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Nikitas J, Ong WL, Carrier N, Romero T, Millar J, Steinberg ML, Rettig MB, Boutros PC, Reiter R, Nickols NG, Valle L, McGuire SE, Spratt DE, Souhami L, Roy S, Martin JM, Joseph D, Nabid A, Kishan AU. Prostate-Specific Antigen Response to Androgen Deprivation Therapy in the Neoadjuvant Setting for High-Risk Prostate Adenocarcinoma (PIRANHA): Pooled Analysis of Two Randomized Clinical Trials. Int J Radiat Oncol Biol Phys 2024; 119:826-831. [PMID: 38151191 DOI: 10.1016/j.ijrobp.2023.12.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 11/30/2023] [Accepted: 12/15/2023] [Indexed: 12/29/2023]
Abstract
PURPOSE A suboptimal prostate-specific antigen (PSA) response to neoadjuvant androgen deprivation therapy (ADT) among men who go on to receive definitive radiation therapy for prostate cancer might suggest the existence of castration-resistant disease or altered androgen receptor signaling. This in turn may portend worse long-term clinical outcomes, especially in men with high-risk disease. We set out to evaluate the prognostic impact of poor PSA response to neoadjuvant ADT in men with high-risk prostate cancer. METHODS AND MATERIALS This was a post hoc analysis of the multicenter TROG 03.04 RADAR and PCS IV randomized clinical trials. Inclusion criteria for this analysis were patients with high-risk prostate cancer (defined as Gleason score ≥8, initial PSA ≥20 ng/mL, or cT3a disease or higher) who received definitive radiation therapy, at least 18 months of ADT, and had a preradiation therapy PSA level drawn after at least 3 months of neoadjuvant ADT. Poor PSA response was defined as PSA >0.5 ng/mL. Cox regression and Fine-Gray models were used to test whether poor PSA response was associated with metastasis-free survival, biochemical recurrence, prostate-cancer specific mortality, and overall survival. RESULTS Nine hundred thirty men met inclusion criteria for this analysis. Median follow-up was 130 months (interquartile range [IQR], 89-154 months). After a median of 3 months (IQR, 3-4.2 months) of neoadjuvant ADT, the median PSA was 0.60 ng/mL (IQR, 0.29-1.59). Overall, 535 men (57%) had a PSA >0.5 ng/mL. Poor PSA response was associated with significantly worse metastasis-free survival (hazard ratio [HR], 3.93; P = .02), worse biochemical recurrence (subdistribution HR, 2.39; P = .003), worse prostate-cancer specific mortality (subdistribution HR, 1.50; P = .005), and worse overall survival (HR, 4.51; P = .05). CONCLUSIONS Patients with PSA >0.5 mg/mL after at least 3 months of neoadjuvant ADT had worse long-term clinical outcomes and should be considered for treatment intensification.
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Affiliation(s)
- John Nikitas
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, California
| | - Wee Loon Ong
- Alfred Health Radiation Oncology, Central Clinical School, Monash University, Melbourne, Victoria, Australia; Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Heath Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Nathalie Carrier
- Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Tahmineh Romero
- Department of Medicine Statistics Core, University of California, Los Angeles, Los Angeles, California
| | - Jeremy Millar
- Alfred Health Radiation Oncology, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Michael L Steinberg
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, California
| | - Matthew B Rettig
- Division of Hematology and Oncology, David Geffen School of Medicine, University of California, Los Angeles, California; Hematology-Oncology Section, Medicine Service, Greater Los Angeles Veterans Affairs Healthcare System, Los Angeles, California
| | - Paul C Boutros
- Department of Urology, University of California, Los Angeles, Los Angeles, California
| | - Robert Reiter
- Department of Urology, University of California, Los Angeles, Los Angeles, California
| | - Nicholas G Nickols
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, California; Radiation Oncology Service, Greater Los Angeles Veterans Affairs Healthcare System, Los Angeles, California
| | - Luca Valle
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, California; Radiation Oncology Service, Greater Los Angeles Veterans Affairs Healthcare System, Los Angeles, California
| | - Sean E McGuire
- Department of Radiation Oncology, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Daniel E Spratt
- Department of Radiation Oncology, University Hospital Seidman Cancer Center, Case Western Reserve University, Cleveland, Ohio
| | - Luis Souhami
- Department of Radiation Oncology, McGill University Health Centre, Montreal, Quebec, Canada
| | - Soumyajit Roy
- Department of Radiation Oncology, Rush University, Chicago, Illinois
| | - Jarad M Martin
- Department of Radiation Oncology, Calvary Mater Newcastle & School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia
| | - David Joseph
- University of Western Australia, Perth, Western Australia, Australia; Genesis Cancer Care, Perth, Western Australia, Australia; 5D Clinics, Perth, Western Australia, Australia
| | - Abdenour Nabid
- Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Amar U Kishan
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, California.
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Ong WL, Nikitas J, Joseph D, Steigler A, Millar J, Valle L, Steinberg ML, Ma TM, Reiter RE, Rettig MB, Nickols NG, Chang A, Zaorsky NG, Spratt DE, Romero T, Kishan AU. Long-Term Quality-of-Life Outcomes After Prostate Radiation Therapy With or Without High-Dose-Rate Brachytherapy Boost: Post Hoc Analysis of TROG 03.04 RADAR. Int J Radiat Oncol Biol Phys 2024; 119:813-825. [PMID: 37802226 DOI: 10.1016/j.ijrobp.2023.09.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 09/15/2023] [Accepted: 09/28/2023] [Indexed: 10/08/2023]
Abstract
PURPOSE Adding high-dose-rate brachytherapy (BT) boost to external beam radiation therapy (EBRT) improves biochemical control but may affect patient-reported quality of life (QOL). We sought to determine long-term QOL outcomes for EBRT+BT versus EBRT alone. METHODS AND MATERIALS This was a post hoc analysis of the Trans-Tasman Radiation Oncology Group 03.04 Randomized Androgen Deprivation and Radiotherapy (TROG 03.04 RADAR) trial. Only patients who received 74 Gy conventionally fractionated EBRT (n = 260) or 46 Gy conventionally fractionated EBRT plus 19.5 Gy in 3 fractions high-dose-rate BT boost (n = 237) were included in this analysis. The primary endpoint was patient-reported QOL measured using the European Organisation for Research and Treatment of Cancer QOL (EORTC QLQ-C30) and prostate-specific QOL module (EORTC QLQ-PR25) questionnaires. We evaluated temporal changes in QOL scores, rates of symptom resolution, and the proportion of men who had decrements from baseline of >2 × the threshold for minimal clinically important change (2 × MCIC) for each domain. RESULTS At 5, 17, and 29 months after radiation therapy, the EBRT+BT group had 2.5 times (95% confidence interval [CI], 1.4-4.2; P < .001), 2.9 times (95% CI, 1.7-4.9; P < .001), and 2.6 times (95% CI, 1.4-4.6; P = .002) greater odds of reporting 2 × MCIC in urinary QOL score compared with EBRT. There were no differences beyond 29 months. EBRT+BT led to a slower rate of urinary QOL symptom score resolution up to 17 months after radiation therapy compared with EBRT (P < .001) but not at later intervals. In contrast, at the end of the radiation therapy period and at 53 months after radiation therapy, the EBRT+BT group had 0.65 times (95% CI, 0.44-0.96; P = .03) and 0.51 times (95% CI, 0.32-0.79; P = .003) the odds of reporting 2 × MCIC in bowel QOL symptom scores compared with EBRT. There were no significant differences in the rate of bowel QOL score resolution. There were no significant differences in global health status or sexual activity scores between the 2 groups. CONCLUSIONS There were no persistent differences in patient-reported QOL measures between EBRT alone and EBRT+BT. BT boost does not appear to negatively affect long-term, patient-reported QOL.
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Affiliation(s)
- Wee Loon Ong
- Alfred Health Radiation Oncology, Central Clinical School, Monash University, Melbourne, Victoria, Australia; Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Heath Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - John Nikitas
- Department of Radiation Oncology, University of California, Los Angeles, California
| | - David Joseph
- Department of Medicine and Surgery, University of Western Australia, Perth, Western Australia, Australia
| | - Allison Steigler
- School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia
| | - Jeremy Millar
- Alfred Health Radiation Oncology, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Luca Valle
- Department of Radiation Oncology, University of California, Los Angeles, California
| | - Michael L Steinberg
- Department of Radiation Oncology, University of California, Los Angeles, California
| | - Ting Martin Ma
- Department of Radiation Oncology, University of California, Los Angeles, California
| | - Robert E Reiter
- Department of Urology, University of California, Los Angeles, California
| | - Matthew B Rettig
- Division of Hematology and Oncology, David Geffen School of Medicine, University of California, Los Angeles, California; Division of Hematology and Oncology, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California
| | - Nicholas G Nickols
- Department of Radiation Oncology, University of California, Los Angeles, California; Department of Radiation Oncology, Veteran Affairs Greater Los Angeles Healthcare System, Los Angeles, California
| | - Albert Chang
- Department of Radiation Oncology, University of California, Los Angeles, California
| | - Nicholas G Zaorsky
- Department of Radiation Oncology, University Hospitals Seidman Cancer Centre, Cleveland Medical Centre, Cleveland, Ohio
| | - Daniel E Spratt
- Department of Radiation Oncology, University Hospitals Seidman Cancer Centre, Cleveland Medical Centre, Cleveland, Ohio
| | - Tahmineh Romero
- Department of Medicine Statistics Core, University of California, Los Angeles, California
| | - Amar U Kishan
- Department of Radiation Oncology, University of California, Los Angeles, California.
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Nikitas J, Kishan A, Chang A, Duriseti S, Nichols NG, Reiter R, Rettig M, Brisbane W, Steinberg ML, Valle L. Treatment intensification strategies for men undergoing definitive radiotherapy for high-risk prostate cancer. World J Urol 2024; 42:165. [PMID: 38492111 DOI: 10.1007/s00345-024-04862-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 02/08/2024] [Indexed: 03/18/2024] Open
Abstract
PURPOSE Treatment intensification of external beam radiotherapy (EBRT) plays a crucial role in the treatment of high-risk prostate cancer. METHODS We performed a critical narrative review of the relevant literature and present new developments in evidence-based treatment intensification strategies. RESULTS For men with high-risk prostate cancer, there is strong evidence to support prolonging androgen deprivation therapy (ADT) to 18-36 months and escalating the dose to the prostate using a brachytherapy boost. A potentially less toxic alternative to a brachytherapy boost is delivering a focal boost to dominant intraprostatic lesions using EBRT. In patients who meet STAMPEDE high-risk criteria, there is evidence to support adding a second-generation anti-androgen agent, such as abiraterone acetate, to long-term ADT. Elective pelvic lymph node irradiation may be beneficial in select patients, though more prospective data is needed to elucidate the group of patients who may benefit the most. Tumor genomic classifier (GC) testing and advanced molecular imaging will likely play a role in improving patient selection for treatment intensification as well as contribute to the evolution of treatment intensification strategies for future patients. CONCLUSION Treatment intensification using a combination of EBRT, advanced hormonal therapies, and brachytherapy may improve patient outcomes and survival in men with high-risk prostate cancer. Shared decision-making between patients and multidisciplinary teams of radiation oncologists, urologists, and medical oncologists is essential for personalizing care in this setting and deciding which strategies make sense for individual patients.
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Affiliation(s)
- John Nikitas
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, USA
| | - Amar Kishan
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, USA
| | - Albert Chang
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, USA
| | - Sai Duriseti
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, USA
- Radiation Oncology Service, Greater Los Angeles Veterans Affairs Healthcare System, Los Angeles, USA
| | - Nicholas G Nichols
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, USA
- Radiation Oncology Service, Greater Los Angeles Veterans Affairs Healthcare System, Los Angeles, USA
| | - Robert Reiter
- Department of Urology, University of California, Los Angeles, Los Angeles, USA
| | - Matthew Rettig
- Department of Urology, University of California, Los Angeles, Los Angeles, USA
- Hematology-Oncology Section, Medicine Service, Greater Los Angeles Veterans Affairs Healthcare System, Los Angeles, USA
| | - Wayne Brisbane
- Department of Urology, University of California, Los Angeles, Los Angeles, USA
| | - Michael L Steinberg
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, USA
| | - Luca Valle
- Radiation Oncology Service, Greater Los Angeles Veterans Affairs Healthcare System, Los Angeles, USA.
- Department of Radiation Oncology, University of California, Los Angeles, 200 Medical Plaza, Ste B265, Los Angeles, CA, 90095, USA.
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Gomez-Iturriaga A, Büchser D, Lopez-Campos F, Maldonado X. Enhancing Androgen Deprivation Therapy (ADT) integration in prostate cancer: Insights for Stereotactic Body Radiotherapy (SBRT) and brachytherapy modalities. Clin Transl Radiat Oncol 2024; 45:100733. [PMID: 38322544 PMCID: PMC10844661 DOI: 10.1016/j.ctro.2024.100733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 01/17/2024] [Accepted: 01/21/2024] [Indexed: 02/08/2024] Open
Abstract
The utilization of Androgen Deprivation Therapy (ADT) in conjunction with Stereotactic Body Radiotherapy (SBRT) and Brachytherapy (BT) boost in prostate cancer treatment is a subject of ongoing debate and evolving clinical practice. While contemporary trends lean towards underutilizing ADT with these modalities, existing evidence suggests that its omission may lead to potentially inferior oncologic outcomes. Recommendations for ADT use should be patient-centric, considering individual risk profiles and comorbidities, with a focus on achieving optimal oncologic outcomes while minimizing potential side effects. Ongoing clinical trials, such as PACE-C, SPA, SHIP 0804, and SHIP 36B, are anticipated to provide valuable insights into the optimal use and duration of ADT in both SBRT and BT settings. Until new evidence emerges, it is recommended to initiate ADT for unfavorable intermediate-risk and high-risk prostate cancer patients undergoing radiotherapy, with a minimum duration of 6 months for unfavorable intermediate-risk patients and at least 12 months for those with high-risk characteristics. The decision to incorporate ADT into these radiation therapy modalities should be individualized, acknowledging the unique needs of each patient and emphasizing a tailored approach to achieve the best possible oncologic outcomes.
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Affiliation(s)
- A. Gomez-Iturriaga
- Hospital Universitario Cruces/ Biobizkaia Health Research Institute, Radiation Oncology, Barakaldo, Spain
- Department of Surgery and Radiology and Physical Medicine, University of the Basque Country UPV/EHU, Spain
| | - D. Büchser
- Hospital Universitario Cruces/ Biobizkaia Health Research Institute, Radiation Oncology, Barakaldo, Spain
- Department of Surgery and Radiology and Physical Medicine, University of the Basque Country UPV/EHU, Spain
| | - F. Lopez-Campos
- Hospital Universitario Ramon y Cajal, Radiation Oncology, Madrid, Spain
| | - X. Maldonado
- Hospital Vall d́Hebron, Radiation Oncology, Barcelona, Spain
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King MT, Orio PF, D'Amico AV. Can Extreme Dose Escalation With External Beam Radiation Therapy and Low-Dose-Rate Brachytherapy Boost Obviate the Need for Long-Term Androgen Deprivation Therapy in Patients With High-Risk Localized Prostate Cancer? Int J Radiat Oncol Biol Phys 2024; 118:402-403. [PMID: 38220257 DOI: 10.1016/j.ijrobp.2023.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 11/05/2023] [Indexed: 01/16/2024]
Affiliation(s)
- Martin T King
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, Massachusetts.
| | - Peter F Orio
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Anthony V D'Amico
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, Massachusetts
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Norquest CJ, Rogic A, Gimotty PA, Maitz CA, Rindt H, Ashworth HL, Bryan JN, Donnelly LL, McCleary-Wheeler AL, Flesner BK. Effects of neoadjuvant zoledronate and radiation therapy on cell survival, cell cycle distribution, and clinical status in canine osteosarcoma. Front Vet Sci 2024; 11:1237084. [PMID: 38362299 PMCID: PMC10867971 DOI: 10.3389/fvets.2024.1237084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 01/12/2024] [Indexed: 02/17/2024] Open
Abstract
Introduction Zoledronic acid (ZOL) is a third-generation bisphosphonate with a higher affinity for bone resorption areas than earlier bisphosphonates (i.e., pamidronate, PAM). In human medicine, ZOL provides improved bone pain relief and prolonged time to skeletal-related events compared to its older generational counterparts. Preclinical studies have investigated its role as an anti-neoplastic agent, both independently and synergistically, with radiation therapy (RT). ZOL and RT act synergistically in several neoplastic human cell lines: prostate, breast, osteosarcoma, and fibrosarcoma. However, the exact mechanism of ZOL's radiosensitization has not been fully elucidated. Methods We investigated ZOL's ability to induce apoptosis in canine osteosarcoma cell lines treated with various doses of megavoltage external beam radiotherapy. Second, we evaluated cell cycle arrest in ZOL-treated cells to assess several neo-adjuvant time points. Finally, we treated 20 dogs with naturally occurring appendicular OS with 0.1 mg/kg ZOL IV 24 h before receiving 8 Gy of RT (once weekly fraction x 4 weeks). Results We found that apoptosis was increased in all ZOL-treated cell lines compared to controls, and the combination of ZOL and RT resulted in dissimilar apoptosis between Abrams and D-17 and HMPOS cell lines. Cell cycle arrest (G2/M phase) was minimal and variable between cell lines but perhaps greatest at 48 h post-ZOL treatment. Only 10% of dogs treated with ZOL and RT developed pathologic fractures, compared to 44% of dogs historically treated with PAM and RT (p = 0.027). Discussion ZOL and RT appear to be a well-tolerated combination treatment scheme for non-surgical candidates; future studies must elucidate the ideal timing of ZOL.
