guidelines were updated, and a strength rating for each recommendation was added based on a systematic review of the evidence. KEY FINDINGS AND LIMITATIONS A risk-adapted strategy for identifying men who may develop PCa is advised, generally commencing at 50 yr of age and based on individualised life expectancy. The use of multiparametric magnetic resonance imaging in order to avoid unnecessary biopsies is recommended. When a biopsy is considered, a combination of targeted and regional biopsies should be performed. Prostate-specific membrane antigen positron emission tomography imaging is the most sensitive technique for identifying metastatic spread. Active surveillance is the appropriate management for men with low-risk PCa, as well as for selected favourable intermediate-risk patients with International Society of Urological Pathology grade group 2 lesions. Local therapies are addressed, as well as the management of persistent prostate-specific antigen after surgery. A recommendation to consider hypofractionation in intermediate-risk patients is provided. Patients with cN1 PCa should be offered a local treatment combined with long-term intensified hormonal treatment. CONCLUSIONS AND CLINICAL IMPLICATIONS The evidence in the field of diagnosis, staging, and treatment of localised PCa is evolving rapidly. These PCa guidelines reflect the multidisciplinary nature of PCa management. PATIENT SUMMARY This article is the summary of the guidelines for "curable" prostate cancer. Prostate cancer is "found" through a multistep risk-based screening process. The objective is to find as many men as possible with a curable cancer. Prostate cancer is curable if it resides in the prostate; it is then classified into low-, intermediary-, and high-risk localised and locally advanced prostate cancer. These risk classes are the basis of the treatments. Low-risk prostate cancer is treated with "active surveillance", a treatment with excellent prognosis. For low-intermediary-risk active surveillance should also be discussed as an option. In other cases, active treatments, surgery, or radiation treatment should be discussed along with the potential side effects to allow shared decision-making.
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Affiliation(s)
- Philip Cornford
- Department of Urology, Liverpool University Hospitals NHS Trust, Liverpool, UK.
| | | | | | | | | | - Julie Darraugh
- European Association of Urology, Arnhem, The Netherlands
| | - Daniel Eberli
- Department of Urology, University Hospital Zurich, Zurich, Switzerland
| | - Gert De Meerleer
- Department of Radiation Oncology, University Hospital Leuven, Leuven, Belgium
| | - Maria De Santis
- Department of Urology, Universitätsmedizin Berlin, Berlin, Germany; Department of Urology, Medical University of Vienna, Vienna, Austria
| | - Andrea Farolfi
- Nuclear Medicine, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Giorgio Gandaglia
- Division of Oncology/Unit of Urology, Soldera Prostate Cancer Laboratory, Urological Research Institute, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Silke Gillessen
- Oncology Institute of Southern Switzerland (IOSI), EOC, Bellinzona, Switzerland; Faculty of Biomedical Sciences, USI, Lugano, Switzerland
| | - Nikolaos Grivas
- Department of Urology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Ann M Henry
- Leeds Cancer Centre, St. James's University Hospital and University of Leeds, Leeds, UK
| | - Michael Lardas
- Department of Urology, Metropolitan General Hospital, Athens, Greece
| | | | - Matthew Liew
- Department of Urology, Liverpool University Hospitals NHS Trust, Liverpool, UK
| | | | - Jan Oldenburg
- Akershus University Hospital (Ahus), Lørenskog, Norway; Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Inge M van Oort
- Department of Urology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Daniela E Oprea-Lager
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, VU Medical Center, Amsterdam, The Netherlands
| | | | - Matthew J Roberts
- Department of Urology, Royal Brisbane and Women's Hospital, Brisbane, Australia; Faculty of Medicine, The University of Queensland Centre for Clinical Research, Herston, QLD, Australia
| | - Olivier Rouvière
- Department of Imaging, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France; Université de Lyon, Université Lyon 1, UFR Lyon-Est, Lyon, France
| | - Ivo G Schoots
- Department of Radiology and Nuclear Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands; Department of Radiology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | | | - Emma J Smith
- European Association of Urology, Arnhem, The Netherlands
| | - Johan Stranne
- Department of Urology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Urology, Sahlgrenska University Hospital-Västra Götaland, Gothenburg, Sweden
| | - Thomas Wiegel
- Department of Radiation Oncology, University Hospital Ulm, Ulm, Germany
| | - Peter-Paul M Willemse
- Department of Urology, Cancer Center University Medical Center Utrecht, Utrecht, The Netherlands
| | - Derya Tilki
- Martini-Klinik Prostate Cancer Center, University Hospital Hamburg Eppendorf, Hamburg, Germany; Department of Urology, University Hospital Hamburg-Eppendorf, Hamburg, Germany; Department of Urology, Koc University Hospital, Istanbul, Turkey
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4
