Prostate cancer patient subsets showing improved bNED control with adjuvant androgen deprivation

Androgen Ablation Therapy Does not Increase the Risk of Late Morbidity following 3D-conformal Radiotherapy of Organ-confined Prostate Cancer: The Experience of the European Institute of Oncology

Aims and Background

Androgen ablation therapy in conjunction with radiotherapy-neoadjuvant and adjuvant – has consistently been shown to be associated with improved biochemical and local control, whereas controversy still remains as regards its benefit in terms of overall survival. The objective of this study is to determine the impact of androgen ablation in combination to 3D-conformal radiotherapy on late treatment-related toxicity.

Methods

236 patients were treated with 3D-conformal radiotherapy to a total dose ranging from 70 and 78.6 Gy. Fifty-six patients did not receive any form of androgen ablation whereas 176 were given at least 3 months of neoadjuvant androgen ablation. Of these, 64 stayed on androgen ablation for a median time of 6 months post-radiotherapy. Acute toxicity was evaluated weekly during the course of treatment. Late toxicity was assessed at 3-months intervals during the follow-up. Toxicity was scored according to the RTOG criteria.

Results

The median follow-up was 24.6 months (range, 12-62). The incidence of late genitourinary toxicity was: 3% G2, 3.5% G3, 0.5% G4. The incidence of late gastrointestinal toxicity was: 12% G2, 2% G3, 1% G4. No association was observed between the use of androgen ablation and late treatment-related toxicity. High-risk patients who continued on androgen ablation long-term were not found to have an increased risk of developing late toxicity with respect to those who never had any form of androgen ablation or those only treated neoadjuvantly.

Conclusions

In our experience, the use of androgen ablation does not impact on late toxicity following high dose 3D-conformal radiotherapy for prostate cancer.

Intermediate-Risk Localized Prostate Cancer in the PSA Era: Radiotherapeutic Alternatives

OBJECTIVES

To retrospectively compare the biochemical disease-free survival (BDFS) of patients treated with standard dose external beam radiotherapy (SD-EBRT), SD-EBRT plus androgen deprivation (AD), and brachytherapy-based treatment (brachytherapy with or without EBRT with or without AD).

METHODS

All 297 patients with intermediate-risk prostate cancer treated with these radiation-based treatments at our institution from August 1989 to June 2001 were included. Biochemical relapse was defined according to the American Society for Therapeutic Radiology and Oncology (ASTRO) definition, a prostate-specific antigen level of 1.5 ng/mL or greater and rising on two consecutive occasions (the "Bolla" definition), and the current prostate-specific antigen nadir plus 2 ng/mL with failure dated "at call" (the "Houston/Phoenix" definition). The number of patients treated with SD-EBRT, SD-EBRT plus AD, and brachytherapy-based treatment was 141, 84, and 72, respectively. The year of treatment was analyzed as a prognostic factor. The median follow-up was 32.3, 34.7, and 41.5 months for the ASTRO, Bolla, and Houston/Phoenix definitions, respectively.

RESULTS

The brachytherapy-based treatment resulted in improved BDFS compared with SD-EBRT (ASTRO definition, 5-year BDFS rate 88% +/- 5% versus 49% +/- 5%, P <0.01; Bolla definition, 88% +/- 8% versus 49% +/- 5%, P <0.01; Houston/Phoenix definition, 81% +/- 10% versus 64% +/- 5%, P = 0.01). SD-EBRT plus AD was superior to SD-EBRT alone using the Bolla definition (5-year BDFS 76% +/- 7% versus 49% +/- 5%, P <0.01) and the Houston/Phoenix definition (85% +/- 6% versus 64% +/- 5%, P = 0.01), but not using the ASTRO definition (P = 0.17). Multivariate analysis, including prostate-specific antigen, clinical stage, Gleason score, and year of treatment, demonstrated improved biochemical outcomes for brachytherapy-based treatment versus SD-EBRT (ASTRO, P <0.01; Bolla, P <0.01; and a trend toward significance with Houston/Phoenix, P = 0.07) and for the addition of AD to SD-EBRT (Bolla, P <0.01 and Houston/Phoenix, P = 0.03). The year of treatment trended toward significance (P = 0.077) on multivariate analysis using the ASTRO definition.

