The impact of age at the time of radiotherapy for localized prostate cancer on the development of second primary malignancies

The impact of baseline health factors on second primary cancer risk after radiotherapy for prostate cancer

PURPOSE

In evaluating second primary cancers (SPCs) following External Beam Radiotherapy (EBRT), the role of lifestyle factors is frequently not considered due to data limitations. We investigated the association between smoking, comorbidities, and SPC risks within EBRT-treated patients for localized prostate cancer (PCa).

PATIENTS & METHODS

The study included 1,883 PCa survivors aged 50-79, treated between 2006 and 2013, with intensity-modulated radiotherapy (IMRT) or three-dimensional conformal radiotherapy (3D-CRT). Clinical data were combined with SPC and survival data from the Netherlands Cancer Registry with a 12-month latency period. Standardized Incidence Ratios (SIRs) were calculated comparing the EBRT cohort with the general Dutch population. To explore the effect of patient and treatment characteristics on SPCs we conducted a Cox regression analysis. Lastly, we estimated cumulative incidences of developing solid SPC, pelvis SPC, and non-pelvis SPC using a competing risk analysis.

RESULTS

Significantly increased SIRs were observed for all SPC (SIR = 1.21, 95% confidence interval [CI]: 1.08-1.34), pelvis SPC (SIR = 1.46, 95% CI: 1.18-1.78), and non-pelvis SPC (SIR = 1.18, 95% CI [1.04-1.34]). Smoking status was significantly associated with pelvic and non-pelvic SPCs. Charlson comorbidity index (CCI) ≥ 1 (Hazard Ratio [HR] = 1.45, 95% CI: 1.10-1.91), cardiovascular disease (HR = 1.41, 95% CI: 1.05-1.88), and chronic obstructive pulmonary disease (COPD) (HR = 1.91, 95% CI: 1.30-2.79) were significantly associated with non-pelvis SPC. The proportion of active smoking numbers in the cohort was similar to the general population.

INTERPRETATION

We conclude that the presence of comorbidities in the EBRT population might be a relevant factor in observed excess non-pelvis SPC risk, but not for excess pelvis SPC risk.

Incorporating Genetic Risk Into Prostate Cancer Care: Implications for Early Detection and Precision Oncology

The availability and cost of germline and somatic genetic testing have dramatically improved over the past two decades, enabling precision medicine approaches in oncology, with significant implications for prostate cancer (PCa) care. Roughly 12% of individuals with advanced disease are carriers of rare pathogenic germline variants that predispose to particularly aggressive and earlier-onset disease. Several of these variants are already established as clinically actionable by modern precision oncology therapeutics, while others may come to aid the selection of active surveillance, definitive local therapies, and systemic therapies. Concurrently, the number of common variants (ie, incorporated into polygenic risk scores) associated with PCa risk has continued to grow, but with several important considerations both at the intersection of race and ancestry and for early detection of aggressive disease. Family history has historically been used as a proxy for this inherited genetic risk of PCa, but recently emerging evidence examining this relation has shifted our understanding of how best to leverage this tool in PCa care. This review seeks to clarify and contextualize the existing and emerging precision oncology paradigms that use inherited genetic risk in PCa care, for both early detection and localized disease management.

Influence factors of the survival in colorectal cancer patients with second primary malignancy after surgery: A SEER database analysis