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Moore A, Kollmeier MA, McBride SM, Toumbacaris N, Zhang Z, Lacy-Elsayegh A, Dreyfuss A, Grossman CE, Gorovets D, Zelefsky MJ. Long-term Outcomes from a Phase 1 Dose Escalation Study Using Stereotactic Body Radiotherapy for Patients with Low- or Intermediate-risk Prostate Cancer. Eur Urol Oncol 2024; 7:812-820. [PMID: 37949730 DOI: 10.1016/j.euo.2023.10.019] [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: 08/30/2023] [Revised: 10/10/2023] [Accepted: 10/24/2023] [Indexed: 11/12/2023]
Abstract
BACKGROUND Ultrahypofractionated stereotactic body radiation therapy (SBRT) has become a standard treatment intervention for localized prostate cancer. OBJECTIVE To report final long-term tumor control outcomes and late gastrointestinal (GI) and genitourinary (GU) toxicities from a single-center phase 1 dose escalation study using SBRT for patients with low- or intermediate-risk prostate cancer. DESIGN, SETTING AND PARTICIPANTS Between 2009 and 2012, 136 patients were enrolled and treated. The initial dose level was 32.5 Gy in five fractions. Doses were then sequentially escalated to 35 Gy, 37.5 Gy, and 40 Gy in five fractions delivered every other day. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS The primary endpoint was late treatment-related toxicity. Secondary endpoints included prostate-specific antigen (PSA) failure. RESULTS AND LIMITATIONS The median follow-up was 10.5 yr for the 32.5-Gy group, 9.9 yr for the 35-Gy group, 8.2 yr for the 37.5-Gy group, and 7.3 yr for the 40-Gy group. The 8-yr cumulative incidence of PSA failure was 26% for 32.5 Gy, 15% for 35 Gy, 3.4% for 37.5 Gy, and 6.6% for 40 Gy. Higher radiation dose (37.5-40 Gy) and favorable intermediate risk (vs unfavorable intermediate risk) were associated with better PSA recurrence rates (p = 0.011 and 0.002, respectively). The 8-yr actuarial probability rates for survival free from late grade ≥2 toxicity were 94% for GI toxicity and 86% for GU toxicity. No grade 4 events were recorded. Higher dose levels were not associated with higher rates of late grade ≥2 GI (p = 0.2) or GU (p > 0.9) toxicity. CONCLUSIONS SBRT doses ranging from 32.5 to 40 Gy were associated with low incidence of moderate or severe toxicities. Higher doses resulted in superior disease control outcomes 8 yr after treatment. PATIENT SUMMARY We investigated the association between the radiotherapy dose used and the rate of control of prostate cancer. We found that higher doses resulted in more favorable outcomes without excess toxicity. This trial is registered on ClinicalTrials.gov as NCT00911118.
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Affiliation(s)
- Assaf Moore
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Department of Radiation Oncology, Davidoff Cancer Center, Petach Tikva, Israel; Tel Aviv University, Tel Aviv, Israel
| | - Marisa A Kollmeier
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Sean M McBride
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Nicolas Toumbacaris
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Zhigang Zhang
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Ahmed Lacy-Elsayegh
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Alexandra Dreyfuss
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Craig E Grossman
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Daniel Gorovets
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Michael J Zelefsky
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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5
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Hoskin P, Rojas A, Ostler P, Hughes R, Alonzi R, Lowe G. Single-dose high-dose-rate brachytherapy versus two and three fractions for locally advanced prostate cancer. Radiother Oncol 2024; 199:110426. [PMID: 38997094 DOI: 10.1016/j.radonc.2024.110426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2024] [Revised: 07/03/2024] [Accepted: 07/08/2024] [Indexed: 07/14/2024]
Abstract
BACKGROUND Single-dose high-dose-rate brachytherapy (SD-HDR-BT) was compared to two or three fraction HDR BT in intermediate and high-risk localized prostate cancer with median follow-up of 10 years. MATERIALS AND METHODS 293 patients received 1 × 19Gy or 1 × 20Gy (Group A = 49), 2 × 13Gy (Group B = 138), or 3 × 10.5 Gy (Group C = 106) HDR BT. The primary endpoint was biochemical relapse-free interval (bRFI). Late genitourinary (GU) and gastrointestinal (GI) morbidity used RTOG scales and the International Prostate Symptom Score (IPSS). Freedom from biochemical relapse (bRFI), overall survival (OS) and GU, GI and IPSS morbidity were calculated using Kaplan-Meier (K-M) method and log-rank test. Univariate and multivariate hazard ratios (HR) were obtained using Cox's proportional hazard. RESULTS At 10 years, K-M estimates of bRFI were 64 % (Group A), 72 % (Group B), and 76 % (Group C) (p = 0.2). No statistically significant difference was seen in OS. In multivariate analysis risk-category and ADT administration, but not dose, were significant predictors of relapse (p = 0.0003 and 0.03, respectively). At ten years, GU grade 3 events were 8 % (A), 2 % (B) and 13 % (C); (p = 0.01). IPSS ≥ 20 was 31 % (A), 20 % (B) and 23 % (C); (p = 0.6) and grade 3 GI was 0 % in groups A and B and 2 % in C; (p = 0.3). No GU or GI grade-4 events were observed. Pre-treatment IPSS was a highly significant predictor of failure in multivariate analysis. CONCLUSIONS Long-term outcome data show reduced but not statistically significant difference in PSA control, and no difference in overall survival, between SD-HDR-BT and 2 or 3 fractions of HDR-BT.
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Affiliation(s)
- Peter Hoskin
- Mount Vernon Cancer Centre, Northwood, Middlesex HA6 2RN, UK.