CONCLUSIONS

For patients with intermediate-risk prostate cancer, brachytherapy-based treatment and the addition of AD to SD-EBRT resulted in improved biochemical outcomes compared with the outcomes with SD-EBRT alone; however, these findings were dependent on the definition of biochemical failure used. The year of treatment may be an important prognostic factor in intermediate-risk prostate cancer.

Neo-adjuvant and adjuvant hormone therapy for localised and locally advanced prostate cancer

BACKGROUND

Hormone therapy for early prostate cancer has demonstrated an improvement in clinical and pathological variables, but not always an improvement in overall survival. We performed a systematic review of both adjuvant and neo-adjuvant hormone therapy combined with surgery or radiotherapy in localised or locally advanced prostate cancer.

OBJECTIVES

The objective of this review was to undertake a systematic review and, if possible, a meta-analysis of neo-adjuvant and adjuvant hormone therapy in localised or locally advanced prostate cancer.

SEARCH STRATEGY

We searched MEDLINE (1966-2006), EMBASE, The Cochrane Library, Science Citation Index, LILACS, and SIGLE for relevant randomised trials. Handsearching of appropriate publications was also undertaken.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials of patients with localised or locally advanced prostate cancer, that is, stages T1-T4, any N, M0, comparing neo-adjuvant or adjuvant hormonal deprivation in combination with primary therapy (radical radiotherapy or radical prostatectomy) versus primary therapy alone were included in this review.

DATA COLLECTION AND ANALYSIS

Data were extracted from eligible studies and assessed for quality, and included information on study design, participants, interventions, and outcomes. Comparable data were pooled together for meta-analysis with intention-to treat principle.

MAIN RESULTS

Men with prostate cancer have different clinical outcomes based on their risk (T1-T2, T3-T4, PSA levels and Gleason score). However, the majority of studies included in this review did not report results by risk groups; therefore, it was not possible to perform sub-group analysis. Neo-adjuvant hormonal therapy prior to prostatectomy did not improve overall survival (OR 1.11, 95% CI 0.67 to 1.85, P = 0.69). However, there was a significant reduction in the positive surgical margin rate (OR 0.34, 95% CI 0.27 to 0.42, P < 0.00001) and a significant improvement in other pathological variables such as lymph node involvement, pathological staging and organ confined rates. There was a borderline significant reduction of disease recurrence rates (OR 0.74, 95% CI 0.55 to 1.0, P = 0.05), in favour of treatment. The use of longer duration of neo-adjuvant hormones, that is either 6 or 8 months prior to prostatectomy, was associated with a significant reduction in positive surgical margins (OR 0.56, 95% CI 0.39 to 0.80, P = 0.002). In one study, neo-adjuvant hormones prior to radiotherapy significantly improved overall survival for Gleason 2 to 6 patients; although, in two studies, there was no improvement in disease-specific survival (OR 0.99, 95% CI 0.75 to 1.32, P = 0.97). However, there was a significant improvement in both clinical disease-free survival (OR 1.86, 95% CI 1.93 to 2.40, P < 0.00001) and biochemical disease-free survival (OR 1.93, 95% CI 1.45 to 2.56, P < 0.00001). Adjuvant androgen deprivation following prostatectomy did not significantly improve overall survival at 5 years (OR 1.50, 95% CI 0.79 to 2.85, P = 0.2); although one study reported a significant disease-specific survival advantage with adjuvant therapy (P = 0.001). In addition, there was a significant improvement in disease-free survival at both 5 years (OR 3.73, 95%CI 2.30 to 6.03, P < 0.00001) and 10 years (OR 2.06, 95% CI 1.34 to 3.15, P = 0.0009). Adjuvant therapy following radiotherapy resulted in a significant overall survival gain apparent at 5 (OR 1.46, 95% CI 1.17 to 1.83, P = 0.0009) and 10 years (OR 1.44, 95% CI 1.13 to 1.84, P = 0.003); although there was significant heterogeneity (P = 0.09 and P = 0.07, respectively). There was also a significant improvement in disease-specific survival (OR 2.10, 95% CI 1.53 to 2.88, P = 0.00001) and disease-free survival (OR 2.53, 95% CI 2.05 to 3.12, P < 0.00001) at 5 years.