The survival rate is significantly reduced in patients with colorectal cancer (CRC) who developing a second primary malignancy (SPM), and however, little has known about the factors that contribute to the mortality of SPMs among CRC survivors. This study aims to explore the influence factors in both the all-cause and cancer-specific mortality of patients with SPMs after CRC surgery. Data of adult CRC patients with SPMs were extracted from the Surveillance, Epidemiology, and End Results (SEER) database in this retrospective cohort study. The associations between potential influence factors and all-cause mortality and cancer-specific mortality were explored using univariate and multivariate Cox proportional hazards analyses. The evaluation indexes were hazard ratios (HRs), and 95% confidence intervals (CIs). We also drew pie charts to respectively reflect the distributions of SPMs sites and time interval in study population. A total of 1202 (56.14%) patients died for all-cause, and 464 (21.67%) died due to CRC. The results showed that after adjusting for covariates, age, sex, marital status, T stage of CRC, second primary cancer site, stage of SPMs, grade of SPMs, TNM stage of SPMs, and time interval were associated with all-cause mortality, while marital status, stage of CRC, T stage of CRC, chemotherapy, second primary cancer site, stage of SPMs, grade of SPMs, TNM stage of SPMs, and time interval were associated with cancer-specific mortality in patients with CRC. In addition, colon (23.5%) was the most common site of SPMs, followed by digestive system (19.0%), and the time interval between CRC and SPMs in most patients was over 5 years (28.4%). Our findings may assist clinicians to identify high-risk patients for SPMs after CRC surgery. Also, the postoperative long-term follow-up and close attention on the key systems where the SPMs may occur are of great necessary in patients with CRC.

Impact of Advanced External Beam Radiotherapy on Second Haematological Cancer Risk in Prostate Cancer Survivors

AIMS

External beam radiotherapy (EBRT) for prostate cancer (PCa) has rapidly advanced over the years. Advanced techniques with altered dose distributions may have an impact on second haematological cancer (SHC) risks. We assessed SHC risk after EBRT for PCa and explored whether this risk has changed over the years.

MATERIALS AND METHODS

Patients diagnosed with a T1-T3 PCa between 1990 and 2015 were selected from the Netherlands Cancer Registry. Patients treated with EBRT were assigned to EBRT eras based on the date of diagnosis. These eras represented two-dimensional radiotherapy (2D-RT; 1991-1996), three-dimensional conformal radiotherapy (3D-CRT; 1998-2005) or advanced EBRT (2008-2015). Standardised incidence ratios (SIR) and absolute excess risks (AER) were calculated overall and by EBRT era. Sub-hazard ratios (sHRs) were calculated for the comparison of EBRT versus radical prostatectomy and active surveillance.

RESULTS

PCa patients with EBRT as the primary treatment (n = 37 762) had an increased risk of developing a SHC (SIR = 1.20; 95% confidence interval 1.13-1.28) compared with the Dutch male general population. Estimated risks were highest for the 2D-RT era (SIR = 1.32; 95% confidence interval 1.14-1.67) compared with the 3D-CRT era (SIR = 1.16; 95% confidence interval 1.05-1.27) and the advanced EBRT era (SIR = 1.21; 95% confidence interval 1.07-1.36). AER were limited, with about five to six extra cases per 10 000 person-years. Relative risk analysis (EBRT versus radical prostatectomy/active surveillance) showed significant elevation with EBRT versus active surveillance (sHR = 1.17; 95% confidence interval 1.03-1.33; P = 0.017), but not for EBRT versus radical prostatectomy (sHR = 1.08; 95% confidence interval 0.94-1.23; P = 0.281).

CONCLUSION

Increased SHC risks after EBRT for PCa cancer were observed for all EBRT eras compared with the general Dutch male population. Excess risks for EBRT versus other PCa treatment groups were found for only EBRT versus active surveillance.

Proton therapy for prostate cancer: current state and future perspectives

OBJECTIVE

Localized prostate cancer can be treated with several radiotherapeutic approaches. Proton therapy (PT) can precisely target tumors, thus sparing normal tissues and reducing side-effects without sacrificing cancer control. However, PT is a costly treatment compared with conventional photon radiotherapy, which may undermine its overall efficacy. In this review, we summarize current data on the dosimetric rationale, clinical benefits, and cost of PT for prostate cancer.

METHODS

An extensive literature review of PT for prostate cancer was performed with emphasis on studies investigating dosimetric advantage, clinical outcomes, cost-effective strategies, and novel technology trends.

