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Slevin F, Zattoni F, Checcucci E, Cumberbatch MGK, Nacchia A, Cornford P, Briers E, De Meerleer G, De Santis M, Eberli D, Gandaglia G, Gillessen S, Grivas N, Liew M, Linares Espinós EE, Oldenburg J, Oprea-Lager DE, Ploussard G, Rouvière O, Schoots IG, Smith EJ, Stranne J, Tilki D, Smith CT, Van Den Bergh RCN, Van Oort IM, Wiegel T, Yuan CY, Van den Broeck T, Henry AM. A Systematic Review of the Efficacy and Toxicity of Brachytherapy Boost Combined with External Beam Radiotherapy for Nonmetastatic Prostate Cancer. Eur Urol Oncol 2024; 7:677-696. [PMID: 38151440 DOI: 10.1016/j.euo.2023.11.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Revised: 11/14/2023] [Accepted: 11/28/2023] [Indexed: 12/29/2023]
Abstract
CONTEXT The optimum use of brachytherapy (BT) combined with external beam radiotherapy (EBRT) for localised/locally advanced prostate cancer (PCa) remains uncertain. OBJECTIVE To perform a systematic review to determine the benefits and harms of EBRT-BT. EVIDENCE ACQUISITION Ovid MEDLINE, Embase, and EBM Reviews-Cochrane Central Register of Controlled Trials databases were systematically searched for studies published between January 1, 2000 and June 7, 2022, according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. Eligible studies compared low- or high-dose-rate EBRT-BT against EBRT ± androgen deprivation therapy (ADT) and/or radical prostatectomy (RP) ± postoperative radiotherapy (RP ± EBRT). The main outcomes were biochemical progression-free survival (bPFS), severe late genitourinary (GU)/gastrointestinal toxicity, metastasis-free survival (MFS), cancer-specific survival (CSS), and overall survival (OS), at/beyond 5 yr. Risk of bias was assessed and confounding assessment was performed. A meta-analysis was performed for randomised controlled trials (RCTs). EVIDENCE SYNTHESIS Seventy-three studies were included (two RCTs, seven prospective studies, and 64 retrospective studies). Most studies included participants with intermediate-or high-risk PCa. Most studies, including both RCTs, used ADT with EBRT-BT. Generally, EBRT-BT was associated with improved bPFS compared with EBRT, but similar MFS, CSS, and OS. A meta-analysis of the two RCTs showed superior bPFS with EBRT-BT (estimated fixed-effect hazard ratio [HR] 0.54 [95% confidence interval {CI} 0.40-0.72], p < 0.001), with absolute improvements in bPFS at 5-6 yr of 4.9-16%. However, no difference was seen for MFS (HR 0.84 [95% CI 0.53-1.28], p = 0.4) or OS (HR 0.87 [95% CI 0.63-1.19], p = 0.4). Fewer studies examined RP ± EBRT. There is an increased risk of severe late GU toxicity, especially with low-dose-rate EBRT-BT, with some evidence of increased prevalence of severe GU toxicity at 5-6 yr of 6.4-7% across the two RCTs. CONCLUSIONS EBRT-BT can be considered for unfavourable intermediate/high-risk localised/locally advanced PCa in patients with good urinary function, although the strength of this recommendation based on the European Association of Urology guideline methodology is weak given that it is based on improvements in biochemical control. PATIENT SUMMARY We found good evidence that radiotherapy combined with brachytherapy keeps prostate cancer controlled for longer, but it could lead to worse urinary side effects than radiotherapy without brachytherapy, and its impact on cancer spread and patient survival is less clear.
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Affiliation(s)
- Finbar Slevin
- University of Leeds, Leeds, UK; Leeds Cancer Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK.
