1
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Knoppers BM, Bernier A, Granados Moreno P, Pashayan N. Of Screening, Stratification, and Scores. J Pers Med 2021; 11:736. [PMID: 34442379 PMCID: PMC8398020 DOI: 10.3390/jpm11080736] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 07/24/2021] [Indexed: 12/16/2022] Open
Abstract
Technological innovations including risk-stratification algorithms and large databases of longitudinal population health data and genetic data are allowing us to develop a deeper understanding how individual behaviors, characteristics, and genetics are related to health risk. The clinical implementation of risk-stratified screening programmes that utilise risk scores to allocate patients into tiers of health risk is foreseeable in the future. Legal and ethical challenges associated with risk-stratified cancer care must, however, be addressed. Obtaining access to the rich health data that are required to perform risk-stratification, ensuring equitable access to risk-stratified care, ensuring that algorithms that perform risk-scoring are representative of human genetic diversity, and determining the appropriate follow-up to be provided to stratification participants to alert them to changes in their risk score are among the principal ethical and legal challenges. Accounting for the great burden that regulatory requirements could impose on access to risk-scoring technologies is another critical consideration.
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Affiliation(s)
- Bartha M. Knoppers
- Centre of Genomics and Policy, Faculty of Medicine, McGill University, 740 Avenue Dr. Penfield, Suite 5200, Montreal, QC H3A 0G1, Canada; (A.B.); (P.G.M.)
| | - Alexander Bernier
- Centre of Genomics and Policy, Faculty of Medicine, McGill University, 740 Avenue Dr. Penfield, Suite 5200, Montreal, QC H3A 0G1, Canada; (A.B.); (P.G.M.)
| | - Palmira Granados Moreno
- Centre of Genomics and Policy, Faculty of Medicine, McGill University, 740 Avenue Dr. Penfield, Suite 5200, Montreal, QC H3A 0G1, Canada; (A.B.); (P.G.M.)
| | - Nora Pashayan
- Department of Applied Health Research, University College London, 1-19 Torrington Place, London WC1E 7HB, UK;
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2
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Yamazaki H, Suzuki G, Masui K, Aibe N, Shimizu D, Kimoto T, Yamada K, Shiraishi T, Fujihara A, Okihara K, Yoshida K, Nakamura S, Okabe H. Novel Prognostic Index of High-Risk Prostate Cancer Using Simple Summation of Very High-Risk Factors. Cancers (Basel) 2021; 13:cancers13143486. [PMID: 34298697 PMCID: PMC8306376 DOI: 10.3390/cancers13143486] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Revised: 07/06/2021] [Accepted: 07/09/2021] [Indexed: 01/01/2023] Open
Abstract
This study aimed to examine the role of very high-risk (VHR) factors (T3b-4 and Gleason score 9-10) for prognosis of clinically localized high-risk prostate cancer. We reviewed multi-institutional retrospective data of 1413 patients treated with radiotherapy (558 patients treated with external beam radiotherapy (EBRT) and 855 patients treated with brachytherapy (BT) ± EBRT. We introduced an index by simple summation of the number of VHR factors-VHR-0, VHR-1, and VHR-2. With median follow-up of 69.6 months, the 5-year biochemical disease free survival rate (bDFS), prostate cancer-specific mortality (PCSM), and distant metastasis-free survival (DMSF) rates were 59.4%, 7.65%, and 83.2% for the VHR-2 group, respectively; 86.7%, 1.50%, and 95.4% for the VHR-1 group, respectively; and 93.1%, 0.12%, and 98.2% for the VHR-0 group, respectively. The VHR-2 group had significantly worse bDFS, PCSM, and DMSF than the VHR-0 (hazard ratios: 4.55, 9.607, and 7.904, respectively) and VHR-1 (hazard ratios: 1.723, 2.391, and 1.491, respectively) groups. The VHR-2 group could be identified as a super high-risk group compared with other groups, and could be a good candidate for clinical trials using multimodal intensified treatments. Simple summation of the number of VHR factors is an easy and useful predictive index for bDFS, PCSM, and DMSF.
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Affiliation(s)
- Hideya Yamazaki
- Department of Radiology, and Urology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajiicho Kawaramachi Hirokoji, Kamigyo-ku, Kyoto 602-8566, Japan; (G.S.); (K.M.); (N.A.); (D.S.); (T.K.); (K.Y.); (T.S.); (A.F.); (K.O.)
- Correspondence: ; Tel.: +81-(752)-515-111
| | - Gen Suzuki
- Department of Radiology, and Urology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajiicho Kawaramachi Hirokoji, Kamigyo-ku, Kyoto 602-8566, Japan; (G.S.); (K.M.); (N.A.); (D.S.); (T.K.); (K.Y.); (T.S.); (A.F.); (K.O.)
| | - Koji Masui
- Department of Radiology, and Urology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajiicho Kawaramachi Hirokoji, Kamigyo-ku, Kyoto 602-8566, Japan; (G.S.); (K.M.); (N.A.); (D.S.); (T.K.); (K.Y.); (T.S.); (A.F.); (K.O.)
| | - Norihiro Aibe
- Department of Radiology, and Urology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajiicho Kawaramachi Hirokoji, Kamigyo-ku, Kyoto 602-8566, Japan; (G.S.); (K.M.); (N.A.); (D.S.); (T.K.); (K.Y.); (T.S.); (A.F.); (K.O.)
| | - Daisuke Shimizu
- Department of Radiology, and Urology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajiicho Kawaramachi Hirokoji, Kamigyo-ku, Kyoto 602-8566, Japan; (G.S.); (K.M.); (N.A.); (D.S.); (T.K.); (K.Y.); (T.S.); (A.F.); (K.O.)
| | - Takuya Kimoto
- Department of Radiology, and Urology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajiicho Kawaramachi Hirokoji, Kamigyo-ku, Kyoto 602-8566, Japan; (G.S.); (K.M.); (N.A.); (D.S.); (T.K.); (K.Y.); (T.S.); (A.F.); (K.O.)
| | - Kei Yamada
- Department of Radiology, and Urology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajiicho Kawaramachi Hirokoji, Kamigyo-ku, Kyoto 602-8566, Japan; (G.S.); (K.M.); (N.A.); (D.S.); (T.K.); (K.Y.); (T.S.); (A.F.); (K.O.)
| | - Takumi Shiraishi
- Department of Radiology, and Urology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajiicho Kawaramachi Hirokoji, Kamigyo-ku, Kyoto 602-8566, Japan; (G.S.); (K.M.); (N.A.); (D.S.); (T.K.); (K.Y.); (T.S.); (A.F.); (K.O.)
| | - Atsuko Fujihara
- Department of Radiology, and Urology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajiicho Kawaramachi Hirokoji, Kamigyo-ku, Kyoto 602-8566, Japan; (G.S.); (K.M.); (N.A.); (D.S.); (T.K.); (K.Y.); (T.S.); (A.F.); (K.O.)
| | - Koji Okihara
- Department of Radiology, and Urology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajiicho Kawaramachi Hirokoji, Kamigyo-ku, Kyoto 602-8566, Japan; (G.S.); (K.M.); (N.A.); (D.S.); (T.K.); (K.Y.); (T.S.); (A.F.); (K.O.)
| | - Ken Yoshida
- Department of Department of Radiology, Kansai Medical University, Hirakata 573-1010, Japan; (K.Y.); (S.N.)
| | - Satoaki Nakamura
- Department of Department of Radiology, Kansai Medical University, Hirakata 573-1010, Japan; (K.Y.); (S.N.)
| | - Haruumi Okabe
- Department of Radiology, Ujitakeda Hospital, Uji-City 611-0021, Japan;
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3
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Guy D, Karp I, Wilk P, Chin J, Rodrigues G. Propensity score matching versus coarsened exact matching in observational comparative effectiveness research. J Comp Eff Res 2021; 10:939-951. [PMID: 34060903 DOI: 10.2217/cer-2021-0069] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim & methods: We compared propensity score matching (PSM) and coarsened exact matching (CEM) in balancing baseline characteristics between treatment groups using observational data obtained from a pan-Canadian prostate cancer radiotherapy database. Changes in effect estimates were evaluated as a function of improvements in balance, using results from randomized clinical trials to guide interpretation. Results: CEM and PSM improved balance between groups in both comparisons, while retaining the majority of original data. Improvements in balance were associated with effect estimates closer to those obtained in randomized clinical trials. Conclusion: CEM and PSM led to substantial improvements in balance between comparison groups, while retaining a considerable proportion of original data. This could lead to improved accuracy in effect estimates obtained using observational data in a variety of clinical situations.
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Affiliation(s)
- David Guy
- Department of Epidemiology and Biostatistics, Schulich School of Medicine & Dentistry, Western University, London, ON N6A 3K7, Canada.,Department of Radiation Oncology, London Health Sciences Centre, London, ON N6A 5W9, Canada
| | - Igor Karp
- Department of Epidemiology and Biostatistics, Schulich School of Medicine & Dentistry, Western University, London, ON N6A 3K7, Canada
| | - Piotr Wilk
- Department of Epidemiology and Biostatistics, Schulich School of Medicine & Dentistry, Western University, London, ON N6A 3K7, Canada
| | - Joseph Chin
- Department of Urology, Schulich School of Medicine & Dentistry, Western University, London, ON N6A 3K7, Canada
| | - George Rodrigues
- Department of Epidemiology and Biostatistics, Schulich School of Medicine & Dentistry, Western University, London, ON N6A 3K7, Canada.,Department of Radiation Oncology, London Health Sciences Centre, London, ON N6A 5W9, Canada
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van Wijk Y, Ramaekers B, Vanneste BGL, Halilaj I, Oberije C, Chatterjee A, Marcelissen T, Jochems A, Woodruff HC, Lambin P. Modeling-Based Decision Support System for Radical Prostatectomy Versus External Beam Radiotherapy for Prostate Cancer Incorporating an In Silico Clinical Trial and a Cost-Utility Study. Cancers (Basel) 2021; 13:cancers13112687. [PMID: 34072509 PMCID: PMC8198879 DOI: 10.3390/cancers13112687] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 05/20/2021] [Accepted: 05/24/2021] [Indexed: 12/24/2022] Open
Abstract
Simple Summary Low–intermediate prostate cancer has a number of viable treatment options, such as radical prostatectomy and radiotherapy, with similar survival outcomes but different treatment-related side effects. The aim of this study is to facilitate patient-specific treatment selection by developing a decision support system (DSS) that incorporates predictive models for cancer-free survival and treatment-related side effects. We challenged this DSS by validating it against randomized clinical trials and assessing the benefit through a cost–utility analysis. We aim to expand upon the applications of this DSS by using it as the basis for an in silico clinical trial for an underrepresented patient group. This modeling study shows that DSS-based treatment decisions will result in a clinically relevant increase in the patients’ quality of life and can be used for in silico trials. Abstract The aim of this study is to build a decision support system (DSS) to select radical prostatectomy (RP) or external beam radiotherapy (EBRT) for low- to intermediate-risk prostate cancer patients. We used an individual state-transition model based on predictive models for estimating tumor control and toxicity probabilities. We performed analyses on a synthetically generated dataset of 1000 patients with realistic clinical parameters, externally validated by comparison to randomized clinical trials, and set up an in silico clinical trial for elderly patients. We assessed the cost-effectiveness (CE) of the DSS for treatment selection by comparing it to randomized treatment allotment. Using the DSS, 47.8% of synthetic patients were selected for RP and 52.2% for EBRT. During validation, differences with the simulations of late toxicity and biochemical failure never exceeded 2%. The in silico trial showed that for elderly patients, toxicity has more influence on the decision than TCP, and the predicted QoL depends on the initial erectile function. The DSS is estimated to result in cost savings (EUR 323 (95% CI: EUR 213–433)) and more quality-adjusted life years (QALYs; 0.11 years, 95% CI: 0.00–0.22) than randomized treatment selection.
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Affiliation(s)
- Yvonka van Wijk
- The D-Lab, Department of Precision Medicine, GROW—School for Oncology and Developmental Biology, Maastricht University, 6229 ER Maastricht, The Netherlands; (I.H.); (C.O.); (A.C.); (A.J.); (H.C.W.); (P.L.)