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Affiliation(s)
- Carissa J. Norquest
- Department of Veterinary Medicine & Surgery, University of Missouri College of Veterinary Medicine, Columbia, MO, United States
| | - Anita Rogic
- Department of Veterinary Medicine & Surgery, University of Missouri College of Veterinary Medicine, Columbia, MO, United States
| | - Phyllis A. Gimotty
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania School of Medicine, Philadelphia, PA, United States
| | - Charles A. Maitz
- Department of Veterinary Medicine & Surgery, University of Missouri College of Veterinary Medicine, Columbia, MO, United States
| | - Hansjorg Rindt
- Department of Veterinary Medicine & Surgery, University of Missouri College of Veterinary Medicine, Columbia, MO, United States
| | - Hayley L. Ashworth
- Department of Veterinary Medicine & Surgery, University of Missouri College of Veterinary Medicine, Columbia, MO, United States
| | - Jeffrey N. Bryan
- Department of Veterinary Medicine & Surgery, University of Missouri College of Veterinary Medicine, Columbia, MO, United States
| | - Lindsay L. Donnelly
- Department of Veterinary Medicine & Surgery, University of Missouri College of Veterinary Medicine, Columbia, MO, United States
| | - Angela L. McCleary-Wheeler
- Department of Veterinary Medicine & Surgery, University of Missouri College of Veterinary Medicine, Columbia, MO, United States
| | - Brian K. Flesner
- Department of Veterinary Medicine & Surgery, University of Missouri College of Veterinary Medicine, Columbia, MO, United States
- Department of Clinical Sciences & Advanced Medicine, University of Pennsylvania School of Veterinary Medicine, Philadelphia, PA, United States
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Zhou W, Zhang W, Yan S, Zhang K, Wu H, Chen H, Shi M, Zhou T. Novel Therapeutic Targets on the Horizon: An Analysis of Clinical Trials on Therapies for Bone Metastasis in Prostate Cancer. Cancers (Basel) 2024; 16:627. [PMID: 38339378 PMCID: PMC10854912 DOI: 10.3390/cancers16030627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Revised: 12/03/2023] [Accepted: 12/11/2023] [Indexed: 02/12/2024] Open
Abstract
In the absence of early detection and initial treatment, prostate cancer often progresses to an advanced stage, frequently spreading to the bones and significantly impacting patients' well-being and healthcare resources. Therefore, managing patients with prostate cancer that has spread to the bones often involves using bone-targeted medications like bisphosphonates and denosumab to enhance bone structure and minimize skeletal complications. Additionally, researchers are studying the tumor microenvironment and biomarkers to understand the mechanisms and potential treatment targets for bone metastases in prostate cancer. A literature search was conducted to identify clinical studies from 2013 to 2023 that focused on pain, performance status, or quality of life as primary outcomes. The analysis included details such as patient recruitment, prior palliative therapies, baseline characteristics, follow-up, and outcome reporting. The goal was to highlight the advancements and trends in bone metastasis research in prostate cancer over the past decade, with the aim of developing strategies to prevent and treat bone metastases and improve the quality of life and survival rates for prostate cancer patients.
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Affiliation(s)
- Wenhao Zhou
- Department of Urology, Shanghai Fourth People’s Hospital, School of Medicine, Tongji University, Shanghai 200434, China; (W.Z.); (S.Y.); (K.Z.); (H.W.)
| | - Wei Zhang
- Department of Urology, Changhai Hospital, Naval Medical University, Shanghai 200433, China;
| | - Shi Yan
- Department of Urology, Shanghai Fourth People’s Hospital, School of Medicine, Tongji University, Shanghai 200434, China; (W.Z.); (S.Y.); (K.Z.); (H.W.)
| | - Kaixuan Zhang
- Department of Urology, Shanghai Fourth People’s Hospital, School of Medicine, Tongji University, Shanghai 200434, China; (W.Z.); (S.Y.); (K.Z.); (H.W.)
| | - Han Wu
- Department of Urology, Shanghai Fourth People’s Hospital, School of Medicine, Tongji University, Shanghai 200434, China; (W.Z.); (S.Y.); (K.Z.); (H.W.)
| | - Hongyu Chen
- School of Medicine, Tongji University, Shanghai 200092, China;
| | - Minfeng Shi
- Reproduction Center, Changhai Hospital, Naval Medical University, Shanghai 200433, China
| | - Tie Zhou
- Department of Urology, Shanghai Fourth People’s Hospital, School of Medicine, Tongji University, Shanghai 200434, China; (W.Z.); (S.Y.); (K.Z.); (H.W.)
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Deville C, Kamran SC, Morgan SC, Yamoah K, Vapiwala N. Radiation Therapy Summary of the AUA/ASTRO Guideline on Clinically Localized Prostate Cancer. Pract Radiat Oncol 2024; 14:47-56. [PMID: 38182303 DOI: 10.1016/j.prro.2023.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 09/12/2023] [Accepted: 09/14/2023] [Indexed: 01/07/2024]
Abstract
PURPOSE Our purpose was to develop a summary of recommendations regarding the management of patients with clinically localized prostate cancer based on the American Urologic Association/ ASTRO Guideline on Clinically Localized Prostate Cancer. METHODS The American Urologic Association and ASTRO convened a multidisciplinary, expert panel to develop recommendations based on a systematic literature review using an a priori defined consensus-building methodology. The topics covered were risk assessment, staging, risk-based management, principles of management including active surveillance, surgery, radiation, and follow-up after treatment. Presented are recommendations from the guideline most pertinent to radiation oncologists with an additional statement on health equity, diversity, and inclusion related to guideline panel composition and the topic of clinically localized prostate cancer. SUMMARY Staging, risk assessment, and management options in prostate cancer have advanced over the last decade and significantly affect shared decision-making for treatment management. Current advancements and controversies discussed to guide staging, risk assessment, and treatment recommendations include the use of advanced imaging and tumor genomic profiling. An essential active surveillance strategy includes prostate-specific antigen monitoring and periodic digital rectal examination with changes triggering magnetic resonance imaging and possible biopsy thereafter and histologic progression or greater tumor volume prompting consideration of definitive local treatment. The panel recommends against routine use of adjuvant radiation therapy (RT) for patients with prostate cancer after prostatectomy with negative nodes and an undetectable prostate-specific antigen, while acknowledging that patients at highest risk of recurrence were relatively poorly represented in the 3 largest randomized trials comparing adjuvant RT to early salvage and that a role may exist for adjuvant RT in selected patients at highest risk. RT for clinically localized prostate cancer has evolved rapidly, with new trial results, therapeutic combinations, and technological advances. The recommendation of moderately hypofractionated RT has not changed, and the updated guideline incorporates a conditional recommendation for the use of ultrahypofractionated treatment. Health disparities and inequities exist in the management of clinically localized prostate cancer across the continuum of care that can influence guideline concordance.
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Affiliation(s)
- Curtiland Deville
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, Maryland.
| | - Sophia C Kamran
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Scott C Morgan
- Department of Radiology, Radiation Oncology and Medical Physics, University of Ottawa, Ottawa, Ontario, Canada
| | - Kosj Yamoah
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
| | - Neha Vapiwala
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania
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Jahreiβ MC, Incrocci L, Dirkx M, de Vries KC, Aben KKH, Bangma C, Heemsbergen WD. Long-term Overall Survival after External Beam Radiotherapy for Localised Prostate Cancer. Clin Oncol (R Coll Radiol) 2023; 35:e689-e698. [PMID: 37852813 DOI: 10.1016/j.clon.2023.09.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 08/28/2023] [Accepted: 09/28/2023] [Indexed: 10/20/2023]
Abstract
AIMS Knowledge on survival probabilities is essential for determining optimal treatment strategies. We studied overall survival and associated prognostic factors in Dutch patients with localised prostate cancer (PCa) selected for external beam radiotherapy. MATERIALS AND METHODS For this single-centre retrospective cohort study, we identified all T1-T3 PCa patients (aged 55-80 years) in the radiotherapy planning database with a start date between January 2006 and December 2013, treated with 72-78 Gy in 2 Gy fractions to the prostate ± seminal vesicles (n = 1536). Long-term androgen deprivation therapy (ADT) was predominantly prescribed in the case of extracapsular disease (>T3). Overall survival was estimated using the Kaplan-Meier method. Prognostic factors were evaluated in Cox regression models for the intermediate-risk and high-risk groups. RESULTS The median follow-up was 12 years for patients who were alive. Ten-year survival rates were 79.0% for low-risk (n = 120), 59.9% for intermediate-risk (n = 430) and 56.8% for high-risk patients (n = 986). A higher age, higher comorbidity score, active smoking and Gleason score ≥8 had a statistically significant negative impact on overall survival at multivariable analysis. ADT was associated with superior overall survival in the high-risk group translating into overall survival rates similar to the intermediate-risk group. CONCLUSIONS Although PCa patients selected for external beam radiotherapy are typically in good health, their comorbidity score and smoking habits appeared to be dominant predictors for overall survival. Overall survival rates within the high-risk group varied, showing improved overall survival with ADT prescription and worse overall survival in the case of Gleason score ≥8.
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Affiliation(s)
- M-C Jahreiβ
- Department of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - L Incrocci
- Department of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - M Dirkx
- Department of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - K C de Vries
- Department of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - K K H Aben
- Department of Research, Netherlands Comprehensive Cancer Organization, Utrecht, The Netherlands; Department for Health Evidence, Radboud University Medical Center, Nijmegen, The Netherlands
| | - C Bangma
- Department of Urology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - W D Heemsbergen
- Department of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands.
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10
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Nakazono M, Urabe F, Iwatani K, Imai Y, Tashiro K, Honda M, Koike Y, Shimomura T, Sato S, Takahashi H, Miki K, Aoki M, Kimura T. Patients with PSA below 0.2 ng/mL at 8 years post high-dose-rate brachytherapy have an extremely low risk of subsequent recurrence. Int J Urol 2023; 30:1147-1154. [PMID: 37650359 DOI: 10.1111/iju.15289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 08/17/2023] [Indexed: 09/01/2023]
Abstract
OBJECTIVES We have analyzed the long-term follow-up data of patients with prostate cancer (PCa) who underwent high-dose-rate brachytherapy (HDR-BT) and external beam radiotherapy (EBRT) combined with long-term androgen deprivation therapy (ADT). The objective was to determine the optimal time for cessation of PSA monitoring after HDR-BT. METHODS We included 309 patients with clinical stage T1c-T4 N0-1 M0 PCa who received HDR-BT and EBRT combined with long-term ADT between 2005 and 2018. We stratified the patients based on their prostate-specific antigen (PSA) levels and identified the factors associated with biochemical recurrence (BCR) and clinical progression (CP). RESULTS The median follow-up duration was 98 months (range: 31-207 months). Among the 306 patients, 76 developed BCR and 47 developed CP subsequently. We found that the PSA levels at 3, 5, and 8 years significantly correlated with the oncological outcomes of brachytherapy. No patient with a PSA level ≤ 0.2 ng/mL at 8 years later developed BCR or CP. CONCLUSION Our long-term data suggest that in the presence of a PSA level ≤ 0.2 ng/mL at 8 years later, PSA monitoring may be safely discontinued due to the extremely low risk of subsequent oncological events. The data presented in this study will assist clinicians in determining the optimal management strategy for patients with PCa following HDR-BT and EBRT combined with long-term ADT.
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Affiliation(s)
- Minoru Nakazono
- Department of Urology, The Jikei University School of Medicine, Tokyo, Japan
| | - Fumihiko Urabe
- Department of Urology, The Jikei University School of Medicine, Tokyo, Japan
| | - Kosuke Iwatani
- Department of Urology, The Jikei University School of Medicine, Tokyo, Japan
| | - Yu Imai
- Department of Urology, The Jikei University School of Medicine, Tokyo, Japan
| | - Kojiro Tashiro
- Department of Urology, The Jikei University School of Medicine, Tokyo, Japan
| | - Mariko Honda
- Department of Urology, The Jikei University School of Medicine, Tokyo, Japan
| | - Yusuke Koike
- Department of Urology, The Jikei University School of Medicine, Tokyo, Japan
| | - Tatsuya Shimomura
- Department of Urology, The Jikei University School of Medicine, Tokyo, Japan
| | - Shun Sato
- Department of Pathology, The Jikei University School of Medicine, Tokyo, Japan
| | - Hiroyuki Takahashi
- Department of Pathology, The Jikei University School of Medicine, Tokyo, Japan
| | - Kenta Miki
- Department of Urology, The Jikei University School of Medicine, Tokyo, Japan
| | - Manabu Aoki
- Department of Radiology, The Jikei University School of Medicine, Tokyo, Japan
| | - Takahiro Kimura
- Department of Urology, The Jikei University School of Medicine, Tokyo, Japan
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11
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Roy S, Romero T, Michalski JM, Feng FY, Efstathiou JA, Lawton CA, Bolla M, Maingon P, de Reijke T, Joseph D, Ong WL, Sydes MR, Dearnaley DP, Tree AC, Carrier N, Nabid A, Souhami L, Incrocci L, Heemsbergen WD, Pos FJ, Zapatero A, Guerrero A, Alvarez A, San-Segundo CG, Maldonado X, Reiter RE, Rettig MB, Nickols NG, Steinberg ML, Valle LF, Ma TM, Farrell MJ, Neilsen BK, Juarez JE, Deng J, Vangala S, Avril N, Jia AY, Zaorsky NG, Sun Y, Spratt D, Kishan AU. Biochemical Recurrence Surrogacy for Clinical Outcomes After Radiotherapy for Adenocarcinoma of the Prostate. J Clin Oncol 2023; 41:5005-5014. [PMID: 37639648 PMCID: PMC10642893 DOI: 10.1200/jco.23.00617] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 05/30/2023] [Accepted: 07/12/2023] [Indexed: 08/31/2023] Open
Abstract
PURPOSE The surrogacy of biochemical recurrence (BCR) for overall survival (OS) in localized prostate cancer remains controversial. Herein, we evaluate the surrogacy of BCR using different surrogacy analytic methods. MATERIALS AND METHODS Individual patient data from 11 trials evaluating radiotherapy dose escalation, androgen deprivation therapy (ADT) use, and ADT prolongation were obtained. Surrogate candidacy was assessed using the Prentice criteria (including landmark analyses) and the two-stage meta-analytic approach (estimating Kendall's tau and the R2). Biochemical recurrence-free survival (BCRFS, time from random assignment to BCR or any death) and time to BCR (TTBCR, time from random assignment to BCR or cancer-specific deaths censoring for noncancer-related deaths) were assessed. RESULTS Overall, 10,741 patients were included. Dose escalation, addition of short-term ADT, and prolongation of ADT duration significantly improved BCR (hazard ratio [HR], 0.71 [95% CI, 0.63 to 0.79]; HR, 0.53 [95% CI, 0.48 to 0.59]; and HR, 0.54 [95% CI, 0.48 to 0.61], respectively). Adding short-term ADT (HR, 0.91 [95% CI, 0.84 to 0.99]) and prolonging ADT (HR, 0.86 [95% CI, 0.78 to 0.94]) significantly improved OS, whereas dose escalation did not (HR, 0.98 [95% CI, 0.87 to 1.11]). BCR at 48 months was associated with inferior OS in all three groups (HR, 2.46 [95% CI, 2.08 to 2.92]; HR, 1.51 [95% CI, 1.35 to 1.70]; and HR, 2.31 [95% CI, 2.04 to 2.61], respectively). However, after adjusting for BCR at 48 months, there was no significant treatment effect on OS (HR, 1.10 [95% CI, 0.96 to 1.27]; HR, 0.96 [95% CI, 0.87 to 1.06] and 1.00 [95% CI, 0.90 to 1.12], respectively). The patient-level correlation (Kendall's tau) for BCRFS and OS ranged between 0.59 and 0.69, and that for TTBCR and OS ranged between 0.23 and 0.41. The R2 values for trial-level correlation of the treatment effect on BCRFS and TTBCR with that on OS were 0.563 and 0.160, respectively. CONCLUSION BCRFS and TTBCR are prognostic but failed to satisfy all surrogacy criteria. Strength of correlation was greater when noncancer-related deaths were considered events.