| | - Fabio Zattoni
- Department Surgery, Oncology and Gastroenterology, Urologic Unit, University of Padova, Padova, Italy
| | - Enrico Checcucci
- Division of Urology, Department of Oncology, School of Medicine, San Luigi Hospital, University of Turin, Turin, Italy
| | | | | | - Philip Cornford
- Department of Urology, Liverpool University Hospitals NHS Trust, Liverpool, UK
| | | | - Gert De Meerleer
- Department of Radiotherapy, University Hospitals Leuven, Leuven, Belgium
| | - Maria De Santis
- Department of Urology, Charité Universitätsmedizin, Berlin, Germany; Department of Urology, Medical University of Vienna, Vienna, Austria
| | - Daniel Eberli
- Department of Urology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | | | - Silke Gillessen
- Oncology Institute of Southern Switzerland, EOC, Bellinzona, Switzerland; Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland
| | - Nikolaos Grivas
- Department of Urology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Matthew Liew
- Department of Urology, Wrightington, Wigan and Leigh NHS Foundation Trust, Wigan, UK
| | | | - Jan Oldenburg
- Department of Oncology, Akershus University Hospital, Lørenskog, Norway; Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Daniela E Oprea-Lager
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | | | - Olivier Rouvière
- Hospices Civils de Lyon, Department of Urinary and Vascular Imaging, Hôpital Edouard Herriot, Lyon, France
| | - Ivo G Schoots
- Department of Radiology & Nuclear Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Emma Jane Smith
- European Association of Urology Guidelines Office, Arnhem, The Netherlands
| | - Johan Stranne
- Department of Urology, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden; Department of Urology, Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Sweden
| | - Derya Tilki
- Martini-Klinik Prostate Cancer Center, University Hospital Hamburg Eppendorf, Hamburg, Germany; Department of Urology, University Hospital Hamburg-Eppendorf, Hamburg, Germany; Department of Urology, Koc University Hospital, Istanbul, Turkey
| | - Catrin Tudur Smith
- Department of Health Data Science, University of Liverpool, Liverpool, UK
| | | | - Inge M Van Oort
- Radboud University Medical Center, Department of Urology, Radboud Institute for Molecular Life Sciences, Nijmegen, The Netherlands
| | | | - Cathy Y Yuan
- Department of Medicine, Health Science Centre, McMaster University, Hamilton, Ontario, Canada
| | | | - Ann M Henry
- University of Leeds, Leeds, UK; Leeds Cancer Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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A comparative study of patient-reported outcomes after contemporary radiation techniques for prostate cancer. Radiother Oncol 2022; 171:164-172. [DOI: 10.1016/j.radonc.2022.04.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 04/20/2022] [Accepted: 04/25/2022] [Indexed: 11/19/2022]
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Musunuru HB, Cheung P, Vesprini D, Liu SK, Chu W, Chung HT, Morton G, Deabreu A, Davidson M, Ravi A, Helou J, Ho L, Zhang L, Loblaw A. Stereotactic pelvic radiotherapy with HDR boost for dose escalation in intermediate and high-risk prostate cancer (SPARE): Efficacy, toxicity and quality of life. Radiother Oncol 2021; 161:40-46. [PMID: 34089752 DOI: 10.1016/j.radonc.2021.05.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 05/24/2021] [Accepted: 05/26/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND The ASCO/CCO guidelines recommend brachytherapy (BT) boost for eligible intermediate- (IR) or high-risk (HR) prostate cancer (PCa) patients. We present efficacy, toxicity and quality-of-life (QoL) outcomes in patients treated on a prospective protocol of MRI dose-painted high-dose-rate BT boost (HDR-BT) followed by 5-fraction pelvic radiotherapy (RT) and 6-18 months of androgen deprivation therapy (ADT). METHODS In this phase I/II study, IR or HR PCa patients received HDR-BT 15 Gy × 1 to prostate and up to 22.5 Gy to MRI nodule, followed by 25 Gy in 5, weekly fractions to pelvis. Toxicity was assessed using CTCAEv3.0, and QoL was captured using EPIC questionnaire. Biochemical failure (BF; nadir + 2.0), and proportion of patients with PSA < 0.4 ng/ml at 4-years (4yPSARR) were evaluated. A minimally clinically important change (MCIC) was recorded if QoL score decreased >0.5 standard deviation of baseline scores. RESULTS Thirty-one patients (NCCN 3.2% favorable IR, 48.4% unfavorable IR and 48.4% HR) completed treatment with a median follow-up of 61 months. Median D90 to MR nodule was 19.0 Gy and median prostate V100% was 96.5%. The actuarial 5-year BF rate was 18.2%, and the 4yPSARR was 71%. One patient died of PCa. Acute grade 2 and 3 toxicities: GU: 50%, 7%, and GI: 3%, none, respectively. Late grade 2 and 3 toxicities were: GU: 23%, 3%, and GI: 7%, none, respectively. Proportion of patients with MCIC was 7.7% for urinary domain and 32.0% for bowel domain. CONCLUSIONS This novel treatment protocol incorporating MRI dose-painted HDR-BT boost and 5-fraction pelvic RT with ADT is well tolerated.
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Affiliation(s)
| | - Patrick Cheung
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Canada; Department of Radiation Oncology, University of Toronto, Canada
| | - Danny Vesprini
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Canada; Department of Radiation Oncology, University of Toronto, Canada
| | - Stanley K Liu
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Canada; Department of Radiation Oncology, University of Toronto, Canada
| | - William Chu
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Canada; Department of Radiation Oncology, University of Toronto, Canada
| | - Hans T Chung
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Canada; Department of Radiation Oncology, University of Toronto, Canada
| | - Gerard Morton
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Canada; Department of Radiation Oncology, University of Toronto, Canada
| | - Andrea Deabreu
- Clinical Trials and Epidemiology Program, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Canada
| | - Melanie Davidson
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Canada; Department of Radiation Oncology, University of Toronto, Canada
| | - Ananth Ravi
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Canada; Department of Radiation Oncology, University of Toronto, Canada
| | - Joelle Helou
- Department of Radiation Oncology, University of Toronto, Canada; Princess Margaret Cancer Centre, Canada
| | - Ling Ho
- Department of Radiation Oncology, University of Toronto, Canada
| | - Liying Zhang
- Clinical Trials and Epidemiology Program, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Canada
| | - Andrew Loblaw
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Canada; Department of Radiation Oncology, University of Toronto, Canada; Institute of Health Policy, Management and Evaluation, Canada.