- Correspondence:
| | - Bram Ramaekers
- Department of Clinical Epidemiology and Medical Technology Assessment (KEMTA), Maastricht University Medical Centre+, 6229 HX Maastricht, The Netherlands;
| | - Ben G. L. Vanneste
- Department of Radiation Oncology (MAASTRO), GROW—School for Oncology and Developmental Biology, Maastricht University Medical Center+, 6229 HX Maastricht, The Netherlands;
| | - Iva Halilaj
- The D-Lab, Department of Precision Medicine, GROW—School for Oncology and Developmental Biology, Maastricht University, 6229 ER Maastricht, The Netherlands; (I.H.); (C.O.); (A.C.); (A.J.); (H.C.W.); (P.L.)
| | - Cary Oberije
- The D-Lab, Department of Precision Medicine, GROW—School for Oncology and Developmental Biology, Maastricht University, 6229 ER Maastricht, The Netherlands; (I.H.); (C.O.); (A.C.); (A.J.); (H.C.W.); (P.L.)
| | - Avishek Chatterjee
- The D-Lab, Department of Precision Medicine, GROW—School for Oncology and Developmental Biology, Maastricht University, 6229 ER Maastricht, The Netherlands; (I.H.); (C.O.); (A.C.); (A.J.); (H.C.W.); (P.L.)
| | - Tom Marcelissen
- Department of Urology, Maastricht University Medical Centre+, 6229 HX Maastricht, The Netherlands;
| | - Arthur Jochems
- The D-Lab, Department of Precision Medicine, GROW—School for Oncology and Developmental Biology, Maastricht University, 6229 ER Maastricht, The Netherlands; (I.H.); (C.O.); (A.C.); (A.J.); (H.C.W.); (P.L.)
| | - Henry C. Woodruff
- The D-Lab, Department of Precision Medicine, GROW—School for Oncology and Developmental Biology, Maastricht University, 6229 ER Maastricht, The Netherlands; (I.H.); (C.O.); (A.C.); (A.J.); (H.C.W.); (P.L.)
| | - Philippe Lambin
- The D-Lab, Department of Precision Medicine, GROW—School for Oncology and Developmental Biology, Maastricht University, 6229 ER Maastricht, The Netherlands; (I.H.); (C.O.); (A.C.); (A.J.); (H.C.W.); (P.L.)
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5
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Favorable intermediate risk prostate cancer with biopsy Gleason score of 6. BMC Urol 2021; 21:52. [PMID: 33820533 PMCID: PMC8022526 DOI: 10.1186/s12894-021-00827-2] [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: 01/05/2021] [Accepted: 03/26/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To identify potential prognostic factors among patients with favorable intermediate risk prostate cancer with a biopsy Gleason score 6. METHODS From 2003 to 2019, favorable intermediate risk patients who underwent radical prostatectomy were included in this study. All patients were evaluated preoperatively with MRI. Using PI-RADS scores, patients were divided into two groups, and clinic-pathological outcomes were compared. The impact of preoperative factors on significant pathologic Gleason score upgrading (≥ 4 + 3) and biochemical recurrence were assessed via multivariate analysis. Subgroup analysis was performed in patients with PI-RADS ≤ 2. RESULTS Among the 239 patients, 116 (48.5%) were MRI-negative (PI-RADS ≤ 3) and 123 (51.5%) were MRI-positive (PI-RADS > 3). Six patients in the MRI-negative group (5.2%) were characterized as requiring significant pathologic Gleason score upgrading compared with 34 patients (27.6%) in the MRI-positive group (p < 0.001). PI-RADS score was shown to be a significant predictor of significant pathologic Gleason score upgrading (OR = 6.246, p < 0.001) and biochemical recurrence (HR = 2.595, p = 0.043). 10-years biochemical recurrence-free survival was estimated to be 84.4% and 72.6% in the MRI-negative and MRI-positive groups (p = 0.035). In the 79 patients with PI-RADS ≤ 2, tumor length in biopsy cores was identified as a significant predictor of pathologic Gleason score (OR = 11.336, p = 0.014). CONCLUSIONS Among the patients with favorable intermediate risk prostate cancer with a biopsy Gleason score 6, preoperative MRI was capable of predicting significant pathologic Gleason score upgrading and biochemical recurrence. Especially, the patients with PI-RADS ≤ 2 and low biopsy tumor length could be a potential candidate to active surveillance.
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6
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Nair SM, Warner A, Lavi A, Rodrigues G, Chin JL. Does adding local salvage ablation therapy provide survival advantage for patients with locally recurrent prostate cancer following radiotherapy? Whole gland salvage ablation post-radiation failure in prostate cancer. Can Urol Assoc J 2020; 15:123-129. [PMID: 33007180 DOI: 10.5489/cuaj.6676] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Some men who experience prostate cancer recurrence post-radiotherapy may be candidates for local salvage therapy, avoiding and delaying systemic treatments. Our aim was to assess the impact of clinical outcomes of adding salvage local treatment in prostate cancer patients who have failed radiation therapy. METHODS Following radiation biochemical failure, salvage transperineal cryotherapy (sCT, n=186), transrectal high intensity focused ultrasound ablation (sHIFU, n=113), or no salvage treatment (NST, identified from the pan-Canadian Prostate Cancer Risk Stratification [ProCaRS] database, n=982) were compared with propensity-score matching. Primary endpoints were cancer-specific survival (CSS) and overall survival (OS). RESULTS Median followup was 11.6, 25.1, and 14.3 years following NST, sCT, and sHIFU, respectively. Two propensity score-matched analyses were performed: 1) 196 NST vs. 98 sCT; and 2) 177 NST vs. 59 sHIFU. In the first comparison, there were 78 deaths and 49 prostate cancer deaths for NST vs. 80 deaths and 24 prostate cancer deaths for sCT. There were significant benefits in CSS (p<0.001) and OS (p<0.001) favoring sCT. In the second comparison, there were 52 deaths (31 from prostate cancer) for NST vs. 18 deaths (nine from prostate cancer) for sHIFU. There were no significant differences in CSS or OS possibility attributed to reduced sample size and shorter followup of sHIFU cohort. CONCLUSIONS In select men with recurrent prostate cancer post-radiation, further local treatment may lead to benefits in CSS. These hypothesis-generating findings should ideally be validated in a prospective clinical trial setting.
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Affiliation(s)
- Shiva Madhwan Nair
- Departments of Urology and Oncology, Western University, London, ON, Canada
| | - Andrew Warner
- Department of Radiation Oncology, Western University, London, ON, Canada
| | - Arnon Lavi
- Departments of Urology and Oncology, Western University, London, ON, Canada
| | - George Rodrigues
- Department of Radiation Oncology, Western University, London, ON, Canada
| | - Joseph L Chin
- Departments of Urology and Oncology, Western University, London, ON, Canada
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7
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Martell K, Roy S, Meyer T, Stosky J, Jiang W, Thind K, Roumeliotis M, Bosch J, Angyalfi S, Quon H, Husain S. Analysis of outcomes after non-contour-based dose painting of dominant intra-epithelial lesion in intra-operative low-dose rate brachytherapy. Heliyon 2020; 6:e04092. [PMID: 32548323 PMCID: PMC7286970 DOI: 10.1016/j.heliyon.2020.e04092] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 05/20/2020] [Accepted: 05/26/2020] [Indexed: 11/27/2022] Open
Abstract
Purpose To compare the outcomes of patients with intermediate risk prostate cancer (IR-PCa) treated with low-dose rate I-125 seed brachytherapy (LDR-BT) and targeted dose painting of a histologic dominant intra-epithelial lesion (DIL) to those without a DIL. Methods 455 patients with IR-PCa were treated at a single center with intra-operatively planned LDR-BT, each following the same in-house dose constraints. Patients with a DIL on pathology had hot spots localized to that region but no specific contouring during the procedure. Results 396 (87%) patients had a DIL. Baseline tumor characteristics and overall prostate dosimetry were similar between patients with and without DIL except the median number of biopsy cores taken: 10 (10–12) vs 12 (10–12) (p = 0.002). 19 (5%) and 18 (5%) of patients with and 1 (2%) and 0 (0%) of those without DIL experienced CTCAE grade 2 and 3 toxicity respectively. Overall, toxicity grade did not significantly correlate with presence of DIL (p = 0.10). Estimated 7-year freedom from biochemical failure (FFBF) was 84% (95% confidence interval: 79–89) and 70% (54–89) in patients with and without a DIL (log-rank p = 0.315). In DIL patients, cox regression revealed location of DIL (“Base” vs “Apex” HR: 1.03; 1.00–1.06; p = 0.03) and older age (70 vs 60 HR: 1.62; 1.06–2.49; p = 0.03) was associated with poor FFBF. Conclusions Targeting DIL through dose painting during intraoperatively planned LDR-BT provided no statistically significant change in FFBF. Patients with DILs in the prostate base had slightly lower FFBF despite DIL boost.
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Affiliation(s)
- Kevin Martell
- University of Calgary, Department of Oncology, Calgary, AB, Canada.,Alberta Health Services, Calgary Zone, Calgary, AB, Canada
| | - Soumyajit Roy
- University of Calgary, Department of Oncology, Calgary, AB, Canada.,Alberta Health Services, Calgary Zone, Calgary, AB, Canada.,Radiation Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Tyler Meyer
- University of Calgary, Department of Oncology, Calgary, AB, Canada.,Alberta Health Services, Calgary Zone, Calgary, AB, Canada
| | - Jordan Stosky
- University of Calgary, Department of Oncology, Calgary, AB, Canada.,Alberta Health Services, Calgary Zone, Calgary, AB, Canada
| | - Will Jiang
- University of Calgary, Department of Oncology, Calgary, AB, Canada.,Alberta Health Services, Calgary Zone, Calgary, AB, Canada
| | - Kundan Thind
- University of Calgary, Department of Oncology, Calgary, AB, Canada.,Alberta Health Services, Calgary Zone, Calgary, AB, Canada
| | - Michael Roumeliotis
- University of Calgary, Department of Oncology, Calgary, AB, Canada.,Alberta Health Services, Calgary Zone, Calgary, AB, Canada
| | - John Bosch
- Alberta Health Services, Calgary Zone, Calgary, AB, Canada
| | - Steve Angyalfi
- University of Calgary, Department of Oncology, Calgary, AB, Canada.,Alberta Health Services, Calgary Zone, Calgary, AB, Canada
| | - Harvey Quon
- University of Calgary, Department of Oncology, Calgary, AB, Canada.,Alberta Health Services, Calgary Zone, Calgary, AB, Canada
| | - Siraj Husain
- University of Calgary, Department of Oncology, Calgary, AB, Canada.,Alberta Health Services, Calgary Zone, Calgary, AB, Canada
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8
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Roy S, Hyndman ME, Danielson B, Fairey A, Lee-Ying R, Cheung WY, Afzal AR, Xu Y, Abedin T, Quon HC. Active treatment in low-risk prostate cancer: a population-based study. ACTA ACUST UNITED AC 2019; 26:e535-e540. [PMID: 31548822 DOI: 10.3747/co.26.4953] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background Active surveillance instead of active treatment (at) is preferred for patients with low-risk prostate cancer (lr-pca), but practice varies widely. We conducted a population-based study to assess the proportion of patients who underwent at between January 2011 and December 2014, and to evaluate factors associated with at. Methods The provincial cancer registry was linked to administrative health datasets to identify patients with lr-pca and to acquire demographic, tumour, and treatment data. The primary outcome was receipt of at during the first 12 months after diagnosis, defined as any receipt of external-beam radiotherapy, brachytherapy, radical prostatectomy, cryotherapy, or androgen deprivation. Univariate and multivariate logistic regression were used to analyze the correlation between patient and tumour factors and at. Results Of 1565 patients with lr-pca, 554 (35.4%) underwent at within 12 months of diagnosis. Radical prostatectomy was the most common treatment (58%), followed by brachytherapy (29.6%). Younger age [odds ratio (or) 0.92; 95% confidence interval (ci): 0.91 to 0.94], lower score (≥3) on the Charlson comorbidity index (OR: 0.36; 95% ci: 0.19 to 0.68), T2 stage (or: 3.05; 95% ci: 2.03 to 4.58), higher prostate-specific antigen (psa) at diagnosis (or: 1.13; 95% ci: 1.06 to 1.21), radiation oncologist consultation (or: 3.35; 95% ci: 2.55 to 4.39), and earlier diagnosis year (2012 or: 0.46; 95% ci: 0.34 to 0.63; 2013 or: 0.45; 95% ci: 0.32 to 0.63; 2014 or: 0.33; 95% ci: 0.23 to 0.47) were associated with a higher probability of at. Conclusions This contemporary population-based study demonstrates that approximately one third of patients with lr-pca undergo at. Patients of younger age, with less comorbidity, a higher tumour stage, higher psa, earlier year of diagnosis, and radiation oncologist consultation were more likely to undergo at. Further investigation is needed to identify strategies that could minimize overtreatment.