AUTHORS' CONCLUSIONS

Hormone therapy combined with either prostatectomy or radiotherapy is associated with significant clinical benefits in patients with local or locally advanced prostate cancer. Significant local control may be achieved when given prior to prostatectomy or radiotherapy, which may improve patient's quality of life. When given adjuvant to these primary therapies, hormone therapy, not only provides a method for local control, but there is also evidence for a significant survival advantage. However, hormone therapy is associated with significant side effects, such as hot flushes and gynaecomastia, as well as cost implications. The decision to use hormone therapy should, therefore, be taken at a local level, between the patient, clinician and policy maker, taking into account the clinical benefits, toxicity and cost. More research is needed to guide the choice, the duration, and the schedule of hormonal deprivation therapy, and the impact of long-term hormone therapy with regard to toxicity and the patient's quality of life.

The role of radical prostatectomy in patients with clinically localized prostate cancer and a prostate-specific antigen level >20 ng/ml

OBJECTIVES

To determine the outcome of patients with a serum prostate-specific antigen (PSA) level >20 ng/ml that underwent radical prostatectomy (RP).

METHODS

We retrospectively reviewed the medical records of 147 patients who underwent RP for clinically localized prostate cancer with a pre-treatment PSA (PSApt) >20 ng/ml. Fifty-two patients had positive pelvic lymph nodes and were excluded from analysis. Of 95 patients remaining, 15 were lost to follow-up. Therefore, the study group included 80 patients. The end points for this analysis were biochemical relapse-free survival (bRFS), surgical and post-operative complications and urinary continence. PSApt, pathological grade, surgical margin status, age, clinical stage and immediate androgen ablation were evaluated in a multivariate analysis regarding bRFS.

RESULTS

Forty-nine resected specimens (61.2%) were pathologically classified as pT3 or pT4. After a mean follow-up of 64 months, the estimated 5-year bRFS rate was 58% for the overall group. Immediate androgen ablation was the only independent prognostic factor for biochemical relapse (P=0.001). Concerning the 21 patients who received an immediate androgen ablation after RP, the estimated 5-year bRFS rate was 92%. Complete urinary continence was achieved in 76.5% of patients. Early complications occurred in 13 patients (16.2%).

CONCLUSIONS

Clinically localized prostate cancer with a PSApt >20 ng/ml is considered as having a poor prognosis. However, RP performed in these patients led to an acceptable morbidity and good functional results. Immediate adjuvant hormonal therapy seems mandatory in this setting to improve bRFS.

Impact of short course hormonal therapy on overall and cancer specific survival after permanent prostate brachytherapy

PURPOSE

To review the impact of prior hormonal therapy on 10-year overall and prostate cancer specific survival after primary brachytherapy.

METHODS AND MATERIALS

A retrospective review was performed on the Arizona Oncology Services tumor registry for 2,378 consecutive permanent prostate brachytherapy cases from 1988 through 2001. Hormonal therapy was administered before the implant in 464 patients for downsizing of the prostate or at the discretion of the referring physician. All deceased patients with known clinical recurrence were considered to have died of prostate cancer, irrespective of the immediate cause of death. Risk groups were defined, with 1,135 favorable (prostate-specific antigen [PSA] < 10, Gleason < 7, Stage T1-T2a), 787 intermediate (single adverse feature), and 456 unfavorable (two or more adverse features) patients. Kaplan-Meier actuarial survival curves were generated for both overall and cause-specific survival from the time of treatment. Multivariate analysis was performed to assess the impact of hormonal intervention in comparison with known risk factors of grade, PSA, and age.

RESULTS

With follow-up ranging up to 12.6 years and a median of 4.1 year, a total of 474 patients died, with 67 recorded as due to prostate cancer. Overall and cause-specific 10-year survival rates are 43% and 88%, respectively. Overall survival is 44% for the hormone naive patients, compared with 20% for the hormone-treated cohort (p = 0.02). The cancer-specific survival is 89% vs. 81% for the same groups (p = 0.133). Multivariate analysis confirms the significance of age > 70 years (p = 0.0013), Gleason score >/= 7 (p = 0.0005), and prior hormone use (p = 0.0065) on overall survival.

CONCLUSIONS

At 10 years, in prostate cancer patients receiving brachytherapy, overall survival is worse in men receiving neoadjuvant hormonal therapy, compared with hormone naive patients. This does not appear to be due to other known risk factors for survival (i.e., stage, grade, PSA, age) on multivariate analysis. The leading causes of death were cardiovascular, prostate cancer, and other cancers with no obvious discrepancy between the two groups. This finding is unexpected and requires confirmation from other centers.