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Alayed Y, Loblaw A, McGuffin M, Chung HT, Tseng CL, D'Alimonte L, Cheung P, Liu S, Chu W, Szumacher E, Helou J, Ravi A, Haider M, Mamedov A, Zhang L, Morton G. Single-fraction HDR brachytherapy as monotherapy in low and intermediate risk prostate cancer: Outcomes from two clinical trials with and without an MRI-guided boost. Radiother Oncol 2021; 154:29-35. [DOI: 10.1016/j.radonc.2020.09.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 08/31/2020] [Accepted: 09/01/2020] [Indexed: 11/16/2022]
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Prostate high dose-rate brachytherapy as monotherapy for prostate cancer: Late toxicity and patient reported outcomes from a randomized phase II clinical trial. Radiother Oncol 2020; 156:160-165. [PMID: 33359269 DOI: 10.1016/j.radonc.2020.12.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Revised: 12/09/2020] [Accepted: 12/11/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND AND PURPOSE Long-term toxicity of high dose-rate brachytherapy as monotherapy for prostate cancer is not well defined. We report late toxicity and health related quality of life (HRQOL) changes from a randomized phase II clinical trial of two different fractionation schemes. MATERIALS AND METHODS Eligible patients had NCCN low or intermediate risk prostate cancer. 170 patients were randomized to receive either a single 19 Gy or two-fractions of 13.5 Gy one week apart. Toxicity was measured using Common Terminology for Adverse Events (CTCAE) v4.0, and HRQOL was measured using the Expanded Prostate Index Composite (EPIC). RESULTS Median follow-up was 63 months. The 5-year cumulative incidence of Grade 2 or higher genitourinary (GU) and gastrointestinal (GI) toxicity was 62% and 12% in the single-fraction arm, and 47% and 9% in the two-fraction arm, respectively. Grade 3 GU toxicity was only seen in the single fraction arm with a cumulative incidence of 2%. The 5-year prevalence of Grade 2 GU toxicity was 29% and 21%, in the single- and two-fraction arms, respectively, with Grade 2 GI toxicity of 1% and 2%. Beyond the first year, no significant differences in mean urinary HRQOL were seen compared to baseline in the two-fraction arm, in contrast to the single-fraction arm where a decline in urinary HRQOL was seen at 4 and 5 years. Sexual HRQOL was significantly reduced in both treatment arms at all timepoints, with no changes in the bowel domain. CONCLUSIONS HDR monotherapy is well tolerated with minimal impact on HRQOL.
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Ultrahypofractionation Should be a Standard of Care Option for Intermediate-Risk Prostate Cancer. Clin Oncol (R Coll Radiol) 2020; 32:170-174. [DOI: 10.1016/j.clon.2019.11.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Accepted: 11/12/2019] [Indexed: 11/22/2022]
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Abstract
Stereotactic ablative radiotherapy (SABR) is a relatively novel form of high precision radiotherapy. For low- and intermediate risk patients, ultrahypofractionation (UHF - more than 5 Gy per day) has been compared to conventionally fractionated or moderately hypofractionated radiotherapy in two large randomized studies. A third smaller randomized study examined the question of the optimal frequency of treatments. The results of these studies will be reviewed. SABR for high risk prostate cancer has been shown to be feasible and is well tolerated with careful planning and setup techniques. However, there is currently insufficient data supporting its use for high-risk patients to offer SABR outside of a clinical trial. SABR costs less to the radiotherapydepartments and, the patient, as well as increasing system capacity. Therefore, it has the potential to be widely adopted in the next few years.