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Affiliation(s)
- S Roy
- Tom Baker Cancer Centre, Calgary, AB.,Department of Oncology, University of Calgary, Calgary, AB
| | - M E Hyndman
- Southern Alberta Institute of Urology, Calgary, AB.,Department of Surgical Oncology, University of Calgary, Calgary, AB
| | - B Danielson
- Cross Cancer Institute, Edmonton, AB.,Department of Oncology, University of Alberta, Edmonton, AB
| | - A Fairey
- Division of Urology, Department of Surgery, University of Alberta, Edmonton, AB
| | - R Lee-Ying
- Tom Baker Cancer Centre, Calgary, AB.,Department of Oncology, University of Calgary, Calgary, AB
| | - W Y Cheung
- Tom Baker Cancer Centre, Calgary, AB.,Department of Oncology, University of Calgary, Calgary, AB
| | - A R Afzal
- Tom Baker Cancer Centre, Calgary, AB
| | - Y Xu
- Department of Community Health Sciences, University of Calgary, Calgary, AB
| | - T Abedin
- Tom Baker Cancer Centre, Calgary, AB
| | - H C Quon
- Tom Baker Cancer Centre, Calgary, AB.,Department of Oncology, University of Calgary, Calgary, AB
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9
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Martell K, Mendez LC, Chung H, Tseng CL, Zhang L, Alayed Y, Liu S, Vesprini D, Chu W, Paudel M, Cheung P, Szumacher E, Ravi A, Loblaw A, Morton G. Absolute percentage of biopsied tissue positive for Gleason pattern 4 disease (APP4) appears predictive of disease control after high dose rate brachytherapy and external beam radiotherapy in intermediate risk prostate cancer. Radiother Oncol 2019; 135:170-177. [PMID: 31015164 DOI: 10.1016/j.radonc.2019.03.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Revised: 03/06/2019] [Accepted: 03/10/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND PURPOSE To identify if, in intermediate risk prostate cancer (IR-PCa), the absolute percentage of biopsied tissue positive for pattern 4 disease (APP4) may be a predictor of outcome. MATERIALS AND METHODS 411 patients with IR-PCa were retrospectively reviewed. APP4 was calculated based on biopsy reports. Multivariable competing risk analysis was then performed on optimized APP4 cutpoints to predict for biochemical failure (BF), androgen deprivation use for BF (ADT-BF) and development of metastases (MD). RESULTS Median follow-up for the cohort was 5.2 (Inter Quartile Range: 2.9-6.6) years. Median baseline PSA was 7.3 (5.3-9.8) ng/mL. 234 (56.9%) patients had T1 and 177 (43.1%) had T2 disease. Median APP4 was 2.00 (0.75-7.50)%. 38 (9.3%) patients experienced BF. The optimal cutpoint of APP4 for BF was >3.3% with an area under the curve (AUC) of 0.66. 17 (4.1%) received ADT-BF. The ADT-BF cutpoint was >6.6% with an AUC of 0.72. Eight (2.0%) developed MD. The MD cutpoint was >17.5% with an AUC of 0.86. Using APP4 >3.3 vs ≤ 3.3, log-transformed baseline PSA ln(PSA) (HR 2.5, 1.1-6.1; p = 0.037) and APP4 (HR 2.3, 1.1-4.7; p = 0.031) predicted for BF. Using APP4 >6.6 vs ≤ 6.6, ln(PSA) (HR 4.2, 1.4-12.4; p = 0.010) and APP4 (HR 3.7, 1.4-10.0; p = 0.009) were predictive of ADT-BF. APP4 >17.5 vs ≤ 17.5 alone was predictive of MD (HR 25.7, 4.9-135.3; p < 0.001). CONCLUSION APP4 cutpoints of >3.3%, >6.6% and >17.5% were strongly associated with increased risk of BF, ADT-BF and developing MD respectively. These findings may inform future practice when treating IR-PCa but require external validation.
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Affiliation(s)
- K Martell
- University of Toronto, Department of Radiation Oncology, Toronto, Canada; Sunnybrook Health Sciences Centre, Toronto, Canada
| | - L C Mendez
- University of Toronto, Department of Radiation Oncology, Toronto, Canada; Western University, Department of Radiation Oncology, London, Canada; London Health Sciences Centre, London, Canada
| | - H Chung
- University of Toronto, Department of Radiation Oncology, Toronto, Canada; Sunnybrook Health Sciences Centre, Toronto, Canada
| | - C L Tseng
- University of Toronto, Department of Radiation Oncology, Toronto, Canada; Sunnybrook Health Sciences Centre, Toronto, Canada
| | - L Zhang
- Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Y Alayed
- University of Toronto, Department of Radiation Oncology, Toronto, Canada; Sunnybrook Health Sciences Centre, Toronto, Canada; Division of Radiation Oncology, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - S Liu
- University of Toronto, Department of Radiation Oncology, Toronto, Canada; Sunnybrook Health Sciences Centre, Toronto, Canada
| | - D Vesprini
- University of Toronto, Department of Radiation Oncology, Toronto, Canada; Sunnybrook Health Sciences Centre, Toronto, Canada
| | - W Chu
- University of Toronto, Department of Radiation Oncology, Toronto, Canada; Sunnybrook Health Sciences Centre, Toronto, Canada
| | - M Paudel
- University of Toronto, Department of Radiation Oncology, Toronto, Canada; Sunnybrook Health Sciences Centre, Toronto, Canada
| | - P Cheung
- University of Toronto, Department of Radiation Oncology, Toronto, Canada; Sunnybrook Health Sciences Centre, Toronto, Canada
| | - E Szumacher
- University of Toronto, Department of Radiation Oncology, Toronto, Canada; Sunnybrook Health Sciences Centre, Toronto, Canada
| | - A Ravi
- University of Toronto, Department of Radiation Oncology, Toronto, Canada; Sunnybrook Health Sciences Centre, Toronto, Canada
| | - A Loblaw
- University of Toronto, Department of Radiation Oncology, Toronto, Canada; Sunnybrook Health Sciences Centre, Toronto, Canada
| | - G Morton
- University of Toronto, Department of Radiation Oncology, Toronto, Canada; Sunnybrook Health Sciences Centre, Toronto, Canada.
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10
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A prognostic nomogram for overall survival after neoadjuvant radiotherapy or chemoradiotherapy in thoracic esophageal squamous cell carcinoma: a retrospective analysis. Oncotarget 2018; 8:41102-41112. [PMID: 28456788 PMCID: PMC5522220 DOI: 10.18632/oncotarget.17062] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Accepted: 03/22/2017] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Currently, the AJCC staging system or pathological complete response (pCR) are considered not sufficiently accurate to evaluate the survival of patients with esophageal squamous cell carcinoma after neoadjuvant radiotherapy or chemoradiotherapy. This study aimed to establish a nomogram and a recursive partitioning analysis (RPA) model to estimate prognosis and to provide advice for subsequent treatments. METHODS We analyzed retrospectively 407 patients that were diagnosed with thoracic esophageal squamous cell carcinoma (TESCC) and received neoadjuvant radiotherapy or chemoradiotherapy. Hazard ratios and 95% confidence intervals of categorical clinicopathological characteristics with overall survival (OS) were calculated using the Cox proportional hazard model. The nomogram and RPA model were then established and total scores according to each variable were calculated and stratified to predict OS. RESULTS Patients were followed-up over a median 49.9 months. AJCC did not perform well in distinguishing OS among each stage except for IIB and IIIA. Patients were divided into 4 groups according to the total scores based on nomogram (low risk: ≤180; intermediate risk: 180-270; high risk: 270-340; very high risk: >340). The 5-year OS was 57.3%, 40.7%, 18.3%, 6.1% respectively (p<0.05). RPA model also divide the patients into 4 groups, though group2 and group3 were not statistically significant (p=0.574). CONCLUSION The nomogram is a good evaluation model for estimating the prognosis of patients with TESCC after neoadjuvant radiotherapy or chemoradiotherapy compared with the AJCC and RPA. The results of this study also suggested that the high-risk subgroups need further treatments.
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11
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Alayed Y, Cheung P, Pang G, Mamedov A, D'Alimonte L, Deabreu A, Commisso K, Commisso A, Zhang L, Quon HC, Musunuru HB, Helou J, Loblaw DA. Dose escalation for prostate stereotactic ablative radiotherapy (SABR): Late outcomes from two prospective clinical trials. Radiother Oncol 2018; 127:213-218. [PMID: 29588072 DOI: 10.1016/j.radonc.2018.03.005] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Revised: 03/07/2018] [Accepted: 03/10/2018] [Indexed: 11/19/2022]
Abstract
PURPOSE Optimal prostate SABR dose-fractionation is unknown. This study compares long-term outcomes from two prospective trials. METHODS Study1 patients had low-risk PCa and received 35 Gy/5. Study2 patients had low/intermediate-risk PCa and received 40 Gy/5. Biochemical failure (BF) was defined as nadir + 2. RESULTS 114 patients were included (study1, n = 84; study2, n = 30). Median follow-up was 9.6 years and 6.9 years. Median nPSA was 0.4 and 0.1 ng/ml. Nine patients had BF (8 in study1, 1 in study2); two were managed with ADT and four had local salvage. The BF rate was 2.5% and 12.8% at 5 and 10 years for study1 and 3.3% at 5 years for study 2. BF probability was 0% if PSA <0.4 at 4 years, and 20.5% at 10 years if PSA ≥0.4 (p = 0.02). Nine patients died, none of PCa. No patient has metastases or castrate-resistance. At 10 years, OS and CSS were 90.4% (p = 0.25) and 100%. CONCLUSIONS Dose-escalated prostate SABR was associated with lower nPSAs but no difference in BF, OS, CSS or MFS. PSA <0.4 at 4 years was a predictor of biochemical control. Half of patients with BF were successfully salvaged. Given that this is a favorable-risk cohort, longer follow-up will be needed to see if the lower nPSA translates into lower BF rates.
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Affiliation(s)
- Yasir Alayed
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Patrick Cheung
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Geordi Pang
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Alexandre Mamedov
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Laura D'Alimonte
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Andrea Deabreu
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Kristina Commisso
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Angela Commisso
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Liang Zhang
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | | | - Hima Bindu Musunuru
- Department of Human Oncology, University of Wisconsin, Madison, United States
| | - Joelle Helou
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - D Andrew Loblaw
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Measurement & Evaluation, University of Toronto, Toronto, ON, Canada.
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12
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Frank SJ, Pugh TJ, Blanchard P, Mahmood U, Graber WJ, Kudchadker RJ, Davis JW, Kim J, Choi H, Troncoso P, Kuban DA, Choi S, McGuire S, Hoffman KE, Chen HC, Wang X, Swanson DA. Prospective Phase 2 Trial of Permanent Seed Implantation Prostate Brachytherapy for Intermediate-Risk Localized Prostate Cancer: Efficacy, Toxicity, and Quality of Life Outcomes. Int J Radiat Oncol Biol Phys 2018; 100:374-382. [DOI: 10.1016/j.ijrobp.2017.09.050] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Revised: 09/05/2017] [Accepted: 09/29/2017] [Indexed: 01/23/2023]
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13
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Pickles T, Morris WJ, Keyes M. High-intermediate prostate cancer treated with low-dose-rate brachytherapy with or without androgen deprivation therapy. Brachytherapy 2017; 16:1101-1105. [PMID: 29032014 DOI: 10.1016/j.brachy.2017.08.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Revised: 08/06/2017] [Accepted: 08/08/2017] [Indexed: 11/19/2022]
Abstract
PURPOSE To describe outcomes of men with unfavorable (high-tier) intermediate risk prostate cancer (H-IR) treated with low-dose-rate (LDR) brachytherapy, with or without 6 months of androgen deprivation therapy (ADT). METHODS AND MATERIALS Patients with H-IR prostate cancer, treated before 2012 with LDR brachytherapy without external radiation are included. Baseline tumor characteristics are described. Outcomes between groups receiving ADT are measured by Phoenix (nadir +2 ng/mL), and threshold 0.4 ng/mL biochemical relapse definitions (bNEDs), as well as clinical end points. Standard descriptive and actuarial statistics are used. RESULTS Two hundred sixty men were eligible, 139 (53%) did not receive ADT and 121 (47%) did. Median follow-up was 5 years. Men treated with ADT had higher T stage and percent positive cores but lower pathologic grade group. bNED rates with and without ADT at 5 years are 86% and 85% (p = 0.52) with the Phoenix definition, and 83% and 78% (p = 0.13) with the threshold definition. Local recurrence or metastasis were rare in both groups (<5%, p = not significant). Death from prostate cancer only occurred in 4 patients, 2 in each group. Overall survival was 85% in those treated with ADT and 93% without at 8 years, p = 0.15. CONCLUSIONS The addition of 6 months of ADT to LDR brachytherapy for H-IR prostate cancer does not improve 5 year prostate specific antigen control, and we no longer routinely recommended it.