RESULTS

PT is safe, and its efficacy is comparable to that of standard photon-based therapy or brachytherapy. Data on gastrointestinal, genitourinary, and sexual function toxicity profiles are conflicting; however, PT is associated with a low risk of second cancer and has no effects on testosterone levels. Regarding cost-effectiveness, PT is suboptimal, although evolving trends in radiation delivery and construction of PT centers may help reduce the cost.

CONCLUSION

PT has several advantages over conventional photon radiotherapy, and novel approaches may increase its efficacy and safety. Large prospective randomized trials comparing photon therapy with proton-based treatments are ongoing and may provide data on the differences in efficacy, toxicity profile, and quality of life between proton- and photon-based treatments for prostate cancer in the modern era.

ADVANCES IN KNOWLEDGE

PT provides excellent physical advantages and has a superior dose profile compared with X-ray radiotherapy. Further evidence from clinical trials and research studies will clarify the role of PT in the treatment of prostate cancer, and facilitate the implementation of PT in a more accessible, affordable, efficient, and safe way.

Risk of second primary malignancies associated with radiotherapy in prostate cancer patients: competing risk analysis

Background: The effect of radiotherapy (RT) for second primary malignancies (SPMs) among prostate cancer survivors is controversial. Methods: Applying logistic regression, competing risk analysis and propensity score matching method, this study analyzed clinical data from the Surveillance, Epidemiology, and End Results program to compare the risk for SPMs between patients receiving RT and non-RT. Results: In this study, prostate cancer patients treated with RT developed more SPMs in the anus, bladder, rectum, liver, lung and bronchus and lymphoma than non-RT groups. Conclusion: More intensive surveillance should be adopted for these cancers among prostate cancer survivors.

The Risk of Second Primary Cancers in Prostate Cancer Survivors Treated in the Modern Radiotherapy Era

Purpose

Concerns have been raised that modern intensity modulated radiotherapy (IMRT) may be associated with increased second primary cancer risks (SPC) compared to previous three-dimensional conformal radiation techniques (3DCRT), due to increased low dose volumes and more out-of-field ionizing dose to peripheral tissue further away from the target. We assessed the impact of treatment technique on SPC risks in a cohort of prostate cancer (PCa) survivors.

Material and Methods

The study cohort comprised 1,561 PCa survivors aged 50–79 years at time of radiotherapy, treated between 2006–2013 (N=707 IMRT, N=854 3DCRT). Treatment details were extracted from radiotherapy systems and merged with longitudinal data of the Netherlands Cancer Registry to identify SPCs. Primary endpoint was the development of a solid SPC (excluding skin cancer) in peripheral anatomical regions, i.e. non-pelvic. Applied latency period was 12 months. SPC rates in the IMRT cohort (total cohort and age subgroups) were compared to 1) the 3DCRT cohort by calculating Sub-Hazard Ratios (sHR) using a competing risk model, and 2) to the general male population by calculating Standardized Incidence Ratios (SIR). Models were adjusted for calendar period and age.

Results

Median follow-up was 8.0 years (accumulated 11,664 person-years at-risk) with 159 cases developing ≥1 non-pelvic SPC. For IMRT vs 3DCRT we observed a significantly (p=0.03) increased risk (sHR=1.56, 95% Confidence Interval (CI) 1.03–2.36, corresponding estimated excess absolute risk (EAR) of +7 cases per 10,000 person-years). At explorative analysis, IMRT was in particular associated with increased risks within the subgroup of active smokers (sHR 2.94, p=0.01). Within the age subgroups 50–69 and 70–79 years, the sHR for non-pelvic SPC was 3.27 (p=0.001) and 0.96 (p=0.9), respectively. For pelvic SPC no increase was observed (sHR=0.8, p=0.4). Compared to the general population, IMRT was associated with significantly increased risks for non-pelvic SPC in the 50–69 year age group (SIR=1.90, p<0.05) but not in the 70–79 years group (SIR=1.08).

Conclusion

IMRT is associated with increased SPC risks for subjects who are relatively young at time of treatment. Additional research on aspects of IMRT that may cause this effect is essential to minimize risks for future patients receiving modern radiotherapy.