| | - Ana Rojas
- Mount Vernon Cancer Centre, Northwood, Middlesex HA6 2RN, UK
| | - Peter Ostler
- Mount Vernon Cancer Centre, Northwood, Middlesex HA6 2RN, UK
| | - Robert Hughes
- Mount Vernon Cancer Centre, Northwood, Middlesex HA6 2RN, UK
| | - Roberto Alonzi
- Mount Vernon Cancer Centre, Northwood, Middlesex HA6 2RN, UK
| | - Gerry Lowe
- Mount Vernon Cancer Centre, Northwood, Middlesex HA6 2RN, UK
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Ong WL, Nikitas J, Joseph D, Steigler A, Millar J, Valle L, Steinberg ML, Ma TM, Reiter RE, Rettig MB, Nickols NG, Chang A, Zaorsky NG, Spratt DE, Romero T, Kishan AU. Long-Term Quality-of-Life Outcomes After Prostate Radiation Therapy With or Without High-Dose-Rate Brachytherapy Boost: Post Hoc Analysis of TROG 03.04 RADAR. Int J Radiat Oncol Biol Phys 2024; 119:813-825. [PMID: 37802226 DOI: 10.1016/j.ijrobp.2023.09.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 09/15/2023] [Accepted: 09/28/2023] [Indexed: 10/08/2023]
Abstract
PURPOSE Adding high-dose-rate brachytherapy (BT) boost to external beam radiation therapy (EBRT) improves biochemical control but may affect patient-reported quality of life (QOL). We sought to determine long-term QOL outcomes for EBRT+BT versus EBRT alone. METHODS AND MATERIALS This was a post hoc analysis of the Trans-Tasman Radiation Oncology Group 03.04 Randomized Androgen Deprivation and Radiotherapy (TROG 03.04 RADAR) trial. Only patients who received 74 Gy conventionally fractionated EBRT (n = 260) or 46 Gy conventionally fractionated EBRT plus 19.5 Gy in 3 fractions high-dose-rate BT boost (n = 237) were included in this analysis. The primary endpoint was patient-reported QOL measured using the European Organisation for Research and Treatment of Cancer QOL (EORTC QLQ-C30) and prostate-specific QOL module (EORTC QLQ-PR25) questionnaires. We evaluated temporal changes in QOL scores, rates of symptom resolution, and the proportion of men who had decrements from baseline of >2 × the threshold for minimal clinically important change (2 × MCIC) for each domain. RESULTS At 5, 17, and 29 months after radiation therapy, the EBRT+BT group had 2.5 times (95% confidence interval [CI], 1.4-4.2; P < .001), 2.9 times (95% CI, 1.7-4.9; P < .001), and 2.6 times (95% CI, 1.4-4.6; P = .002) greater odds of reporting 2 × MCIC in urinary QOL score compared with EBRT. There were no differences beyond 29 months. EBRT+BT led to a slower rate of urinary QOL symptom score resolution up to 17 months after radiation therapy compared with EBRT (P < .001) but not at later intervals. In contrast, at the end of the radiation therapy period and at 53 months after radiation therapy, the EBRT+BT group had 0.65 times (95% CI, 0.44-0.96; P = .03) and 0.51 times (95% CI, 0.32-0.79; P = .003) the odds of reporting 2 × MCIC in bowel QOL symptom scores compared with EBRT. There were no significant differences in the rate of bowel QOL score resolution. There were no significant differences in global health status or sexual activity scores between the 2 groups. CONCLUSIONS There were no persistent differences in patient-reported QOL measures between EBRT alone and EBRT+BT. BT boost does not appear to negatively affect long-term, patient-reported QOL.
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Affiliation(s)
- Wee Loon Ong
- Alfred Health Radiation Oncology, Central Clinical School, Monash University, Melbourne, Victoria, Australia; Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Heath Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - John Nikitas
- Department of Radiation Oncology, University of California, Los Angeles, California
| | - David Joseph
- Department of Medicine and Surgery, University of Western Australia, Perth, Western Australia, Australia
| | - Allison Steigler
- School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia
| | - Jeremy Millar
- Alfred Health Radiation Oncology, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Luca Valle
- Department of Radiation Oncology, University of California, Los Angeles, California
| | - Michael L Steinberg
- Department of Radiation Oncology, University of California, Los Angeles, California
| | - Ting Martin Ma
- Department of Radiation Oncology, University of California, Los Angeles, California
| | - Robert E Reiter
- Department of Urology, University of California, Los Angeles, California
| | - Matthew B Rettig
- Division of Hematology and Oncology, David Geffen School of Medicine, University of California, Los Angeles, California; Division of Hematology and Oncology, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California
| | - Nicholas G Nickols
- Department of Radiation Oncology, University of California, Los Angeles, California; Department of Radiation Oncology, Veteran Affairs Greater Los Angeles Healthcare System, Los Angeles, California
| | - Albert Chang
- Department of Radiation Oncology, University of California, Los Angeles, California
| | - Nicholas G Zaorsky
- Department of Radiation Oncology, University Hospitals Seidman Cancer Centre, Cleveland Medical Centre, Cleveland, Ohio
| | - Daniel E Spratt
- Department of Radiation Oncology, University Hospitals Seidman Cancer Centre, Cleveland Medical Centre, Cleveland, Ohio
| | - Tahmineh Romero
- Department of Medicine Statistics Core, University of California, Los Angeles, California
| | - Amar U Kishan
- Department of Radiation Oncology, University of California, Los Angeles, California.