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Affiliation(s)
- Tom Pickles
- Radiation Program, BC Cancer Agency, and Department of Radiotherapy and Developmental Radiotherapeutics, University of British Columbia, Vancouver, Canada.
| | - W James Morris
- Radiation Program, BC Cancer Agency, and Department of Radiotherapy and Developmental Radiotherapeutics, University of British Columbia, Vancouver, Canada
| | - Mira Keyes
- Radiation Program, BC Cancer Agency, and Department of Radiotherapy and Developmental Radiotherapeutics, University of British Columbia, Vancouver, Canada
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14
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Chin J, Rumble RB, Kollmeier M, Heath E, Efstathiou J, Dorff T, Berman B, Feifer A, Jacques A, Loblaw DA. Brachytherapy for Patients With Prostate Cancer: American Society of Clinical Oncology/Cancer Care Ontario Joint Guideline Update. J Clin Oncol 2017; 35:1737-1743. [DOI: 10.1200/jco.2016.72.0466] [Citation(s) in RCA: 107] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose To jointly update the Cancer Care Ontario guideline on brachytherapy for patients with prostate cancer to account for new evidence. Methods An Update Panel conducted a targeted systematic literature review and identified more recent randomized controlled trials comparing dose-escalated external beam radiation therapy (EBRT) with brachytherapy in men with prostate cancer. Results Five randomized controlled trials provided the evidence for this update. Recommendations For patients with low-risk prostate cancer who require or choose active treatment, low–dose rate brachytherapy (LDR) alone, EBRT alone, and/or radical prostatectomy (RP) should be offered to eligible patients. For patients with intermediate-risk prostate cancer choosing EBRT with or without androgen-deprivation therapy, brachytherapy boost (LDR or high–dose rate [HDR]) should be offered to eligible patients. For low-intermediate risk prostate cancer (Gleason 7, prostate-specific antigen < 10 ng/mL or Gleason 6, prostate-specific antigen, 10 to 20 ng/mL), LDR brachytherapy alone may be offered as monotherapy. For patients with high-risk prostate cancer receiving EBRT and androgen-deprivation therapy, brachytherapy boost (LDR or HDR) should be offered to eligible patients. Iodine-125 and palladium-103 are each reasonable isotope options for patients receiving LDR brachytherapy; no recommendation can be made for or against using cesium-131 or HDR monotherapy. Patients should be encouraged to participate in clinical trials to test novel or targeted approaches to this disease. Additional information is available at www.asco.org/Brachytherapy-guideline and www.asco.org/guidelineswiki .
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Affiliation(s)
- Joseph Chin
- Joseph Chin, London Health Sciences Centre, London; Andrew Feifer, Trillium Health Partners’ Fidani Cancer Centre, University Health Network, Mississauga; Arthur Jacques, Patient Representative; D. Andrew Loblaw, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; R. Bryan Rumble, American Society of Clinical Oncology, Alexandria, VA; Marisa Kollmeier, Memorial Sloan Kettering Cancer Center, New York, NY; Elisabeth Heath, Karmanos Cancer Institute, Detroit, MI; Jason Efstathiou, Massachusetts
| | - R. Bryan Rumble
- Joseph Chin, London Health Sciences Centre, London; Andrew Feifer, Trillium Health Partners’ Fidani Cancer Centre, University Health Network, Mississauga; Arthur Jacques, Patient Representative; D. Andrew Loblaw, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; R. Bryan Rumble, American Society of Clinical Oncology, Alexandria, VA; Marisa Kollmeier, Memorial Sloan Kettering Cancer Center, New York, NY; Elisabeth Heath, Karmanos Cancer Institute, Detroit, MI; Jason Efstathiou, Massachusetts
| | - Marisa Kollmeier
- Joseph Chin, London Health Sciences Centre, London; Andrew Feifer, Trillium Health Partners’ Fidani Cancer Centre, University Health Network, Mississauga; Arthur Jacques, Patient Representative; D. Andrew Loblaw, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; R. Bryan Rumble, American Society of Clinical Oncology, Alexandria, VA; Marisa Kollmeier, Memorial Sloan Kettering Cancer Center, New York, NY; Elisabeth Heath, Karmanos Cancer Institute, Detroit, MI; Jason Efstathiou, Massachusetts
| | - Elisabeth Heath
- Joseph Chin, London Health Sciences Centre, London; Andrew Feifer, Trillium Health Partners’ Fidani Cancer Centre, University Health Network, Mississauga; Arthur Jacques, Patient Representative; D. Andrew Loblaw, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; R. Bryan Rumble, American Society of Clinical Oncology, Alexandria, VA; Marisa Kollmeier, Memorial Sloan Kettering Cancer Center, New York, NY; Elisabeth Heath, Karmanos Cancer Institute, Detroit, MI; Jason Efstathiou, Massachusetts
| | - Jason Efstathiou
- Joseph Chin, London Health Sciences Centre, London; Andrew Feifer, Trillium Health Partners’ Fidani Cancer Centre, University Health Network, Mississauga; Arthur Jacques, Patient Representative; D. Andrew Loblaw, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; R. Bryan Rumble, American Society of Clinical Oncology, Alexandria, VA; Marisa Kollmeier, Memorial Sloan Kettering Cancer Center, New York, NY; Elisabeth Heath, Karmanos Cancer Institute, Detroit, MI; Jason Efstathiou, Massachusetts
| | - Tanya Dorff
- Joseph Chin, London Health Sciences Centre, London; Andrew Feifer, Trillium Health Partners’ Fidani Cancer Centre, University Health Network, Mississauga; Arthur Jacques, Patient Representative; D. Andrew Loblaw, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; R. Bryan Rumble, American Society of Clinical Oncology, Alexandria, VA; Marisa Kollmeier, Memorial Sloan Kettering Cancer Center, New York, NY; Elisabeth Heath, Karmanos Cancer Institute, Detroit, MI; Jason Efstathiou, Massachusetts
| | - Barry Berman
- Joseph Chin, London Health Sciences Centre, London; Andrew Feifer, Trillium Health Partners’ Fidani Cancer Centre, University Health Network, Mississauga; Arthur Jacques, Patient Representative; D. Andrew Loblaw, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; R. Bryan Rumble, American Society of Clinical Oncology, Alexandria, VA; Marisa Kollmeier, Memorial Sloan Kettering Cancer Center, New York, NY; Elisabeth Heath, Karmanos Cancer Institute, Detroit, MI; Jason Efstathiou, Massachusetts
| | - Andrew Feifer
- Joseph Chin, London Health Sciences Centre, London; Andrew Feifer, Trillium Health Partners’ Fidani Cancer Centre, University Health Network, Mississauga; Arthur Jacques, Patient Representative; D. Andrew Loblaw, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; R. Bryan Rumble, American Society of Clinical Oncology, Alexandria, VA; Marisa Kollmeier, Memorial Sloan Kettering Cancer Center, New York, NY; Elisabeth Heath, Karmanos Cancer Institute, Detroit, MI; Jason Efstathiou, Massachusetts
| | - Arthur Jacques
- Joseph Chin, London Health Sciences Centre, London; Andrew Feifer, Trillium Health Partners’ Fidani Cancer Centre, University Health Network, Mississauga; Arthur Jacques, Patient Representative; D. Andrew Loblaw, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; R. Bryan Rumble, American Society of Clinical Oncology, Alexandria, VA; Marisa Kollmeier, Memorial Sloan Kettering Cancer Center, New York, NY; Elisabeth Heath, Karmanos Cancer Institute, Detroit, MI; Jason Efstathiou, Massachusetts
| | - D. Andrew Loblaw
- Joseph Chin, London Health Sciences Centre, London; Andrew Feifer, Trillium Health Partners’ Fidani Cancer Centre, University Health Network, Mississauga; Arthur Jacques, Patient Representative; D. Andrew Loblaw, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; R. Bryan Rumble, American Society of Clinical Oncology, Alexandria, VA; Marisa Kollmeier, Memorial Sloan Kettering Cancer Center, New York, NY; Elisabeth Heath, Karmanos Cancer Institute, Detroit, MI; Jason Efstathiou, Massachusetts
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15
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Raymond E, O'Callaghan ME, Campbell J, Vincent AD, Beckmann K, Roder D, Evans S, McNeil J, Millar J, Zalcberg J, Borg M, Moretti K. An appraisal of analytical tools used in predicting clinical outcomes following radiation therapy treatment of men with prostate cancer: a systematic review. Radiat Oncol 2017; 12:56. [PMID: 28327203 PMCID: PMC5359887 DOI: 10.1186/s13014-017-0786-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Accepted: 02/22/2017] [Indexed: 11/10/2022] Open
Abstract
Background Prostate cancer can be treated with several different modalities, including radiation treatment. Various prognostic tools have been developed to aid decision making by providing estimates of the probability of different outcomes. Such tools have been demonstrated to have better prognostic accuracy than clinical judgment alone. Methods A systematic review was undertaken to identify papers relating to the prediction of clinical outcomes (biochemical failure, metastasis, survival) in patients with prostate cancer who received radiation treatment, with the particular aim of identifying whether published tools are adequately developed, validated, and provide accurate predictions. PubMed and EMBASE were searched from July 2007. Title and abstract screening, full text review, and critical appraisal were conducted by two reviewers. A review protocol was published in advance of commencing literature searches. Results The search strategy resulted in 165 potential articles, of which 72 were selected for full text review and 47 ultimately included. These papers described 66 models which were newly developed and 31 which were external validations of already published predictive tools. The included studies represented a total of 60,457 patients, recruited between 1984 and 2009. Sixty five percent of models were not externally validated, 57% did not report accuracy and 31% included variables which are not readily accessible in existing datasets. Most models (72, 74%) related to external beam radiation therapy with the remainder relating to brachytherapy (alone or in combination with external beam radiation therapy). Conclusions A large number of prognostic models (97) have been described in the recent literature, representing a rapid increase since previous reviews (17 papers, 1966–2007). Most models described were not validated and a third utilised variables which are not readily accessible in existing data collections. Where validation had occurred, it was often limited to data taken from single institutes in the US. While validated and accurate models are available to predict prostate cancer specific mortality following external beam radiation therapy, there is a scarcity of such tools relating to brachytherapy. This review provides an accessible catalogue of predictive tools for current use and which should be prioritised for future validation. Electronic supplementary material The online version of this article (doi:10.1186/s13014-017-0786-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Elspeth Raymond
- South Australian Prostate Cancer Clinical Outcomes Collaborative (SA-PCCOC), Adelaide, Australia
| | - Michael E O'Callaghan
- South Australian Prostate Cancer Clinical Outcomes Collaborative (SA-PCCOC), Adelaide, Australia. .,Freemasons Foundation Centre for Men's Health, University of Adelaide, Adelaide, Australia. .,SA Health, Repatriation General Hospital, Urology Unit, Daws Road, Daw Park, 5041, SA, Australia. .,Flinders Centre for Innovation in Cancer, Bedford Park, Australia.
| | - Jared Campbell
- Joanna Briggs Institute, University of Adelaide, Adelaide, Australia
| | - Andrew D Vincent
- South Australian Prostate Cancer Clinical Outcomes Collaborative (SA-PCCOC), Adelaide, Australia.,Freemasons Foundation Centre for Men's Health, University of Adelaide, Adelaide, Australia
| | - Kerri Beckmann
- South Australian Prostate Cancer Clinical Outcomes Collaborative (SA-PCCOC), Adelaide, Australia.,Centre for Population Health Research, University of South Australia, Adelaide, Australia
| | - David Roder
- Centre for Population Health Research, University of South Australia, Adelaide, Australia
| | - Sue Evans
- Epidemiology & Preventative Medicine, Monash University, Clayton, Australia
| | - John McNeil
- Epidemiology & Preventative Medicine, Monash University, Clayton, Australia
| | - Jeremy Millar
- Radiation Oncology, Alfred Health, Melbourne, Australia
| | - John Zalcberg
- Epidemiology & Preventative Medicine, Monash University, Clayton, Australia.,School of Public Health and Preventive Medicine, Monash University, Clayton, Australia
| | - Martin Borg
- Adelaide Radiotherapy Centre, Adelaide, Australia
| | - Kim Moretti
- South Australian Prostate Cancer Clinical Outcomes Collaborative (SA-PCCOC), Adelaide, Australia.,Freemasons Foundation Centre for Men's Health, University of Adelaide, Adelaide, Australia.,Centre for Population Health Research, University of South Australia, Adelaide, Australia.,Joanna Briggs Institute, University of Adelaide, Adelaide, Australia.,Discipline of Surgery, University of Adelaide, Adelaide, Australia
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16
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Loblaw A, Pickles T, Crook J, Martin AG, Vigneault E, Souhami L, Cury F, Morris J, Catton C, Lukka H, Cheung P, Sethukavalan P, Warner A, Yang Y, Rodrigues G. Stereotactic Ablative Radiotherapy Versus Low Dose Rate Brachytherapy or External Beam Radiotherapy: Propensity Score Matched Analyses of Canadian Data. Clin Oncol (R Coll Radiol) 2017; 29:161-170. [DOI: 10.1016/j.clon.2016.10.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Revised: 08/25/2016] [Accepted: 09/22/2016] [Indexed: 02/05/2023]
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17
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Quon HC, Musunuru HB, Cheung P, Pang G, Mamedov A, D'Alimonte L, Deabreu A, Zhang L, Loblaw A. Dose-Escalated Stereotactic Body Radiation Therapy for Prostate Cancer: Quality-of-Life Comparison of Two Prospective Trials. Front Oncol 2016; 6:185. [PMID: 27622157 PMCID: PMC5002986 DOI: 10.3389/fonc.2016.00185] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Accepted: 08/04/2016] [Indexed: 11/13/2022] Open
Abstract
Introduction The optimal prostate stereotactic body radiation therapy (SBRT) dose-fractionation scheme is controversial. This study compares long-term quality of life (QOL) from two prospective trials of prostate SBRT to investigate the effect of increasing dose (NCT01578902 and NCT01146340). Material and methods Patients with localized prostate cancer received SBRT 35 or 40 Gy delivered in five fractions, once per week. QOL was measured using the Expanded Prostate Cancer Index Composite at baseline and every 6 months. Fisher’s exact test and generalized estimating equations were used to analyze proportions of patients with clinically significant change and longitudinal changes in QOL. Results One hundred fourteen patients were included, 84 treated with 35 Gy and 30 treated with 40 Gy. Median QOL follow-up was 56 months [interquartile range (IQR) 46–60] and 38 months (IQR 32–42), respectively. The proportion of patients reporting clinically significant declines in average urinary, bowel, and sexual scores were not significantly different between dose levels, and were 20.5 vs. 24.1% (p = 0.60), 26.8 vs. 41.4% (p = 0.16), and 42.9 vs. 38.5% (p = 0.82), respectively. Similarly, longitudinal analysis did not identify significant differences in QOL between treatment groups. Conclusion Dose-escalated prostate SBRT from 35 to 40 Gy in five fractions was not associated with significant decline in long-term QOL.