Report of a multicenter Canadian phase III randomized trial of 3 months vs. 8 months neoadjuvant androgen deprivation before standard-dose radiotherapy for clinically localized prostate cancer

PURPOSE

To evaluate the effect of 3 months vs. 8 months of neoadjuvant hormonal therapy before conventional dose radiotherapy (RT) on disease-free survival using prostate-specific antigen PSA and biopsies as end points for clinically localized prostate cancer.

METHODS AND MATERIALS

Between February 1995 and June 2001, 378 men were randomized to either 3 or 8 months of flutamide and goserelin before conventional-dose RT (66 Gy) at four participating centers. The median patient age was 72 years (range, 50-84 years). The stage distribution was 17% T1c, 35% T2a, 34% T2b-T2c, 13% T3-T4. The Gleason score (GS) was < or =6 in 51%, 7 in 38%, and 8-10 in 11%. The median baseline PSA level was 9.7 ng/mL (range, 1.3-189 ng/mL). Of the 378 men, 26% were low risk (Stage T1c-T2a, GS < or =6, PSA <10 ng/mL), 43% were intermediate risk (Stage T2b or GS 7 or PSA 10-20 ng/mL), and 31% were high risk (Stage T3 or GS 8-10 or PSA >20 ng/mL). The two arms were balanced in terms of age, GS, T stage, risk group, and presenting PSA level. The median follow-up was 44 months (range, 10-84 months), and 361 patients were available for evaluation.

RESULTS

The 8-month arm achieved a lower PSA level before starting RT (0.37 vs. 0.74 ng/mL, p < or =0.001) and had a greater downsizing of the prostate (mean volume 26.6 cm(3) vs. 30.5 cm(3), p < or =0.001). However, the actuarial freedom from failure rate (biochemical by American Society for Therapeutic Radiology and Oncology definition, local or distant) for the 3-month vs. 8-month arms at 3 years was 66% vs. 68% and by 5 years was 61% vs. 62%, respectively (p = 0.36). No statistically significant difference was noted in the types of failure between the two arms (crude final status): biochemical, 22.2% vs. 22.3%; local, 10.2% vs. 6.5%; and distant, 3.4% vs. 4.4% (p = 0.61). Two-year post-RT biopsies were done in 57% (n = 205). Negative biopsies were obtained in 68% of the 3-month and 77% of the 8-month patients; 18% and 14% had indeterminate biopsies and 14% and 9% were positive for residual cancer (p = 0.34) in the two arms, respectively. The median PSA level for nonfailing patients was 0.50 ng/mL in both the 3-months and 8-month arms. A suggestion of improvement was found in the 8-month arm for disease-free survival at 5 years for high-risk patients (39% vs. 52%) but did not achieve statistical significance.

CONCLUSION

A longer period of neoadjuvant hormonal therapy before standard-dose RT does not appear to confer a benefit in terms of disease-free survival or to alter failure patterns. Failure was delayed in the 8-month arm, but this advantage was lost by 5 years of follow-up. A suggestion of benefit was noted with a longer period of hormonal therapy for high-risk patients.

Does short-term androgen deprivation substitute for radiation dose in the treatment of high-risk prostate cancer?

PURPOSE

Randomized trials have corroborated the clinical benefit of adding androgen deprivation (AD) to radiotherapy (RT) in the treatment of high-risk prostate cancer. Another competing strategy is to escalate the RT dose using three-dimensional conformal RT (3D-CRT). In this analysis, we asked whether the addition of short-term AD (STAD) (<or=6 months) to RT in the treatment of high-risk (prostate-specific antigen >20 ng/mL, Gleason score 8-10, or T3-4) prostate cancer is an effective substitute for dose escalation.

METHODS AND MATERIALS

Between March 1, 1990 and November 30, 1998, 296 high-risk prostate cancer patients were treated with 3D-CRT alone (n = 206) or in combination with STAD (n = 90). The patient characteristics were median age 68 years, median follow-up 58 months, pretreatment initial prostate-specific antigen 21.8 ng/mL, RT dose 75 Gy, STAD duration 3 months, and time off STAD 64 months. The impact of STAD with respect to dose was examined using univariate analysis for dose ranges of <75 Gy and >or=75 Gy. Stepwise Cox proportional hazards regression multivariate analysis was performed to determine independent correlates of freedom from biochemical failure (bNED), freedom from distant metastasis (FDM), and overall survival. In a separate matched-pair analysis (n = 44 per group), those treated to <75 Gy + STAD (Group A) were compared with those who received >or=75 Gy alone (Group B).