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7
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Moll M, Magrowski Ł, Mittlböck M, Heinzl H, Kirisits C, Ciepał J, Masri O, Heilemann G, Stando R, Krzysztofiak T, Depowska G, d'Amico A, Techmański T, Kozub A, Majewski W, Suwiński R, Wojcieszek P, Sadowski J, Widder J, Goldner G, Miszczyk M. Biochemical control in intermediate- and high-risk prostate cancer after EBRT with and without brachytherapy boost. Strahlenther Onkol 2024:10.1007/s00066-024-02245-3. [PMID: 38829436 DOI: 10.1007/s00066-024-02245-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Accepted: 05/05/2024] [Indexed: 06/05/2024]
Abstract
PURPOSE External beam radiotherapy (EBRT) with or without brachytherapy boost (BTB) has not been compared in prospective studies using guideline-recommended radiation dose and recommended androgen-deprivation therapy (ADT). In this multicenter retrospective analysis, we compared modern-day EBRT with BTB in terms of biochemical control (BC) for intermediate-risk (IR) and high-risk (HR) prostate cancer. METHODS Patients were treated for primary IR or HR prostate cancer during 1999-2019 at three high-volume centers. Inclusion criteria were prescribed ≥ 76 Gy EQD2 (α/β = 1.5 Gy) for IR and ≥ 78 Gy EQD2 (α/β = 1.5 Gy) for HR as EBRT alone or with BTB. All HR patients received ADT and pelvic irradiation, which were optional in IR cases. BC between therapies was compared in survival analyses. RESULTS Of 2769 initial patients, 1176 met inclusion criteria: 468 HR (260 EBRT, 208 BTB) and 708 IR (539 EBRT, 169 BTB). Median follow-up was 49 and 51 months for HR and IR, respectively. BTB patients with ≥ 113 Gy EQD2Gy experienced a stable, good BC outcome compared with BTB at lower doses. Patients treated with ≥ 113 Gy EQD2Gy also experienced significantly improved BC compared with EBRT (10-year BC failure rates after ≥ 113 Gy BTB and EBRT: respectively 20.4 and 41.8% for HR and 7.5 and 20.8% for IR). CONCLUSIONS In patients with IR and HR prostate cancer, BTB with ≥ 113 Gy EQD2Gy offered a BC advantage compared with dose-escalated EBRT and lower BTB doses.
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Affiliation(s)
- Matthias Moll
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria.
- Center for Medical Data Science, Medical University of Vienna, Vienna, Austria.
| | - Łukasz Magrowski
- IIIrd, Maria Skłodowska-Curie National Research Institute of Oncology, Wybrzeże Armii Krajowej 15, 44-102, Gliwice, Poland
| | - Martina Mittlböck
- Center for Medical Data Science, Medical University of Vienna, Vienna, Austria
| | - Harald Heinzl
- Center for Medical Data Science, Medical University of Vienna, Vienna, Austria
| | - Christian Kirisits
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Jakub Ciepał
- IIIrd, Maria Skłodowska-Curie National Research Institute of Oncology, Wybrzeże Armii Krajowej 15, 44-102, Gliwice, Poland
| | - Oliwia Masri
- IIIrd, Maria Skłodowska-Curie National Research Institute of Oncology, Wybrzeże Armii Krajowej 15, 44-102, Gliwice, Poland
| | - Gerd Heilemann
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Rafał Stando
- Radiotherapy Department, Holycross Cancer Centre, Kielce, Poland
| | - Tomasz Krzysztofiak
- Brachytherapy Department, Maria Skłodowska-Curie National Research Institute of Oncology, Wybrzeże Armii Krajowej 15, 44-102, Gliwice, Poland
| | - Gabriela Depowska
- IIIrd, Maria Skłodowska-Curie National Research Institute of Oncology, Wybrzeże Armii Krajowej 15, 44-102, Gliwice, Poland
| | - Andrea d'Amico
- Department of PET Diagnostic, Maria Sklodowska-Curie National Research Institute of Oncology Gliwice Branch, Wybrzeze Armii Krajowej 15, 44-101, Gliwice, Poland
| | - Tomasz Techmański
- IIIrd, Maria Skłodowska-Curie National Research Institute of Oncology, Wybrzeże Armii Krajowej 15, 44-102, Gliwice, Poland
| | - Anna Kozub
- IIIrd, Maria Skłodowska-Curie National Research Institute of Oncology, Wybrzeże Armii Krajowej 15, 44-102, Gliwice, Poland
| | - Wojciech Majewski
- Radiotherapy Department, Maria Skłodowska-Curie National Research Institute of Oncology, Wybrzeże Armii Krajowej 15, 44-102, Gliwice, Poland
| | - Rafał Suwiński
- IInd, Maria Skłodowska-Curie National Research Institute of Oncology, Wybrzeże Armii Krajowej 15, 44-102, Gliwice, Poland
| | - Piotr Wojcieszek
- Brachytherapy Department, Maria Skłodowska-Curie National Research Institute of Oncology, Wybrzeże Armii Krajowej 15, 44-102, Gliwice, Poland
| | - Jacek Sadowski
- Radiotherapy Department, Holycross Cancer Centre, Kielce, Poland
| | - Joachim Widder
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Gregor Goldner
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Marcin Miszczyk
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
- IIIrd, Maria Skłodowska-Curie National Research Institute of Oncology, Wybrzeże Armii Krajowej 15, 44-102, Gliwice, Poland
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
- Collegium Medicum - Faculty of Medicine, WSB University, Dąbrowa Górnicza, Poland
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8
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Nikitas J, Kishan A, Chang A, Duriseti S, Nichols NG, Reiter R, Rettig M, Brisbane W, Steinberg ML, Valle L. Treatment intensification strategies for men undergoing definitive radiotherapy for high-risk prostate cancer. World J Urol 2024; 42:165. [PMID: 38492111 DOI: 10.1007/s00345-024-04862-0] [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: 08/02/2023] [Accepted: 02/08/2024] [Indexed: 03/18/2024] Open
Abstract
PURPOSE Treatment intensification of external beam radiotherapy (EBRT) plays a crucial role in the treatment of high-risk prostate cancer. METHODS We performed a critical narrative review of the relevant literature and present new developments in evidence-based treatment intensification strategies. RESULTS For men with high-risk prostate cancer, there is strong evidence to support prolonging androgen deprivation therapy (ADT) to 18-36 months and escalating the dose to the prostate using a brachytherapy boost. A potentially less toxic alternative to a brachytherapy boost is delivering a focal boost to dominant intraprostatic lesions using EBRT. In patients who meet STAMPEDE high-risk criteria, there is evidence to support adding a second-generation anti-androgen agent, such as abiraterone acetate, to long-term ADT. Elective pelvic lymph node irradiation may be beneficial in select patients, though more prospective data is needed to elucidate the group of patients who may benefit the most. Tumor genomic classifier (GC) testing and advanced molecular imaging will likely play a role in improving patient selection for treatment intensification as well as contribute to the evolution of treatment intensification strategies for future patients. CONCLUSION Treatment intensification using a combination of EBRT, advanced hormonal therapies, and brachytherapy may improve patient outcomes and survival in men with high-risk prostate cancer. Shared decision-making between patients and multidisciplinary teams of radiation oncologists, urologists, and medical oncologists is essential for personalizing care in this setting and deciding which strategies make sense for individual patients.