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Affiliation(s)
- Harvey C Quon
- University of Calgary, Calgary, AB, Canada; Tom Baker Cancer Centre, Calgary, AB, Canada
| | - Hima Bindu Musunuru
- University of Toronto, Toronto, ON, Canada; Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Patrick Cheung
- University of Toronto, Toronto, ON, Canada; Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Geordi Pang
- Odette Cancer Centre, Sunnybrook Health Sciences Centre , Toronto, ON , Canada
| | - Alexandre Mamedov
- Odette Cancer Centre, Sunnybrook Health Sciences Centre , Toronto, ON , Canada
| | - Laura D'Alimonte
- Odette Cancer Centre, Sunnybrook Health Sciences Centre , Toronto, ON , Canada
| | - Andrea Deabreu
- Odette Cancer Centre, Sunnybrook Health Sciences Centre , Toronto, ON , Canada
| | - Liying Zhang
- Odette Cancer Centre, Sunnybrook Health Sciences Centre , Toronto, ON , Canada
| | - Andrew Loblaw
- University of Toronto, Toronto, ON, Canada; Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
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Musunuru HB, Yamamoto T, Klotz L, Ghanem G, Mamedov A, Sethukavalan P, Jethava V, Jain S, Zhang L, Vesprini D, Loblaw A. Active Surveillance for Intermediate Risk Prostate Cancer: Survival Outcomes in the Sunnybrook Experience. J Urol 2016; 196:1651-1658. [PMID: 27569437 DOI: 10.1016/j.juro.2016.06.102] [Citation(s) in RCA: 105] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/23/2016] [Indexed: 12/22/2022]
Abstract
PURPOSE To assess the applicability of active surveillance in patients with intermediate risk prostate cancer, we compared the survival outcomes of patients with low risk and intermediate risk disease. MATERIALS AND METHODS Active surveillance was offered to all patients with low risk (cT1-T2b and Gleason score 6 and prostate specific antigen 10 ng/ml or less) and select intermediate risk disease (age greater than 70 years with cT2c or prostate specific antigen 15 ng/ml or less, or Gleason score 3+4 or less). Data from November 1995 to May 2013 were extracted from a prospectively collected database. The primary outcome was metastasis-free survival, and secondary outcomes were overall survival, cause specific survival and treatment-free survival. RESULTS A total of 213 intermediate risk and 732 low risk cases were identified. Median age was 72 years (IQR 67.3, 76.8) in the intermediate risk cohort and 67 years (IQR 60.6, 71.9) in the low risk group. Median followup was comparable (6.7 years for intermediate risk vs 6.5 years for low risk). Gleason 7 disease comprised 60% of the intermediate risk cohort. The 15-year metastasis-free, overall, cause specific and treatment-free survival rates were inferior in the intermediate risk group (metastasis-free survival HR 3.14, 95% CI 1.51-6.53, p=0.001, 82% for intermediate risk vs 95% for low risk). On further evaluation the estimated 15-year metastasis-free survival for cases of Gleason 6 or less with prostate specific antigen less than 10 ng/ml was 94%, Gleason 6 or less with prostate specific antigen 10 to 20 ng/ml was 94%, Gleason 3+4 with prostate specific antigen 20 ng/ml or less was 84% and Gleason 4+3 with prostate specific antigen 20 ng/ml or less was 63%. CONCLUSIONS These data support the use of active surveillance in low risk and intermediate risk cases of Gleason 6 but not Gleason 7 prostate cancer. Multiparametric magnetic resonance imaging and novel biomarkers might be vital in detecting favorable Gleason 7 disease.
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Affiliation(s)
- Hima Bindu Musunuru
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Toshihiro Yamamoto
- Department of Surgical Urology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Laurence Klotz
- Department of Surgical Urology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Gabriella Ghanem
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Alexandre Mamedov
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Peraka Sethukavalan
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Vibhuti Jethava
- Department of Surgical Urology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Suneil Jain
- Centre for Cancer Research and Cell Biology, Queen's University, Belfast, Ireland
| | - Liying Zhang
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Danny Vesprini
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Andrew Loblaw
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy, Measurement and Evaluation, University of Toronto, Toronto, Ontario, Canada.
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19
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Gnanapragasam VJ, Lophatananon A, Wright KA, Muir KR, Gavin A, Greenberg DC. Improving Clinical Risk Stratification at Diagnosis in Primary Prostate Cancer: A Prognostic Modelling Study. PLoS Med 2016; 13:e1002063. [PMID: 27483464 PMCID: PMC4970710 DOI: 10.1371/journal.pmed.1002063] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Accepted: 05/24/2016] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Over 80% of the nearly 1 million men diagnosed with prostate cancer annually worldwide present with localised or locally advanced non-metastatic disease. Risk stratification is the cornerstone for clinical decision making and treatment selection for these men. The most widely applied stratification systems use presenting prostate-specific antigen (PSA) concentration, biopsy Gleason grade, and clinical stage to classify patients as low, intermediate, or high risk. There is, however, significant heterogeneity in outcomes within these standard groupings. The International Society of Urological Pathology (ISUP) has recently adopted a prognosis-based pathological classification that has yet to be included within a risk stratification system. Here we developed and tested a new stratification system based on the number of individual risk factors and incorporating the new ISUP prognostic score. METHODS AND FINDINGS Diagnostic clinicopathological data from 10,139 men with non-metastatic prostate cancer were available for this study from the Public Health England National Cancer Registration Service Eastern Office. This cohort was divided into a training set (n = 6,026; 1,557 total deaths, with 462 from prostate cancer) and a testing set (n = 4,113; 1,053 total deaths, with 327 from prostate cancer). The median follow-up was 6.9 y, and the primary outcome measure was prostate-cancer-specific mortality (PCSM). An external validation cohort (n = 1,706) was also used. Patients were first categorised as low, intermediate, or high risk using the current three-stratum stratification system endorsed by the National Institute for Health and Care Excellence (NICE) guidelines. The variables used to define the groups (PSA concentration, Gleason grading, and clinical stage) were then used to sub-stratify within each risk category by testing the individual and then combined number of risk factors. In addition, we incorporated the new ISUP prognostic score as a discriminator. Using this approach, a new five-stratum risk stratification system was produced, and its prognostic power was compared against the current system, with PCSM as the outcome. The results were analysed using a Cox hazards model, the log-rank test, Kaplan-Meier curves, competing-risks regression, and concordance indices. In the training set, the new risk stratification system identified distinct subgroups with different risks of PCSM in pair-wise comparison (p < 0.0001). Specifically, the new classification identified a very low-risk group (Group 1), a subgroup of intermediate-risk cancers with a low PCSM risk (Group 2, hazard ratio [HR] 1.62 [95% CI 0.96-2.75]), and a subgroup of intermediate-risk cancers with an increased PCSM risk (Group 3, HR 3.35 [95% CI 2.04-5.49]) (p < 0.0001). High-risk cancers were also sub-classified by the new system into subgroups with lower and higher PCSM risk: Group 4 (HR 5.03 [95% CI 3.25-7.80]) and Group 5 (HR 17.28 [95% CI 11.2-26.67]) (p < 0.0001), respectively. These results were recapitulated in the testing set and remained robust after inclusion of competing risks. In comparison to the current risk stratification system, the new system demonstrated improved prognostic performance, with a concordance index of 0.75 (95% CI 0.72-0.77) versus 0.69 (95% CI 0.66-0.71) (p < 0.0001). In an external cohort, the new system achieved a concordance index of 0.79 (95% CI 0.75-0.84) for predicting PCSM versus 0.66 (95% CI 0.63-0.69) (p < 0.0001) for the current NICE risk stratification system. The main limitations of the study were that it was registry based and that follow-up was relatively short. CONCLUSIONS A novel and simple five-stratum risk stratification system outperforms the standard three-stratum risk stratification system in predicting the risk of PCSM at diagnosis in men with primary non-metastatic prostate cancer, even when accounting for competing risks. This model also allows delineation of new clinically relevant subgroups of men who might potentially receive more appropriate therapy for their disease. Future research will seek to validate our results in external datasets and will explore the value of including additional variables in the system in order in improve prognostic performance.
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Affiliation(s)
- Vincent J. Gnanapragasam
- Academic Urology Group, Department of Surgery, University of Cambridge, Cambridge, United Kingdom
- * E-mail:
| | - Artitaya Lophatananon
- Institute of Population Health, University of Manchester, Manchester, United Kingdom
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Karen A. Wright
- National Cancer Registration Service Eastern Office, Public Health England, Cambridge, United Kingdom
| | - Kenneth R. Muir
- Institute of Population Health, University of Manchester, Manchester, United Kingdom
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Anna Gavin
- Northern Ireland Cancer Registry, Centre for Public Health, Queen’s University Belfast, Belfast, United Kingdom
| | - David C. Greenberg
- National Cancer Registration Service Eastern Office, Public Health England, Cambridge, United Kingdom
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20
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McPartlin AJ, Glicksman R, Pintilie M, Tsuji D, Mok G, Bayley A, Chung P, Bristow RG, Gospodarowicz MK, Catton CN, Milosevic M, Warde PR. PMH 9907: Long-term outcomes of a randomized phase 3 study of short-term bicalutamide hormone therapy and dose-escalated external-beam radiation therapy for localized prostate cancer. Cancer 2016; 122:2595-603. [PMID: 27219522 DOI: 10.1002/cncr.30093] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Revised: 04/06/2016] [Accepted: 04/12/2016] [Indexed: 11/12/2022]
Abstract
BACKGROUND The role of hormone therapy (HT) with dose-escalated external-beam radiotherapy (DE-EBRT) in the treatment of intermediate-risk prostate cancer (IRPC) remains controversial. The authors report the long-term outcome of a phase 3 study of DE-EBRT with or without HT for patients with localized prostate cancer (LPC). METHODS From 1999 to 2006, 252 of an intended 338 patients with LPC were randomized to receive DE-EBRT with or without 5 months of neoadjuvant and concurrent bicalutamide 150 mg once daily. The study was closed early because of contemporary concerns surrounding bicalutamide. The primary outcome was biochemical failure (BF) incidence, and the secondary endpoints were overall survival (OS), local control (LC), and quality of life. The BF and OS rates were estimated using the cumulative incidence function and Kaplan-Meier methods and were compared using the Gray test and the log-rank test. RESULTS Eleven patients were excluded from analysis. Characteristics were well balanced in each treatment arm. Ninety-five percent of patients had IRPC. The prescribed dose increased from 75.6 grays (Gy) in 42 fractions to 78 Gy in 39 fractions over the period. At a median follow-up of 9.1 years, 98 BFs occurred, with no significant effect of HT versus no HT on the BF rate (40% vs 47%; P = .32), the OS rate (82% vs 86%; P = .37), the LC rate (52% vs 48 %; P = .32) or quality of life, in the patients who completed the questionnaires. Dose escalation to 75.6 Gy versus >75.6 Gy reduced the BF rate by 26% (P = .004). CONCLUSIONS For patients who predominantly have IRPC, the addition of HT to DE-EBRT did not significantly affect BF, OS, or LC. Bicalutamide appeared to be well tolerated. The conclusions from the study are limited by incomplete recruitment. Cancer 2016;122:2595-603. © 2016 American Cancer Society.