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Affiliation(s)
- Soumyajit Roy
- Department of Radiation Oncology, Rush University Medical Center, Chicago, IL
| | - Tahmineh Romero
- Department of Medicine Statistics Core, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA
| | - Jeff M. Michalski
- Department of Radiation Oncology, Washington University, St Louis, MO
| | - Felix Y. Feng
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA
| | - Jason A. Efstathiou
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Colleen A.F. Lawton
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI
| | - Michel Bolla
- Radiotherapy Department, University Hospital, Grenoble, France
| | - Philippe Maingon
- Department of Oncology, Hematology, and Supportive Care, Sorbonne University, Paris, France
| | - Theo de Reijke
- Department of Urology, Prostate Cancer Network in the Netherlands, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - David Joseph
- Department of Medicine and Surgery, University of Western Australia, Perth, WA, Australia
| | - Wee Loon Ong
- Alfred Health Radiation Oncology, Monash University, Melbourne, VIC, Australia
| | - Matthew R. Sydes
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, University College London, London, United Kingdom
| | - David P. Dearnaley
- Division of Radiotherapy and Imaging, The Institute of Cancer Research and Department of Urology, The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Alison C. Tree
- Department of Radiation Oncology, University of Washington, Seattle, WA
| | - Nathalie Carrier
- Clinical Research Center, Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC, Canada
| | - Abdenour Nabid
- Department of Radiation Oncology, Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC, Canada
| | - Luis Souhami
- Department of Radiation Oncology, McGill University Health Centre, Montréal, QC, Canada
| | - Luca Incrocci
- Department of Radiation Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Wilma D. Heemsbergen
- Department of Radiation Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Floris J. Pos
- Department of Radiation Oncology, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, the Netherlands
| | | | | | - Ana Alvarez
- Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | | | | | - Robert E. Reiter
- Department of Urology, University of California Los Angeles, Los Angeles, CA
| | - Matthew B. Rettig
- Department of Medical Oncology, University of California Los Angeles, Los Angeles, CA
| | - Nicholas G. Nickols
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA
| | - Michael L. Steinberg
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA
| | - Luca F. Valle
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA
| | - T. Martin Ma
- Department of Radiation Oncology, University of Washington, Seattle, WA
| | - Matthew J. Farrell
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA
| | - Beth K. Neilsen
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA
| | - Jesus E. Juarez
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA
| | - Jie Deng
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA
| | - Sitaram Vangala
- Department of Medicine Statistics Core, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA
| | - Norbert Avril
- Department of Radiology, Division of Nuclear Medicine, Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland, OH
| | - Angela Y. Jia
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Nicholas G. Zaorsky
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Yilun Sun
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Case Western Reserve University School of Medicine, Cleveland, OH
- Department of Population Quantitative Health Sciences, Case Western Reserve University, Cleveland, OH
| | - Daniel Spratt
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Amar U. Kishan
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA
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12
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Kato M, Higashi S, Sugino Y, Kajiwara S, Tanaka S, Kitano G, Yamashita Y, Ogura Y, Tachibana H, Kojima T, Inoue T. Clinical Efficacy and Openness to New Challenges of Low Dose Rate Brachytherapy for Prostate Cancer. Curr Oncol 2023; 30:9824-9835. [PMID: 37999133 PMCID: PMC10670683 DOI: 10.3390/curroncol30110713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 10/02/2023] [Accepted: 11/05/2023] [Indexed: 11/25/2023] Open
Abstract
Over a century ago, low-dose-rate (LDR) brachytherapy was introduced to treat prostate cancer (PCa). Since then, it has been widely applied worldwide, including in East Asia. LDR brachytherapy has been performed in 88 institutes in Japan. Beneficial clinical outcomes of LDR brachytherapy for intermediate-to-high-risk PCa have been demonstrated in large clinical trials. These clinical outcomes were achieved through advances in methods, such as urological precise needle puncture and seed placement, and the quantitative decision making regarding radiological parameters by radiation oncologists. The combined use of LDR brachytherapy with other therapeutic modalities, such as external beam radiation and androgen deprivation therapy, for the clinical risk classification of PCa has led to better anticancer treatment efficacy. In this study, we summarized basic LDR brachytherapy findings that should remain unchanged and be passed down in urology departments. We also discussed the applications of LDR brachytherapy for PCa in various clinical settings, including focal and salvage therapies. In addition, we highlighted technologies associated with brachytherapy that are under development.
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Affiliation(s)
- Manabu Kato
- Aichi Cancer Center, Urology, Nagoya 464-8681, Japan; (S.T.); (G.K.); (H.T.); (T.K.)
| | - Shinichiro Higashi
- Department of Nephro-Urologic Surgery and Andrology, Mie University Graduate School of Medicine, Tsu 514-0001, Japan; (S.H.); (Y.S.); (S.K.); (T.I.)
| | - Yusuke Sugino
- Department of Nephro-Urologic Surgery and Andrology, Mie University Graduate School of Medicine, Tsu 514-0001, Japan; (S.H.); (Y.S.); (S.K.); (T.I.)
| | - Shinya Kajiwara
- Department of Nephro-Urologic Surgery and Andrology, Mie University Graduate School of Medicine, Tsu 514-0001, Japan; (S.H.); (Y.S.); (S.K.); (T.I.)
| | - Shiori Tanaka
- Aichi Cancer Center, Urology, Nagoya 464-8681, Japan; (S.T.); (G.K.); (H.T.); (T.K.)
| | - Goshi Kitano
- Aichi Cancer Center, Urology, Nagoya 464-8681, Japan; (S.T.); (G.K.); (H.T.); (T.K.)
| | | | - Yuji Ogura
- Kuwana City Medical Center, Urology, Kuwana 511-0061, Japan;
| | - Hiroyuki Tachibana
- Aichi Cancer Center, Urology, Nagoya 464-8681, Japan; (S.T.); (G.K.); (H.T.); (T.K.)
| | - Takahiro Kojima
- Aichi Cancer Center, Urology, Nagoya 464-8681, Japan; (S.T.); (G.K.); (H.T.); (T.K.)
| | - Takahiro Inoue
- Department of Nephro-Urologic Surgery and Andrology, Mie University Graduate School of Medicine, Tsu 514-0001, Japan; (S.H.); (Y.S.); (S.K.); (T.I.)
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13
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Sosa AJ, Thames HD, Sanders JW, Choi SL, Nguyen QN, Mok H, Ron Zhu X, Shah S, Mayo LL, Hoffman KE, Tang C, Lee AK, Pugh TJ, Kudchadker R, Frank SJ. Proton therapy for the management of localized prostate cancer: Long-term clinical outcomes at a comprehensive cancer center. Radiother Oncol 2023; 188:109854. [PMID: 37597805 DOI: 10.1016/j.radonc.2023.109854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Revised: 08/02/2023] [Accepted: 08/09/2023] [Indexed: 08/21/2023]
Abstract
BACKGROUND AND PURPOSE Proton therapy (PT) has emerged as a standard-of-care treatment option for localized prostate cancer at our comprehensive cancer center. However, there are few large-scale analyses examining the long-term clinical outcomes. Therefore, this article aims to evaluate the long-term effectiveness and toxicity of PT in patients with localized prostate cancer. MATERIALS AND METHODS Review of 2772 patients treated from May 2006 through January 2020. Disease risk was stratified according to National Comprehensive Cancer Network guidelines as low [LR, n = 640]; favorable-intermediate [F-IR, n = 850]; unfavorable-intermediate [U-IR, n = 851]; high [HR, n = 315]; or very high [VHR, n = 116]. Biochemical failure and toxicity were analyzed using Kaplan-Meier estimates and multivariate models. RESULTS The median patient age was 66 years; the median follow-up time was 7.0 years. Pelvic lymph node irradiation was prescribed to 28 patients (1%) (2 [0.2%] U-IR, 11 [3.5%] HR, and 15 [12.9%] VHR). The median dose was 78 Gy in 1.8-2.0 Gy(RBE) fractions. Freedom from biochemical relapse (FFBR) rates at 5 years and 10 years were 98.2% and 96.8% for the LR group; 98.3% and 93.6%, F-IR; 94.2% and 90.2%, U-IR; 94.3% and 85.2%, HR; and 86.1% and 68.5%, VHR. Two patients died of prostate cancer. Overall rates of late grade ≥ 3 GU and GI toxicity were 0.87% and 1.01%. CONCLUSIONS Proton therapy for localized prostate cancer demonstrated excellent clinical outcomes in this large cohort, even among higher-risk groups with historically poor outcomes despite aggressive therapy.
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Affiliation(s)
- Alan J Sosa
- Departments of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Howard D Thames
- Departments of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jeremiah W Sanders
- Departments of Imaging Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Seungtaek L Choi
- Departments of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Quynh-Nhu Nguyen
- Departments of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Henry Mok
- Departments of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - X Ron Zhu
- Departments of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Shalin Shah
- Departments of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Lauren L Mayo
- Departments of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Karen E Hoffman
- Departments of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Chad Tang
- Departments of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Andrew K Lee
- Texas Center for Proton Therapy, Irving, TX, USA
| | | | - Reena Kudchadker
- Departments of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Steven J Frank
- Departments of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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14
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Casey G, Quon H, Meyer T, Sia M, Thind K, Das S, Cho D, McGeachy P, Husain S, Martell K. Estimated absolute percentage of biopsied tissue positive for Gleason pattern 4 (eAPP4) in low dose rate prostate brachytherapy: Evaluation of prognostic utility in a large cohort. Radiother Oncol 2023; 188:109859. [PMID: 37604278 DOI: 10.1016/j.radonc.2023.109859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 07/24/2023] [Accepted: 08/11/2023] [Indexed: 08/23/2023]
Abstract
PURPOSE To determine whether a system to estimate Absolute Percentage of Biopsied Tissue Positive for Gleason Pattern 4 (eAPP4) is useful as a prognostication tool for patients with intermediate risk prostate cancer (IR-PCa) undergoing low dose rate prostate brachytherapy. METHODS 497 patients with IR-PCa and known grade group 2 or 3 disease treated with low dose rate seed brachytherapy (LDR-BT) at a quaternary cancer centre were retrospectively reviewed. Prostate biopsies for each patient included Gleason grading with synoptic reporting that did not include percentage of pattern 4 disease found within the sample. Each core was assigned a grade grouping, however, and that was used with optimized estimates of percentage of pattern four disease to estimate eAPP4. Outcomes including cumulative incidence of recurrence (CIR), treatment of recurrent disease (RRX), and metastasis-free survival (MFS) were then reviewed and the prognostic value of eAPP4 evaluated. RESULTS 428 (86%) patients had Gleason grade group 2 and 69 (14%) patients had Gleason grade group 3 disease. 230 (46%) patients had National Comprehensive Cancer Network (NCCN) favourable intermediate at baseline, while 267 (54%) of patients had NCCN unfavourable intermediate at baseline. Median follow-up was 7.3 (5.5-9.6) years. eAPP4 was predictive of CIR (p = 0.003), RRX (p = 0.003), or MFS (p = 0.001) events, while Gleason grade grouping alone was not. eAPP4 was strongest as a predictor for MFS when estimates of 30% (grade group 2) and 80% (grade group 3) were used [HR 1.07 (1.03-1.12); p = 0.001]. CONCLUSIONS eAPP4 was strongly predictive of recurrence and metastasis-free survival in a large cohort of patients receiving LDR-BT treatment for IR-PCa. Treatment of future patients with IR-PCa could include the use of eAPP4 prognostication.
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Affiliation(s)
- Geoffrey Casey
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Harvey Quon
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Department of Oncology, University of Calgary, Calgary, AB, Canada
| | - Tyler Meyer
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Department of Oncology, University of Calgary, Calgary, AB, Canada
| | - Michael Sia
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Department of Oncology, University of Calgary, Calgary, AB, Canada
| | | | - Subhadip Das
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Department of Oncology, University of Calgary, Calgary, AB, Canada
| | - Daniel Cho
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Department of Oncology, University of Calgary, Calgary, AB, Canada
| | - Philip McGeachy
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Department of Oncology, University of Calgary, Calgary, AB, Canada
| | - Siraj Husain
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Department of Oncology, University of Calgary, Calgary, AB, Canada
| | - Kevin Martell
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Department of Oncology, University of Calgary, Calgary, AB, Canada.
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15
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Herr DJ, Elliott DA, Duchesne G, Stensland KD, Caram ME, Chapman C, Burns JA, Hollenbeck BK, Sparks JB, Shin C, Zaslavsky A, Tsodikov A, Skolarus TA. Outcomes after definitive radiation therapy for localized prostate cancer in a national health care delivery system. Cancer 2023; 129:3326-3333. [PMID: 37389814 PMCID: PMC10528965 DOI: 10.1002/cncr.34916] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 05/10/2023] [Accepted: 05/18/2023] [Indexed: 07/01/2023]
Abstract
PURPOSE Accurate information regarding real-world outcomes after contemporary radiation therapy for localized prostate cancer is important for shared decision-making. Clinically relevant end points at 10 years among men treated within a national health care delivery system were examined. METHODS National administrative, cancer registry, and electronic health record data were used for patients undergoing definitive radiation therapy with or without concurrent androgen deprivation therapy within the Veterans Health Administration from 2005 to 2015. National Death Index data were used through 2019 for overall and prostate cancer-specific survival and identified date of incident metastatic prostate cancer using a validated natural language processing algorithm. Metastasis-free, prostate cancer-specific, and overall survival using Kaplan-Meier methods were estimated. RESULTS Among 41,735 men treated with definitive radiation therapy, the median age at diagnosis was 65 years and median follow-up was 8.7 years. Most had intermediate (42%) and high-risk (33%) disease, with 40% receiving androgen deprivation therapy as part of initial therapy. Unadjusted 10-year metastasis-free survival was 96%, 92%, and 80% for low-, intermediate-, and high-risk disease. Similarly, unadjusted 10-year prostate cancer-specific survival was 98%, 97%, and 90% for low-, intermediate-, and high-risk disease. The unadjusted overall survival was lower across increasing disease risk categories at 77%, 71%, and 62% for low-, intermediate-, and high-risk disease (p < .001). CONCLUSIONS These data provide population-based 10-year benchmarks for clinically relevant end points, including metastasis-free survival, among patients with localized prostate cancer undergoing radiation therapy using contemporary techniques. The survival rates for high-risk disease in particular suggest that outcomes have recently improved.