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Affiliation(s)
- John Nikitas
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, USA
| | - Amar Kishan
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, USA
| | - Albert Chang
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, USA
| | - Sai Duriseti
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, USA
- Radiation Oncology Service, Greater Los Angeles Veterans Affairs Healthcare System, Los Angeles, USA
| | - Nicholas G Nichols
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, USA
- Radiation Oncology Service, Greater Los Angeles Veterans Affairs Healthcare System, Los Angeles, USA
| | - Robert Reiter
- Department of Urology, University of California, Los Angeles, Los Angeles, USA
| | - Matthew Rettig
- Department of Urology, University of California, Los Angeles, Los Angeles, USA
- Hematology-Oncology Section, Medicine Service, Greater Los Angeles Veterans Affairs Healthcare System, Los Angeles, USA
| | - Wayne Brisbane
- Department of Urology, University of California, Los Angeles, Los Angeles, USA
| | - Michael L Steinberg
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, USA
| | - Luca Valle
- Radiation Oncology Service, Greater Los Angeles Veterans Affairs Healthcare System, Los Angeles, USA.
- Department of Radiation Oncology, University of California, Los Angeles, 200 Medical Plaza, Ste B265, Los Angeles, CA, 90095, USA.
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9
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Gomez-Iturriaga A, Büchser D, Lopez-Campos F, Maldonado X. Enhancing Androgen Deprivation Therapy (ADT) integration in prostate cancer: Insights for Stereotactic Body Radiotherapy (SBRT) and brachytherapy modalities. Clin Transl Radiat Oncol 2024; 45:100733. [PMID: 38322544 PMCID: PMC10844661 DOI: 10.1016/j.ctro.2024.100733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 01/17/2024] [Accepted: 01/21/2024] [Indexed: 02/08/2024] Open
Abstract
The utilization of Androgen Deprivation Therapy (ADT) in conjunction with Stereotactic Body Radiotherapy (SBRT) and Brachytherapy (BT) boost in prostate cancer treatment is a subject of ongoing debate and evolving clinical practice. While contemporary trends lean towards underutilizing ADT with these modalities, existing evidence suggests that its omission may lead to potentially inferior oncologic outcomes. Recommendations for ADT use should be patient-centric, considering individual risk profiles and comorbidities, with a focus on achieving optimal oncologic outcomes while minimizing potential side effects. Ongoing clinical trials, such as PACE-C, SPA, SHIP 0804, and SHIP 36B, are anticipated to provide valuable insights into the optimal use and duration of ADT in both SBRT and BT settings. Until new evidence emerges, it is recommended to initiate ADT for unfavorable intermediate-risk and high-risk prostate cancer patients undergoing radiotherapy, with a minimum duration of 6 months for unfavorable intermediate-risk patients and at least 12 months for those with high-risk characteristics. The decision to incorporate ADT into these radiation therapy modalities should be individualized, acknowledging the unique needs of each patient and emphasizing a tailored approach to achieve the best possible oncologic outcomes.
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Affiliation(s)
- A. Gomez-Iturriaga
- Hospital Universitario Cruces/ Biobizkaia Health Research Institute, Radiation Oncology, Barakaldo, Spain
- Department of Surgery and Radiology and Physical Medicine, University of the Basque Country UPV/EHU, Spain
| | - D. Büchser
- Hospital Universitario Cruces/ Biobizkaia Health Research Institute, Radiation Oncology, Barakaldo, Spain
- Department of Surgery and Radiology and Physical Medicine, University of the Basque Country UPV/EHU, Spain
| | - F. Lopez-Campos
- Hospital Universitario Ramon y Cajal, Radiation Oncology, Madrid, Spain
| | - X. Maldonado
- Hospital Vall d́Hebron, Radiation Oncology, Barcelona, Spain
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10
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Yorozu A, Namiki M, Saito S, Egawa S, Yaegashi H, Konaka H, Momma T, Fukagai T, Tanaka N, Ohashi T, Takahashi H, Nakagawa Y, Kikuchi T, Mizokami A, Stone NN. Trimodality Therapy With Iodine-125 Brachytherapy, External Beam Radiation Therapy, and Short- or Long-Term Androgen Deprivation Therapy for High-Risk Localized Prostate Cancer: Results of a Multicenter, Randomized Phase 3 Trial (TRIP/TRIGU0907). Int J Radiat Oncol Biol Phys 2024; 118:390-401. [PMID: 37802225 DOI: 10.1016/j.ijrobp.2023.08.046] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 08/05/2023] [Accepted: 08/11/2023] [Indexed: 10/08/2023]
Abstract