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Affiliation(s)
- Andrew J McPartlin
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada.,Princess Margaret Hospital, University Health Network, Toronto, Ontario, Canada
| | - Rachel Glicksman
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada.,Princess Margaret Hospital, University Health Network, Toronto, Ontario, Canada
| | - Melania Pintilie
- Division of Biostatistics, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Debbie Tsuji
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Gary Mok
- Department of Radiology, Radiation Oncology, and Nuclear Medicine, University Hospital Center of Montreal, Montreal, Quebec, Canada
| | - Andrew Bayley
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada.,Princess Margaret Hospital, University Health Network, Toronto, Ontario, Canada
| | - Peter Chung
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada.,Princess Margaret Hospital, University Health Network, Toronto, Ontario, Canada
| | - Robert G Bristow
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada.,Princess Margaret Hospital, University Health Network, Toronto, Ontario, Canada
| | - Mary K Gospodarowicz
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada.,Princess Margaret Hospital, University Health Network, Toronto, Ontario, Canada
| | - Charles N Catton
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada.,Princess Margaret Hospital, University Health Network, Toronto, Ontario, Canada
| | - Michael Milosevic
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada.,Princess Margaret Hospital, University Health Network, Toronto, Ontario, Canada
| | - Padraig R Warde
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada.,Princess Margaret Hospital, University Health Network, Toronto, Ontario, Canada
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Guy D, Ghanem G, Loblaw A, Buckley R, Persaud B, Cheung P, Chung H, Danjoux C, Morton G, Noakes J, Spevack L, Hajek D, Flax S. Diagnosis, referral, and primary treatment decisions in newly diagnosed prostate cancer patients in a multidisciplinary diagnostic assessment program. Can Urol Assoc J 2016; 10:120-5. [PMID: 27217859 DOI: 10.5489/cuaj.3510] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
INTRODUCTION We aimed to report on data from the multidisciplinary diagnostic assessment program (DAP) at the Gale and Graham Wright Prostate Centre (GGWPC) at North York General Hospital (NYGH). We assessed referral, diagnosis, and treatment decisions for newly diagnosed prostate cancer (PCa) patients as seen over time, risk stratification, and clinic type to establish a deeper understanding of current decision-making trends. METHODS From June 2007 to April 2012, 1277 patients who were diagnosed with PCa at the GGWPC were included in this study. Data was collected and reviewed retrospectively using electronic patient records. RESULTS 1031 of 1260 patients (81.8%) were seen in a multidisciplinary clinic (MDC). Over time, a decrease in low-risk (LR) diagnoses and an increase intermediate-risk (IR) diagnoses was observed (p<0.0001). With respect to overall treatment decisions 474 (37.1%) of patients received primary radiotherapy, 340 (26.6%) received surgical therapy, and 426 (33.4%) had conservative management; 57% of patients who were candidates for active surveillance were managed this way. No significant treatment trends were observed over time (p=0.8440). Significantly, different management decisions were made in those who attended the MDC compared to those who only saw a urologist (p<0.0001). CONCLUSIONS In our DAP, the vast majority of patients presented with screen-detected disease, but there was a gradual shift from low- to intermediate-risk disease over time. Timely multidisciplinary consultation was achievable in over 80% of patients and was associated with different management decisions. We recommend that all patients at risk for prostate cancer be worked up in a multi-disciplinary DAP.
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Affiliation(s)
- David Guy
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Gabriella Ghanem
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Andrew Loblaw
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada;; Department of Health Policy, Measurement and Evaluation, University of Toronto, Toronto, ON, Canada;; Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Roger Buckley
- Division of Urology, North York General Hospital, Toronto, ON, Canada
| | - Beverly Persaud
- Division of Urology, North York General Hospital, Toronto, ON, Canada
| | - Patrick Cheung
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada;; Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Hans Chung
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada;; Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Cyril Danjoux
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada;; Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Gerard Morton
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada;; Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Jeff Noakes
- Division of Urology, North York General Hospital, Toronto, ON, Canada
| | - Les Spevack
- Division of Urology, North York General Hospital, Toronto, ON, Canada
| | - David Hajek
- Division of Urology, North York General Hospital, Toronto, ON, Canada
| | - Stanley Flax
- Division of Urology, North York General Hospital, Toronto, ON, Canada
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22
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Prostate cancer radiation therapy: A physician’s perspective. Phys Med 2016; 32:438-45. [DOI: 10.1016/j.ejmp.2016.02.012] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2015] [Revised: 01/27/2016] [Accepted: 02/17/2016] [Indexed: 02/07/2023] Open
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23
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Musunuru HB, Quon H, Davidson M, Cheung P, Zhang L, D'Alimonte L, Deabreu A, Mamedov A, Loblaw A. Dose-escalation of five-fraction SABR in prostate cancer: Toxicity comparison of two prospective trials. Radiother Oncol 2016; 118:112-7. [PMID: 26796591 DOI: 10.1016/j.radonc.2015.12.020] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Revised: 12/23/2015] [Accepted: 12/27/2015] [Indexed: 01/22/2023]
Abstract
PURPOSE To compare biochemical outcome and toxicities of two prospective 5-fraction stereotactic ablative radiotherapy (SABR) studies in prostate cancer. MATERIALS AND METHODS 84 patients in pHART3 received 35 Gy, 30 patients in pHART6 received 40 Gy in 5-fractions to the prostate alone, once weekly. 4mm and 5mm PTV margins were used, respectively. Biochemical outcome, acute, late and cumulative genitourinary (GU)/gastrointestinal (GI) toxicities were compared. RESULTS Median follow-up was 74 and 36 months, respectively. Median prostate specific antigen nadir was 0.4 ng/ml and 0.3 ng/ml. 2-, 4- and 6-year biochemical relapse-free survival (bRFS-2+nadir) was 100%, 98.7% and 95.9% in pHART3; 100%, 100% and not reached in pHART6 (p=0.91). There was one acute grade 3 GU (retention) and late grade 4 GI (fistula) toxicity in pHART3, none in pHART6. One patient in each study had persisting grade 2+ toxicity at the last follow-up. pHART6 patients had a greater grade 2+ cumulative GU (5% versus 24.2%) and GI (7.6% versus 26.2%) toxicities. CONCLUSIONS Patients receiving dose-escalated SABR had slightly lower PSA nadir and similar bRFS, longer follow-up is needed to better estimate biochemical outcomes. There was a greater risk of grade 2 toxicity in pHART6 but not grade 3+ toxicities. Persisting toxicity at the last follow-up is similar.
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Affiliation(s)
- H Bindu Musunuru
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Canada; Department of Radiation Oncology, University of Toronto, Canada
| | - Harvey Quon
- Department of Radiation Oncology, CancerCare Manitoba, Canada
| | - Melanie Davidson
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Canada; Department of Medical Physics, Odette Cancer Centre, Canada
| | - Patrick Cheung
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Canada; Department of Radiation Oncology, University of Toronto, Canada
| | | | - Laura D'Alimonte
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Canada; Department of Radiation Oncology, University of Toronto, Canada
| | - Andrea Deabreu
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Canada
| | - Alexandre Mamedov
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Canada
| | - Andrew Loblaw
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Canada; Department of Radiation Oncology, University of Toronto, Canada; Institute of Health Policy, Measurement and Evaluation, University of Toronto, Canada.
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Yamaguchi S, Ohguri T, Fujii M, Yahara K, Hayashida Y, Fujimoto N, Korogi Y. Definitive 3D-CRT for clinically localized prostate cancer: modifications of the clinical target volume following a prostate MRI and the clinical benefits. SPRINGERPLUS 2015; 4:347. [PMID: 26191474 PMCID: PMC4502053 DOI: 10.1186/s40064-015-1138-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Accepted: 07/06/2015] [Indexed: 12/29/2022]
Abstract
Purpose To evaluate the modifications of the tumor stage and clinical target volume following a prostate magnetic resonance imaging (MRI) to evaluate the tumor (T) staging, and the clinical benefits for prostate cancer. Methods A total of 410 patients with newly diagnosed and clinically localized prostate cancer were retrospectively analyzed. The patients were treated with definitive three-dimensional conformal radiotherapy (3D-CRT). In all of the patients, digital rectal examination, transrectal ultrasound, prostate biopsy and computed tomography were performed to evaluate the clinical stage. Of the 410 patients, 189 patients had undergone a prostate MRI study to evaluate the T staging, and 221 patients had not. Results Modification of the T stage after the prostate MRI was seen in 39 (25%) of the 157 evaluable patients, and a modification of the risk group was made in 14 (9%) patients. Eventually, a modification of the CTV in 3D-CRT planning was made in 13 (8%) patients, and 10 of these had extracapsular disease. Most of the other modifications of the T staging were associated with intracapsular lesions of prostate cancer which did not change the CTV. There were no significant differences in the biological relapse-free survival between the patients with and without a prostate MRI study. Conclusions Modification of the CTV were recognized in only 8% of the patients, most of whom had extracapsular disease, although that of the T stage was seen in approximately one-quarter of the patients. Prostate MRI should only be selected for patients with a high probability of extracapsular involvement.
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Affiliation(s)
| | - Takayuki Ohguri
- Department of Radiology, University of Occupational and Environmental Health, 1-1 Iseigaoka, Yahatanishi-ku, Kitakyushu, 807-8555 Japan
| | - Masami Fujii
- Department of Radiology, University of Occupational and Environmental Health, 1-1 Iseigaoka, Yahatanishi-ku, Kitakyushu, 807-8555 Japan
| | - Katsuya Yahara
- Department of Radiology, University of Occupational and Environmental Health, 1-1 Iseigaoka, Yahatanishi-ku, Kitakyushu, 807-8555 Japan
| | - Yoshiko Hayashida
- Department of Radiology, University of Occupational and Environmental Health, 1-1 Iseigaoka, Yahatanishi-ku, Kitakyushu, 807-8555 Japan
| | - Naohiro Fujimoto
- Department of Urology, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Yukunori Korogi
- Department of Radiology, University of Occupational and Environmental Health, 1-1 Iseigaoka, Yahatanishi-ku, Kitakyushu, 807-8555 Japan
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Warner A, Pickles T, Crook J, Martin AG, Souhami L, Catton C, Lukka H, Rodrigues G. Development of ProCaRS Clinical Nomograms for Biochemical Failure-free Survival Following Either Low-Dose Rate Brachytherapy or Conventionally Fractionated External Beam Radiation Therapy for Localized Prostate Cancer. Cureus 2015; 7:e276. [PMID: 26180700 PMCID: PMC4494461 DOI: 10.7759/cureus.276] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2015] [Accepted: 06/11/2015] [Indexed: 11/27/2022] Open
Abstract
Purpose: Although several clinical nomograms predictive of biochemical failure-free survival (BFFS) for localized prostate cancer exist in the medical literature, making valid comparisons can be challenging due to variable definitions of biochemical failure, the disparate distribution of prognostic factors, and received treatments in patient populations. The aim of this investigation was to develop and validate clinically-based nomograms for 5-year BFFS using the ASTRO II “Phoenix” definition for two patient cohorts receiving low-dose rate (LDR) brachytherapy or conventionally fractionated external beam radiation therapy (EBRT) from a large Canadian multi-institutional database. Methods and Materials: Patients were selected from the GUROC (Genitourinary Radiation Oncologists of Canada) Prostate Cancer Risk Stratification (ProCaRS) database if they received (1) LDR brachytherapy ≥ 144 Gy (n=4208) or (2) EBRT ≥ 70 Gy (n=822). Multivariable Cox regression analysis for BFFS was performed separately for each cohort and used to generate clinical nomograms predictive of 5-year BFFS. Nomograms were validated using calibration plots of nomogram predicted probability versus observed probability via Kaplan-Meier estimates. Results: Patients receiving LDR brachytherapy had a mean age of 64 ± 7 years, a mean baseline PSA of 6.3 ± 3.0 ng/mL, 75% had a Gleason 6, and 15% had a Gleason 7, whereas patients receiving EBRT had a mean age of 70 ± 6 years, a mean baseline PSA of 11.6 ± 10.7 ng/mL, 30% had a Gleason 6, 55% had a Gleason 7, and 14% had a Gleason 8-10. Nomograms for 5-year BFFS included age, use and duration of androgen deprivation therapy (ADT), baseline PSA, T stage, and Gleason score for LDR brachytherapy and an ADT (months), baseline PSA, Gleason score, and biological effective dose (Gy) for EBRT. Conclusions: Clinical nomograms examining 5-year BFFS were developed for patients receiving either LDR brachytherapy or conventionally fractionated EBRT and may assist clinicians in predicting an outcome. Future work should be directed at examining the role of additional prognostic factors, comorbidities, and toxicity in predicting survival outcomes.
