Early and late side effects, dosimetric parameters and quality of life after proton beam therapy and IMRT for prostate cancer: a matched-pair analysis

Long-Term Medical Resource Consumption of Radical Prostatectomy vs. Intensity-Modulated Radiotherapy for Old Patients With Prostate Cancer: A Nationwide Population-Based Cohort Study

Purpose

Few studies have compared the long-term medical resource consumption between radical prostatectomy (RP) and intensity-modulated radiation therapy (IMRT) among old (≥80 years) patients with localized prostate cancer (LPC), particularly in those at high risk of prostate adenocarcinoma.

Patients and Methods

The propensity score matching was conducted to investigate the medical expenditure of two therapeutic modalities (RP and IMRT) in elderly patients with high-risk LPC (HR-LPC). The generalized linear mixed and logistic regression models were employed to evaluate the number of postdischarge visits and medical reimbursement for urinary diseases or complications and the number of hospitalizations for treatment-related complications over 5 years after treatment, respectively.

Results

Significant differences were observed in the median or mean urology clinic visit numbers across the two therapeutic modalities from the first until fifth year post treatment (p < 0.0001). After adjustment for covariates, the mean difference [95% confidence interval (CI)] of urology clinic visit numbers between RP and IMRT was 13.07 (10.45-15.49, P < 0.0001), 7.47 (8.01-14.92, P < 0.0001), 8.24 (4.59-9.90, P < 0.0001), 6.63 (3.55-11.70, P < 0.0001), and 5.02 (1.12-8.73, P < 0.0001) for the first, second, third, fourth, and fifth years, respectively. In the logistic regression multivariate model with adjustment for covariates [therapy type, age, diagnosis year, income, hospital area, hospital level (academic or nonacademic), clinical and pathological T-stage, grade (Gleason score), pretreatment PSA level (ng/ml), and D'Amico risk classification], the adjusted odds ratio (95% CI) of IMRT was 2.10 (1.37-2.56, P = 0.0013), 1.55 (1.08-2.21, P = 0.0151), 1.35 (1.08-2.21, P = 0.0084), 1.24 (1.07-2.21, P = 0.0071), and 1.09 (1.02-1.81, P = 0.0379) for the first, second, third, fourth, and fifth years, respectively, compared with those of RP. The mean difference (95% CI) of total medical claims amounts of RP and IMRT between the RP and IMRT + ADT groups was 2,69,823 New Taiwan Dollars (NTD) (247,676-291,970, P < 0.0001), 40,803 NTD (17,379-54,228, P < 0.0001), 36,202 NTD (24,375-68,029, P < 0.0001), 26,708 NTD (11,179-54,595, P = 0.0321), and 12,173 NTD (17,140-41,487, P = 0.0187) for the first, second, third, fourth, and fifth years, respectively.

Conclusion

The long-term medical resource consumption was higher in old men with HR-LPC undergoing IMRT than in those undergoing RP.

Estimating the percentage of patients who might benefit from proton beam therapy instead of X-ray radiotherapy

OBJECTIVES

High-energy Proton Beam Therapy (PBT) commenced in England in 2018 and NHS England commissions PBT for 1.5% of patients receiving radical radiotherapy. We sought expert opinion on the level of provision.

METHODS

Invitations were sent to 41 colleagues working in PBT, most at one UK centre, to contribute by completing a spreadsheet. 39 responded: 23 (59%) completed the spreadsheet; 16 (41%) declined, arguing that clinical outcome data are lacking, but joined six additional site-specialist oncologists for two consensus meetings. The spreadsheet was pre-populated with incidence data from Cancer Research UK and radiotherapy use data from the National Cancer Registration and Analysis Service. 'Mechanisms of Benefit' of reduced growth impairment, reduced toxicity, dose escalation and reduced second cancer risk were examined.

RESULTS

The most reliable figure for percentage of radical radiotherapy patients likely to benefit from PBT was that agreed by 95% of the 23 respondents at 4.3%, slightly larger than current provision. The median was 15% (range 4-92%) and consensus median 13%. The biggest estimated potential benefit was from reducing toxicity, median benefit to 15% (range 4-92%), followed by dose escalation median 3% (range 0 to 47%); consensus values were 12 and 3%. Reduced growth impairment and reduced second cancer risk were calculated to benefit 0.5% and 0.1%.