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Alayed Y, Davidson M, Liu S, Chu W, Tseng E, Cheung P, Vesprini D, Cheung H, Morton G, Musunuru HB, Ravi A, Korol R, Deabreu A, Ho L, Commisso K, Bhounr Z, D'Alimonte L, Mittmann N, Dragomir A, Zhang L, Loblaw A. Evaluating the Tolerability of a Simultaneous Focal Boost to the Gross Tumor in Prostate SABR: A Toxicity and Quality-of-Life Comparison of Two Prospective Trials. Int J Radiat Oncol Biol Phys 2020; 107:136-142. [PMID: 31987962 DOI: 10.1016/j.ijrobp.2019.12.044] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Revised: 12/14/2019] [Accepted: 12/18/2019] [Indexed: 12/18/2022]
Abstract
PURPOSE Dose-escalated stereotactic ablative radiotherapy (SABR) to the whole prostate may be associated with better outcomes but has a risk of increased toxicity. An alternative approach is to focally boost the dominant intraprostatic lesion (DIL) seen on magnetic resonance imaging. We report the toxicity and quality-of-life (QOL) outcomes of 2 phase 2 trials of prostate and pelvic SABR, with or without a simultaneous DIL boost. METHODS AND MATERIALS The first trial treated patients with high-risk prostate cancer to a dose of 40 Gy to the prostate and 25 Gy to the pelvis in 5 fractions. The second trial treated patients with intermediate-risk and high-risk prostate cancer to a dose of 35 Gy to the prostate, 25 Gy to the pelvis, and a DIL boost up to 50 Gy in 5 fractions. Acute toxicities, late toxicities, and QOL were assessed. RESULTS Thirty patients were enrolled in each trial. In the focal boost cohort, the median DIL D90% was 48.3 Gy. There was no significant difference in acute grade ≥2 gastrointestinal or genitourinary toxicity between the 2 trials or in cumulative worst late gastrointestinal or genitourinary toxicity up to 24 months. There was no significant difference in QOL domain scores or minimally clinical important change between the 2 trials. CONCLUSIONS Prostate and pelvic SABR with a simultaneous DIL boost was feasible. Acute grade ≥2 toxicity, late toxicity, and QOL seemed to be comparable to a cohort that did not receive a focal boost. Further follow-up will be required to assess long-term outcomes, and randomized data are required to confirm these findings.
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Affiliation(s)
- Yasir Alayed
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Division of Radiation Oncology, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Melanie Davidson
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Stanley Liu
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - William Chu
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Eric Tseng
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Patrick Cheung
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, 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
| | - Hans Cheung
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Gerard Morton
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - H B Musunuru
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Anath Ravi
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Renee Korol
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Andrea Deabreu
- Clinical Trials and Epidemiology Program, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Ling Ho
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Kristina Commisso
- Clinical Trials and Epidemiology Program, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Zeeba Bhounr
- Clinical Trials and Epidemiology Program, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Laura D'Alimonte
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Nicole Mittmann
- Cancer Care Ontario, Toronto, Ontario, Canada; Department of Pharmacology and Toxicology, University of Toronto, Toronto, Ontario, Canada
| | - Alice Dragomir
- Department of Surgery, McGill University, Montreal, Quebec, Canada
| | - Liang Zhang
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, 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, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.
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Loi M, Wortel RC, Francolini G, Incrocci L. Sexual Function in Patients Treated With Stereotactic Radiotherapy For Prostate Cancer: A Systematic Review of the Current Evidence. J Sex Med 2019; 16:1409-1420. [DOI: 10.1016/j.jsxm.2019.05.019] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Revised: 05/20/2019] [Accepted: 05/28/2019] [Indexed: 12/14/2022]
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Two versus five stereotactic ablative radiotherapy treatments for localized prostate cancer: A quality of life analysis of two prospective clinical trials. Radiother Oncol 2019; 140:105-109. [PMID: 31265940 DOI: 10.1016/j.radonc.2019.06.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Revised: 06/11/2019] [Accepted: 06/12/2019] [Indexed: 11/20/2022]
Abstract
PURPOSE Stereotactic ablative radiotherapy (SABR) is appealing for prostate cancer (PCa) due to low α/β, and increasing the dose per fraction could improve the therapeutic index and lead to a better quality of life (QOL). Here we report the outcomes of a QOL comparison between two phase II clinical trials: two vs. five fraction prostate SABR. METHODS Patients had low or intermediate risk PCa. The doses prescribed were 26 Gy/2 and 40 Gy/5. Expanded prostate cancer index composite was collected. Urinary, bowel and sexual domains were analyzed. Minimal clinically important change (MCIC) was defined as >0.5 standard deviation. RESULTS 30 and 152 patients were treated with 2-fraction and 5-fraction SABR. Median follow-up was 55 and 62 months. Five-year biochemical failure rate was 3.3% and 4.6%. The 2-fraction cohort had a significantly better mean QOL over time in the bowel domain (p = 0.0004), without a significant difference in the urinary or sexual domains. The 2-fraction cohort had a significantly lower rate of bowel MCIC (17.8% vs 42.3%, p = 0.01), but there was no difference in urinary (24.1% vs 35.7%) or sexual (15.3% vs 29.2%) MCIC. For MCIC x2 (moderate QOL change), the 2-fraction trial had significantly lower MCIC rates in both the bowel (7.1% vs 24%, p = 0.04) and sexual (0 vs 17.6%, p = 0.01) domains. CONCLUSIONS 2-Fraction SABR is feasible to deliver and well tolerated, with significant signals of improved bowel and sexual QOL. A randomized trial of two vs. five fractions for prostate SABR is needed to confirm the promising findings of this study.
