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Swensen S, Liao JJ, Chen JJ, Kim K, Ma TM, Weg ES. The expanding role of radiation oncology across the prostate cancer continuum. Abdom Radiol (NY) 2024:10.1007/s00261-024-04408-3. [PMID: 38900319 DOI: 10.1007/s00261-024-04408-3] [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: 03/31/2024] [Revised: 05/23/2024] [Accepted: 05/24/2024] [Indexed: 06/21/2024]
Abstract
Radiotherapy is used in the treatment of prostate cancer in a variety of disease states with significant reliance on imaging to guide clinical decision-making and radiation delivery. In the definitive setting, the choice of radiotherapy treatment modality, dose, and fractionation for localized prostate cancer is determined by the patient's initial risk stratification and other clinical considerations. Radiation is also an option as salvage therapy in patients with locoregionally recurrent disease after prior definitive radiation or surgery. In recent years, the role of radiation has expanded for patients with metastatic disease, including prostate-directed radiotherapy in de novo low volume metastatic disease, metastasis-directed therapy for oligorecurrent disease, and palliative management of symptomatic metastases in the advanced setting. Here we review the expanding role of radiation in the treatment of prostate cancer in the definitive, locoregionally recurrent, and metastatic settings, as well as highlight the role of imaging in clinical reasoning, radiation planning, and treatment delivery.
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Affiliation(s)
- Sasha Swensen
- Department of Radiation Oncology, University of Washington, Fred Hutchinson Cancer Center, 1959 NE Pacific St, Seattle, WA, 98195, USA
| | - Jay J Liao
- Department of Radiation Oncology, University of Washington, Fred Hutchinson Cancer Center, 1959 NE Pacific St, Seattle, WA, 98195, USA
| | - Jonathan J Chen
- Department of Radiation Oncology, University of Washington, Fred Hutchinson Cancer Center, 1959 NE Pacific St, Seattle, WA, 98195, USA
| | - Katherine Kim
- Department of Radiation Oncology, University of Washington, Fred Hutchinson Cancer Center, 1959 NE Pacific St, Seattle, WA, 98195, USA
| | - Ting Martin Ma
- Department of Radiation Oncology, University of Washington, Fred Hutchinson Cancer Center, 1959 NE Pacific St, Seattle, WA, 98195, USA
| | - Emily S Weg
- Department of Radiation Oncology, University of Washington, Fred Hutchinson Cancer Center, 1959 NE Pacific St, Seattle, WA, 98195, USA.
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2
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Martin T, Sun Y, Spratt DE, Kishan AU. Reply to A. Abner et al. J Clin Oncol 2023; 41:2449-2450. [PMID: 36857621 DOI: 10.1200/jco.22.02928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 01/10/2023] [Accepted: 01/11/2023] [Indexed: 03/03/2023] Open
Affiliation(s)
- Ting Martin
- Ting Martin, MA, Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA; Yilun Sun, PhD, Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, OH; Daniel E. Spratt, MD, Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Cleveland Medical Center, Cleveland, OH; and Amar U. Kishan, MD, Departments of Radiation Oncology and Urology, University of California, Los Angeles, Los Angeles, CA
| | - Yilun Sun
- Ting Martin, MA, Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA; Yilun Sun, PhD, Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, OH; Daniel E. Spratt, MD, Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Cleveland Medical Center, Cleveland, OH; and Amar U. Kishan, MD, Departments of Radiation Oncology and Urology, University of California, Los Angeles, Los Angeles, CA
| | - Daniel E Spratt
- Ting Martin, MA, Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA; Yilun Sun, PhD, Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, OH; Daniel E. Spratt, MD, Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Cleveland Medical Center, Cleveland, OH; and Amar U. Kishan, MD, Departments of Radiation Oncology and Urology, University of California, Los Angeles, Los Angeles, CA
| | - Amar U Kishan
- Ting Martin, MA, Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA; Yilun Sun, PhD, Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, OH; Daniel E. Spratt, MD, Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Cleveland Medical Center, Cleveland, OH; and Amar U. Kishan, MD, Departments of Radiation Oncology and Urology, University of California, Los Angeles, Los Angeles, CA
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3