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Affiliation(s)
- Daniel J. Herr
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI
| | - David A. Elliott
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI
- Department of Radiation Oncology, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI
| | | | | | - Megan E.V. Caram
- HSR&D Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | | | - Jennifer A. Burns
- HSR&D Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI
| | | | - Jordan B. Sparks
- HSR&D Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI
| | - Chris Shin
- Department of Biostatistics, University of Michigan, Ann Arbor, MI
| | | | | | - Ted A. Skolarus
- HSR&D Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI
- Section of Urology, Department of Surgery, University of Chicago, Chicago, IL
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16
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Sebastian N, Goyal S, Liu Y, Janopaul-Naylor JR, Patel PR, Dhere VR, Hanasoge S, Shelton JW, Godette KD, Jani AB, Hershatter B, Fischer-Valuck B, Patel SA. Radiation Facility Volume and Survival for Men With Very High-Risk Prostate Cancer Treated with Radiation and Androgen Deprivation Therapy. JAMA Netw Open 2023; 6:e2327637. [PMID: 37552479 PMCID: PMC10410484 DOI: 10.1001/jamanetworkopen.2023.27637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Accepted: 06/21/2023] [Indexed: 08/09/2023] Open
Abstract
IMPORTANCE Very high-risk (VHR) prostate cancer is an aggressive substratum of high-risk prostate cancer, characterized by high prostate-specific antigen levels, high Gleason score, and/or advanced T category. Contemporary management paradigms involve advanced molecular imaging and multimodal treatment with intensified prostate-directed or systemic treatment-resources more readily available at high-volume centers. OBJECTIVE To examine radiation facility case volume and overall survival (OS) in men with VHR prostate cancer. DESIGN, SETTING, AND PARTICIPANTS A retrospective cohort study was performed from November 11, 2022, to March 4, 2023, analyzing data from US facilities reporting to the National Cancer Database. Patients included men diagnosed with nonmetastatic VHR prostate cancer by National Comprehensive Cancer Network criteria (clinical T3b-T4 category, primary Gleason pattern 5, >4 cores with grade group 4-5, and/or 2-3 high-risk features) and treated with curative-intent radiotherapy and androgen deprivation therapy between January 1, 2004, to December 31, 2016. EXPOSURES Treatment at high- vs low-average cumulative facility volume (ACFV), defined as the total number of prostate radiotherapy cases at an individual patient's treatment facility from 2004 until the year of their diagnosis. The nonlinear association between a continuous ACFV and OS was examined through a Martingale residual plot; an optimal ACFV cutoff was identified that maximized the separation between high vs low ACFV via a bias-adjusted log rank test. MAIN OUTCOMES AND MEASURES Overall survival was assessed between high vs low ACFV using Kaplan-Meier analysis with and without inverse probability score weighted adjustment and multivariable Cox proportional hazards. RESULTS A total of 25 219 men (median age, 71 [IQR, 64-76] years; 78.7% White) with VHR prostate cancer were identified, 6438 (25.5%) of whom were treated at high ACFV facilities. Median follow-up was 57.4 (95% CI, 56.7-58.1) months. Median OS for patients treated at high ACFV centers was 123.4 (95% CI, 116.6-127.4) months vs 109.0 (95% CI, 106.5-111.2) months at low ACFV centers (P < .001). On multivariable analysis, treatment at a high ACFV center was associated with lower risk of death (hazard ratio, 0.89; 95% CI, 0.84-0.95; P < .001). These results were also significant after inverse probability score weighted-based adjustment. CONCLUSIONS AND RELEVANCE In this cohort study of patients with VHR prostate cancer who underwent definitive radiotherapy and androgen deprivation therapy, facility case volume was independently associated with longer OS. Further studies are needed to identify which factors unique to high-volume centers may be responsible for this benefit.
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Affiliation(s)
- Nikhil Sebastian
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Subir Goyal
- Biostatistics and Bioinformatics Shared Resource, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Yuan Liu
- Biostatistics and Bioinformatics Shared Resource, Winship Cancer Institute, Emory University, Atlanta, Georgia
- Department of Biostatistics and Bioinformatics, Emory University, Atlanta, Georgia
| | | | - Pretesh R. Patel
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Vishal R. Dhere
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Sheela Hanasoge
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Jay W. Shelton
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Karen D. Godette
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Ashesh B. Jani
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Bruce Hershatter
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | | | - Sagar A. Patel
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
- Department of Urology, Emory University, Atlanta, Georgia
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Parr H, Porta N, Tree AC, Dearnaley D, Hall E. A Personalized Clinical Dynamic Prediction Model to Characterize Prognosis for Patients With Localized Prostate Cancer: Analysis of the CHHiP Phase 3 Trial. Int J Radiat Oncol Biol Phys 2023; 116:1055-1068. [PMID: 36822374 DOI: 10.1016/j.ijrobp.2023.02.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 01/24/2023] [Accepted: 02/07/2023] [Indexed: 02/24/2023]
Abstract
PURPOSE The CHHiP trial assessed moderately hypofractionated radiation therapy in localized prostate cancer. We utilized longitudinal prostate-specific antigen (PSA) measurements collected over time to evaluate and characterize patient prognosis. METHODS AND MATERIALS We developed a clinical dynamic prediction joint model to predict the risk of biochemical or clinical recurrence. Modeling included repeated PSA values and adjusted for baseline prognostic risk factors of age, tumor characteristics, and treatment received. We included 3071 trial participants for model development using a mixed-effect submodel for the longitudinal PSAs and a time-to-event hazard submodel for predicting recurrence of prostate cancer. We evaluated how baseline prognostic factor subgroups affected the nonlinear PSA levels over time and quantified the association of PSA on time to recurrence. We assessed bootstrapped optimism-adjusted predictive performance on calibration and discrimination. Additionally, we performed comparative dynamic predictions on patients with contrasting prognostic factors and investigated PSA thresholds over landmark times to correlate with prognosis. RESULTS Patients who developed recurrence had generally higher baseline and overall PSA values during follow-up and had an exponentially rising PSA in the 2 years before recurrence. Additionally, most baseline risk factors were significant in the mixed-effect and relative-risk submodels. PSA value and rate of change were predictive of recurrence. Predictive performance of the model was good across different prediction times over an 8-year period, with an overall mean area under the curve of 0.70, mean Brier score of 0.10, and mean integrated calibration index of 0.048; these were further improved for predictions after 5 years of accrued longitudinal posttreatment PSA assessments. PSA thresholds <0.23 ng/mL after 3 years were indicative of a minimal risk of recurrence by 8 years. CONCLUSIONS We successfully developed a joint statistical model to predict prostate cancer recurrence, evaluating prognostic factors and longitudinal PSA. We showed dynamically updated PSA information can improve prognostication, which can be used to guide follow-up and treatment management options.
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Affiliation(s)
- Harry Parr
- Clinical Trials and Statistics Unit, Institute of Cancer Research, London, United Kingdom
| | - Nuria Porta
- Clinical Trials and Statistics Unit, Institute of Cancer Research, London, United Kingdom
| | - Alison C Tree
- Royal Marsden NHS Foundation Trust, London, United Kingdom; Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, United Kingdom
| | - David Dearnaley
- Royal Marsden NHS Foundation Trust, London, United Kingdom; Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, United Kingdom
| | - Emma Hall
- Clinical Trials and Statistics Unit, Institute of Cancer Research, London, United Kingdom.
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Cartes R, Karim MU, Tisseverasinghe S, Tolba M, Bahoric B, Anidjar M, McPherson V, Probst S, Rompré-Brodeur A, Niazi T. Neoadjuvant versus Concurrent Androgen Deprivation Therapy in Localized Prostate Cancer Treated with Radiotherapy: A Systematic Review of the Literature. Cancers (Basel) 2023; 15:3363. [PMID: 37444473 DOI: 10.3390/cancers15133363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 06/21/2023] [Accepted: 06/23/2023] [Indexed: 07/15/2023] Open
Abstract
BACKGROUND There is an ongoing debate on the optimal sequencing of androgen deprivation therapy (ADT) and radiotherapy (RT) in patients with localized prostate cancer (PCa). Recent data favors concurrent ADT and RT over the neoadjuvant approach. METHODS We conducted a systematic review in PubMed, EMBASE, and Cochrane Databases assessing the combination and optimal sequencing of ADT and RT for Intermediate-Risk (IR) and High-Risk (HR) PCa. FINDINGS Twenty randomized control trials, one abstract, one individual patient data meta-analysis, and two retrospective studies were selected. HR PCa patients had improved survival outcomes with RT and ADT, particularly when a long-course Neoadjuvant-Concurrent-Adjuvant ADT was used. This benefit was seen in IR PCa when adding short-course ADT, although less consistently. The best available evidence indicates that concurrent over neoadjuvant sequencing is associated with better metastases-free survival at 15 years. Although most patients had IR PCa, HR participants may have been undertreated with short-course ADT and the absence of pelvic RT. Conversely, retrospective data suggests a survival benefit when using the neoadjuvant approach in HR PCa patients. INTERPRETATION The available literature supports concurrent ADT and RT initiation for IR PCa. Neoadjuvant-concurrent-adjuvant sequencing should remain the standard approach for HR PCa and is an option for IR PCa.
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Affiliation(s)
- Rodrigo Cartes
- Department of Radiation Oncology, McGill University, Montreal, QC H3A 0G4, Canada
| | - Muneeb Uddin Karim
- Department of Radiation Oncology, McGill University, Montreal, QC H3A 0G4, Canada
| | | | - Marwan Tolba
- Department of Radiation Oncology, Dalhousie University, and Nova Scotia Health Authority, Sydney, NS B1P 1P3, Canada
| | - Boris Bahoric
- Department of Radiation Oncology, McGill University, Montreal, QC H3A 0G4, Canada
| | - Maurice Anidjar
- Department of Urology, McGill University, Montreal, QC H3A 0G4, Canada
| | - Victor McPherson
- Department of Urology, McGill University, Montreal, QC H3A 0G4, Canada
| | - Stephan Probst
- Department of Nuclear Medicine, McGill University, Montreal, QC H3A 0G4, Canada
| | | | - Tamim Niazi
- Department of Radiation Oncology, McGill University, Montreal, QC H3A 0G4, Canada
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Archer Goode E, Wang N, Munkley J. Prostate cancer bone metastases biology and clinical management (Review). Oncol Lett 2023; 25:163. [PMID: 36960185 PMCID: PMC10028493 DOI: 10.3892/ol.2023.13749] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 02/09/2023] [Indexed: 03/25/2023] Open
Abstract
Prostate cancer (PCa) is one of the most prominent causes of cancer-related mortality in the male population. A highly impactful prognostic factor for patients diagnosed with PCa is the presence or absence of bone metastases. The formation of secondary tumours at the bone is the most commonly observed site for the establishment of PCa metastases and is associated with reduced survival of patients in addition to a cohort of life-debilitating symptoms, including mobility issues and chronic pain. Despite the prevalence of this disease presentation and the high medical relevance of bone metastases, the mechanisms underlying the formation of metastases to the bone and the understanding of what drives the osteotropism exhibited by prostate tumours remain to be fully elucidated. This lack of in-depth understanding manifests in limited effective treatment options for patients with advanced metastatic PCa and culminates in the low rate of survival observed for this sub-set of patients. The present review aims to summarise the most recent promising advances in the understanding of how and why prostate tumours metastasise to the bone, with the ultimate aim of highlighting novel treatment and prognostic targets, which may provide the opportunity to improve the diagnosis and treatment of patients with PCa with bone metastases.
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Affiliation(s)
- Emily Archer Goode
- Newcastle University Centre for Cancer, Newcastle University Institute of Biosciences, International Centre for Life, Newcastle NE1 3BZ, UK
| | - Ning Wang
- The Mellanby Centre for Musculoskeletal Research, Department of Oncology and Metabolism, The University of Sheffield, Sheffield S10 2RX, UK
| | - Jennifer Munkley
- Newcastle University Centre for Cancer, Newcastle University Institute of Biosciences, International Centre for Life, Newcastle NE1 3BZ, UK
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20
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Valle LF, Jiang T, Weiner AB, Reiter RE, Rettig MB, Shen J, Chang AJ, Nickols NG, Steinberg ML, Kishan AU. Multimodality Therapies for Localized Prostate Cancer. Curr Oncol Rep 2023; 25:221-229. [PMID: 36723856 PMCID: PMC11288626 DOI: 10.1007/s11912-023-01374-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/14/2022] [Indexed: 02/02/2023]
Abstract
PURPOSE OF REVIEW Multimodality therapy including radical prostatectomy, radiation therapy, and hormone therapy are frequently deployed in the management of localized prostate cancer. We sought to perform a critical appraisal of the most contemporary literature focusing on the multimodality management of localized prostate cancer. RECENT FINDINGS Men who are ideal candidates for multimodality therapy include those with unfavorable intermediate-risk disease, high-risk disease, and very high-risk disease. Enhancements in both systemic agents (including second-generation antiandrogens) as well as localized therapies (such as stereotactic body radiotherapy and brachytherapy) are refining the optimal balance between the use of systemic and local therapies for localized prostate cancer. Genomic predictors are emerging as critical tools for more precisely allocating treatment intensification with multimodality therapies as well as treatment de-intensification. Close collaboration among medical oncologists, surgeons, and radiation oncologists will be critical for coordinating evidence-based multimodality therapies when clearly indicated and for supporting shared decision-making in areas where the evidence is mixed.
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Affiliation(s)
- Luca F Valle
- Department of Radiation Oncology, University of California Los Angeles, 200 Medical Plaza, Suite B265, Los Angeles, CA, 90095, USA
- Department of Radiation Oncology, Greater Los Angeles Veterans Affairs Healthcare System, Los Angeles, USA
| | - Tommy Jiang
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, USA
| | - Adam B Weiner
- Department of Urology, University of California Los Angeles, Los Angeles, USA
| | - Robert E Reiter
- Department of Urology, University of California Los Angeles, Los Angeles, USA
| | - Matthew B Rettig
- Department of Hematology/Oncology, University of California Los Angeles, Los Angeles, USA
- Department of Hematology/Oncology, Greater Los Angeles Veterans Affairs Healthcare System, Los Angeles, USA
| | - John Shen
- Department of Hematology/Oncology, University of California Los Angeles, Los Angeles, USA
| | - Albert J Chang
- Department of Radiation Oncology, University of California Los Angeles, 200 Medical Plaza, Suite B265, Los Angeles, CA, 90095, USA
| | - Nicholas G Nickols
- Department of Radiation Oncology, University of California Los Angeles, 200 Medical Plaza, Suite B265, Los Angeles, CA, 90095, USA
- Department of Radiation Oncology, Greater Los Angeles Veterans Affairs Healthcare System, Los Angeles, USA
- Department of Urology, University of California Los Angeles, Los Angeles, USA
| | - Michael L Steinberg
- Department of Radiation Oncology, University of California Los Angeles, 200 Medical Plaza, Suite B265, Los Angeles, CA, 90095, USA
| | - Amar U Kishan
- Department of Radiation Oncology, University of California Los Angeles, 200 Medical Plaza, Suite B265, Los Angeles, CA, 90095, USA.
- Department of Urology, University of California Los Angeles, Los Angeles, USA.
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21
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ESTRO-ACROP recommendations for evidence-based use of androgen deprivation therapy in combination with external-beam radiotherapy in prostate cancer. Radiother Oncol 2023; 183:109544. [PMID: 36813168 DOI: 10.1016/j.radonc.2023.109544] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 02/03/2023] [Accepted: 02/04/2023] [Indexed: 02/22/2023]
Abstract
BACKGROUND AND PURPOSE There is no consensus concerning the appropriate use of androgen deprivation therapy (ADT) during primary and postoperative external-beam radiotherapy (EBRT) in the management of prostate cancer (PCa). Thus, the European Society for Radiotherapy and Oncology (ESTRO) Advisory Committee for Radiation Oncology Practice (ACROP) guidelines seeks to present current recommendations for the clinical use of ADT in the various indications of EBRT. MATERIAL AND METHODS A literature search was conducted in MEDLINE PubMed that evaluated EBRT and ADT in prostate cancer. The search focused on randomized, Phase II and III trials published in English from January 2000 to May 2022. In case topics were addressed in the absence of Phase II or III trials, recommendations were labelled accordingly based on the limited body of evidence. Localized PCa was classified according to D'Amico et al. classification in low-, intermediate and high risk PCa. The ACROP clinical committee identified 13 European experts who discussed and analyzed the body of evidence concerning the use of ADT with EBRT for prostate cancer. RESULTS Key issues were identified and are discussed: It was concluded that no additional ADT is recommended for low-risk prostate cancer patients, whereas for intermediate- and high-risk patients four to six months and two to three years of ADT are recommended. Likewise, patients with locally advanced prostate cancer are recommended to receive ADT for two to three years and when ≥ 2 high-risk factors (cT3-4, ISUP grade ≥ 4 or PSA ≥ 40 ng/ml) or cN1 is present ADT for three years plus additional Abiraterone for two years is recommended. For postoperative patients no ADT is recommended for adjuvant EBRT in pN0 patients whereas for pN1 patients adjuvant EBRT with long-term ADT is performed for at least 24 to 36 months. In the setting of salvage EBRT ADT is performed in biochemically persistent PCa patients with no evidence of metastatic disease. Long-term ADT (24 months) is recommended in pN0 patients with high risk of further progression (PSA ≥ 0.7 ng/ml and ISUP grade group ≥ 4) and a life expectancy of over ten years, whereas short-term ADT (6 months) is recommended in pN0 patients with lower risk profile (PSA < 0.7 ng/ml and ISUP grade group 4). Patients considered for ultra-hypofractionated EBRT as well as patients with image based local recurrence within the prostatic fossa or lymph node recurrence should participate in appropriate clinical trials evaluating the role of additional ADT. CONCLUSION These ESTRO-ACROP recommendations are evidence-based and relevant to the use of ADT in combination with EBRT in PCa for the most common clinical settings.