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Eade T, Hruby G, Booth J, Bromley R, Guo L, O'Toole A, Le A, Wu K, Whitaker M, Rasiah K, Chalasani V, Vass J, Kwong C, Atyeo J, Kneebone A. Results of a Prospective Dose Escalation Study of Linear Accelerator-Based Virtual Brachytherapy (BOOSTER) for Prostate Cancer; Virtual HDR Brachytherapy for Prostate Cancer. Adv Radiat Oncol 2019; 4:623-630. [PMID: 31673655 PMCID: PMC6817545 DOI: 10.1016/j.adro.2019.03.015] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Revised: 03/07/2019] [Accepted: 03/31/2019] [Indexed: 01/16/2023] Open
Abstract
Purpose To demonstrate feasibility and toxicity of linear accelerator–based stereotactic radiation therapy boost (SBRT) for prostate cancer, mimicking a high-dose-rate brachytherapy boost. Methods and Materials A phase 1 sequential dose escalation study of SBRT compared 20 Gy, 22 Gy, and 24 Gy to the prostate and 25 Gy, 27.5 Gy, and 30 Gy to the gross tumor volume in 2 fractions, combined with 46 Gy in 23 fractions of external beam radiation. Feasibility of dose escalation (volume receiving 125% and 150% of the dose) while meeting organ-at-risk dose constraints, grade 2 acute and late gastrointestinal and genitourinary toxicity, and freedom from biochemical failure were secondary endpoints. Results Thirty-six men with intermediate- and high-risk prostate cancer were enrolled with a median follow-up of 24 months. Sixty-four percent of patients had high-risk features. Nine men were enrolled to dose level 1, 6 to level 2, and 6 to level 3. Another 15 patients were treated at dose level 3 on the continuation study. Dose level 3 achieved superior 125% (23.75 Gy) and 150% (28.5 Gy) dose compared to dose levels 1 and 2, with minimal differences in organ-at-risk doses. Kaplan-Meier estimate of freedom from biochemical failure at 3 years was 93.3%. There were no late grade 2 or 3 gastrointestinal events. The late grade 2 genitourinary toxicity at 2 years was 19.3%. Prostate-specific membrane antigen positron emission tomography was performed at 2 years with no local recurrences. Conclusions We have shown that a linear accelerator–based SBRT boost for prostate cancer is feasible and can achieve doses comparable to high-dose-rate boost up to the 150% isodose volumes. Rectal, bladder, and urethral doses remained low, and long-term toxicity was the same as or better than previous reports from high-dose-rate or low-dose-rate boost protocols.
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Affiliation(s)
- Thomas Eade
- Department of Radiation Oncology Royal North Shore Hospital, St. Leonards, New South Wales, Australia
- Sydney Medical School, University of Sydney, Sydney, Australia
- Corresponding author. Department of Radiation Oncology, Royal North Shore Hospital, Reserve Road, St Leonards NSW 2065, Australia.
| | - George Hruby
- Department of Radiation Oncology Royal North Shore Hospital, St. Leonards, New South Wales, Australia
- Sydney Medical School, University of Sydney, Sydney, Australia
| | - Jeremy Booth
- Department of Radiation Oncology Royal North Shore Hospital, St. Leonards, New South Wales, Australia
| | - Regina Bromley
- Department of Radiation Oncology Royal North Shore Hospital, St. Leonards, New South Wales, Australia
| | - Lesley Guo
- Department of Radiation Oncology Royal North Shore Hospital, St. Leonards, New South Wales, Australia
| | - Andrew O'Toole
- Department of Radiation Oncology Royal North Shore Hospital, St. Leonards, New South Wales, Australia
| | - Andrew Le
- Department of Radiation Oncology Royal North Shore Hospital, St. Leonards, New South Wales, Australia
| | - Kenny Wu
- Department of Radiation Oncology Royal North Shore Hospital, St. Leonards, New South Wales, Australia
| | - May Whitaker
- Department of Radiation Oncology, Chris O'Brien Lifehouse, Camperdown, New South Wales, Australia
| | - Krishan Rasiah
- Department of Urology, Royal North Shore Hospital, St. Leonards, New South Wales, Australia
| | - Venu Chalasani
- Department of Urology, Royal North Shore Hospital, St. Leonards, New South Wales, Australia
| | - Justin Vass
- Department of Urology, Royal North Shore Hospital, St. Leonards, New South Wales, Australia
| | - Carolyn Kwong
- Department of Radiation Oncology Royal North Shore Hospital, St. Leonards, New South Wales, Australia
| | - John Atyeo
- Department of Radiation Oncology Royal North Shore Hospital, St. Leonards, New South Wales, Australia
| | - Andrew Kneebone
- Department of Radiation Oncology Royal North Shore Hospital, St. Leonards, New South Wales, Australia
- Sydney Medical School, University of Sydney, Sydney, Australia