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Xuan H, Lyu Y, Tao J, Xu J, Zhang Y, Chen Z, Ding H, Sheng L, Qian W, Sun Z. Long-term prognosis and prognostic factors of brachytherapy and propensity score matched comparisons of the outcomes between brachytherapy and radical prostatectomy: a retrospective cohort study. Transl Androl Urol 2022; 11:1735-1746. [PMID: 36632163 PMCID: PMC9827410 DOI: 10.21037/tau-22-755] [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: 10/31/2022] [Accepted: 12/16/2022] [Indexed: 12/29/2022] Open
Abstract
Background To report outcomes of patients undergoing brachytherapy (BT), investigate factors associated with biochemical progression-free survival (bPFS) and to compare its long-term prognosis with that of radical prostatectomy (RP) in localized prostate cancer. Methods The clinical data of 87 elderly patients with localized prostate cancer who underwent BT at Huadong Hospital affiliated to Fudan University from January 2009 to December 2016 were retrospectively analyzed. Patient prognoses and associated factors were investigated using univariate and multivariate Cox regression models. The clinical data of the 142 patients with localized prostate cancer who underwent RP during the same period were also collected. By using propensity score matching (PSM), the 42 patients who underwent BT were matched to 42 patients who underwent RP, and the differences in the survival curves were investigated using the Kaplan-Meier method. Results The median follow-up period of the patients who underwent BT was 101 months. The 5- and 10-year overall survival (OS) rates of the patients who underwent BT were 82.8% and 64.0%, respectively, while the 5- and 10-year bPFS rates were 97.2% and 87.5%, respectively. The preoperative clinical Tumor (T) stage was identified as a prognostic factor of bPFS, as patients who underwent BT whose clinical stage was T3 had a worse prognosis than those whose clinical stage was T1-T2 (HR =0.097, P=0.049). After PSM, the average follow-up time of the BT group was 90 months and that of the RP group was 94 months. No significant differences in bPFS or cause-specific survival were observed between the 2 groups. The OS of the RP group was significantly higher than that of the BP group (P=0.030). Among the patients with a prostate volume >35 mL, those who underwent BT had significantly higher pPFS than those who underwent RP (P=0.041). Conclusions In the localized prostate cancer, BT and RP offered similar oncological control in the localized prostate cancer. Stage T3 prostate cancer who undergo BT was associated with worse biochemical failure and was the only variable significantly predictive of biochemical recurrence.
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Affiliation(s)
- Haojie Xuan
- Department of Urology, Huadong Hospital Affiliated to Fudan University, Shanghai, China
| | - Yinfeng Lyu
- Department of Urology, Huashan Hospital Affiliated to Fudan University, Shanghai, China
| | - Jing Tao
- Department of Urology, Huadong Hospital Affiliated to Fudan University, Shanghai, China
| | - Jun Xu
- Department of Urology, Huadong Hospital Affiliated to Fudan University, Shanghai, China
| | - Yang Zhang
- Department of Urology, Huadong Hospital Affiliated to Fudan University, Shanghai, China
| | - Zhihao Chen
- Department of Urology, Huadong Hospital Affiliated to Fudan University, Shanghai, China
| | - Haiyong Ding
- Department of Urology, Huadong Hospital Affiliated to Fudan University, Shanghai, China
| | - Lu Sheng
- Department of Urology, Huadong Hospital Affiliated to Fudan University, Shanghai, China
| | - Weiqing Qian
- Department of Urology, Huadong Hospital Affiliated to Fudan University, Shanghai, China
| | - Zhongquan Sun
- Department of Urology, Huadong Hospital Affiliated to Fudan University, Shanghai, China
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Radioresistance Mechanisms in Prostate Cancer Cell Lines Surviving Ultra-Hypo-Fractionated EBRT: Implications and Possible Clinical Applications. Cancers (Basel) 2022; 14:cancers14225504. [PMID: 36428597 PMCID: PMC9688510 DOI: 10.3390/cancers14225504] [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: 10/19/2022] [Revised: 11/03/2022] [Accepted: 11/04/2022] [Indexed: 11/12/2022] Open
Abstract