PURPOSE This phase 3 randomized investigation was designed to determine whether 30 months of androgen deprivation therapy (ADT) was superior to 6 months of ADT when combined with brachytherapy and external beam radiation therapy (EBRT) for localized high-risk prostate cancer. METHODS AND MATERIALS This study was conducted at 37 hospitals on men aged 40 to 79 years, with stage T2c-3a, prostate-specific antigen >20 ng/mL, or Gleason score >7, who received 6 months of ADT combined with iodine-125 brachytherapy followed by EBRT. After stratification, patients were randomly assigned to either no further treatment (short arm) or 24 months of adjuvant ADT (long arm). According to the Phoenix definition of failure, the primary endpoint was the cumulative incidence of biochemical progression. Secondary endpoints included clinical progression, metastasis, salvage treatment, disease-specific mortality, overall survival, and grade 3+ adverse events. An intention-to-treat analysis was conducted using survival estimates determined using competing risk analyses. RESULTS Of 332 patients, 165 and 167 were randomly assigned to the short and long arms, respectively. The median follow-up period was 9.2 years. The cumulative incidence of biochemical progression at 7 years was 9.0% (95% CI, 5.5-14.5) and 8.0% (4.7-13.5) in the short and long arms, respectively (P = .65). The outcomes of secondary endpoints did not differ significantly between the arms. Incidence rates of endocrine- and radiation-related grade 3+ adverse events for the short versus long arms were 0.6 versus 1.8% (P = .62) and 1.2 versus 0.6% (P = .62), respectively. CONCLUSIONS Both treatment arms showed similar efficacy among selected populations with high-risk features. The toxicity of the trimodal therapy was acceptable. The present investigation, designed as a superiority trial, failed to demonstrate that 30-month ADT yielded better biochemical control than 6-month ADT when combined with brachytherapy and EBRT. Therefore, a noninferiority study is warranted to obtain further evidence supporting these preliminary results.
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Affiliation(s)
- Atsunori Yorozu
- Department of Radiation Oncology, National Hospital Organization Tokyo Medical Center, Tokyo, Japan.
| | - Mikio Namiki
- Department of Urology, Hasegawa Hospital, Toyama, Japan
| | - Shiro Saito
- Department of Urology, Ofuna Chuo Hospital, Kanagawa, Japan
| | - Shin Egawa
- Department of Urology, the Jikei University Hospital, Tokyo, Japan
| | - Hiroshi Yaegashi
- Department of Urology, Kanazawa University, Graduate School of Medical Science, Kanazawa, Japan
| | - Hiroyuki Konaka
- Department of Urology, Japanese Red Cross Society Kanazawa Hospital, Kanazawa, Japan
| | - Tetsuo Momma
- Department of Urology, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
| | - Takashi Fukagai
- Department of Urology, Showa University School of Medicine, Tokyo, Japan
| | - Nobumichi Tanaka
- Departments of Urology and Prostate Brachytherapy, Nara Medical University, Nara, Japan
| | - Toshio Ohashi
- Department of Radiation Oncology, Keio University, Tokyo, Japan
| | - Hiroyuki Takahashi
- Department of Pathology, the Jikei University School of Medicine, Tokyo, Japan
| | - Yoko Nakagawa
- Foundation for Biomedical Research and Innovation, Translational Research Informatics Center, Kobe, Japan
| | - Takashi Kikuchi
- Foundation for Biomedical Research and Innovation, Translational Research Informatics Center, Kobe, Japan
| | - Atsushi Mizokami
- Department of Urology, Kanazawa University, Graduate School of Medical Science, Kanazawa, Japan
| | - Nelson N Stone
- Department of Urology and Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York
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11
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Dornisch AM, Zhong AY, Poon DMC, Tree AC, Seibert TM. Focal radiotherapy boost to MR-visible tumor for prostate cancer: a systematic review. World J Urol 2024; 42:56. [PMID: 38244059 PMCID: PMC10799816 DOI: 10.1007/s00345-023-04745-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 10/30/2023] [Indexed: 01/22/2024] Open
Abstract
PURPOSE The FLAME trial provides strong evidence that MR-guided external beam radiation therapy (EBRT) focal boost for localized prostate cancer increases biochemical disease-free survival (bDFS) without increasing toxicity. Yet, there are many barriers to implementation of focal boost. Our objectives are to systemically review clinical outcomes for MR-guided EBRT focal boost and to consider approaches to increase implementation of this technique. METHODS We conducted literature searches in four databases according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guideline. We included prospective phase II/III trials of patients with localized prostate cancer underdoing definitive EBRT with MR-guided focal boost. The outcomes of interest were bDFS and acute/late gastrointestinal and genitourinary toxicity. RESULTS Seven studies were included. All studies had a median follow-up of greater than 4 years. There were heterogeneities in fractionation, treatment planning, and delivery. Studies demonstrated effectiveness, feasibility, and tolerability of focal boost. Based on the Phoenix criteria for biochemical recurrence, the reported 5-year biochemical recurrence-free survival rates ranged 69.7-100% across included studies. All studies reported good safety profiles. The reported ranges of acute/late grade 3 + gastrointestinal toxicities were 0%/1-10%. The reported ranges of acute/late grade 3 + genitourinary toxicities were 0-13%/0-5.6%. CONCLUSIONS There is strong evidence that it is possible to improve oncologic outcomes without substantially increasing toxicity through MR-guided focal boost, at least in the setting of a 35-fraction radiotherapy regimen. Barriers to clinical practice implementation are addressable through additional investigation and new technologies.