RESULTS

On univariate analysis, the addition of STAD had no impact on bNED, FDM, or overall survival in either dose group. On multivariate analysis, initial prostate-specific antigen level, palpation T stage, and RT dose were significant correlates of bNED. For FDM and overall survival, the significant covariates were palpation T stage and Gleason score, respectively. Finally, in matched-pair analysis, the higher RT dose group had a significantly greater bNED rate at 5 years (Group A 35% vs. Group B 57%, p = 0.0190).

CONCLUSION

Our data suggest that STAD, as used here (median 3 months), is not a substitute for RT dose in the treatment of high-risk prostate cancer. RT dose is an essential element in the treatment of high-risk prostate cancer.

Evaluation of the Houston biochemical relapse definition in men treated with prolonged neoadjuvant and adjuvant androgen ablation and assessment of follow-up lead-time bias

PURPOSE

To validate the Houston prostate-specific antigen relapse definition in a mature cohort of men treated with external beam radiotherapy (EBRT) and adjuvant androgen ablation (AA) and men treated with EBRT monotherapy, and to compare these results with the American Society for Therapeutic Radiology and Oncology (ASTRO) and Vancouver prostate-specific antigen relapse (biochemical no evidence of disease) definitions.

METHODS AND MATERIALS

A prospective database of 1490 men treated with EBRT, with or without AA, was examined. The impact on hazard proportions, as well as the predictive ability, of the Houston, ASTRO, and Vancouver definitions was tested.

RESULTS

For all patients, the Houston definition was more accurate (79.5%) than the ASTRO (76.7%) or Vancouver (77.2%) definitions in predicting subsequent clinical relapse. The Houston definition was superior to the ASTRO definition in those treated both with and without AA and equivalent to the Vancouver definition in those receiving AA. The Houston definition demonstrated proportional hazards when categorized for the use of AA, unlike the ASTRO and Vancouver definitions. The effect of inadequate follow-up on the projected relapse rates was negligible with the Houston definition.

CONCLUSION

The Houston relapse definition is favored after EBRT monotherapy or combined EBRT and AA. Use of the Cox proportional hazard multivariate analysis is appropriate with the Houston definition, but not with the ASTRO or Vancouver definitions if AA and non-AA patients are combined.

High and intermediate risk prostate cancer treated with three-dimensional computed tomography-guided brachytherapy: 2-8-year follow-up

PURPOSE

To report post-brachytherapy results in high and intermediate risk patients of prostatic adenocarcinoma.

METHODS AND MATERIALS

From June 1994 to June 2000, 356 consecutive high and intermediate risk patients were treated with three-dimensional computed tomography-guided stereotactic pararectal brachytherapy. The age was 42-90 years (median, 68 years), the initial prostate volume was 14-180 cm3 (median, 59 cm3), and initial PSA was 1.7-143 ng/ml (median, 10.5 ng/ml). Three hundred forty-eight patients were available for follow-up for 2-8 years (median, 4.5 years). Two hundred eighty patients had one or more high risk factors (PSA >20 ng/ml, Gleason>7, Stage T2b, T3a, or T3b). Sixty-eight patients had only one intermediate risk factor (PSA 10-20 ng/ml or Gleason=7). Patients with both intermediate risks were considered high risk. The high-risk group was further stratified into subgroups with similar risk profile. A dose of 144 Gy with 125I or 120 Gy with 103Pd was achieved in 90-100% of the target. Thirty (30) patients (9%) had prior transurethral resection and 229 (64%) were treated with 3 months neoadjuvant androgen ablation.

RESULTS

Biochemical disease-free survival was 92% of 280 high risk patients and 96% of 68 intermediate risk patients. Seven patients (2%) required catheterization during the first year for urinary retention, nine patients (3%) required TUR 1-3 years post-implant, three patients (1%) developed grade 1 or 2 incontinence after a second TUR, and four patients (1%) developed grade 3 rectal complications.

CONCLUSION

This method produces a high level of biochemical control 2-8 years (median 4.5 years). Morbidity is acceptable regardless of risk profile or initial prostate volume.

Role of hormonal therapy in the management of intermediate- to high-risk prostate cancer treated with permanent radioactive seed implantation

PURPOSE

To study the impact of hormonal therapy (HTx) on intermediate- to high-risk prostate cancer treated with permanent radioactive seed implantation.