CONCLUSIONS

The most secure estimate of percentage benefit was 4.3% but insufficient clinical outcome data exist for confident estimates. The study supports the NHS approach of using the evidence base and developing it through randomised trials, non-randomised studies and outcomes tracking.

ADVANCES IN KNOWLEDGE

Less is known about the percentage of patients who may benefit from PBT than is generally acknowledged. Expert opinion varies widely. Insufficient clinical outcome data exist to provide robust estimates. Considerable further work is needed to address this, including international collaboration; much is already underway but will take time to provide mature data.

Dose-volume histogram parameters and patient-reported EPIC-Bowel domain in prostate cancer proton therapy

Purpose

To analyze rectal dose and changes in quality of life (QOL) measured with the Expanded Prostate and Cancer Index Composite (EPIC) bowel domain in patients being treated for prostate cancer with curative-intent proton beam therapy (PBT) within a large single-institution prospective registry.

Materials and Methods

Data was collected from 243 patients with localized prostate cancer treated with PBT from 2016 to 2018. The EPIC survey was administered at baseline, end-of-treatment, 3, 6, and 12 months, then annually. Dose-volume histogram (DVH) parameters for the rectum were computed, and rectal dose was analyzed using BED (α/β = 3), EQD_2Gy, and total dose. Repeated measures mixed models were implemented to determine the effect of patient, clinical, and treatment factors (including DVH) on patient-reported bowel symptom burden (EPIC-Bowel).

Results

Treatment overall resulted in changes in EPIC-Bowel scores (baseline score = 93.7), most notably at end-of-treatment (90.6) and 12 months (89.7). However, they returned to baseline at 36 months (92.9). On multivariate modeling, rectal BED D₂₅ (Gy) ≥23% was significantly associated with decline in QOL scores measuring bother (p < 0.01; 4.06 points different).

Conclusion

Rectal doses, specifically BED D₂₅ (Gy) ≥23%, are significantly associated with decline in bowel bother-related QOL in patients undergoing definitive radiotherapy for localized prostate cancer. This study demonstrates BED as an independent predictor of bowel QOL across dose fractionations of PBT.

Measuring Radiation Toxicity Using Circulating Cell-Free DNA in Prostate Cancer Patients

Background

After radiation therapy (RT), circulating plasma cell-free DNA (cfDNA) released in response to RT damage to tissue can be measured within hours. We examined for a correlation between cfDNA measured during the first week of therapy and early and late gastrointestinal (GI) and genitourinary (GU) toxicity.

Material and Methods

Patients were eligible for enrollment if they planned to receive proton or photon RT for nonmetastatic prostate cancer in the setting of an intact prostate or after prostatectomy. Blood was collected before treatment and on sequential treatment days for the first full week of therapy. Toxicity assessments were performed at baseline, weekly during RT, and 6 months and 12 months after RT. Data were analyzed to examine correlations among patient-reported GI and GU toxicities.

Results

Fifty-four patients were evaluable for this study. Four (7%) and 3 (6%) patients experienced acute and late grade 2 GI toxicity, respectively. Twenty-two (41%) and 18 (35%) patients experienced acute and late grade 2 GU toxicity, respectively. No patients developed grade 3 or higher toxicity. Grade 2 acute GI toxicity, but not grade 2 acute GU toxicity, was significantly correlated with pre-RT cfDNA levels and on all days 1, 2, 3, 4, and 5 of RT (P < .005). Grade 2 late GI toxicity, but not GU toxicity, was significantly correlated with pre-RT cfDNA levels (P = .021).

Conclusions

Based on this preliminary study, cfDNA levels can potentially predict the subset of patients destined to develop GI toxicity during prostate cancer treatment. Given that the toxicity profiles of the various fractionations and modalities are highly similar, the data support the expectation that cfDNA could provide a biological estimate to complement the dose-volume histogram. A test of this hypothesis is under evaluation in a National Cancer Institute–funded multi-institutional study.

Androgen Deprivation Therapy Combined With Particle Therapy for Prostate Cancer: A Systematic Review

Purpose

There is high-level evidence for addition of androgen deprivation therapy to photon-based radiotherapy of the prostate in intermediate- and high-risk prostate cancer. Little is known about the value of ADT in particle therapy of prostate cancer. We are conducting a systematic review on biochemical disease-free survival, overall survival, and morbidity after combined particle therapy and ADT for prostate cancer.