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Affiliation(s)
- Anna M Dornisch
- Department of Radiation Medicine and Applied Sciences, UC San Diego School of Medicine, La Jolla, CA, USA
| | - Allison Y Zhong
- Department of Radiation Medicine and Applied Sciences, UC San Diego School of Medicine, La Jolla, CA, USA
- University of California San Diego School of Medicine, La Jolla, CA, USA
| | - Darren M C Poon
- Comprehensive Oncology Centre, Hong Kong Sanatorium and Hospital, Happy Valley, Hong Kong, Special Administrative Region of China
| | - Alison C Tree
- The Royal Marsden NHS Foundation Trust, Sutton, UK
- Division of Radiotherapy and Imaging, Institute of Cancer Research, Sutton, UK
| | - Tyler M Seibert
- Department of Radiation Medicine and Applied Sciences, UC San Diego School of Medicine, La Jolla, CA, USA.
- Department of Bioengineering, UC San Diego Jacobs School of Engineering, La Jolla, CA, USA.
- Department of Radiology, UC San Diego School of Medicine, La Jolla, CA, USA.
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12
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Kamran SC, Vapiwala N. Approach to Patients with High-Risk Localized Prostate Cancer: Radiation Oncology Perspective. Curr Treat Options Oncol 2024; 25:84-96. [PMID: 38167980 DOI: 10.1007/s11864-023-01163-3] [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] [Accepted: 12/10/2023] [Indexed: 01/05/2024]
Abstract
OPINION STATEMENT High-risk localized prostate cancer is a challenging clinical entity to treat, with heterogeneous responses to an evolving array of multidisciplinary treatment approaches. In addition, this disease state is growing in incidence due to a variety of factors, including shifting recommendations that discouraged routine prostate cancer screening. Current guidelines now incorporate an informed decision-making process for prostate cancer screening and evaluation. More work is underway to improve targeted screening for certain at-risk populations and to implement greater personalization in the use of diagnostic tools. Once diagnosed with high-risk localized disease, a multimodality treatment paradigm is warranted. Radiation-in its various forms and combinations-plays a large and continually evolving role in the management of high-risk prostate cancer, yet treatment outcomes are still suboptimal. There is a growing need to improve upon current treatment approaches, and better personalize a particular treatment recommendation based on both tumor and patient characteristics, as well as patient preference and goals of therapy. Given that treatment generally requires more than one therapy, there are notable implications on long-term quality of life, especially with respect to overlapping and cumulative side effects of local and systemic therapies, respectively. The desire for aggressive therapy to optimize cancer control outcomes must be weighed against the risk of morbidities and overtreatment and discussed with each patient so that an informed decision about treatment and care can be determined. High-level evidence to support treatment recommendations, where available, is critical for a data-driven and tailored approach to address all goals of care.
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Affiliation(s)
- Sophia C Kamran
- Department of Radiation Oncology, Massachusetts General Cancer Center, Harvard Medical School, 55 Fruit Street, Cox 3, Boston, MA, 02114, USA.
| | - Neha Vapiwala
- Department of Radiation Oncology, Hospital of the University of Pennsylvania, Perelman School of Medicine, 3400 Civic Center Boulevard, TRC 4 West, Philadelphia, PA, 19104, USA
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13
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Poder J, Radvan S, Howie A, Kasraei F, Parker A, Bucci J, Haworth A. Viability of focal dose escalation to prostate cancer intraprostatic lesions using HDR prostate brachytherapy. Brachytherapy 2023; 22:800-807. [PMID: 37748989 DOI: 10.1016/j.brachy.2023.09.001] [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: 05/07/2023] [Revised: 08/31/2023] [Accepted: 09/01/2023] [Indexed: 09/27/2023]
Abstract
PURPOSE This study aimed to determine the viability of focal dose escalation to prostate cancer intraprostatic lesions (IPLs) from multiparametric magnetic resonance (mpMRI) and prostate-specific membrane antigen positron emission tomography (PSMA-PET) images using high-dose-rate (HDR) prostate brachytherapy (pBT). METHODS AND MATERIALS Retrospective data from 20 patients treated with HDR pBT was utilized. The interobserver contouring variability of 5 observers was quantified using the dice similarity coefficient (DSC) and mean distance to agreement (MDA). Uncertainty in propagating IPL contours to trans-rectal ultrasound (TRUS) was quantified using a tissue equivalent prostate phantom. Feasibility of incorporating IPLs into HDR pBT planning was tested on retrospective patient data. RESULTS The average observer DSC was 0.65 (PSMA-PET) and 0.52 (mpMRI). The uncertainty in propagating IPL contours was 0.6 mm (PSMA-PET), and 0.4 mm (mpMRI). Uncertainties could be accounted for by expanding IPL contours by 2 mm to create IPL PTVs. The mean D98% achieved using HDR pBT was 166% and 135% for the IPL and IPL PTV contours, respectively. CONCLUSIONS Focal dose escalation to IPLs identified on either PSMA-PET or mpMRI is viable using TRUS-based HDR pBT. Utilizing HDR pBT allows dose escalation of up to 166% of the prescribed dose to the prostate.