METHODS AND MATERIALS

Patients with Stage T1b-T3bN0 prostate cancer, and Gleason score > or = 7 or prostate-specific antigen (PSA) level >10 ng/mL were treated with seed implantation with or without HTx. Their disease was defined as intermediate risk (PSA 10-20, Gleason score 7, or Stage T2b) or high risk (two or more intermediate criteria, or PSA >20 ng/mL, Gleason score 8-10, or Stage T2c-T3). The median follow-up for 201 eligible patients was 42 months (range 18-110). Biochemical failure was defined as a rising PSA >1.0 ng/mL. Pretreatment disease characteristics, implant dose, and HTx were evaluated using univariate and multivariate analyses.

RESULTS

HTx significantly improved 5-year actuarial freedom from biochemical failure rate, 79% vs. 54% without HTx. In addition, high-dose, PSA < or = 15 ng/mL, intermediate risk, and Stage T2a or lower significantly improved outcome in the univariate analyses. HTx was the most significant predictor of 5-year actuarial freedom from biochemical failure (p <0.0001) in a multivariate analysis. The best outcome was in the intermediate-risk patients treated with a high implant dose and HTx, resulting in a 4-year actuarial freedom from biochemical failure rate of 94%.

CONCLUSION

In this retrospective review, HTx improved outcome in intermediate- to high-risk prostate cancer patients treated with brachytherapy. HTx was the most important prognostic factor in the univariate and multivariate analyses.

The cost effectiveness of 3D conformal radiation therapy compared with conventional techniques for patients with clinically localized prostate cancer

BACKGROUND

We previously demonstrated the advantages of three-dimensional conformal radiation therapy (3DCRT) in improved rates of biochemical (bNED) control in certain subsets of patients with clinically localized prostate cancer. However, in this era of cost consciousness and limited resources, the cost effectiveness of 3DCRT compared with conventional external beam irradiation (CRT) remains unexamined.

METHODS AND MATERIALS

Between October 1, 1987 and November 30, 1991, 193 patients with clinically localized prostate cancer received definitive external beam irradiation at Fox Chase Cancer Center. The 1998 Medicare fee schedule was used to determine treatment charges and to provide a reference for a national comparison. Complete charges for pretreatment work-up, treatment, and follow-up were tabulated for each patient. The mean total charges (MTC) using the Lin method of estimating medical costs was used to analyze and compare costs between groups. A matched case/control analysis was performed to further evaluate the effect of cost between techniques. The median follow-up was 72 months (range 3-118).

RESULTS

The overall 5-year actuarial rate of bNED control was 41% and 53%, respectively, for the CRT and 3DCRT patients (p = 0.03). The MTC for the CRT patients was $10,544.53. For the 3DCRT patients, the MTC was $8,955.48. The sample mean of the total costs from the observed deaths for the two patient groups by follow-up interval ranged from $9,800.63 to $59,635.01 for the CRT patients to $17,259.00 to $24,250.38 for the 3DCRT patients. No statistically significant difference in cost was observed between groups using the matched case/control analysis.

CONCLUSION

Initial work-up and treatment costs were greater for patients treated with 3DCRT compared with patients treated with conventional techniques. However, with longer follow-up, the mean total cost of treatment was not statistically different between the two treatment groups. Because of improved rates of bNED control for these patients and the increased costs associated with the treatment of a greater fraction of patients with recurrent disease following CRT, 3DCRT was cost effective for patients with clinically localized prostate cancer.

Is there a role for short-term hormone use in the treatment of nonmetastatic prostate cancer?