The use of a higher dose per fraction to overcome the high radioresistance of prostate cancer cells has been unsuccessfully proposed. Herein, we present PC3 and DU-145, castration-resistant prostate cancer cell lines that survived a clinically used ultra-higher dose per fraction, namely, radioresistant PC3 and DU-145 cells (PC3RR and DU-145RR). Compared to PC3, PC3RR showed a higher level of aggressive behaviour, with enhanced clonogenic potential, DNA damage repair, migration ability and cancer stem cell features. Furthermore, compared to PC3, PC3RR more efficiently survived further radiation by increasing proliferation and down-regulating pro-apoptotic proteins. No significant changes of the above parameters were described in DU-145RR, suggesting that different prostate cancer cell lines that survive ultra-higher dose per fraction do not display the same grade of aggressive phenotype. Furthermore, both PC3RR and DU-145RR increased antioxidant enzymes and mesenchymal markers. Our data suggest that different molecular mechanisms could be potential targets for future treatments plans based on sequential strategies and synergistic effects of different modalities, possibly in a patient-tailored fashion. Moreover, PC3RR cells displayed an increase in specific markers involved in bone remodeling, indicating that radiotherapy selects a PC3 population capable of migrating to secondary metastatic sites. Finally, PC3RR cells showed a better sensitivity to Docetaxel as compared to native PC3 cells. This suggests that a subset of patients with castration-resistant metastatic disease could benefit from upfront Docetaxel treatment after the failure of radiotherapy.
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Dose-escalation in prostate cancer: Results of randomized trials. Cancer Radiother 2022; 26:899-904. [PMID: 36030191 DOI: 10.1016/j.canrad.2022.07.011] [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: 06/13/2022] [Revised: 07/21/2022] [Accepted: 07/22/2022] [Indexed: 11/22/2022]
Abstract
In 1998, an editorial from the International Journal of Radiation Oncology - Biology - Physics (IJROBP) on the occasion of the publication of Phase I by Zelefsky et al. on 3D radiotherapy dose escalation asked the question: "will more prove better?". More than 20 years later, several prospective studies have supported the authors' conclusions, making dose escalation a new standard in prostate cancer. The data from prospective randomized studies were ultimately disappointing in that they failed to show an overall survival benefit from dose escalation. However, there is a clear and consistent benefit in biochemical recurrence-free survival, which must be weighed on an individual patient basis against the potential additional toxicity of dose escalation. Techniques and concepts have become more and more precise, such as intensity modulated irradiation, simultaneous integrated boost, hypofractionated dose-escalation, pelvic irradiation with involved node boost or focal dose-escalation on gross recurrence after prostatectomy. The objective here was to summarize the prospective data on dose escalation in prostate cancer and in particular on recent advances in the field. In 2022, can we finally say that more has proven better?
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Faustino FDLC, Altei WF, Canton HP, Morato L, de Paula LLRJ, Salvador GB, Fonseca DDSL, Gonçalves TK, Kupelian PA, Zaparolli JC, Ercolin L, Marconi DG. RAdiotherapy for Prostate cancer using HYpofractionation Directed by UltraSound (RAPHYDUS): a Brazilian public health care system study. Pract Radiat Oncol 2022; 12:e286-e295. [DOI: 10.1016/j.prro.2022.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 03/28/2022] [Accepted: 04/01/2022] [Indexed: 10/18/2022]
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Zumsteg ZS. Local versus systemic treatment intensification: what is the optimal strategy for localized prostate cancer? Prostate Cancer Prostatic Dis 2022; 25:7-8. [PMID: 35125494 DOI: 10.1038/s41391-022-00505-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 01/18/2022] [Accepted: 01/21/2022] [Indexed: 02/04/2023]
Affiliation(s)
- Zachary S Zumsteg
- Department of Radiation Oncology, Cedars-Sinai Medical Center, Los Angeles, CA, USA. .,Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
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Glicksman RM, Berlin A. FACE Value of Patient-Reported Outcomes in Dose-Escalated Radiation Therapy for Prostate Cancer. Int J Radiat Oncol Biol Phys 2022; 112:93-95. [PMID: 34919885 DOI: 10.1016/j.ijrobp.2021.08.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 08/16/2021] [Accepted: 08/24/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Rachel M Glicksman
- Department of Radiation Oncology, University of Toronto, Toronto, Canada; Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada
| | - Alejandro Berlin
- Department of Radiation Oncology, University of Toronto, Toronto, Canada; Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada; Data Science and Smart Cancer Care Programs, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada; Techna Institute, University Health Network, Toronto, Canada.