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Vigneault E, Morton G, Parulekar WR, Niazi TM, Springer CW, Barkati M, Chung P, Koll W, Kamran A, Monreal M, Ding K, Loblaw A. Randomised Phase II Feasibility Trial of Image-guided External Beam Radiotherapy With or Without High Dose Rate Brachytherapy Boost in Men with Intermediate-risk Prostate Cancer (CCTG PR15/ NCT01982786). Clin Oncol (R Coll Radiol) 2018; 30:527-533. [PMID: 29903505 DOI: 10.1016/j.clon.2018.05.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Revised: 05/10/2018] [Accepted: 05/12/2018] [Indexed: 12/01/2022]
Abstract
AIMS We conducted a multicentre feasibility study to assess the ability to randomise patients between image-guided radiotherapy (IGRT) and IGRT + high dose rate (HDR) brachytherapy boost and to adhere to appropriate radiation quality assurance standards. MATERIALS AND METHODS The primary end point was to determine the ability to randomise 60 patients over an 18 month period. Arm 1 (IGRT) patients received 78 Gy in 39 fractions or 60 Gy in 20 fractions (physician's preference), whereas arm 2 (IGRT + HDR) received 37.5 Gy in 15 fractions with HDR boost of 15 Gy. The secondary end points included >grade 3 acute genitourinary and gastrointestinal toxicity, using Common Terminology Criteria for Adverse Events version 4.0 at 3 months, validation of a prospectively defined radiation oncology quality assurance to assess treatment compliance. All analyses were descriptive; no formal comparisons between treatment arms were carried out. RESULTS Between April 2014 and September 2015, 57 National Comprehensive Cancer Network (NCCN)-defined intermediate-risk prostate cancer patients were randomised between IGRT alone (arm 1; n = 29) and IGRT plus HDR brachytherapy boost (arm 2; n = 28). Overall, 93% received the treatment as randomised. There were four patients (one on IGRT arm 1 and three patients on the IGRT + HDR arm 2) who were treated differently from randomisation assignment. For the 29 patients receiving IGRT (arm 1), there were 14 cases reported with minor deviations and three with major deviations. For patients on IGRT + HDR (arm 2), there were 18 cases reported with minor deviations and two with major deviations. At 3 months in the IGRT group (arm 1), one patient reported grade 3 diarrhoea, whereas in the IGRT + HDR group (arm 2), two patients reported grade 3 haematuria. No other gastrointestinal and genitourinary toxicities were reported. CONCLUSION The pilot study showed the feasibility of randomisation between treatment with IGRT alone versus IGRT + HDR boost. Treatment compliance was good, including adherence to quality assurance standards.
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Affiliation(s)
- E Vigneault
- Département de Radio-Oncologie, Centre de Recherche sur le Cancer, CHU de Québec, Université Laval, Québec, Canada.
| | - G Morton
- Department of Radiation Oncology, Odette Cancer Centre, Toronto, Ontario, Canada
| | - W R Parulekar
- Canadian Cancer Trials Group, Queen's University, Kingston, Ontario, Canada
| | - T M Niazi
- Division of Radiation Oncology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | - C W Springer
- Department of Radiation Oncology, Windsor Regional Hospital, Windsor, Ontario, Canada
| | - M Barkati
- Département de Radio-Oncologie, CHUM Hôpital Notre-Dame, Montréal, Québec, Canada
| | - P Chung
- Department of Radiation Oncology, University Health Network, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - W Koll
- Department of Radiation Oncology, Lakeridge Hospital, Oshawa, Ontario, Canada
| | - A Kamran
- Department of Radiation Oncology, Dr H Bliss Murphy Cancer Centre, St John's, Newfoundland, Canada
| | - M Monreal
- Canadian Cancer Trials Group, Queen's University, Kingston, Ontario, Canada
| | - K Ding
- Canadian Cancer Trials Group, Queen's University, Kingston, Ontario, Canada
| | - A Loblaw
- Department of Radiation Oncology, Odette Cancer Centre, Toronto, Ontario, Canada
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13
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Kothari G, Loblaw A, Tree AC, van As NJ, Moghanaki D, Lo SS, Ost P, Siva S. Stereotactic Body Radiotherapy for Primary Prostate Cancer. Technol Cancer Res Treat 2018; 17:1533033818789633. [PMID: 30064301 PMCID: PMC6069023 DOI: 10.1177/1533033818789633] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Revised: 06/07/2018] [Accepted: 06/14/2018] [Indexed: 12/25/2022] Open
Abstract