Immune Modulation in Prostate Cancer Patients Treated with Androgen Receptor (AR)-Targeted Therapy

Androgen deprivation therapy (ADT) is a cornerstone of treatment for prostate cancer and, in recent years, androgen receptor (AR)-targeted therapies (abiraterone and enzalutamide) have both been used for the treatment of castration-resistant prostate cancer (CRPC). In our study, we sought to investigate the association between ADT and immune disorders, considering a potential role of androgens in the immune modulation. We retrospectively evaluated CRPC patients treated with abiraterone/enzalutamide between July 2011 and December 2018. We assessed the risk of developing immune alterations and their impact on outcome. We included 844 CRPC patients receiving AR-directed therapies, of whom 36 (4.3%) had autoimmune diseases and 47 (5.6%) second tumors as comorbidities. Median age was 70 years [interquartile range (IQR) = 63–75)]. We showed higher significant incidence of autoimmune diseases during their hormone sensitive status (p = 0.021) and the presence of autoimmune comorbidities before starting treatment with abiraterone/enzalutamide was significantly associated with worse overall survival (OS) (10.1 vs. 13.7 months, HR = 1.59, 95% CI 1.03–2.27, p = 0.038). In a multivariate analysis, the presence of autoimmune disorders was an independent predictor of OS (HR = 1.65, 95% CI 1.05–2.60, p = 0.031). In conclusion, CRPC patients with autoimmune alterations before starting AR-directed therapies may have worse prognosis. Further prospective studies are warranted to assess the role of immune modulation in the management of prostate cancer patients.

Survival Analysis of Cancer Patients in North Eastern Nigeria from 2004 - 2017 - A Kaplan - Meier Method

BACKGROUND:

Cancer is a deadly malignant disease and is prevalent in Sub Saharan Africa. The North East part of Nigeria in particular and the country, in general, are struggling to cope with the increasing burden of cancer and other communicable and non-communicable diseases. The situation is worsened by the ongoing insurgency and terrorist activities in the area.

AIM:

The aim of this paper is to present the research findings from a cohort study aimed at the analysis of the estimation of the survivorship time of the real data of cancer patients in the North-eastern part of Nigeria and to establish if the insurgency in the region has contributed negatively to the life expectancy of its inhabitants.

MATERIAL AND METHODS:

The record of 1,090 patients from medical records departments of the University of Maiduguri Teaching Hospital (UMTH), located in Maiduguri, the capital city of Borno State in northeast Nigeria was obtained. The record showed patients that were diagnosed and died of one type of cancer or the other from 2004 to 2017. All the cancer cases included in the present study were grouped into sex, age, marital status, occupation, date admitted and date of death/discharge. Descriptive statistics and Kaplan-Meier method were used to analyse the data using SPSS version 23 while Microsoft EXCEL and Minitab 16.0 were used for data cleansing and organisation.

RESULTS:

Of the 1,090 patients analysed, 920 (84.40%) experienced the event, i.e. death, while 170 (15.60%) patients were censored. The data were analysed based on the ages and sex of the patients. 50.20% of the patients were of ages 21-50 years. The proportions of patients in this age bracket surviving past 7 days are 75%, while those between ages 80 years and above is 12 days. Others are of survival time of 5 days (ages 0-20 years) and 7 days (51-79 years). Using sex, 75% of the patients’ survival time is 7 days in the case of male and 6 days for females. It is safe to say that the survival time for cancer patients of the university the Maiduguri is 6 days and the result reflects the Northeastern part of Nigeria. This is because the hospital is one of few tertiary healthcare facilities in that area and consequently, cancer cases are often referred there.

CONCLUSION:

Cancer incidence is high, and the probability of survival reduces as the survival time increases. This is a dire situation in need of urgent intervention from the government, groups and individuals to tackle the scourge of cancer, thereby improving on the life expectancy battered by the ongoing Boko Haram insurgency in that region.