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9
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Hall WA, Deshmukh S, Bruner DW, Michalski JM, Purdy JA, Bosch W, Bahary JP, Patel MP, Parliament MB, Lock MI, Lau HY, Souhami L, Fisher SA, Kwok Y, Seider MJ, Vigneault E, Rosenthal SA, Gustafson GS, Gay HA, Pugh SL, Sandler HM, Movsas B. Quality of Life Implications of Dose-Escalated External Beam Radiation for Localized Prostate Cancer: Results of a Prospective Randomized Phase 3 Clinical Trial, NRG/RTOG 0126. Int J Radiat Oncol Biol Phys 2022; 112:83-92. [PMID: 34919884 PMCID: PMC8789217 DOI: 10.1016/j.ijrobp.2021.07.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 05/13/2021] [Accepted: 07/02/2021] [Indexed: 02/07/2023]
Abstract
PURPOSE External beam radiation therapy (EBRT) dose escalation has been tested in multiple prospective trials. However, the impact on patient reported outcomes (PROs) associated with higher doses of EBRT remain poorly understood. We sought to assess the differences in PROs between men treated with a dose of 70.2 Gy versus 79.2 Gy of EBRT for prostate cancer. METHODS AND MATERIALS The phase 3 clinical trial RTOG 0126 randomized 1532 patients with prostate cancer between March 2002 and August 2008 to 79.2 Gy over 44 fractions versus 70.2 Gy over 39 fractions. Eligible patients participated in the PRO data collection. PROs completed included the International Index of Erectile Function Questionnaire (IIEF), Functional Alterations due to Changes in Elimination (FACE), and the Spitzer Quality of Life Index (SQLI). The timepoints for the IIEF were collected pre-entry and at 6, 12, and 24 months. The FACE and SQLI were collected pre-entry and at 3, 6, 12, 18, and 24 months. The impact of EBRT dose to normal structures (penile bulb, rectum, and bladder) on PROs was also examined. Mixed effects models were used to analyze trends across time. RESULTS In total, 1144 patients completed baseline IIEF forms and of these, 56%, 64%, and 61% completed the IIEF at 6, 12, and 24 months, respectively; 1123 patients completed the FACE score at baseline and 50%, 61%, 73%, 61%, and 65% completed all 15 items for the FACE metric at timepoints of 3, 6, 12, 18, and 24 months, respectively. Erectile dysfunction at 12 months based on the single question was not significantly different between arms (38.1% for the standard dose radiation therapy arm vs 49.7% for the dose escalated radiation therapy arm; P = .051). Treatment arm (70.2 vs 79.2) had no significant impact on any PRO metrics measured across all collected domains. Comprehensive dosimetric analyses are presented and reveal multiple significant differences to regional organs at risk. CONCLUSIONS Compliance with PRO data collection was lower than anticipated in this phase 3 trial. Examining the available data, dose escalated EBRT did not appear to be associated with any detriment to PROs across numerous prospectively collected domains. These data, notwithstanding limitations, add to our understanding of the implications of EBRT dose escalation in prostate cancer. Furthermore, these results illustrate challenges associated with PRO data collection.