Prostate cancer is the most common non-cutaneous cancer in males. There are a number of options for patients with localized early stage disease, including active surveillance for low-risk disease, surgery, brachytherapy, and external beam radiotherapy. Increasingly, external beam radiotherapy, in the form of dose-escalated and moderately hypofractionated regimens, is being utilized in prostate cancer, with randomized evidence to support their use. Stereotactic body radiotherapy, which is a form of extreme hypofractionation, delivered with high precision and conformality typically over 1 to 5 fractions, offers a more contemporary approach with several advantages including being non-invasive, cost-effective, convenient for patients, and potentially improving patient access. In fact, one study has estimated that if half of the patients currently eligible for conventional fractionated radiotherapy in the United States were treated instead with stereotactic body radiotherapy, this would result in a total cost savings of US$250 million per year. There is also a strong radiobiological rationale to support its use, with prostate cancer believed to have a low α/β ratio and therefore being preferentially sensitive to larger fraction sizes. To date, there are no published randomized trials reporting on the comparative efficacy of stereotactic body radiotherapy compared to alternative treatment modalities, although multiple randomized trials are currently accruing. Yet, early results from the randomized phase III study of HYPOfractionated RadioTherapy of intermediate risk localized Prostate Cancer (HYPO-RT-PC) trial, as well as multiple single-arm phase I/II trials, indicate low rates of late adverse effects with this approach. In patients with low- to intermediate-risk disease, excellent biochemical relapse-free survival outcomes have been reported, albeit with relatively short median follow-up times. These promising early results, coupled with the enormous potential cost savings and implications for resource availability, suggest that stereotactic body radiotherapy will take center stage in the treatment of prostate cancer in the years to come.
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Affiliation(s)
- Gargi Kothari
- Royal Marsden NHS Foundation Trust, London, United Kingdom
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia
| | - Andrew Loblaw
- Department of Radiation Oncology, Odette Cancer Center, Sunnybrook Health Sciences Center, Toronto, Ontario, Canada
| | - Alison C. Tree
- Royal Marsden NHS Foundation Trust, London, United Kingdom
| | | | - Drew Moghanaki
- Hunter Holmes McGuire VA Medical Center, Virginia Commonwealth University, Richmond, VA, USA
| | - Simon S. Lo
- University of Washington School of Medicine, Seattle, WA, USA
| | - Piet Ost
- Department of Radiation Oncology, Ghent University Hospital, Ghent, Belgium
| | - Shankar Siva
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia
- Peter MacCallum Cancer Center, Melbourne, Victoria, Australia
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14
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Helou J, Torres S, Musunuru HB, Raphael J, Cheung P, Vesprini D, Chung HT, D'Alimonte L, Krahn M, Morton G, Loblaw A. Stereotactic Body Radiotherapy versus Low Dose Rate Brachytherapy for Localised Prostate Cancer: a Cost-Utility Analysis. Clin Oncol (R Coll Radiol) 2017; 29:718-731. [PMID: 28916284 DOI: 10.1016/j.clon.2017.08.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Revised: 07/23/2017] [Accepted: 07/24/2017] [Indexed: 12/14/2022]
Abstract
AIMS To conduct a cost-utility analysis comparing stereotactic body radiotherapy (SBRT) with low dose rate brachytherapy (LDR-BT) for localised prostate cancer (PCa). MATERIALS AND METHODS A decision-analytic Markov model was developed from the healthcare payer perspective to simulate the history of a 66-year-old man with low-risk PCa. The model followed patients yearly over their remaining lifetimes. Health states included 'recurrence-free', 'biochemical recurrence' (BR), 'metastatic' and 'death'. Transition probabilities were based on a retrospective cohort analysis undertaken at our institution. Utilities were derived from the literature. Costs were assigned in 2015 Canadian dollars ($) and reflected Ontario's health system and departmental costs. Outcomes included quality-adjusted life years (QALYs), costs and incremental cost-effectiveness ratios. A willingness-to-pay threshold of $50 000/QALY was used. RESULTS SBRT was the dominant strategy with 0.008LYs and 0.029QALYs gained and a reduction in cost of $2615. Under base case conditions, our results were sensitive to the BR probability associated with both strategies. LDR-BT becomes the preferred strategy if the BR with SBRT is 1.3*[baseline BR_SBRT] or if the BR with LDR-BT is 0.76*[baseline BR_LDR-BT]. When assuming the same BR for both strategies, LDR-BT becomes marginally more effective with 0.009QALYs gained at a cost of $272 848/QALY. CONCLUSIONS SBRT represents an economically attractive radiation strategy. Further research should be carried out to provide longer-term follow-up and high-quality evidence.