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22
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Antitumor Therapy Targeting the Tumor Microenvironment. JOURNAL OF ONCOLOGY 2023; 2023:6886135. [PMID: 36908706 PMCID: PMC10005879 DOI: 10.1155/2023/6886135] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 02/13/2023] [Accepted: 02/20/2023] [Indexed: 03/06/2023]
Abstract
The development and progression of tumors in human tissues extensively rely on its surrounding environment, that is, tumor microenvironment which includes a variety of cells, molecules, and blood vessels. These components are modified, organized, and integrated to support and facilitate the growth, invasion, and metabolism of tumor cells, suggesting them as potential therapeutic targets in anticancer treatment. An increasing number of pharmacological agents have been developed and clinically applied to target the oncogenic components in the tumor microenvironment, and in this review, we will summarize these pharmacological agents that directly or indirectly target the cellular or molecular components in the tumor microenvironment. However, difficulties and challenges still exist in this field, which will also be reported in this literature.
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23
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Ayoub Z, Khader J, Bulbul M, Khauli RB, Andraos TY, Shamseddine A, Mukherji D, Geara FB. Adjusting the duration of androgen deprivation therapy (ADT) based on nadir PSA for high risk localized prostate cancer patients treated with definitive external beam radiation therapy and ADT. BMC Urol 2022; 22:204. [PMID: 36503556 PMCID: PMC9743609 DOI: 10.1186/s12894-022-01145-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 11/08/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND A nadir Prostate-Specific Antigen (nPSA) of 0.06 ng/mL has been shown to be a strong independent predictor of biochemical recurrence-free survival (bRFS) in patients with intermediate or high-risk (HR) prostate cancer treated with definitive external beam radiation therapy (RT) and androgen deprivation therapy (ADT). We aimed to examine the association between the duration of ADT and bRFS in HR localized prostate cancer, based on nPSA. METHODS Between 1998 and 2015, 204 patients with HR localized prostate cancer were identified. Of them, 157 patients (77.0%) reached the desired nPSA of < 0.06 ng/mL (favorable group), while 47 (23.0%) did not (unfavorable group). Duration of ADT varied among patients depending on physician preference, patient tolerance, and/or compliance. Survival outcomes were calculated using Kaplan-Meier methods and predictors of outcomes using multi-variable cox regression model. RESULTS In the favorable group, ADT for at least 12 months lead to superior bRFS compared to ≤ 9 months of ADT (P = 0.036). However, no significant difference was seen when examining the value of receiving ADT beyond 12, 18, or 24 months, respectively. On univariate analysis for bRFS, the use of ADT for at least 12 months was significant (P = 0.012) as well as time to nadir PSA (tnPSA), (≤ 6 vs > 6 months); (P = 0.043). The presenting T stage was borderline significant (HR 3.074; 95% CI 0.972-9.719; P = 0.056), while PSA at presentation, Gleason Score and age were not. On multivariate analysis, the use of ADT for 12 months (P = 0.012) and tnPSA (P = 0.037) remained significant. In the unfavorable group, receiving ADT beyond 9 and 12 months was associated with improved bRFS (P = 0.044 and 0.019, respectively). However, beyond 18 months, there was no significant difference. CONCLUSION In HR localized prostate cancer patients treated with definitive RT and ADT, the total duration of ADT may be adjusted according to treatment response using nPSA. In patients reaching a nPSA below 0.06 ng/mL, a total of 12 months of ADT may be sufficient, while in those not reaching a nPSA below 0.06 ng/mL, a total duration of 18 months is required.
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Affiliation(s)
- Zeina Ayoub
- grid.411654.30000 0004 0581 3406Department of Radiation Oncology, The Naef K. Basile Cancer Institute, The American University of Beirut Medical Center, Bliss Street, Riad El Solh, Beirut, 11072030 Lebanon
| | - Jamal Khader
- Department of Radiation Oncology, King Hussein Cancer Center, Amman, Jordan
| | - Muhammad Bulbul
- grid.411654.30000 0004 0581 3406Division of Urology, The American University of Beirut Medical Center, Beirut, Lebanon
| | - Raja B. Khauli
- grid.411654.30000 0004 0581 3406Division of Urology, The American University of Beirut Medical Center, Beirut, Lebanon
| | - Therese Y. Andraos
- grid.411654.30000 0004 0581 3406Department of Radiation Oncology, The Naef K. Basile Cancer Institute, The American University of Beirut Medical Center, Bliss Street, Riad El Solh, Beirut, 11072030 Lebanon
| | - Ali Shamseddine
- grid.411654.30000 0004 0581 3406Division of Medical Oncology, The Naef K. Basile Cancer Institute at the American University of Beirut Medical Center, Beirut, Lebanon
| | - Deborah Mukherji
- grid.411654.30000 0004 0581 3406Division of Medical Oncology, The Naef K. Basile Cancer Institute at the American University of Beirut Medical Center, Beirut, Lebanon
| | - Fady B. Geara
- grid.411654.30000 0004 0581 3406Department of Radiation Oncology, The Naef K. Basile Cancer Institute, The American University of Beirut Medical Center, Bliss Street, Riad El Solh, Beirut, 11072030 Lebanon ,Present Address: Oncology Institute Cleveland Clinic Abu Dhabi, Al Maryah Island, Abu Dhabi, United Arab Emirates
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French AFU Cancer Committee Guidelines - Update 2022-2024: prostate cancer - Diagnosis and management of localised disease. Prog Urol 2022; 32:1275-1372. [DOI: 10.1016/j.purol.2022.07.148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Accepted: 07/11/2022] [Indexed: 11/17/2022]
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Parr H, Hall E, Porta N. Joint models for dynamic prediction in localised prostate cancer: a literature review. BMC Med Res Methodol 2022; 22:245. [PMID: 36123621 PMCID: PMC9487103 DOI: 10.1186/s12874-022-01709-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 08/10/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Prostate cancer is a very prevalent disease in men. Patients are monitored regularly during and after treatment with repeated assessment of prostate-specific antigen (PSA) levels. Prognosis of localised prostate cancer is generally good after treatment, and the risk of having a recurrence is usually estimated based on factors measured at diagnosis. Incorporating PSA measurements over time in a dynamic prediction joint model enables updates of patients' risk as new information becomes available. We review joint model strategies that have been applied to model time-dependent PSA trajectories to predict time-to-event outcomes in localised prostate cancer. METHODS We identify articles that developed joint models for prediction of localised prostate cancer recurrence over the last two decades. We report, compare, and summarise the methodological approaches and applications that use joint modelling accounting for two processes: the longitudinal model (PSA), and the time-to-event process (clinical failure). The methods explored differ in how they specify the association between these two processes. RESULTS Twelve relevant articles were identified. A range of methodological frameworks were found, and we describe in detail shared-parameter joint models (9 of 12, 75%) and joint latent class models (3 of 12, 25%). Within each framework, these articles presented model development, estimation of dynamic predictions and model validations. CONCLUSIONS Each framework has its unique principles with corresponding advantages and differing interpretations. Regardless of the framework used, dynamic prediction models enable real-time prediction of individual patient prognosis. They utilise all available longitudinal information, in addition to baseline prognostic risk factors, and are superior to traditional baseline-only prediction models.
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Affiliation(s)
- Harry Parr
- Clinical Trials and Statistics Unit at The Institute of Cancer Research, London, UK
| | - Emma Hall
- Clinical Trials and Statistics Unit at The Institute of Cancer Research, London, UK
| | - Nuria Porta
- Clinical Trials and Statistics Unit at The Institute of Cancer Research, London, UK
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PROshot: Prone Positioning, Radiation First in Total Neoadjuvant Therapy, Palliative Craniospinal Irradiation, Long-Term Androgen Deprivation Therapy, and Combining Short-Term Androgen Deprivation Therapy and Pelvic Lymph Node Coverage With Salvage Prostate Radiation. Pract Radiat Oncol 2022; 12:387-391. [PMID: 36058617 DOI: 10.1016/j.prro.2022.06.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 06/23/2022] [Accepted: 06/23/2022] [Indexed: 11/21/2022]
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Advancements in the radiooncological treatment of high-risk prostate cancer: a quarter century of achievements. Radiol Oncol 2022; 56:365-370. [PMID: 35502906 PMCID: PMC9400444 DOI: 10.2478/raon-2022-0018] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 03/28/2022] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND The aim of the study was to evaluate the development of treatment of primary high-risk prostate cancer in regards to biochemical no evidence of disease (bNED), acute and late gastrointestinal (GI) and genitourinary (GU) side effects. PATIENTS AND METHODS Primary high-risk prostate cancer patients treated between 1994 and 2016 were included. Applied doses ranged from 60 to 80 Gy, with a dose of 1.8 or 2 Gy per fraction. Techniques were either 3D conformal or intensity modulated radiotherapy and volumetric intensity modulated arc therapy. RESULTS 142 patients were treated with doses up to 70 Gy (median dose 66 Gy; 66 Gy group), 282 with doses between 70 and 76 Gy (median dose 74 Gy; 74 Gy group), and 141 with doses >76 Gy (median dose 78 Gy; 78 Gy group). The median follow-up was 48 months. The bNED rates were 50% after 5 years and 44% after 9 years in the 66 Gy group; 65% and 54%, respectively, in the 74 Gy group; and 83% and 66%, respectively, in the 78 Gy group (p = 0.03 vs. 74 Gy and p < 0.0001 vs. 66 Gy). We found a higher rate of acute GI side effects in the 78 Gy group compared to the other groups, but not in maximum acute GU side effects and late maximum GI and GU effects. CONCLUSIONS High-risk prostate cancer patients treated with doses of 78 Gy had significantly better bNED rates. Compared to the historical 66 Gy group, 50% more patients achieved bNED after a follow-up of 9 years.
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Baude J, Caubet M, Defer B, Teyssier CR, Lagneau E, Créhange G, Lescut N. Combining androgen deprivation and radiation therapy in the treatment of localised prostate cancer: summary of level 1 evidence and current gaps in knowledge. Clin Transl Radiat Oncol 2022; 37:1-11. [PMID: 36039172 PMCID: PMC9418036 DOI: 10.1016/j.ctro.2022.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Revised: 07/17/2022] [Accepted: 07/18/2022] [Indexed: 11/28/2022] Open
Affiliation(s)
- Jérémy Baude
- Department of Radiation Oncology, Centre Georges François Leclerc, 1 rue du professeur Marion, 21000 Dijon, France
- Corresponding author.
| | - Matthieu Caubet
- Department of Radiation Oncology, Institut de Cancérologie de Bourgogne, 18 Cr Général de Gaulle, 21000 Dijon, France
| | - Blanche Defer
- Department of Radiation Oncology, Institut de Cancérologie de Bourgogne, 18 Cr Général de Gaulle, 21000 Dijon, France
| | - Charles Régis Teyssier
- Department of Radiation Oncology, Institut de Cancérologie de Bourgogne, 18 Cr Général de Gaulle, 21000 Dijon, France
| | - Edouard Lagneau
- Department of Radiation Oncology, Institut de Cancérologie de Bourgogne, 18 Cr Général de Gaulle, 21000 Dijon, France
| | - Gilles Créhange
- Department of Radiation Oncology, Institut Curie, 26 rue d’Ulm, 75005 Paris, France
| | - Nicolas Lescut
- Department of Radiation Oncology, Institut de Cancérologie de Bourgogne, 18 Cr Général de Gaulle, 21000 Dijon, France
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Kishan AU, Wang X, Sun Y, Romero T, Michalski JM, Ma TM, Feng FY, Sandler HM, Bolla M, Maingon P, De Reijke T, Neven A, Steigler A, Denham JW, Joseph D, Nabid A, Carrier N, Souhami L, Sydes MR, Dearnaley DP, Syndikus I, Tree AC, Incrocci L, Heemsbergen WD, Pos FJ, Zapatero A, Efstathiou JA, Guerrero A, Alvarez A, San-Segundo CG, Maldonado X, Xiang M, Rettig MB, Reiter RE, Zaorsky NG, Ong WL, Dess RT, Steinberg ML, Nickols NG, Roy S, Garcia JA, Spratt DE. High-dose Radiotherapy or Androgen Deprivation Therapy (HEAT) as Treatment Intensification for Localized Prostate Cancer: An Individual Patient-data Network Meta-analysis from the MARCAP Consortium. Eur Urol 2022; 82:106-114. [PMID: 35469702 DOI: 10.1016/j.eururo.2022.04.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 03/22/2022] [Accepted: 04/04/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND The relative benefits of radiotherapy (RT) dose escalation and the addition of short-term or long-term androgen deprivation therapy (STADT or LTADT) in the treatment of prostate cancer are unknown. OBJECTIVE To perform a network meta-analysis (NMA) of relevant randomized trials to compare the relative benefits of RT dose escalation ± STADT or LTADT. DESIGN, SETTING, AND PARTICIPANTS An NMA of individual patient data from 13 multicenter randomized trials was carried out for a total of 11862 patients. Patients received one of the six permutations of low-dose RT (64 to <74 Gy) ± STADT or LTADT, high-dose RT (≥74 Gy), or high-dose RT ± STADT or LTADT. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSES Metastasis-free survival (MFS) was the primary endpoint. Frequentist and Bayesian NMAs were performed to rank the various treatment strategies by MFS and biochemical recurrence-free survival (BCRFS). RESULTS AND LIMITATIONS Median follow-up was 8.8 yr (interquartile range 5.7-11.5). The greatest relative improvement in outcomes was seen for addition of LTADT, irrespective of RT dose, followed by addition of STADT, irrespective of RT dose. RT dose escalation did not improve MFS either in the absence of ADT (hazard ratio [HR] 0.97, 95% confidence interval [CI] 0.80-1.18) or with STADT (HR 0.99, 95% CI 0.8-1.23) or LTADT (HR 0.94, 95% CI 0.65-1.37). According to P-score ranking and rankogram analysis, high-dose RT + LTADT was the optimal treatment strategy for both BCRFS and longer-term outcomes. CONCLUSIONS Conventionally escalated RT up to 79.2 Gy, alone or in the presence of ADT, does not improve MFS, while addition of STADT or LTADT to RT alone, regardless of RT dose, consistently improves MFS. RT dose escalation does provide a high probability of improving BCRFS and, provided it can be delivered without compromising quality of life, may represent the optimal treatment strategy when used in conjunction with ADT. PATIENT SUMMARY Using a higher radiotherapy dose when treating prostate cancer does not reduce the chance of developing metastases or death, but it does reduce the chance of having a rise in prostate-specific antigen (PSA) signifying recurrence of cancer. Androgen deprivation therapy improves all outcomes. A safe increase in radiotherapy dose in conjunction with androgen deprivation therapy may be the optimal treatment.