Methods

A thorough search in PubMed, Embase, Scopus, and Web of Science databases were conducted, searching for relevant studies. Clinical studies on prostate cancer and the treatment combination of particle therapy and androgen deprivation therapy were included. The review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and registered on PROSPERO (CRD42021230801).

Results

A total of 298 papers were identified. Fifteen papers reporting on 7,202 patients after proton or carbon-ion therapy for localized prostate cancer where a fraction or all patients received ADT were selected for analysis. Three thousand five hundred and nineteen (49%) of the patients had received combined ADT and particle therapy. Primarily high-risk (87%), to a lesser extent intermediate-risk (34%) and low-risk patients (12%) received ADT. There were no comparative studies on the effect of ADT in patients treated with particles and no studies identified ADT as an independent prognostic factor related to survival outcomes.

Conclusions

The review found no evidence to support that the effects on biochemical disease-free survival and morbidity of combining ADT to particle therapy differs from the ADT effects in conventional photon based radiotherapy. The available data on the topic is limited.

Effects of social support, hope and resilience on depressive symptoms within 18 months after diagnosis of prostate cancer

Background

The prevalence of depression symptoms and related modifiable factors in prostate cancer (PCa) are not well evaluated. We aimed to assess the effects of perceived social support, hope and resilience on depressive symptoms within 18 months after diagnosis of PCa, and to evaluate the role of hope and resilience as mediators of that relationship.

Method

A cross-sectional study was analyzed in consecutive inpatients with PCa during the months of January 2018 and August 2019. A total of 667 patients eligible for this study completed questionnaires on demographic and clinic variables, Center for Epidemiologic Studies Depression Scale, Multidimensional Scale of Perceived Social Support, Adult Hope Scale, and Resilience Scale (14 items). All registered patients were all volunteers and anonymous. Depressive symptoms, perceived social support, hope and resilience were measured anonymously. Out of 667 patients, a total of 564 effective respondents (< 30% missing data) became our subjects. Hierarchical linear regression was used to identify the factors associated with depressive symptoms. Asymptotic and resampling strategies were used to conduct the mediating effects of hope and resilience.

Results

The prevalence of depressive symptoms was 65.9% in PCa patients. Hierarchical regression analyses indicated that perceived social support, hope, and resilience together accounted for 27.5% variance of depressive symptoms. Support from family, hope, and resilience significantly associated with depressive symptoms, respectively. Hope (a*b = − 0.0783, BCa95% CI: − 0.134 to − 0.0319, p < 0.05), and resilience (a*b = − 0.1315, BCa95% CI: − 0.1894 to − 0.0783, p < 0.05) significantly mediated the association between perceived social support and depressive symptoms.

Conclusions

The high prevalence of depressive symptoms among PCa patients should receive more attention. Perceived social support, hope and resilience could be positive resources for combating depressive symptoms, and hope and resilience mediated the association between perceived social support and depressive symptoms. Enhancing social support, particularly the support form family, and improving patients’ outlook and resilience may be potential targets for future psychosocial interventions aimed at reducing depressive symptoms.

What will radiation oncology look like in 2050? A look at a changing professional landscape in Europe and beyond

The number of newly diagnosed cancers per year is predicted to almost double in the next two decades worldwide, and it remains unclear if and when this alarming trend will level off or even reverse. As such, cancer is very likely to continue to pose a major threat to human health. Radiation oncology is an indispensable pillar of cancer treatment and a well‐developed discipline. Nevertheless, key trends in cancer research and care, including improved primary prevention, early detection, integrated multidisciplinary approaches, personalized strategies at all levels of care, value‐based assessments of healthcare systems, and global health perspectives, will all shape the future of radiation oncology. Broader scientific advances, such as rapid progress in digitization, automation, and in our biological understanding of cancer, as well as the wider societal view of healthcare systems will also influence radiation oncology and how it is practiced. To stimulate a proactive discussion on how to adapt and reshape our discipline, this review provides some predictions on what the role and practice of radiation oncology might look like in 30 years’ time.