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Affiliation(s)
- J Helou
- Department of Radiation Oncology, University of Toronto, Toronto, Canada; Princess Margaret Cancer Centre, Toronto, Canada; Institute of Health Policy, Measurement and Evaluation, University of Toronto, Toronto, Canada.
| | - S Torres
- Institute of Health Policy, Measurement and Evaluation, University of Toronto, Toronto, Canada; Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - H B Musunuru
- Department of Radiation Oncology, University of Toronto, Toronto, Canada; Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - J Raphael
- Institute of Health Policy, Measurement and Evaluation, University of Toronto, Toronto, Canada; Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - P Cheung
- Department of Radiation Oncology, University of Toronto, Toronto, Canada; Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - D Vesprini
- Department of Radiation Oncology, University of Toronto, Toronto, Canada; Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - H T Chung
- Department of Radiation Oncology, University of Toronto, Toronto, Canada; Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - L D'Alimonte
- Department of Radiation Oncology, University of Toronto, Toronto, Canada; Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - M Krahn
- Institute of Health Policy, Measurement and Evaluation, University of Toronto, Toronto, Canada; Toronto Health Economics and Technology Assessment Collaborative, Toronto, Canada
| | - G Morton
- Department of Radiation Oncology, University of Toronto, Toronto, Canada; Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - A Loblaw
- Department of Radiation Oncology, University of Toronto, Toronto, Canada; Institute of Health Policy, Measurement and Evaluation, University of Toronto, Toronto, Canada; Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada
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15
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Nicolae AM, Venugopal N, Ravi A. Trends in targeted prostate brachytherapy: from multiparametric MRI to nanomolecular radiosensitizers. Cancer Nanotechnol 2016; 7:6. [PMID: 27441041 PMCID: PMC4932125 DOI: 10.1186/s12645-016-0018-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2016] [Accepted: 06/14/2016] [Indexed: 01/21/2023] Open
Abstract
The treatment of localized prostate cancer is expected to become a significant problem in the next decade as an increasingly aging population becomes prone to developing the disease. Recent research into the biological nature of prostate cancer has shown that large localized doses of radiation to the cancer offer excellent long-term disease control. Brachytherapy, a form of localized radiation therapy, has been shown to be one of the most effective methods for delivering high radiation doses to the cancer; however, recent evidence suggests that increasing the localized radiation dose without bound may cause unacceptable increases in long-term side effects. This review focuses on methods that have been proposed, or are already in clinical use, to safely escalate the dose of radiation within the prostate. The advent of multiparametric magnetic resonance imaging (mpMRI) to better identify and localize intraprostatic tumors, and nanomolecular radiosensitizers such as gold nanoparticles (GNPs), may be used synergistically to increase doses to cancerous tissue without the requisite hazard of increased side effects.
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Affiliation(s)
- Alexandru Mihai Nicolae
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, 2075 Bayview Ave, Toronto, ON M4N3M5 Canada
| | | | - Ananth Ravi
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, 2075 Bayview Ave, Toronto, ON M4N3M5 Canada
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16
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Abstract
BACKGROUND Hypoxia is a characteristic feature of solid tumours that significantly reduces the efficacy of conventional radiation therapy. In this study we investigated the role of hypoxia in a stereotactic radiation schedule by using a variety of hypoxic modifiers in a preclinical tumour model. MATERIAL AND METHODS C3H mammary carcinomas were irradiated with 3 × 15 Gy during a one-week period, followed three days later by a clamped top-up dose to produce a dose response curve; the endpoint was tumour control. The hypoxic modifiers were nimorazole (200 mg/kg), nicotinamide (120 mg/kg) and carbogen (95% O2 + 5% CO2) breathing, OXi4503 (10 mg/kg), and hyperthermia (41.5°C; 1 h). RESULTS The radiation dose controlling 50% of clamped tumours (TCD50) following 3 × 15 Gy was 30 Gy. Giving nimorazole or nicotinamide+ carbogen prior to the final 15 Gy fraction non-significantly (χ(2)-test; p < 0.05) reduced this TCD50 to 20-23 Gy; when administered with each 3 × 15 Gy fraction these values were significantly reduced to ≤ 2.5 Gy. Injecting OXi4503 or heating after irradiating significantly reduced the TCD50 to 9-12 Gy regardless of whether administered with one or all three 15 Gy fractions. Combining OXi4503 and heat with the final 15 Gy had a significantly larger effect (TCD50 = 2 Gy). CONCLUSIONS Clinically relevant modifiers of hypoxia effectively enhanced an equivalent stereotactic radiation treatment confirming the importance of hypoxia in such schedules.
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Affiliation(s)
- Thomas R Wittenborn
- a Department of Experimental Clinical Oncology , Aarhus University Hospital , Aarhus , Denmark
| | - Michael R Horsman
- a Department of Experimental Clinical Oncology , Aarhus University Hospital , Aarhus , Denmark
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