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Affiliation(s)
- William A Hall
- Medical College of Wisconsin,Corresponding Author: Froedtert and the Medical College of Wisconsin, 8701 W Watertown Plank Rd, Milwaukee, WI 53226, Telephone: 414-805-4477, Fax: 414-805-4369, , this has been previously presented at the American Society of Radiation Oncology meeting
| | | | | | | | | | | | | | | | | | | | | | | | | | - Young Kwok
- University of Maryland/Greenebaum Cancer Center
| | | | | | - Seth A Rosenthal
- Sutter Cancer Centers Radiation Oncology Services-accruals under Radiological Associates of Sacramento
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Zaorsky NG, Garrett S, Spratt DE, Nguyen PL, Sciamanna C, Schmitz K. Exercise: A Treatment That Should Be Prescribed With Radiation Therapy. Int J Radiat Oncol Biol Phys 2022; 112:96-98. [PMID: 34561128 DOI: 10.1016/j.ijrobp.2021.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 08/05/2021] [Accepted: 08/06/2021] [Indexed: 10/20/2022]
Affiliation(s)
- Nicholas G Zaorsky
- Department of Radiation Oncology, Penn State Cancer Institute, Hershey, Pennsylvania; Department of Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania.
| | - Sara Garrett
- Department of Radiation Oncology, Penn State Cancer Institute, Hershey, Pennsylvania
| | - Daniel E Spratt
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Case Western Reserve University, Cleveland, Ohio
| | - Paul L Nguyen
- Department of Radiation Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, Massachusetts
| | - Chris Sciamanna
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania; Department of Medicine Division of General Internal Medicine, Penn State College of Medicine, Hershey, Pennsylvania
| | - Kathryn Schmitz
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania
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Abstract
More than 40% of men with intermediate-risk or high-risk prostate cancer will experience a biochemical recurrence after radical prostatectomy. Clinical guidelines for the management of these patients largely focus on the use of salvage radiotherapy with or without systemic therapy. However, not all patients with biochemical recurrence will go on to develop metastases or die from their disease. The optimal pre-salvage therapy investigational workup for patients who experience biochemical recurrence should, therefore, include novel techniques such as PET imaging and genomic analysis of radical prostatectomy specimen tissue, as well as consideration of more traditional clinical variables such as PSA value, PSA kinetics, Gleason score and pathological stage of disease. In patients without metastatic disease, the only known curative intervention is salvage radiotherapy but, given the therapeutic burden of this treatment, importance must be placed on accurate timing of treatment, radiation dose, fractionation and field size. Systemic therapy also has a role in the salvage setting, both concurrently with radiotherapy and as salvage monotherapy.
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Urabe F, Kimura S, Tashiro K, Kido M, Sasaki H, Aoki M, Kimura T, Miki K, Egawa S. Prognostic value of PSA bounce in prostate cancer following definitive radiation therapy: a systematic review and meta-analysis. Prostate Cancer Prostatic Dis 2021; 24:976-985. [PMID: 33947976 DOI: 10.1038/s41391-021-00372-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 04/01/2021] [Accepted: 04/15/2021] [Indexed: 11/09/2022]
Abstract
BACKGROUND The prognostic significance of PSA bounce following definitive radiation therapy remains controversial. To develop a sense of current opinion in this area, we performed a systematic search of the literature based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. METHODS In January 2021, we systematically searched PubMed, the Cochrane library, and Scopus for studies that compared patients who had localized prostate cancer with or without PSA bounce after definitive radiation therapy. Our objective was to evaluate the association of PSA bounce with biochemical recurrence-free survival, metastatic-free survival, cancer-specific survival, and overall survival, using multivariate Cox regression analysis. RESULTS A total of 8881 patients in 10 studies matched the selection criteria for the systematic review and meta-analysis. The number of patients with PSA bounce accounted for 2706 of all 8881 patients (30.5%). PSA bounce was associated with better biochemical recurrence-free survival after definitive radiation therapy (pooled HR: 0.62, 95% CI: 0.54-0.71). Subgroup analyses also showed that PSA bounce was independently associated with decreased risk for biochemical recurrence-free survival in prostate cancer patients treated with low dose rate brachytherapy alone (pooled HR: 0.38, 95% CI: 0.27-0.55) and external beam radiotherapy alone (pooled HR: 0.71, 95% CI: 0.57-0.87). CONCLUSIONS This meta-analysis indicated that PSA bounce after definitive radiation therapy is related to improved outcome in terms of biochemical failure in prostate cancer patients.