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Affiliation(s)
- Amar U Kishan
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA, USA; Department of Urology, University of California Los Angeles, Los Angeles, CA, USA.
| | - Xiaoyan Wang
- Division of General Internal Medicine and Health Services Research, University of California Los Angeles, Los Angeles, CA, USA
| | - Yilun Sun
- Department of Population Quantitative Health Sciences, Case Western Reserve University, Cleveland, OH, USA; Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Tahmineh Romero
- Division of General Internal Medicine and Health Services Research, University of California Los Angeles, Los Angeles, CA, USA
| | - Jeff M Michalski
- Department of Radiation Oncology, Washington University, St. Louis, MO, USA
| | - Ting Martin Ma
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA, USA
| | - Felix Y Feng
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA, USA
| | - Howard M Sandler
- Department of Radiation Oncology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Michel Bolla
- Radiotherapy Department, University Hospital, Grenoble, France
| | - Philippe Maingon
- Department of Oncology, Hematology, and Supportive Care, Sorbonne University, Paris, France
| | - Theo De Reijke
- Department of Urology, Prostate Cancer Network in the Netherlands, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Anouk Neven
- Statistics Department, European Organisation for Research and Treatment of Cancer Headquarters, Brussels, Belgium; Competence Center for Methodology and Statistics, Luxembourg Institute of Health, Strassen, Luxembourg
| | - Allison Steigler
- School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia
| | - James W Denham
- School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia
| | - David Joseph
- Department of Medicine and Surgery, University of Western Australia, Perth, WA, Australia
| | - Abdenour Nabid
- Department of Radiation Oncology, Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC, Canada
| | - Nathalie Carrier
- Clinical Research Center, Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC, Canada
| | - Luis Souhami
- Department of Radiation Oncology, McGill University Health Centre, Montréal, QC, Canada
| | - Matt R Sydes
- Medical Research Council Clinical Trials Unit, University College London, London, UK
| | | | | | | | - Luca Incrocci
- Department of Radiation Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Wilma D Heemsbergen
- Department of Radiation Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Floris J Pos
- Department of Radiation Oncology, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, the Netherlands
| | | | - Jason A Efstathiou
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA
| | | | - Ana Alvarez
- Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | | | | | - Michael Xiang
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA, USA
| | - Matthew B Rettig
- Department of Medical Oncology, University of California Los Angeles, Los Angeles, CA, USA
| | - Robert E Reiter
- Department of Urology, University of California Los Angeles, Los Angeles, CA, USA
| | - Nicholas G Zaorsky
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Wee Loon Ong
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Robert T Dess
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, USA
| | - Michael L Steinberg
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA, USA
| | - Nicholas G Nickols
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA, USA
| | - Soumyajit Roy
- Department of Radiation Oncology, Rush University, Chicago, IL, USA
| | - Jorge A Garcia
- Division of Oncology, Seidman Cancer Center, Cleveland, OH, USA
| | - Daniel E Spratt
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA
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Reply to Yongfeng Lao, Yanan Wang, and Zhilong Dong’s Letter to the Editor re: Amar U. Kishan, Xiaoyan Wang, Yilun Sun, et al. High-dose Radiotherapy or Androgen Deprivation Therapy (HEAT) as Treatment Intensification for Localized Prostate Cancer: An Individual Patient–data Network Meta-analysis from the MARCAP Consortium. Eur Urol. In press. https://doi.org/10.1016/j.eururo.2022.04.003. Eur Urol 2022; 82:e82-e83. [DOI: 10.1016/j.eururo.2022.05.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Accepted: 05/31/2022] [Indexed: 11/21/2022]
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The Clinical Cell-Cycle Risk (CCR) Score Is Associated With Metastasis After Radiation Therapy and Provides Guidance on When to Forgo Combined Androgen Deprivation Therapy With Dose-Escalated Radiation. Int J Radiat Oncol Biol Phys 2022; 113:66-76. [PMID: 34610388 DOI: 10.1016/j.ijrobp.2021.09.034] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 09/20/2021] [Accepted: 09/25/2021] [Indexed: 02/07/2023]
Abstract
PURPOSE The clinical cell-cycle risk (CCR) score, which combines the University of California, San Francisco's Cancer of the Prostate Risk Assessment (CAPRA) and the cell cycle progression (CCP) molecular score, has been validated to be prognostic of disease progression for men with prostate cancer. This study evaluated the ability of the CCR score to prognosticate the risk of metastasis in men receiving dose-escalated radiation therapy (RT) with or without androgen deprivation therapy (ADT). METHODS AND MATERIALS This retrospective, multi-institutional cohort study included men with localized National Comprehensive Cancer Network (NCCN) intermediate-, high-, and very high-risk prostate cancer (N = 741). Patients were treated with dose-escalated RT with or without ADT. The primary outcome was time to metastasis. RESULTS The CCR score prognosticated metastasis with a hazard ratio (HR) per unit score of 2.22 (95% confidence interval [CI], 1.71-2.89; P < .001). The CCR score better prognosticated metastasis than NCCN risk group (CCR, P < .001; NCCN, P = .46), CAPRA score (CCR, P = .002; CAPRA, P = .59), or CCP score (CCR, P < .001; CCP, P = .59) alone. In bivariable analyses, CCR score remained highly prognostic when accounting for ADT versus no ADT (HR, 2.18; 95% CI, 1.61-2.96; P < .001), ADT duration as a continuous variable (HR, 2.11; 95% CI, 1.59-2.79; P < .001), or ADT given at or below the recommended duration for each NCCN risk group (HR, 2.19; 95% CI, 1.69-2.86; P < .001). Men with CCR scores below or above the multimodality threshold (CCR score, 2.112) had a 10-year risk of metastasis of 3.7% and 21.24%, respectively. Men with below-threshold scores receiving RT alone had a 10-year risk of metastasis of 3.7%, and for men receiving RT plus ADT, the 10-year risk of metastasis was also 3.7%. CONCLUSIONS The CCR score accurately and precisely prognosticates metastasis and adds clinically actionable information relative to guideline-recommended therapies based on NCCN risk in men undergoing dose-escalated RT with or without ADT. For men with scores below the multimodality threshold, adding ADT may not significantly reduce their 10-year risk of metastasis.
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Kissel M, Créhange G, Graff P. Stereotactic Radiation Therapy versus Brachytherapy: Relative Strengths of Two Highly Efficient Options for the Treatment of Localized Prostate Cancer. Cancers (Basel) 2022; 14:2226. [PMID: 35565355 PMCID: PMC9105931 DOI: 10.3390/cancers14092226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 04/18/2022] [Accepted: 04/20/2022] [Indexed: 11/16/2022] Open
Abstract
Stereotactic body radiation therapy (SBRT) has become a valid option for the treatment of low- and intermediate-risk prostate cancer. In randomized trials, it was found not inferior to conventionally fractionated external beam radiation therapy (EBRT). It also compares favorably to brachytherapy (BT) even if level 1 evidence is lacking. However, BT remains a strong competitor, especially for young patients, as series with 10-15 years of median follow-up have proven its efficacy over time. SBRT will thus have to confirm its effectiveness over the long-term as well. SBRT has the advantage over BT of less acute urinary toxicity and, more hypothetically, less sexual impairment. Data are limited regarding SBRT for high-risk disease while BT, as a boost after EBRT, has demonstrated superiority against EBRT alone in randomized trials. However, patients should be informed of significant urinary toxicity. SBRT is under investigation in strategies of treatment intensification such as combination of EBRT plus SBRT boost or focal dose escalation to the tumor site within the prostate. Our goal was to examine respective levels of evidence of SBRT and BT for the treatment of localized prostate cancer in terms of oncologic outcomes, toxicity and quality of life, and to discuss strategies of treatment intensification.
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Affiliation(s)
| | | | - Pierre Graff
- Department of Radiation Oncology, Institut Curie, 26 Rue d’Ulm, 75005 Paris, France; (M.K.); (G.C.)
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High-dose radiotherapy and risk-adapted androgen deprivation in localised prostate cancer (DART 01/05): 10-year results of a phase 3 randomised, controlled trial. Lancet Oncol 2022; 23:671-681. [DOI: 10.1016/s1470-2045(22)00190-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 03/18/2022] [Accepted: 03/18/2022] [Indexed: 01/20/2023]
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Mollica V, Nuvola G, Tassinari E, Nigro MC, Marchetti A, Rosellini M, Rizzo A, Errani C, Massari F. Bone Targeting Agents in Patients with Prostate Cancer: General Toxicities and Osteonecrosis of the Jaw. Curr Oncol 2022; 29:1709-1722. [PMID: 35323342 PMCID: PMC8947753 DOI: 10.3390/curroncol29030142] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 02/24/2022] [Accepted: 03/02/2022] [Indexed: 11/16/2022] Open
Abstract
Introduction: Bone metastases are the most frequent site of secondary localization of prostate cancer (PCa) and are present in about 90% of cases of advanced disease. Consequently, an adequate management of bone involvement is of pivotal importance in the therapeutic approach and skeletal-related events (SREs) need to be closely monitored and promptly assessed and treated. Bone targeting agents (BTAs), consisting in bisphosphonates and denosumab, are an essential part of the treatment of metastatic prostate cancer that accompanies systemic treatments throughout the most part of the history of the disease. Activity and safety of bone targeting agents: These treatments are correlated to better outcomes in terms of reduction of SREs and, in metastatic castration resistant setting, of increased overall survival (OS), but several important adverse events have to be managed and prevented. Of these, osteonecrosis of the jaw (ONJ) is extremely invalidating and should be managed with a special attention. Discussion: The role of BTAs in prostate cancer is pivotal throughout many stages of the disease, but several toxicities should be quickly recognized and treated. We aim at recollecting evidence on clinical benefit of BTAs, common and specific toxicities, and explore the pathophysiology and clinical aspects of osteonecrosis of the jaw. We present a review of the literature to report the role of the different types of bone targeting agents in the management of prostate cancer with bone metastases with a particular focus on common toxicities and ONJ to recollect current evidences on the activity of these compounds and the correct management of their adverse events.
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Affiliation(s)
- Veronica Mollica
- Medical Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (G.N.); (E.T.); (M.C.N.); (A.M.); (M.R.); (F.M.)
- Correspondence:
| | - Giacomo Nuvola
- Medical Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (G.N.); (E.T.); (M.C.N.); (A.M.); (M.R.); (F.M.)
| | - Elisa Tassinari
- Medical Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (G.N.); (E.T.); (M.C.N.); (A.M.); (M.R.); (F.M.)
| | - Maria Concetta Nigro
- Medical Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (G.N.); (E.T.); (M.C.N.); (A.M.); (M.R.); (F.M.)
| | - Andrea Marchetti
- Medical Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (G.N.); (E.T.); (M.C.N.); (A.M.); (M.R.); (F.M.)
| | - Matteo Rosellini
- Medical Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (G.N.); (E.T.); (M.C.N.); (A.M.); (M.R.); (F.M.)
| | - Alessandro Rizzo
- Struttura Semplice Dipartimentale di Oncologia Medica per la Presa in Carico Globale del Paziente Oncologico ‘Don Tonino Bello’, IRCCS Istituto Tumori ‘Giovanni Paolo II’, Viale Orazio Flacco 65, 70124 Bari, Italy;
| | - Costantino Errani
- Department of Orthopaedic Oncology, IRCCS Istituto Ortopedico Rizzoli, Via Pupilli 1, 40136 Bologna, Italy;
| | - Francesco Massari
- Medical Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (G.N.); (E.T.); (M.C.N.); (A.M.); (M.R.); (F.M.)
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Shee K, de la Calle CM, Chang AJ, Wong AC, Feng FY, Gottschalk AR, Carroll PR, Nguyen HG. Addition of Enzalutamide to Leuprolide and Definitive Radiotherapy is Tolerable and Effective in High-Risk Localized or Regional Non-Metastatic Prostate Cancer: Results from a Phase II Trial. Adv Radiat Oncol 2022; 7:100941. [PMID: 35847550 PMCID: PMC9280039 DOI: 10.1016/j.adro.2022.100941] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Accepted: 03/07/2022] [Indexed: 11/05/2022] Open
Abstract
Background Enzalutamide is an antiandrogen used to treat both metastatic and nonmetastatic prostate cancer. Here we present results from a phase 2 trial designed to determine the safety, tolerability, and efficacy of adding enzalutamide to standard androgen deprivation therapy with radiation therapy in high-risk localized or regional, nonmetastatic patients with prostate cancer. Methods and Materials Enrollment criteria included at least 2 of the following: stage cT3a/b, prostate specific antigen (PSA) ≥20 ng/mL, Gleason grade 8 to 10, ≥33% core involvement on biopsy, or pelvic lymph node involvement on computed tomography or magnetic resonance imaging. Patients with metastatic disease were excluded. All patients received 24 months of leuprolide and enzalutamide, and 5 weeks of intensity modulated radiation therapy followed by a brachytherapy boost. Adverse events (AE), PSA, testosterone, and basic laboratory tests were then followed for up to 36 months. Primary outcomes were safety and tolerability and PSA complete response rate (PSA-CR, defined as PSA ≤0.3). Secondary outcomes included time to biochemical recurrence (BCR; nadir + 2 ng/mL). Results Sixteen patients were enrolled; 2 were ineligible and 3 withdrew before starting treatment. Median age at enrollment was 69.0 years (interquartile range [IQR] 11.5). Median treatment duration was 24.0 months (IQR 11.9). Median follow-up time was 35.5 months (IQR 11.2), and 9 of 11 (81.8%) patients completed the 36 months of follow-up. One of 11 (9%) patients had grade 4 AE (seizure), and no grade 5 AE were reported. Four of 11 (36.4%) patients had grade 3 AE, such as erectile dysfunction and hot flashes. All patients achieved PSA-CR, and median time to PSA-CR was 4.2 months (IQR 1.4). At 24 months follow-up, 0 of 11 (0%) patients had a biochemical recurrence. At 36 months, 1 of 9 (11.1%) patient had a biochemical recurrence. Of note, this patient did not complete the full 24 months of enzalutamide and leuprolide due to AEs. Conclusions Enzalutamide in combination with standard androgen deprivation therapy and radiation therapy was well-tolerated and effective warranting further study in a randomized controlled trial.
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Kishan AU, Steigler A, Denham JW, Zapatero A, Guerrero A, Joseph D, Maldonado X, Wong JK, Stish BJ, Dess RT, Pilar A, Reddy C, Wedde TB, Lilleby WA, Fiano R, Merrick GS, Stock RG, Demanes DJ, Moran BJ, Tran PT, Martin S, Martinez-Monge R, Krauss DJ, Abu-Isa EI, Pisansky TM, Choo CR, Song DY, Greco S, Deville C, McNutt T, DeWeese TL, Ross AE, Ciezki JP, Tilki D, Karnes RJ, Tosoian JJ, Nickols NG, Bhat P, Shabsovich D, Juarez JE, Jiang T, Ma TM, Xiang M, Philipson R, Chang A, Kupelian PA, Rettig MB, Feng FY, Berlin A, Tward JD, Davis BJ, Reiter RE, Steinberg ML, Elashoff D, Boutros PC, Horwitz EM, Tendulkar RD, Spratt DE, Romero T. Interplay Between Duration of Androgen Deprivation Therapy and External Beam Radiotherapy With or Without a Brachytherapy Boost for Optimal Treatment of High-risk Prostate Cancer: A Patient-Level Data Analysis of 3 Cohorts. JAMA Oncol 2022; 8:e216871. [PMID: 35050303 PMCID: PMC8778608 DOI: 10.1001/jamaoncol.2021.6871] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
IMPORTANCE Radiotherapy combined with androgen deprivation therapy (ADT) is a standard of care for high-risk prostate cancer. However, the interplay between radiotherapy dose and the required minimum duration of ADT is uncertain. OBJECTIVE To determine the specific ADT duration threshold that provides a distant metastasis-free survival (DMFS) benefit in patients with high-risk prostate cancer receiving external beam radiotherapy (EBRT) or EBRT with a brachytherapy boost (EBRT+BT). DESIGN, SETTINGS, AND PARTICIPANTS This was a cohort study of 3 cohorts assembled from a multicenter retrospective study (2000-2013); a post hoc analysis of the Randomized Androgen Deprivation and Radiotherapy 03/04 (RADAR; 2003-2007) randomized clinical trial (RCT); and a cross-trial comparison of the RADAR vs the Deprivación Androgénica y Radio Terapía (Androgen Deprivation and Radiation Therapy; DART) 01/05 RCT (2005-2010). In all, the study analyzed 1827 patients treated with EBRT and 1108 patients treated with EBRT+BT from the retrospective cohort; 181 treated with EBRT and 203 with EBRT+BT from RADAR; and 91 patients treated with EBRT from DART. The study was conducted from October 15, 2020, to July 1, 2021, and the data analyses, from January 5 to June 15, 2021. EXPOSURES High-dose EBRT or EBRT+BT for an ADT duration determined by patient-physician choice (retrospective) or by randomization (RCTs). MAIN OUTCOMES AND MEASURES The primary outcome was DMFS; secondary outcome was overall survival (OS). Natural cubic spline analysis identified minimum thresholds (months). RESULTS This cohort study of 3 studies totaling 3410 men (mean age [SD], 68 [62-74] years; race and ethnicity not collected) with high-risk prostate cancer found a significant interaction between the treatment type (EBRT vs EBRT+BT) and ADT duration (binned to <6, 6 to <18, and ≥18 months). Natural cubic spline analysis identified minimum duration thresholds of 26.3 months (95% CI, 25.4-36.0 months) for EBRT and 12 months (95% CI, 4.9-36.0 months) for EBRT+BT for optimal effect on DMFS. In RADAR, the prolongation of ADT for patients receiving only EBRT was not associated with significant improvements in DMFS (hazard ratio [HR], 1.01; 95% CI, 0.65-1.57); however, for patients receiving EBRT+BT, a longer duration was associated with improved DMFS (DMFS HR, 0.56; 95% CI, 0.36-0.87; P = .01). For patients receiving EBRT alone (DART), 28 months of ADT was associated with improved DMFS compared with 18 months (RADAR HR, 0.37; 95% CI, 0.17-0.80; P = .01). CONCLUSIONS AND RELEVANCE These cohort study findings suggest that the optimal minimum ADT duration for treatment with high-dose EBRT alone is more than 18 months; and for EBRT+BT, it is 18 months or possibly less. Additional studies are needed to determine more precise minimum durations.