We reviewed our institution's experience treating patients with prostate cancer with 3-dimensional conformal radiation therapy (3DCRT) and short-term adjuvant hormonal therapy to determine biochemical no evidence of disease (bNED) and clinical outcome compared with patients treated with 3DCRT alone. Between 4/1/89 and 11/30/94, 558 patients with clinically localized prostate cancer received treatment at Fox Chase Cancer Center (Philadelphia, Pa.); 484 patients were treated with 3DCRT alone (Group I); 74 patients were treated with 3DCRT and hormones (Group II). Five-year actuarial rates of bNED control, distant metastasis-free survival (DMFS), cause-specific survival (CSS), and overall survival (OS) were calculated for pretreatment PSA, Gleason score, T stage, use of hormones, treatment field size, age, and dose. A matched case/control analysis was performed to further evaluate the effect of hormones on treatment with 3DCRT. Median follow-up was 47 months (range: 2-97 months). The 5-year actuarial rates of bNED control, DMFS, CSS, and OS were 66%, 93%, 98%, and 86%, respectively, for Group I patients and 68%, 93%, 98%, and 89%, respectively, for Group II patients. Multivariate analysis demonstrated that hormone use was an independent predictor of bNED control only. A significant difference in bNED control was observed between Group I and II (43% vs. 71%) using the matched case/control analysis (P = 0.02). A trend towards significance was observed for different rates of DMFS between Group I and II (79% vs. 94%, P = 0.09). Patients with clinically localized prostate cancer with poor prognostic features (pretreatment PSA > or = 10 ng/ml, Gleason score > or = 7, and/or T2c or greater palpation stage) show improved rates of bNED control and a trend towards improved DMFS when treated with 3DCRT and short-term adjuvant hormones compared with 3DCRT alone. Long-term observation will be necessary to see if improvements in bNED control will translate into improvements in overall survival.

The role of androgen deprivation in the definitive management of clinically localized prostate cancer treated with radiation therapy

PURPOSE

Multiple studies exploring the use of androgen deprivation given in combination with radiotherapy (RT) for localized prostate cancer have reported significant improvements in the rates of local, regional, and biochemical control (BC). The impact of this therapeutic strategy on overall and cancer specific survival (CSS) has not been established, however. We performed a MEDLINE search of all available studies on this topic to determine if any conclusions could be reached on the efficacy of this treatment approach and the patients most suitable for its application.

MATERIALS AND METHODS

A MEDLINE search was conducted to obtain all articles in the English language on the use of androgen deprivation in combination with RT for the treatment of localized prostate cancer. The medical subject headings (MeSH) used to search the MEDLINE database included: a) prostatic neoplasms; b) prostatic neoplasms/radiotherapy; c) prostatic neoplasms/androgen deprivation; d) hormone therapy; e) English; and f) 1980 to 1998.

RESULTS

A total of 14 retrospective studies were identified that compared some form of androgen deprivation given in combination with RT. Most studies showed significant improvements in various measures of local/regional control and disease-free survival (DFS). Three of four studies that analyzed BC rates showed significant improvements in this endpoint but conflicting results were obtained for overall survival (OS). No study showed an improvement in CSS. Six prospective randomized trials were identified that directly compared RT with or without androgen deprivation. Again, all six studies showed improvements in some measure of local/regional control or DFS but only two studies showed an improvement in OS. One study reported a statistically significant improvement in CSS and another study showed an improvement in the rate of negative biopsies with combined treatment.

CONCLUSIONS

When all available literature on androgen withdrawal given in combination with RT for the definitive treatment of localized prostate cancer was reviewed, no definite conclusions could be reached on the impact of this treatment approach on OS and CSS. However, local/regional control, DFS, and BC were almost uniformly improved with the use of androgen withdrawal suggesting that these impressive early results may translate into improved cure rates. Data from recently initiated and completed randomized trials will be needed, however, to define the impact of this approach on cancer specific mortality and the patients most suitable for it's use.

Pion conformal radiation of prostate cancer: results of a randomized study

PURPOSE

To compare the efficacy of pion radiation therapy with conventional external beam photon therapy, for the treatment of locally advanced stage T3/4, N0, M0 adenocarcinoma of the prostate.

METHODS AND MATERIALS

Two hundred seventeen eligible patients were randomly allocated to either photon or pion therapy. No adjuvant hormone therapy was used.

RESULTS

Median follow-up was 42 months (range 2-90). Acute bladder toxicity was worse in the pion arm, p = 0.2, but other acute toxicity did not differ. Late grade 2 toxicity was significantly less in the pion arm (29% at 5 years versus 48%, p = 0.002), but late grade 3 or 4 toxicity did not differ. Clinical local control was not significantly different between treatment arms (64% after 5 years with photons, 56% with pions, p = 0.6). Cause-specific and overall survival also did not differ (p = 0.7). There was a significant delay in time to first failure in the photon arm, largely as a result of decreased biochemical relapse, p = 0.01. A multivariate analysis is presented.

CONCLUSION

Pion therapy was well tolerated, with increased acute toxicity and significantly decreased late tissue injury. This contrasts with the late toxicity observed with higher LET particle therapy such as neutron therapy. No improvement in local control with pion therapy was observed.