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Affiliation(s)
- Fumihiko Urabe
- Department of Urology, The Jikei University School of Medicine, Tokyo, Japan.
| | - Shoji Kimura
- Department of Urology, The Jikei University School of Medicine, Tokyo, Japan
| | - Kojiro Tashiro
- Department of Urology, The Jikei University School of Medicine, Tokyo, Japan
| | - Masahito Kido
- Department of Urology, The Jikei University School of Medicine, Tokyo, Japan
| | - Hiroshi Sasaki
- 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
| | - Kenta Miki
- Department of Urology, The Jikei University School of Medicine, Tokyo, Japan
| | - Shin Egawa
- Department of Urology, The Jikei University School of Medicine, Tokyo, Japan
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Jan I, Parikh RR. Feeding the Controversy: When Pelvic Irradiation Improves Outcomes in High-Risk and Very High-Risk Prostate Cancer. J Clin Oncol 2021; 39:1196-1202. [PMID: 33683923 DOI: 10.1200/jco.20.03636] [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] Open
Abstract
The Oncology Grand Rounds series is designed to place original reports published in the Journal into clinical context. A case presentation is followed by a description of diagnostic and management challenges, a review of the relevant literature, and a summary of the authors' suggested management approaches. The goal of this series is to help readers better understand how to apply the results of key studies, including those published in Journal of Clinical Oncology, to patients seen in their own clinical practice.
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Affiliation(s)
- Imraan Jan
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, Rutgers University, New Brunswick, NJ
| | - Rahul R Parikh
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, Rutgers University, New Brunswick, NJ
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14
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Tree AC, Dearnaley DP, Hall E. Intermediate clinical endpoints in localised prostate cancer. Lancet Oncol 2021; 22:294-296. [PMID: 33662281 DOI: 10.1016/s1470-2045(21)00025-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Revised: 01/13/2021] [Accepted: 01/13/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Alison C Tree
- Urology Unit, The Royal Marsden NHS Foundation Trust, The Institute of Cancer Research, London SM2 5PT, UK; Division of Radiotherapy and Imaging, The Institute of Cancer Research, London SM2 5PT, UK
| | - David P Dearnaley
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London SM2 5PT, UK.
| | - Emma Hall
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London SM2 5PT, UK
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15
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Safety and Efficacy of Ultra-hypofractionation in Node-positive Prostate Cancer. Clin Oncol (R Coll Radiol) 2021; 33:172-180. [DOI: 10.1016/j.clon.2020.10.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 09/06/2020] [Accepted: 10/23/2020] [Indexed: 11/18/2022]
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16
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The Value of Real-World Data in Understanding Prostate Cancer Risk and Improving Clinical Care: Examples from Swedish Registries. Cancers (Basel) 2021; 13:cancers13040875. [PMID: 33669624 PMCID: PMC7923148 DOI: 10.3390/cancers13040875] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2020] [Revised: 02/12/2021] [Accepted: 02/16/2021] [Indexed: 01/04/2023] Open
Abstract
Simple Summary Real-world data (RWD), i.e., data reflecting normal clinical practice collected outside the constraints of randomised controlled trials, provide important insights into our understanding of prostate cancer and its management. Clinical cancer registries are an important source of RWD. Depending on their scope and the potential linkage to other data sources, registry-based data can be utilised to address a variety of questions including risk factors, healthcare utilisation, treatment effectiveness, adverse effects, disparities in healthcare access, quality of care and healthcare economics. This review describes the various registry-based RWD sources for prostate cancer research in Sweden (namely the National Prostate Cancer Register, the Prostate Cancer data Base Sweden (PCBaSe) and the Patient-overview Prostate Cancer) and documents their utility for better understanding prostate cancer aetiology and improving clinical care. Abstract Real-world data (RWD), that is, data from sources other than controlled clinical trials, play an increasingly important role in medical research. The development of quality clinical registers, increasing access to administrative data sources, growing computing power and data linkage capacities have contributed to greater availability of RWD. Evidence derived from RWD increases our understanding of prostate cancer (PCa) aetiology, natural history and effective management. While randomised controlled trials offer the best level of evidence for establishing the efficacy of medical interventions and making causal inferences, studies using RWD offer complementary evidence about the effectiveness, long-term outcomes and safety of interventions in real-world settings. RWD provide the only means of addressing questions about risk factors and exposures that cannot be “controlled”, or when assessing rare outcomes. This review provides examples of the value of RWD for generating evidence about PCa, focusing on studies using data from a quality clinical register, namely the National Prostate Cancer Register (NPCR) Sweden, with longitudinal data on advanced PCa in Patient-overview Prostate Cancer (PPC) and data linkages to other sources in Prostate Cancer data Base Sweden (PCBaSe).