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Affiliation(s)
- Andrew Warner
- Radiation Oncology, London Health Sciences Centre, London, Ontario, CA
| | - Tom Pickles
- Radiation Oncology, BC Cancer Agency, Vancouver Centre, University of British Columbia
| | | | - Andre-Guy Martin
- Radiation Oncology, Centre Hospitalier Universitaire de Québec - L'Hôtel-Dieu de Québec, Québec, QC
| | - Luis Souhami
- Department of Oncology, Division of Radiation Oncology, McGill University Health Center
| | - Charles Catton
- Radiation Oncology, University of Toronto and Universitry Health Network
| | - Himu Lukka
- Radiation Oncology, Juravinski Cancer Centre, Hamilton, ON
| | - George Rodrigues
- Department of Oncology, London Health Sciences Centre; Schulich School of Medicine & Dentistry, Western University, London, Ontario, CA
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Brachytherapy improves biochemical failure-free survival in low- and intermediate-risk prostate cancer compared with conventionally fractionated external beam radiation therapy: a propensity score matched analysis. Int J Radiat Oncol Biol Phys 2015; 91:505-16. [PMID: 25596107 DOI: 10.1016/j.ijrobp.2014.11.018] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2014] [Revised: 11/06/2014] [Accepted: 11/11/2014] [Indexed: 11/24/2022]
Abstract
PURPOSE To compare, in a retrospective study, biochemical failure-free survival (bFFS) and overall survival (OS) in low-risk and intermediate-risk prostate cancer patients who received brachytherapy (BT) (either low-dose-rate brachytherapy [LDR-BT] or high-dose-rate brachytherapy with external beam radiation therapy [HDR-BT+EBRT]) versus external beam radiation therapy (EBRT) alone. METHODS AND MATERIALS Patient data were obtained from the ProCaRS database, which contains 7974 prostate cancer patients treated with primary radiation therapy at four Canadian cancer institutions from 1994 to 2010. Propensity score matching was used to obtain the following 3 matched cohorts with balanced baseline prognostic factors: (1) low-risk LDR-BT versus EBRT; (2) intermediate-risk LDR-BT versus EBRT; and (3) intermediate-risk HDR-BT+EBRT versus EBRT. Kaplan-Meier survival analysis was performed to compare differences in bFFS (primary endpoint) and OS in the 3 matched groups. RESULTS Propensity score matching created acceptable balance in the baseline prognostic factors in all matches. Final matches included 2 1:1 matches in the intermediate-risk cohorts, LDR-BT versus EBRT (total n=254) and HDR-BT+EBRT versus EBRT (total n=388), and one 4:1 match in the low-risk cohort (LDR-BT:EBRT, total n=400). Median follow-up ranged from 2.7 to 7.3 years for the 3 matched cohorts. Kaplan-Meier survival analysis showed that all BT treatment options were associated with statistically significant improvements in bFFS when compared with EBRT in all cohorts (intermediate-risk EBRT vs LDR-BT hazard ratio [HR] 4.58, P=.001; intermediate-risk EBRT vs HDR-BT+EBRT HR 2.08, P=.007; low-risk EBRT vs LDR-BT HR 2.90, P=.004). No significant difference in OS was found in all comparisons (intermediate-risk EBRT vs LDR-BT HR 1.27, P=.687; intermediate-risk EBRT vs HDR-BT+EBRT HR 1.55, P=.470; low-risk LDR-BT vs EBRT HR 1.41, P=.500). CONCLUSIONS Propensity score matched analysis showed that BT options led to statistically significant improvements in bFFS in low- and intermediate-risk prostate cancer patient populations.
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Pisansky TM, Hunt D, Gomella LG, Amin MB, Balogh AG, Chinn DM, Seider MJ, Duclos M, Rosenthal SA, Bauman GS, Gore EM, Rotman MZ, Lukka HR, Shipley WU, Dignam JJ, Sandler HM. Duration of androgen suppression before radiotherapy for localized prostate cancer: radiation therapy oncology group randomized clinical trial 9910. J Clin Oncol 2014; 33:332-9. [PMID: 25534388 DOI: 10.1200/jco.2014.58.0662] [Citation(s) in RCA: 90] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To determine whether prolonged androgen suppression (AS) duration before radiotherapy improves survival and disease control in prostate cancer. PATIENTS AND METHODS One thousand five hundred seventy-nine men with intermediate-risk prostate cancer were randomly assigned to 8 weeks of AS followed by radiotherapy with an additional 8 weeks of concurrent AS (16 weeks total) or to 28 weeks of AS followed by radiotherapy with an additional 8 weeks of AS (36 weeks total). The trial sought primarily to detect a 33% reduction in the hazard of prostate cancer death in the 28-week assignment. Time-to-event end points are reported for up to 10 years of follow-up. RESULTS There were no between-group differences in baseline characteristics of 1,489 eligible patients with follow-up. For the 8- and 28-week assignments, 10-year disease-specific survival rates were 95% (95% CI, 93.3% to 97.0%) and 96% (95% CI, 94.6% to 98.0%; hazard ratio [HR], 0.81; P = .45), respectively, and 10-year overall survival rates were 66% (95% CI, 62.0% to 69.9%) and 67% (95% CI, 63.0% to 70.8%; HR, 0.95; P = .62), respectively. For the 8- and 28-week assignments, 10-year cumulative incidences of locoregional progression were 6% (95% CI, 4.3% to 8.0%) and 4% (95% CI, 2.5% to 5.7%; HR, 0.65; P = .07), respectively; 10-year distant metastasis cumulative incidences were 6% (95% CI, 4.0% to 7.7%) and 6% (95% CI, 4.0% to 7.6%; HR, 1.07; P = .80), respectively; and 10-year prostate-specific antigen-based recurrence cumulative incidences were 27% (95% CI, 23.1% to 29.8%) and 27% (95% CI, 23.4% to 30.3%; HR, 0.97; P = .77), respectively. CONCLUSION Extending AS duration from 8 weeks to 28 weeks before radiotherapy did not improve outcomes. A lower than expected prostate cancer death rate reduced ability to detect a between-group difference in disease-specific survival. The schedule of 8 weeks of AS before radiotherapy plus 8 weeks of AS during radiotherapy remains a standard of care in intermediate-risk prostate cancer.
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Affiliation(s)
- Thomas M Pisansky
- Thomas M. Pisansky, Mayo Clinic, Rochester, MN; Daniel Hunt and James J. Dignam, Radiation Therapy Oncology Group Statistical Center; Leonard G. Gomella, Thomas Jefferson University, Philadelphia, PA; Mahul B. Amin and Howard M. Sandler, Cedars-Sinai Medical Center, Los Angeles; Daniel M. Chinn, John Muir Medical Center-Concord Campus, Concord; Seth A. Rosenthal, Sutter Medical Group, Sacramento, CA; Michael J. Seider, Akron City Hospital, Akron, OH; Elizabeth M. Gore, Zablocki Veterans Administration Medical Center-Wood, Milwaukee, WI; Marvin Z. Rotman, Brooklyn Minority-Based Community Clinical Oncology Program, State University of New York Downstate, Brooklyn, NY; William U. Shipley, Massachusetts General Hospital, Boston, MA; James J. Dignam, University of Chicago, Chicago, IL; Alexander G. Balogh, Tom Baker Cancer Centre, Calgary, Alberta; Marie Duclos, McGill University, Montreal, Quebec; Glenn S. Bauman, London Regional Cancer Program, London; and Himanshu R. Lukka, McMaster University, Hamilton, Ontario, Canada.
| | - Daniel Hunt
- Thomas M. Pisansky, Mayo Clinic, Rochester, MN; Daniel Hunt and James J. Dignam, Radiation Therapy Oncology Group Statistical Center; Leonard G. Gomella, Thomas Jefferson University, Philadelphia, PA; Mahul B. Amin and Howard M. Sandler, Cedars-Sinai Medical Center, Los Angeles; Daniel M. Chinn, John Muir Medical Center-Concord Campus, Concord; Seth A. Rosenthal, Sutter Medical Group, Sacramento, CA; Michael J. Seider, Akron City Hospital, Akron, OH; Elizabeth M. Gore, Zablocki Veterans Administration Medical Center-Wood, Milwaukee, WI; Marvin Z. Rotman, Brooklyn Minority-Based Community Clinical Oncology Program, State University of New York Downstate, Brooklyn, NY; William U. Shipley, Massachusetts General Hospital, Boston, MA; James J. Dignam, University of Chicago, Chicago, IL; Alexander G. Balogh, Tom Baker Cancer Centre, Calgary, Alberta; Marie Duclos, McGill University, Montreal, Quebec; Glenn S. Bauman, London Regional Cancer Program, London; and Himanshu R. Lukka, McMaster University, Hamilton, Ontario, Canada
| | - Leonard G Gomella
- Thomas M. Pisansky, Mayo Clinic, Rochester, MN; Daniel Hunt and James J. Dignam, Radiation Therapy Oncology Group Statistical Center; Leonard G. Gomella, Thomas Jefferson University, Philadelphia, PA; Mahul B. Amin and Howard M. Sandler, Cedars-Sinai Medical Center, Los Angeles; Daniel M. Chinn, John Muir Medical Center-Concord Campus, Concord; Seth A. Rosenthal, Sutter Medical Group, Sacramento, CA; Michael J. Seider, Akron City Hospital, Akron, OH; Elizabeth M. Gore, Zablocki Veterans Administration Medical Center-Wood, Milwaukee, WI; Marvin Z. Rotman, Brooklyn Minority-Based Community Clinical Oncology Program, State University of New York Downstate, Brooklyn, NY; William U. Shipley, Massachusetts General Hospital, Boston, MA; James J. Dignam, University of Chicago, Chicago, IL; Alexander G. Balogh, Tom Baker Cancer Centre, Calgary, Alberta; Marie Duclos, McGill University, Montreal, Quebec; Glenn S. Bauman, London Regional Cancer Program, London; and Himanshu R. Lukka, McMaster University, Hamilton, Ontario, Canada
| | - Mahul B Amin
- Thomas M. Pisansky, Mayo Clinic, Rochester, MN; Daniel Hunt and James J. Dignam, Radiation Therapy Oncology Group Statistical Center; Leonard G. Gomella, Thomas Jefferson University, Philadelphia, PA; Mahul B. Amin and Howard M. Sandler, Cedars-Sinai Medical Center, Los Angeles; Daniel M. Chinn, John Muir Medical Center-Concord Campus, Concord; Seth A. Rosenthal, Sutter Medical Group, Sacramento, CA; Michael J. Seider, Akron City Hospital, Akron, OH; Elizabeth M. Gore, Zablocki Veterans Administration Medical Center-Wood, Milwaukee, WI; Marvin Z. Rotman, Brooklyn Minority-Based Community Clinical Oncology Program, State University of New York Downstate, Brooklyn, NY; William U. Shipley, Massachusetts General Hospital, Boston, MA; James J. Dignam, University of Chicago, Chicago, IL; Alexander G. Balogh, Tom Baker Cancer Centre, Calgary, Alberta; Marie Duclos, McGill University, Montreal, Quebec; Glenn S. Bauman, London Regional Cancer Program, London; and Himanshu R. Lukka, McMaster University, Hamilton, Ontario, Canada
| | - Alexander G Balogh
- Thomas M. Pisansky, Mayo Clinic, Rochester, MN; Daniel Hunt and James J. Dignam, Radiation Therapy Oncology Group Statistical Center; Leonard G. Gomella, Thomas Jefferson University, Philadelphia, PA; Mahul B. Amin and Howard M. Sandler, Cedars-Sinai Medical Center, Los Angeles; Daniel M. Chinn, John Muir Medical Center-Concord Campus, Concord; Seth A. Rosenthal, Sutter Medical Group, Sacramento, CA; Michael J. Seider, Akron City Hospital, Akron, OH; Elizabeth M. Gore, Zablocki Veterans Administration Medical Center-Wood, Milwaukee, WI; Marvin Z. Rotman, Brooklyn Minority-Based Community Clinical Oncology Program, State University of New York Downstate, Brooklyn, NY; William U. Shipley, Massachusetts General Hospital, Boston, MA; James J. Dignam, University of Chicago, Chicago, IL; Alexander G. Balogh, Tom Baker Cancer Centre, Calgary, Alberta; Marie Duclos, McGill University, Montreal, Quebec; Glenn S. Bauman, London Regional Cancer Program, London; and Himanshu R. Lukka, McMaster University, Hamilton, Ontario, Canada
| | - Daniel M Chinn