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Affiliation(s)
- Amar U. Kishan
- Department of Radiation Oncology, University of California, Los Angeles,Department of Urology, University of California, Los Angeles
| | - Alison Steigler
- School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia
| | - James W. Denham
- School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia
| | | | | | - David Joseph
- Sir Charles Gairdner Hospital, Perth, West Australia, Australia,Department of Medicine and Surgery, University of Western Australia, Perth, West Australia, Australia
| | | | - Jessica K. Wong
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Bradley J. Stish
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Robert T. Dess
- Department of Radiation Oncology, University of Michigan, Ann Arbor
| | - Avinash Pilar
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Ontario, Canada,Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Chandana Reddy
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | | | | | - Ryan Fiano
- Schiffler Cancer Center, Wheeling Hospital, Wheeling Jesuit University, Wheeling, West Virginia
| | - Gregory S. Merrick
- Schiffler Cancer Center, Wheeling Hospital, Wheeling Jesuit University, Wheeling, West Virginia
| | - Richard G. Stock
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - D. Jeffrey Demanes
- Department of Radiation Oncology, University of California, Los Angeles,California Endocurietherapy Cancer Center, Oakland
| | | | - Phuoc T. Tran
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Santiago Martin
- Department of Radiation Oncology, Program in Solid Tumors, Clínica Universidad de Navarra, Pamplona, Spain
| | - Rafael Martinez-Monge
- Department of Radiation Oncology, Program in Solid Tumors, Clínica Universidad de Navarra, Pamplona, Spain
| | - Daniel J. Krauss
- William Beaumont School of Medicine, Oakland University, Royal Oak, Michigan
| | - Eyad I. Abu-Isa
- Department of Radiation Oncology, University of Michigan, Ann Arbor
| | | | - C. Richard Choo
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Daniel Y. Song
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Stephen Greco
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Curtiland Deville
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Todd McNutt
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Theodore L. DeWeese
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ashley E. Ross
- Department of Urology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Jay P. Ciezki
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Derya Tilki
- Department of Urology, University Hospital Hamburg-Eppendorf, Hamburg, Germany,Martini-Klinik Prostate Cancer Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | | | - Jeffrey J. Tosoian
- Department of Urology, The James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Nicholas G. Nickols
- Department of Radiation Oncology, University of California, Los Angeles,Department of Radiation Oncology, West Los Angeles Veterans Health Administration, Los Angeles, California
| | - Prashant Bhat
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - David Shabsovich
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Jesus E. Juarez
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Tommy Jiang
- Department of Radiation Oncology, University of California, Los Angeles
| | - T. Martin Ma
- Department of Radiation Oncology, University of California, Los Angeles
| | - Michael Xiang
- Department of Radiation Oncology, University of California, Los Angeles
| | - Rebecca Philipson
- Department of Radiation Oncology, University of California, Los Angeles
| | - Albert Chang
- Department of Radiation Oncology, University of California, Los Angeles
| | | | - Matthew B. Rettig
- Division of Medical Oncology, Ronald Reagan UCLA Medical Center, University of California, Los Angeles,Department of Medical Oncology, West Los Angeles Veterans Health Administration, Los Angeles, California
| | - Felix Y. Feng
- Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco
| | - Alejandro Berlin
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Jonathan D. Tward
- Department of Radiotherapy Oncology, Huntsman Cancer Institute at the University of Utah, Salt Lake City
| | - Brian J. Davis
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | | | | | - David Elashoff
- Division of General Internal Medicine and Health Services Research, University of California, Los Angeles
| | - Paul C. Boutros
- Department of Urology, University of California, Los Angeles,Department of Human Genetics, University of California, Los Angeles
| | - Eric M. Horwitz
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Rahul D. Tendulkar
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Daniel E. Spratt
- Seidman Cancer Center, Case Western Reserve University, Cleveland, Ohio
| | - Tahmineh Romero
- Division of General Internal Medicine and Health Services Research, University of California, Los Angeles
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Kishan AU, Sun Y, Hartman H, Pisansky TM, Bolla M, Neven A, Steigler A, Denham JW, Feng FY, Zapatero A, Armstrong JG, Nabid A, Carrier N, Souhami L, Dunne MT, Efstathiou JA, Sandler HM, Guerrero A, Joseph D, Maingon P, de Reijke TM, Maldonado X, Ma TM, Romero T, Wang X, Rettig MB, Reiter RE, Zaorsky NG, Steinberg ML, Nickols NG, Jia AY, Garcia JA, Spratt DE. Androgen deprivation therapy use and duration with definitive radiotherapy for localised prostate cancer: an individual patient data meta-analysis. Lancet Oncol 2022; 23:304-316. [DOI: 10.1016/s1470-2045(21)00705-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 11/23/2021] [Accepted: 11/26/2021] [Indexed: 12/22/2022]
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Cackowski FC, Heath EI. Prostate cancer dormancy and recurrence. Cancer Lett 2022; 524:103-108. [PMID: 34624433 PMCID: PMC8694498 DOI: 10.1016/j.canlet.2021.09.037] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 09/13/2021] [Accepted: 09/24/2021] [Indexed: 01/03/2023]
Abstract
Prostate cancer can progress rapidly after diagnosis, but can also become undetectable after curative intent radiation or surgery, only to recur years or decades later. This capacity to lie dormant and recur long after a patient was thought to be cured, is relatively unique to prostate cancer, with estrogen receptor positive breast cancer being the other common and well-studied example. Most investigators agree that the bone marrow is an important site for dormant tumor cells, given the frequency of bone metastases and that multiple studies have reported disseminated tumor cells in patients with localized disease. However, while more difficult to study, lymph nodes and the prostate bed are likely to be important reservoirs as well. Dormant tumor cells may be truly quiescent and in the G0 phase of the cell cycle, which is commonly called cellular dormancy. However, tumor growth may also be held in check through a balance of proliferation and cell death (tumor mass dormancy). For induction of cellular dormancy, prostate cancer cells respond to signals from their microenvironment, including TGF-β2, BMP-7, GAS6, and Wnt-5a, which result in signals transduced in part through p38 MAPK and pluripotency associated transcription factors including SOX2 and NANOG, which likely affect the epi-genome through histone modification. Clinical use of adjuvant radiation or androgen deprivation has been modestly successful to prevent recurrence. With the rapid pace of discovery in this field, systemic adjuvant therapy is likely to continue to improve in the future.
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Affiliation(s)
- Frank C Cackowski
- Department of Oncology, Wayne State University School of Medicine and Karmanos Cancer Institute, Detroit, MI, USA.
| | - Elisabeth I Heath
- Department of Oncology, Wayne State University School of Medicine and Karmanos Cancer Institute, Detroit, MI, USA
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An Expert Review on the Combination of Relugolix with Definitive Radiation Therapy for Prostate Cancer. Int J Radiat Oncol Biol Phys 2021; 113:278-289. [PMID: 34923058 DOI: 10.1016/j.ijrobp.2021.12.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Revised: 12/05/2021] [Accepted: 12/06/2021] [Indexed: 11/20/2022]
Abstract
Androgen deprivation therapy (ADT) is an integral component in the management of prostate cancer across multiple disease states. Traditionally, luteinizing hormone-releasing hormone (LHRH) agonists constituted the backbone of ADT. However, gonadotropin-releasing hormone receptor hormone (GnRH) antagonists are also available, which offer faster testosterone suppression and reduced likelihood of ADT-related adverse effects compared to LHRH agonists, including the potential for fewer ADT-associated major cardiac events. Until recently, all forms of LHRH agonists and GnRH antagonist formulations are of parenteral administration. However, recently relugolix gained FDA approval as the first oral GnRH antagonist. Relugolix achieves faster and more complete testosterone suppression compared to an LHRH agonist. This translates to more rapid prostate-specific antigen response compared to LHRH agonists. After discontinuation of relugolix, testosterone recovers faster than after GnRH agonists or injectable GnRH antagonist therapy. Overall, these factors provide opportunities for more precisely defined ADT duration when combined with radiation therapy. The rapid onset and offset testosterone suppression with relugolix, however, may require physicians to rethink the mechanism and goals of ADT when prescribing. As an oral formulation, relugolix enables patients to avoid pain and injection site reactions, limit extra office visits for injections, and achieve a shorter duration of experiencing the side effects of castrate testosterone levels. This convenience and tolerability may enhance physicians' willingness to prescribe ADT and patients' feeling of control over their ADT course, but the potential advantages are accompanied by the risks of patients choosing to discontinue therapy to escape side effects of ADT. This article focuses on different aspects of what is known and unknown regarding the optimal use of ADT and radiation therapy, and how relugolix, due to its properties, fit into our current treatment paradigms for localized prostate cancer.
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Delahunt B, Steigler A, Atkinson C, Christie D, Duchesne G, Egevad L, Joseph D, Kenwright D, Matthews J, Murray J, Oldmeadow C, Samaratunga H, Spry N, Thunders M, Hondermarck H, Denham J. Percentage grade 4 tumour predicts outcome for prostate adenocarcinoma in needle biopsies from patients with advanced disease: 10-year data from the TROG 03.04 RADAR trial. Pathology 2021; 54:49-54. [DOI: 10.1016/j.pathol.2021.11.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Revised: 11/29/2021] [Accepted: 12/01/2021] [Indexed: 11/26/2022]
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Neoadjuvant hormonal therapy before radical prostatectomy in high-risk prostate cancer. Nat Rev Urol 2021; 18:739-762. [PMID: 34526701 DOI: 10.1038/s41585-021-00514-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/11/2021] [Indexed: 02/08/2023]
Abstract
Patients with high-risk prostate cancer treated with curative intent are at an increased risk of biochemical recurrence, metastatic progression and cancer-related death compared with patients treated for low-risk or intermediate-risk disease. Thus, these patients often need multimodal therapy to achieve complete disease control. Over the past two decades, multiple studies on the use of neoadjuvant treatment have been performed using conventional androgen deprivation therapy, which comprises luteinizing hormone-releasing hormone agonists or antagonists and/or first-line anti-androgens. However, despite results from these studies demonstrating a reduction in positive surgical margins and tumour volume, no benefit has been observed in hard oncological end points, such as cancer-related death. The introduction of potent androgen receptor signalling inhibitors (ARSIs), such as abiraterone, apalutamide, enzalutamide and darolutamide, has led to a renewed interest in using neoadjuvant hormonal treatment in high-risk prostate cancer. The addition of ARSIs to androgen deprivation therapy has demonstrated substantial survival benefits in the metastatic castration-resistant, non-metastatic castration-resistant and metastatic hormone-sensitive settings. Intuitively, a similar survival effect can be expected when applying ARSIs as a neoadjuvant strategy in high-risk prostate cancer. Most studies on neoadjuvant ARSIs use a pathological end point as a surrogate for long-term oncological outcome. However, no consensus yet exists regarding the ideal definition of pathological response following neoadjuvant hormonal therapy and pathologists might encounter difficulties in determining pathological response in hormonally treated prostate specimens. The neoadjuvant setting also provides opportunities to gain insight into resistance mechanisms against neoadjuvant hormonal therapy and, consequently, to guide personalized therapy.
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Johnson ED, Butler K, Gupta S. Bone Health in Patients With Prostate Cancer: An Evidence-Based Algorithm. Fed Pract 2021; 38:S20-S26. [PMID: 34733092 DOI: 10.12788/fp.0155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Background The veteran population has an increasingly high number of patients who have either survived, are currently living with, or are being treated for prostate cancer. Survivorship concerns related to the treatment of this disease is a relevant topic in the Veterans Health Administration, given the longevity of life with localized disease treatment and the fairly durable therapies for metastatic disease. Long-term androgen deprivation therapy (ADT) forms the backbone of treatment for advanced and metastatic castration-sensitive prostate cancer. Observations The potential bone-health complications resulting from treatment with ADT should be recognized as many patients live for prolonged periods with stable or controlled disease. It is well established that prolonged ADT can lead to significant bone loss and increased fracture risk, which increases all-cause mortality and disability. Bone-remodeling agents, such as bisphosphonates and receptor-activated nuclear factor κ-B ligand inhibitors, are recommended to reduce the risk of fragility fractures in patients at high risk due to diminished bone density while on hormone deprivation therapy for hormone-naive prostate cancer. These agents are also indicated at a higher dose to prevent complications from bone metastases in castration-resistant prostate cancer with bone metastases. Conclusions This article reviews recent studies on bone health in men with prostate cancer and presents an evidence-based algorithm for bone-health monitoring during treatment and recommended interventions.
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Affiliation(s)
- Eric D Johnson
- and are Oncologists, and is a Clinical Oncology Pharmacist; all at George E. Wahlen Department of Veterans Affairs Medical Center in Salt Lake City, Utah. Eric Johnson is a Clinical Fellow and Sumati Gupta is an Assistant Professor, both at Huntsman Cancer Institute at the University of Utah in Salt Lake City
| | - Katerina Butler
- and are Oncologists, and is a Clinical Oncology Pharmacist; all at George E. Wahlen Department of Veterans Affairs Medical Center in Salt Lake City, Utah. Eric Johnson is a Clinical Fellow and Sumati Gupta is an Assistant Professor, both at Huntsman Cancer Institute at the University of Utah in Salt Lake City
| | - Sumati Gupta
- and are Oncologists, and is a Clinical Oncology Pharmacist; all at George E. Wahlen Department of Veterans Affairs Medical Center in Salt Lake City, Utah. Eric Johnson is a Clinical Fellow and Sumati Gupta is an Assistant Professor, both at Huntsman Cancer Institute at the University of Utah in Salt Lake City
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Influence of Timing Between Androgen Deprivation Therapy and External Beam Radiation Therapy in Patients With Localized, High-Risk Prostate Cancer. Adv Radiat Oncol 2021; 6:100803. [PMID: 34703954 PMCID: PMC8526773 DOI: 10.1016/j.adro.2021.100803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 06/14/2021] [Accepted: 08/30/2021] [Indexed: 11/29/2022] Open
Abstract
Purpose Treatment with long-term androgen deprivation therapy (ADT) and radiation therapy (RT) is the nonsurgical standard-of-care for patients with high- or very high-risk prostate cancer (HR-PC), but the optimal timing between ADT and RT initiation is unknown. We evaluate the influence of timing between ADT and RT on outcomes in patients with HR-PC using a large national cancer database. Methods and Materials Data for patients with clinical T1-T4 N0, M0, National Cancer Comprehensive Network HR-PC who were treated with definitive external RT (≥60 Gy) and ADT starting either before or within 14 days after RT start were extracted from the National Cancer Database (2004-2015). Patients were grouped on the basis of ADT initiation: (1) >11 weeks before RT, (2) 8 to 11weeks before RT, and (3) <8 weeks before RT. Kaplan-Meier, propensity score matching, and multivariable Cox proportional hazards were performed to evaluate overall survival (OS). Results With a median follow-up of 68.9 months, 37,606 patients with HR-PC were eligible for analysis: 13,346 (35.5%) with >11 weeks of neoadjuvant ADT, 11,456 (30.5%) with 8 to 11 weeks of neoadjuvant ADT; and 12,804 (34%) patients with <8 weeks of neoadjuvant ADT. The unadjusted 10-year OS rates for >11 weeks, 8 to 11 weeks, and <8 weeks neoadjuvant ADT groups were 49.9%, 51.2%, and 46.9%, respectively (P = .002). On multivariable and inverse probability of treatment weighting analyses, there was a significant OS advantage for patients in the 8 to 11 weeks neoadjuvant ADT group (adjusted hazard ratio 0.90; 95% confidence interval, 0.86-0.95; P < .001) but not the >11 weeks group. Conclusions Neoadjuvant ADT initiation 8 to 11 weeks before RT is associated with significantly improved OS compared with shorter neoadjuvant ADT duration. Although prospective validation is warranted, this analysis is the largest retrospective study suggesting an influence of timing between ADT and RT initiation in HR-PC.