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Affiliation(s)
- Joel Poder
- Department of Radiation Oncology, St George Hospital Cancer Care Centre, Kogarah, NSW, Australia; Centre for Medical Radiation Physics, University of Wollongong, Wollongong, NSW, Australia; School of Physics, University of Sydney, Camperdown, NSW, Australia.
| | - Samantha Radvan
- School of Physics, University of Sydney, Camperdown, NSW, Australia
| | - Andrew Howie
- Department of Radiation Oncology, St George Hospital Cancer Care Centre, Kogarah, NSW, Australia
| | - Farshad Kasraei
- Department of Radiation Oncology, St George Hospital Cancer Care Centre, Kogarah, NSW, Australia
| | - Annaleise Parker
- Department of Radiation Oncology, St George Hospital Cancer Care Centre, Kogarah, NSW, Australia
| | - Joseph Bucci
- Department of Radiation Oncology, St George Hospital Cancer Care Centre, Kogarah, NSW, Australia
| | - Annette Haworth
- School of Physics, University of Sydney, Camperdown, NSW, Australia
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14
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Numakura K, Kobayashi M, Muto Y, Sato H, Sekine Y, Sobu R, Aoyama Y, Takahashi Y, Okada S, Sasagawa H, Narita S, Kumagai S, Wada Y, Mori N, Habuchi T. The Current Trend of Radiation Therapy for Patients with Localized Prostate Cancer. Curr Oncol 2023; 30:8092-8110. [PMID: 37754502 PMCID: PMC10529045 DOI: 10.3390/curroncol30090587] [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: 06/23/2023] [Revised: 08/22/2023] [Accepted: 08/28/2023] [Indexed: 09/28/2023] Open
Abstract
A recent approach to radiotherapy for prostate cancer is the administration of high doses of radiation to the prostate while minimizing the risk of side effects. Thus, image-guided radiotherapy utilizes advanced imaging techniques and is a feasible strategy for increasing the radiation dose. New radioactive particles are another approach to achieving high doses and safe procedures. Prostate brachytherapy is currently considered as a combination therapy. Spacers are useful to protect adjacent organs, specifically the rectum, from excessive radiation exposure.
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Affiliation(s)
- Kazuyuki Numakura
- Department of Urology, Akita University Graduate School of Medicine, Akita 010-8543, Japan; (M.K.); (Y.M.); (H.S.); (Y.S.); (R.S.); (Y.A.); (Y.T.); (S.O.); (H.S.); (S.N.); (T.H.)
| | - Mizuki Kobayashi
- Department of Urology, Akita University Graduate School of Medicine, Akita 010-8543, Japan; (M.K.); (Y.M.); (H.S.); (Y.S.); (R.S.); (Y.A.); (Y.T.); (S.O.); (H.S.); (S.N.); (T.H.)
| | - Yumina Muto
- Department of Urology, Akita University Graduate School of Medicine, Akita 010-8543, Japan; (M.K.); (Y.M.); (H.S.); (Y.S.); (R.S.); (Y.A.); (Y.T.); (S.O.); (H.S.); (S.N.); (T.H.)
| | - Hiromi Sato
- Department of Urology, Akita University Graduate School of Medicine, Akita 010-8543, Japan; (M.K.); (Y.M.); (H.S.); (Y.S.); (R.S.); (Y.A.); (Y.T.); (S.O.); (H.S.); (S.N.); (T.H.)
| | - Yuya Sekine
- Department of Urology, Akita University Graduate School of Medicine, Akita 010-8543, Japan; (M.K.); (Y.M.); (H.S.); (Y.S.); (R.S.); (Y.A.); (Y.T.); (S.O.); (H.S.); (S.N.); (T.H.)
| | - Ryuta Sobu
- Department of Urology, Akita University Graduate School of Medicine, Akita 010-8543, Japan; (M.K.); (Y.M.); (H.S.); (Y.S.); (R.S.); (Y.A.); (Y.T.); (S.O.); (H.S.); (S.N.); (T.H.)
| | - Yu Aoyama
- Department of Urology, Akita University Graduate School of Medicine, Akita 010-8543, Japan; (M.K.); (Y.M.); (H.S.); (Y.S.); (R.S.); (Y.A.); (Y.T.); (S.O.); (H.S.); (S.N.); (T.H.)
| | - Yoshiko Takahashi
- Department of Urology, Akita University Graduate School of Medicine, Akita 010-8543, Japan; (M.K.); (Y.M.); (H.S.); (Y.S.); (R.S.); (Y.A.); (Y.T.); (S.O.); (H.S.); (S.N.); (T.H.)
| | - Syuhei Okada
- Department of Urology, Akita University Graduate School of Medicine, Akita 010-8543, Japan; (M.K.); (Y.M.); (H.S.); (Y.S.); (R.S.); (Y.A.); (Y.T.); (S.O.); (H.S.); (S.N.); (T.H.)
| | - Hajime Sasagawa
- Department of Urology, Akita University Graduate School of Medicine, Akita 010-8543, Japan; (M.K.); (Y.M.); (H.S.); (Y.S.); (R.S.); (Y.A.); (Y.T.); (S.O.); (H.S.); (S.N.); (T.H.)
| | - Shintaro Narita
- Department of Urology, Akita University Graduate School of Medicine, Akita 010-8543, Japan; (M.K.); (Y.M.); (H.S.); (Y.S.); (R.S.); (Y.A.); (Y.T.); (S.O.); (H.S.); (S.N.); (T.H.)
| | - Satoshi Kumagai
- Department of Radiology, Akita University Graduate School of Medicine, Akita 010-8543, Japan; (S.K.); (Y.W.); (N.M.)
| | - Yuki Wada
- Department of Radiology, Akita University Graduate School of Medicine, Akita 010-8543, Japan; (S.K.); (Y.W.); (N.M.)
| | - Naoko Mori
- Department of Radiology, Akita University Graduate School of Medicine, Akita 010-8543, Japan; (S.K.); (Y.W.); (N.M.)
| | - Tomonori Habuchi
- Department of Urology, Akita University Graduate School of Medicine, Akita 010-8543, Japan; (M.K.); (Y.M.); (H.S.); (Y.S.); (R.S.); (Y.A.); (Y.T.); (S.O.); (H.S.); (S.N.); (T.H.)
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15
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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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