- Thomas M. Pisansky, Mayo Clinic, Rochester, MN; Daniel Hunt and James J. Dignam, Radiation Therapy Oncology Group Statistical Center; Leonard G. Gomella, Thomas Jefferson University, Philadelphia, PA; Mahul B. Amin and Howard M. Sandler, Cedars-Sinai Medical Center, Los Angeles; Daniel M. Chinn, John Muir Medical Center-Concord Campus, Concord; Seth A. Rosenthal, Sutter Medical Group, Sacramento, CA; Michael J. Seider, Akron City Hospital, Akron, OH; Elizabeth M. Gore, Zablocki Veterans Administration Medical Center-Wood, Milwaukee, WI; Marvin Z. Rotman, Brooklyn Minority-Based Community Clinical Oncology Program, State University of New York Downstate, Brooklyn, NY; William U. Shipley, Massachusetts General Hospital, Boston, MA; James J. Dignam, University of Chicago, Chicago, IL; Alexander G. Balogh, Tom Baker Cancer Centre, Calgary, Alberta; Marie Duclos, McGill University, Montreal, Quebec; Glenn S. Bauman, London Regional Cancer Program, London; and Himanshu R. Lukka, McMaster University, Hamilton, Ontario, Canada
| | - Michael J Seider
- Thomas M. Pisansky, Mayo Clinic, Rochester, MN; Daniel Hunt and James J. Dignam, Radiation Therapy Oncology Group Statistical Center; Leonard G. Gomella, Thomas Jefferson University, Philadelphia, PA; Mahul B. Amin and Howard M. Sandler, Cedars-Sinai Medical Center, Los Angeles; Daniel M. Chinn, John Muir Medical Center-Concord Campus, Concord; Seth A. Rosenthal, Sutter Medical Group, Sacramento, CA; Michael J. Seider, Akron City Hospital, Akron, OH; Elizabeth M. Gore, Zablocki Veterans Administration Medical Center-Wood, Milwaukee, WI; Marvin Z. Rotman, Brooklyn Minority-Based Community Clinical Oncology Program, State University of New York Downstate, Brooklyn, NY; William U. Shipley, Massachusetts General Hospital, Boston, MA; James J. Dignam, University of Chicago, Chicago, IL; Alexander G. Balogh, Tom Baker Cancer Centre, Calgary, Alberta; Marie Duclos, McGill University, Montreal, Quebec; Glenn S. Bauman, London Regional Cancer Program, London; and Himanshu R. Lukka, McMaster University, Hamilton, Ontario, Canada
| | - Marie Duclos
- Thomas M. Pisansky, Mayo Clinic, Rochester, MN; Daniel Hunt and James J. Dignam, Radiation Therapy Oncology Group Statistical Center; Leonard G. Gomella, Thomas Jefferson University, Philadelphia, PA; Mahul B. Amin and Howard M. Sandler, Cedars-Sinai Medical Center, Los Angeles; Daniel M. Chinn, John Muir Medical Center-Concord Campus, Concord; Seth A. Rosenthal, Sutter Medical Group, Sacramento, CA; Michael J. Seider, Akron City Hospital, Akron, OH; Elizabeth M. Gore, Zablocki Veterans Administration Medical Center-Wood, Milwaukee, WI; Marvin Z. Rotman, Brooklyn Minority-Based Community Clinical Oncology Program, State University of New York Downstate, Brooklyn, NY; William U. Shipley, Massachusetts General Hospital, Boston, MA; James J. Dignam, University of Chicago, Chicago, IL; Alexander G. Balogh, Tom Baker Cancer Centre, Calgary, Alberta; Marie Duclos, McGill University, Montreal, Quebec; Glenn S. Bauman, London Regional Cancer Program, London; and Himanshu R. Lukka, McMaster University, Hamilton, Ontario, Canada
| | - Seth A Rosenthal
- Thomas M. Pisansky, Mayo Clinic, Rochester, MN; Daniel Hunt and James J. Dignam, Radiation Therapy Oncology Group Statistical Center; Leonard G. Gomella, Thomas Jefferson University, Philadelphia, PA; Mahul B. Amin and Howard M. Sandler, Cedars-Sinai Medical Center, Los Angeles; Daniel M. Chinn, John Muir Medical Center-Concord Campus, Concord; Seth A. Rosenthal, Sutter Medical Group, Sacramento, CA; Michael J. Seider, Akron City Hospital, Akron, OH; Elizabeth M. Gore, Zablocki Veterans Administration Medical Center-Wood, Milwaukee, WI; Marvin Z. Rotman, Brooklyn Minority-Based Community Clinical Oncology Program, State University of New York Downstate, Brooklyn, NY; William U. Shipley, Massachusetts General Hospital, Boston, MA; James J. Dignam, University of Chicago, Chicago, IL; Alexander G. Balogh, Tom Baker Cancer Centre, Calgary, Alberta; Marie Duclos, McGill University, Montreal, Quebec; Glenn S. Bauman, London Regional Cancer Program, London; and Himanshu R. Lukka, McMaster University, Hamilton, Ontario, Canada
| | - Glenn S Bauman
- Thomas M. Pisansky, Mayo Clinic, Rochester, MN; Daniel Hunt and James J. Dignam, Radiation Therapy Oncology Group Statistical Center; Leonard G. Gomella, Thomas Jefferson University, Philadelphia, PA; Mahul B. Amin and Howard M. Sandler, Cedars-Sinai Medical Center, Los Angeles; Daniel M. Chinn, John Muir Medical Center-Concord Campus, Concord; Seth A. Rosenthal, Sutter Medical Group, Sacramento, CA; Michael J. Seider, Akron City Hospital, Akron, OH; Elizabeth M. Gore, Zablocki Veterans Administration Medical Center-Wood, Milwaukee, WI; Marvin Z. Rotman, Brooklyn Minority-Based Community Clinical Oncology Program, State University of New York Downstate, Brooklyn, NY; William U. Shipley, Massachusetts General Hospital, Boston, MA; James J. Dignam, University of Chicago, Chicago, IL; Alexander G. Balogh, Tom Baker Cancer Centre, Calgary, Alberta; Marie Duclos, McGill University, Montreal, Quebec; Glenn S. Bauman, London Regional Cancer Program, London; and Himanshu R. Lukka, McMaster University, Hamilton, Ontario, Canada
| | - Elizabeth M Gore
- Thomas M. Pisansky, Mayo Clinic, Rochester, MN; Daniel Hunt and James J. Dignam, Radiation Therapy Oncology Group Statistical Center; Leonard G. Gomella, Thomas Jefferson University, Philadelphia, PA; Mahul B. Amin and Howard M. Sandler, Cedars-Sinai Medical Center, Los Angeles; Daniel M. Chinn, John Muir Medical Center-Concord Campus, Concord; Seth A. Rosenthal, Sutter Medical Group, Sacramento, CA; Michael J. Seider, Akron City Hospital, Akron, OH; Elizabeth M. Gore, Zablocki Veterans Administration Medical Center-Wood, Milwaukee, WI; Marvin Z. Rotman, Brooklyn Minority-Based Community Clinical Oncology Program, State University of New York Downstate, Brooklyn, NY; William U. Shipley, Massachusetts General Hospital, Boston, MA; James J. Dignam, University of Chicago, Chicago, IL; Alexander G. Balogh, Tom Baker Cancer Centre, Calgary, Alberta; Marie Duclos, McGill University, Montreal, Quebec; Glenn S. Bauman, London Regional Cancer Program, London; and Himanshu R. Lukka, McMaster University, Hamilton, Ontario, Canada
| | - Marvin Z Rotman
- Thomas M. Pisansky, Mayo Clinic, Rochester, MN; Daniel Hunt and James J. Dignam, Radiation Therapy Oncology Group Statistical Center; Leonard G. Gomella, Thomas Jefferson University, Philadelphia, PA; Mahul B. Amin and Howard M. Sandler, Cedars-Sinai Medical Center, Los Angeles; Daniel M. Chinn, John Muir Medical Center-Concord Campus, Concord; Seth A. Rosenthal, Sutter Medical Group, Sacramento, CA; Michael J. Seider, Akron City Hospital, Akron, OH; Elizabeth M. Gore, Zablocki Veterans Administration Medical Center-Wood, Milwaukee, WI; Marvin Z. Rotman, Brooklyn Minority-Based Community Clinical Oncology Program, State University of New York Downstate, Brooklyn, NY; William U. Shipley, Massachusetts General Hospital, Boston, MA; James J. Dignam, University of Chicago, Chicago, IL; Alexander G. Balogh, Tom Baker Cancer Centre, Calgary, Alberta; Marie Duclos, McGill University, Montreal, Quebec; Glenn S. Bauman, London Regional Cancer Program, London; and Himanshu R. Lukka, McMaster University, Hamilton, Ontario, Canada
| | - Himanshu R Lukka
- Thomas M. Pisansky, Mayo Clinic, Rochester, MN; Daniel Hunt and James J. Dignam, Radiation Therapy Oncology Group Statistical Center; Leonard G. Gomella, Thomas Jefferson University, Philadelphia, PA; Mahul B. Amin and Howard M. Sandler, Cedars-Sinai Medical Center, Los Angeles; Daniel M. Chinn, John Muir Medical Center-Concord Campus, Concord; Seth A. Rosenthal, Sutter Medical Group, Sacramento, CA; Michael J. Seider, Akron City Hospital, Akron, OH; Elizabeth M. Gore, Zablocki Veterans Administration Medical Center-Wood, Milwaukee, WI; Marvin Z. Rotman, Brooklyn Minority-Based Community Clinical Oncology Program, State University of New York Downstate, Brooklyn, NY; William U. Shipley, Massachusetts General Hospital, Boston, MA; James J. Dignam, University of Chicago, Chicago, IL; Alexander G. Balogh, Tom Baker Cancer Centre, Calgary, Alberta; Marie Duclos, McGill University, Montreal, Quebec; Glenn S. Bauman, London Regional Cancer Program, London; and Himanshu R. Lukka, McMaster University, Hamilton, Ontario, Canada
| | - William U Shipley
- Thomas M. Pisansky, Mayo Clinic, Rochester, MN; Daniel Hunt and James J. Dignam, Radiation Therapy Oncology Group Statistical Center; Leonard G. Gomella, Thomas Jefferson University, Philadelphia, PA; Mahul B. Amin and Howard M. Sandler, Cedars-Sinai Medical Center, Los Angeles; Daniel M. Chinn, John Muir Medical Center-Concord Campus, Concord; Seth A. Rosenthal, Sutter Medical Group, Sacramento, CA; Michael J. Seider, Akron City Hospital, Akron, OH; Elizabeth M. Gore, Zablocki Veterans Administration Medical Center-Wood, Milwaukee, WI; Marvin Z. Rotman, Brooklyn Minority-Based Community Clinical Oncology Program, State University of New York Downstate, Brooklyn, NY; William U. Shipley, Massachusetts General Hospital, Boston, MA; James J. Dignam, University of Chicago, Chicago, IL; Alexander G. Balogh, Tom Baker Cancer Centre, Calgary, Alberta; Marie Duclos, McGill University, Montreal, Quebec; Glenn S. Bauman, London Regional Cancer Program, London; and Himanshu R. Lukka, McMaster University, Hamilton, Ontario, Canada
| | - James J Dignam
- Thomas M. Pisansky, Mayo Clinic, Rochester, MN; Daniel Hunt and James J. Dignam, Radiation Therapy Oncology Group Statistical Center; Leonard G. Gomella, Thomas Jefferson University, Philadelphia, PA; Mahul B. Amin and Howard M. Sandler, Cedars-Sinai Medical Center, Los Angeles; Daniel M. Chinn, John Muir Medical Center-Concord Campus, Concord; Seth A. Rosenthal, Sutter Medical Group, Sacramento, CA; Michael J. Seider, Akron City Hospital, Akron, OH; Elizabeth M. Gore, Zablocki Veterans Administration Medical Center-Wood, Milwaukee, WI; Marvin Z. Rotman, Brooklyn Minority-Based Community Clinical Oncology Program, State University of New York Downstate, Brooklyn, NY; William U. Shipley, Massachusetts General Hospital, Boston, MA; James J. Dignam, University of Chicago, Chicago, IL; Alexander G. Balogh, Tom Baker Cancer Centre, Calgary, Alberta; Marie Duclos, McGill University, Montreal, Quebec; Glenn S. Bauman, London Regional Cancer Program, London; and Himanshu R. Lukka, McMaster University, Hamilton, Ontario, Canada
| | - Howard M Sandler
- Thomas M. Pisansky, Mayo Clinic, Rochester, MN; Daniel Hunt and James J. Dignam, Radiation Therapy Oncology Group Statistical Center; Leonard G. Gomella, Thomas Jefferson University, Philadelphia, PA; Mahul B. Amin and Howard M. Sandler, Cedars-Sinai Medical Center, Los Angeles; Daniel M. Chinn, John Muir Medical Center-Concord Campus, Concord; Seth A. Rosenthal, Sutter Medical Group, Sacramento, CA; Michael J. Seider, Akron City Hospital, Akron, OH; Elizabeth M. Gore, Zablocki Veterans Administration Medical Center-Wood, Milwaukee, WI; Marvin Z. Rotman, Brooklyn Minority-Based Community Clinical Oncology Program, State University of New York Downstate, Brooklyn, NY; William U. Shipley, Massachusetts General Hospital, Boston, MA; James J. Dignam, University of Chicago, Chicago, IL; Alexander G. Balogh, Tom Baker Cancer Centre, Calgary, Alberta; Marie Duclos, McGill University, Montreal, Quebec; Glenn S. Bauman, London Regional Cancer Program, London; and Himanshu R. Lukka, McMaster University, Hamilton, Ontario, Canada
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