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125I Interstitial brachytherapy with or without androgen deprivation therapy among unfavorable-intermediate and high-risk prostate cancer. Brachytherapy 2021; 21:85-93. [PMID: 34656435 DOI: 10.1016/j.brachy.2021.09.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 08/31/2021] [Accepted: 09/08/2021] [Indexed: 11/24/2022]
Abstract
PURPOSE/OBJECTIVE(S) To determine if patients with unfavorable intermediate-risk (UIR), high-risk (HR), or very high-risk (VHR) prostate cancer (PCa) treated with 125I interstitial brachytherapy benefit from androgen deprivation therapy (ADT). MATERIALS/METHODS We reviewed our institutional database of patients with UIR, HR, or VHR PCa, per 2018 NCCN risk classification, treated with definitive 125I interstitial brachytherapy with or without ADT from 1998-2017. Outcomes including biochemical failure (bF), distant metastases (DM), and overall survival (OS) were analyzed with the Kaplan-Meier method and Cox proportional hazards regression. PCa-specific mortality (PCSM) was analyzed with Fine-Gray competing-risk regression. RESULTS Of 1033 patients, 262 (25%) received ADT and 771 (75%) did not. Median ADT duration was 6 months. By risk group, 764 (74%) patients were UIR, 219 (21%) HR, and 50 (5%) VHR. ADT was more frequently given to HR (50%) and VHR (56%) patients compared to UIR (16%; p<0.001), to older patients (p<0.001), corresponding with increasing PSA (p<0.001) and Grade Group (p<0.001). Median follow-up was 4.9 years (0.3-17.6 years). On multivariable analysis accounting for risk group, age, and year of treatment, ADT was not associated with bF, DM, PCSM, or OS (p≥0.05 each). CONCLUSION Among patients with UIR, HR, and VHR PCa, the addition of ADT to 125I interstitial brachytherapy was not associated with improved outcomes, and no subgroup demonstrated benefit. Our findings do not support the use of ADT in combination with 125I interstitial brachytherapy. Prospective studies are required to elucidate the role of ADT for patients with UIR, HR, and VHR PCa treated with prostate brachytherapy.
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Burgess L, Roy S, Morgan S, Malone S. A Review on the Current Treatment Paradigm in High-Risk Prostate Cancer. Cancers (Basel) 2021; 13:4257. [PMID: 34503067 PMCID: PMC8428221 DOI: 10.3390/cancers13174257] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 08/16/2021] [Accepted: 08/20/2021] [Indexed: 01/17/2023] Open
Abstract
High-risk prostate cancer is traditionally treated with a combination of radiotherapy (RT) and androgen deprivation therapy (ADT). However, recent advancements in systemic treatment and radiotherapy have widened the spectrum of treatment for this patient population. Use of image guidance and intensity modulation, as well as the incorporation of brachytherapy, has led to safe radiotherapy dose escalation with reduced risk of recurrence. Clinical trials have helped define the role of pelvic nodal radiotherapy, the role of stereotactic ablative radiotherapy, and the optimal duration and sequencing of ADT in combination with radiotherapy. Emerging evidence has redefined the role of surgery in this cohort. Contemporary clinical trials have identified new systemic therapy options in high-risk prostate cancer. Finally, new imaging modalities including multi-parametric MRI and molecular imaging and genomic classifiers have ushered a new era in patient selection, risk stratification, and treatment tailoring.
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Affiliation(s)
- Laura Burgess
- Division of Radiation Oncology, Department of Radiology, University of Ottawa, Ottawa, ON K1H 8L6, Canada;
- Radiation Medicine Program, The Ottawa Hospital Cancer Centre, Ottawa, ON K1H 8L6, Canada
| | - Soumyajit Roy
- Department of Radiation Oncology, Rush University Medical Center, Chicago, IL 60605, USA;
| | - Scott Morgan
- Division of Radiation Oncology, Department of Radiology, University of Ottawa, Ottawa, ON K1H 8L6, Canada;
- Radiation Medicine Program, The Ottawa Hospital Cancer Centre, Ottawa, ON K1H 8L6, Canada
| | - Shawn Malone
- Division of Radiation Oncology, Department of Radiology, University of Ottawa, Ottawa, ON K1H 8L6, Canada;
- Radiation Medicine Program, The Ottawa Hospital Cancer Centre, Ottawa, ON K1H 8L6, Canada
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Dhere VR, Fischer-Valuck BW, Goyal S, Liu Y, Morgan TM, Ghavidel E, Moghanaki DM, Hershatter BW, Patel PR, Jani AB, Godette KD, Rossi PJ, Patel SA. Patient-reported outcomes after Low-dose-rate versus High-dose-rate brachytherapy boost in combination with external beam radiation for intermediate and high risk prostate cancer. Brachytherapy 2021; 20:1130-1138. [PMID: 34417136 DOI: 10.1016/j.brachy.2021.07.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 06/24/2021] [Accepted: 07/14/2021] [Indexed: 02/07/2023]
Abstract
PURPOSE Addition of a brachytherapy boost to external beam radiation therapy (EBRT) reduces prostate cancer (PCa) recurrence at the expense of genitourinary (GU) toxicity. Whether brachytherapy boost technique, specifically low-dose-rate (LDR-BT) versus high-dose-rate (HDR-BT), impacts treatment-related toxicity is unclear. METHODS Between 2012-2018, 106 men with intermediate/high risk PCa underwent EBRT (37.5-45 Gy in 1.8-2.5 Gy/fraction) plus brachytherapy boost, either with LDR-BT (110 Gy I-125 or 100 Gy Pd-103; n = 51) or HDR-BT (15 Gy x1 Ir-192; n = 55). Patient-reported outcomes (PRO) were assessed by International Prostate Symptom Score (IPSS) and Expanded Prostate Cancer Index Composite (EPIC-CP) surveys at 3-6-month intervals for up to three years following treatment, with higher scores indicating more severe toxicity. Provider-reported GU and gastrointestinal (GI) toxicity was graded per CTCAE v5.0 at each follow-up. Linear mixed models comparing PROs between LDR-BT versus HDR-BT were fitted. Stepwise multivariable analysis (MVA) was performed to account for age, gland size, androgen deprivation therapy use, and alpha-blocker medication use. Incidence rates of grade 2+ GU/GI toxicity was compared using Fisher's exact test. RESULTS Use of LDR-BT was associated with greater change in IPSS (p=0.003) and EPIC-CP urinary irritative score (p = 0.002) compared with HDR-BT, but effect size diminished over time (LDR-BT versus HDR-BT: baseline to 6-/24-month mean IPSS change, +6.4/+1.4 versus +2.7/-3.0, respectively; mean EPIC-CP irritative/obstructive change, +2.5/+0.1 versus +0.9/+0.1, respectively). Results remained significant on MVA. Post-treatment grade 2+ GU toxicity was significantly higher in the LDR-BT group (67.5% versus 42.9% for LDR-BT and HDR-BT, respectively; p <0.001). There were no differences between groups in incontinence, bowel function, and erectile function, or grade 2+ GI toxicity. CONCLUSION Compared with LDR-BT, HDR-BT was associated with lower acute patient- and provider-reported GU toxicity.
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Affiliation(s)
- Vishal R Dhere
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta GA
| | | | - Subir Goyal
- Department of Biostatistics and Bioinformatics, Emory University, Atlanta GA
| | - Yuan Liu
- Department of Biostatistics and Bioinformatics, Emory University, Atlanta GA
| | | | - Elizabeth Ghavidel
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta GA
| | - Drew M Moghanaki
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta GA
| | - Bruce W Hershatter
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta GA
| | - Pretesh R Patel
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta GA
| | - Ashesh B Jani
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta GA
| | - Karen D Godette
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta GA
| | - Peter J Rossi
- Calaway Young Cancer Center, Valley View Hospital, Glenwood Springs CO
| | - Sagar A Patel
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta GA.
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Intensity-Modulated Radiation Therapy with Simultaneous Integrated Boost for Clinically Node-Positive Prostate Cancer: A Single-Institutional Retrospective Study. Cancers (Basel) 2021; 13:cancers13153868. [PMID: 34359768 PMCID: PMC8345592 DOI: 10.3390/cancers13153868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Revised: 07/23/2021] [Accepted: 07/27/2021] [Indexed: 11/17/2022] Open
Abstract
Simple Summary Recently, it has been shown that radiation therapy (RT) together with androgen-depletion therapy (ADT) might be more beneficial compared with ADT alone for clinically node-positive (cN1) prostate cancer. However, there are a limited number of studies that have addressed specific RT techniques and analyzed their clinical results. The present study was a retrospective analysis of cN1 prostate cancer patients treated with intensity-modulated radiation therapy with simultaneous integrated boost (SIB-IMRT), in addition to ADT, in our hospital. The present study suggests that ADT plus SIB-IMRT for cN1 prostate cancer treatment was safe and effective, was well tolerated, and had acceptable rates of late toxicity. Further prospective multicenter studies would be required to confirm the robustness of the present results. Abstract This study aimed to evaluate clinical outcomes and the toxicity of intensity-modulated radiation therapy with simultaneous integrated boost (SIB-IMRT) combined with androgen-deprivation therapy for clinically node-positive (cN1) prostate cancer. We retrospectively analyzed 97 patients with cN1 prostate cancer who received SIB-IMRT between June 2008 and October 2017 at our hospital. The prescribed dosages delivered to the prostate and seminal vesicle, elective node area, and residual lymph nodes were 69, 54, and 60 Gy in 30 fractions, respectively. Kaplan–Meier analysis was used to determine 5-year biochemical relapse-free survival (bRFS), relapse-free survival (RFS), overall survival (OS), and prostate cancer-specific survival (PCSS). Toxicity was evaluated using the Common Terminology Criteria for Adverse Events ver. 4.0. Over a median follow-up duration of 60 months, the 5-year bRFS, RFS, OS, and PCSS were 85.1%, 88.1%, 92.7% and 95.0%, respectively. Acute Grade 2 genito-urinary (GU) and gastro-intestinal (GI) toxicities were observed in 10.2% and 2.1%, respectively, with no grade ≥3 toxicities being detected. The cumulative incidence rates of 5-year Grade ≥2 late GU and GI toxicities were 4.7% and 7.4%, respectively, with no Grade 4 toxicities being detected. SIB-IMRT for cN1 prostate cancer demonstrated favorable 5-year outcomes with low incidences of toxicity.
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Hsu IC, Rodgers JP, Shinohara K, Purdy J, Michalski J, Roach M, Vigneault E, Ivker RA, Pryzant RM, Kuettel M, Taussky D, Gustafson GS, Raben A, Sandler HM. Long-Term Results of NRG Oncology/RTOG 0321: A Phase II Trial of Combined High Dose Rate Brachytherapy and External Beam Radiation Therapy for Adenocarcinoma of the Prostate. Int J Radiat Oncol Biol Phys 2021; 110:700-707. [PMID: 33186617 PMCID: PMC8107184 DOI: 10.1016/j.ijrobp.2020.11.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 10/19/2020] [Accepted: 11/19/2020] [Indexed: 02/07/2023]
Abstract
PURPOSE To report the long-term outcome of patients with prostate cancer treated with external beam radiation therapy and high dose rate (HDR) brachytherapy from a prospective multi-institutional trial conducted by NRG Oncology/RTOG. METHODS AND MATERIALS Patients with clinically localized (T1c-T3b) prostate cancer without prior history of transurethral resection of prostate or hip prosthesis were eligible for this study. All patients were treated with a combination of 45 Gy in 25 fractions from external beam radiation therapy and one HDR implant delivering 19 Gy in 2 fractions. Adverse events (AE) were collected using Common Toxicity Criteria for Adverse Events, version 3. Cumulative incidence was used to estimate time to severe late gastrointestinal (GI)/genitourinary (GU) toxicity, biochemical failure, disease-specific mortality, local failure, and distant failure. Overall survival was estimated using the Kaplan-Meier method. RESULTS One hundred and twenty-nine patients were enrolled from July 2004 to May 2006. AE data was available for 115 patients. Patients were National Comprehensive Cancer Network (NCCN) intermediate to very high risk. The median age was 68, T1c-T2c 91%, T3a-T3b 9%, PSA ≤10 70%, PSA >10 to ≤20 30%, GS 6 10%, GS 7 72%, and GS 8 to 10 18%. Forty-three percent of patients received hormonal therapy. At a median follow-up time of 10 years, there were 6 (5%) patients with grade 3 GI and GU treatment-related AEs, and no late grade 4 to 5 GI and GU AEs. At 5 and 10 years, the rate of late grade 3 gastrointestinal and genitourinary AEs was 4% and 5%, respectively. Five- and 10-year overall survival rates were 95% and 76%. Biochemical failure rates per Phoenix definition at 5 and 10 years were 14% and 23%. The 10-year rate of disease-specific mortality was 6%. At 5 and 10 years, the rates of distant failure were 4% and 8%, respectively. The rates of local failure at 5 and 10 years were 2% at both time points. CONCLUSIONS Combined modality treatment using HDR prostate brachytherapy leads to excellent long-term clinical outcomes in this prospective multi-institutional trial.
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Affiliation(s)
- I-Chow Hsu
- University of California, San Francisco, California.
| | | | | | - James Purdy
- University of California Davis, Davis, California
| | | | - Mack Roach
- University of California, San Francisco, California
| | | | | | | | | | - Daniel Taussky
- Center Hospitalier de l'Université de Montréal-Notre Dame
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Genomic Strategies to Personalize Use of Androgen Deprivation Therapy With Radiotherapy. ACTA ACUST UNITED AC 2021; 26:13-20. [PMID: 31977380 DOI: 10.1097/ppo.0000000000000419] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The use of combination RT and androgen deprivation therapy in many prostate cancer curative-intent treatment scenarios is supported by level 1 evidence. However, in our current clinical paradigm, we have no ability to determine a priori which patients truly benefit from combination therapy and therefore apply the combination RT and androgen deprivation therapy intensification strategy to all patients, which results in overtreatment or undertreatment of the majority of our patients. Genomics has the ability to more deeply and objectively characterize the disease, in turn refining our prognostication capabilities and enabling the individualization of treatments. We review the commercially available prostate cancer genomic tests, focusing on those able to predict patient outcomes following radiotherapy or guide radiotherapy treatment decisions.
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Peyraga G, Lizee T, Khalifa J, Blais E, Mauriange-Turpin G, Supiot S, Krhili S, Tremolieres P, Graff-Cailleaud P. Brachytherapy boost (BT-boost) or stereotactic body radiation therapy boost (SBRT-boost) for high-risk prostate cancer (HR-PCa). Cancer Radiother 2021; 25:400-409. [PMID: 33478838 DOI: 10.1016/j.canrad.2020.11.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 11/21/2020] [Accepted: 11/25/2020] [Indexed: 11/25/2022]
Abstract
Systematic review for the treatment of high-risk prostate cancer (HR-PCa, D'Amico classification risk system) with external body radiation therapy (EBRT)+brachytherapy-boost (BT-boost) or with EBRT+stereotactic body RT-boost (SBRT-boost). In March 2020, 391 English citations on PubMed matched with search terms "high risk prostate cancer boost". Respectively 9 and 48 prospective and retrospective studies were on BT-boost and 7 retrospective studies were on SBRT-boost. Two SBRT-boost trials were prospective. Only one study (ASCENDE-RT) directly compared the gold standard treatment [dose-escalation (DE)-EBRT+androgen deprivation treatment (ADT)] versus EBRT+ADT+BT-boost. Biochemical control rates at 9 years were 83% in the experimental arm versus 63% in the standard arm. Cumulative incidence of late grade 3 urinary toxicity in the experimental arm and in the standard arm was respectively 18% and 5%. Two recent studies with HR-PCa (National Cancer Database) demonstrated better overall survival with BT-boost (low dose rate LDR or high dose rate HDR) compared with DE-EBRT. These recent findings demonstrate the superiority of EBRT+BT-boost+ADT versus DE-EBRT+ADT for HR-PCa. It seems that EBRT+BT-boost+ADT could now be considered as a gold standard treatment for HR-PCa. HDR or LDR are options. SBRT-boost represents an attractive alternative, but the absence of randomised trials does not allow us to conclude for HR-PCa. Prospective randomised international phase III trials or meta-analyses could improve the level of evidence of SBRT-boost for HR-PCa.
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Affiliation(s)
- G Peyraga
- Radiation department, Toulouse university institute of cancer, Oncopôle, Toulouse, France; Radiation therapy department, Groupe de radiotherapie et d'oncologie des Pyrénées, chemin de l'Ormeau, 65000 Tarbes, France.
| | - T Lizee
- Radiation therapy department, Integrated centre of oncology (Paul Papin), Angers, France
| | - J Khalifa
- Radiation department, Toulouse university institute of cancer, Oncopôle, Toulouse, France
| | - E Blais
- Radiation therapy department, Groupe de radiotherapie et d'oncologie des Pyrénées, chemin de l'Ormeau, 65000 Tarbes, France
| | - G Mauriange-Turpin
- Radiation therapy department, University hospital centre, Limoges, France
| | - S Supiot
- Radiation therapy department, Integrated centre of oncology (Rene Gauducheau), Saint-Herblain, France
| | - S Krhili
- Radiation therapy department, Curie Institute, Paris, France
| | - P Tremolieres
- Radiation therapy department, Integrated centre of oncology (Paul Papin), Angers, France
| | - P Graff-Cailleaud
- Radiation department, Toulouse university institute of cancer, Oncopôle, Toulouse, France
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