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Wakamiya T, Yamashita S, Kikkawa K, Kohjimoto Y, Noda Y, Sonomura T, Hara I. Inverse planning in high-dose rate brachytherapy improves quality of life of prostate cancer patients compared with forward planning. Int J Clin Oncol 2021; 26:728-735. [PMID: 33486638 DOI: 10.1007/s10147-020-01851-2] [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: 09/23/2020] [Accepted: 12/01/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To understand differences in quality of life outcomes between cases with forward planning and cases with inverse planning, we examine patients undergoing high-dose rate brachytherapy combined with external beam radiotherapy for localized prostate cancer. METHODS We prospectively identified 283 patients with localized prostate cancer and divided them into forward planning and inverse planning groups. We extracted data on doses to the prostate, rectum and urethra that could potentially affect quality of life. We also evaluated quality of life using the Japanese version of Medical Outcome Study 8-Items Short Form Health Survey and Expanded Prostate Cancer Index Composite at pre-treatment and at 3, 6, 12 and 24 months after treatment. Wilcoxon signed rank test and Bonferroni correction were used to analyze the irradiation dose and any change in quality of life. RESULTS Doses to the prostate and rectum were not significantly different between the two groups. Notably, however, doses to the urethra were significantly lower in the inverse planning group than in the forward planning group. Patients in the forward planning group had significantly poorer physical component summary scores at 3 months according to survey results. In Expanded Prostate Cancer Index Composite, patients in the forward planning group had statistically significant poorer urinary, bowel and sexual scores than those in the inverse planning group. Quality of life related to decline in sexual function was significantly reduced in the inverse planning group. CONCLUSIONS Inverse planning in high-dose rate brachytherapy could significantly improve quality of life of patients with prostate cancer.
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Affiliation(s)
- Takahito Wakamiya
- Department of Urology, Wakayama Medical University, 811-1 Kimiidera, Wakayama, 641-8509, Japan.
| | - Shimpei Yamashita
- Department of Urology, Wakayama Medical University, 811-1 Kimiidera, Wakayama, 641-8509, Japan
| | - Kazuro Kikkawa
- Department of Urology, Wakayama Medical University, 811-1 Kimiidera, Wakayama, 641-8509, Japan
| | - Yasuo Kohjimoto
- Department of Urology, Wakayama Medical University, 811-1 Kimiidera, Wakayama, 641-8509, Japan
| | - Yasutaka Noda
- Department of Radiology, Wakayama Medical University, 811-1 Kimiidera, Wakayama, 641-8509, Japan
| | - Tetsuo Sonomura
- Department of Radiology, Wakayama Medical University, 811-1 Kimiidera, Wakayama, 641-8509, Japan
| | - Isao Hara
- Department of Urology, Wakayama Medical University, 811-1 Kimiidera, Wakayama, 641-8509, Japan
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Nicholls L, Suh YE, Chapman E, Henderson D, Jones C, Morrison K, Sohaib A, Taylor H, Tree A, van As N. Stereotactic radiotherapy with focal boost for intermediate and high-risk prostate cancer: Initial results of the SPARC trial. Clin Transl Radiat Oncol 2020; 25:88-93. [PMID: 33145444 PMCID: PMC7591551 DOI: 10.1016/j.ctro.2020.10.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 10/14/2020] [Accepted: 10/14/2020] [Indexed: 01/03/2023] Open
Abstract
INTRODUCTION Dose escalation to dominant intraprostatic lesions (DILs) is a novel method to increase the therapeutic ratio in localised prostate cancer. The Stereotactic Prostate Augmented Radiotherapy with Cyberknife (SPARC) trial was designed to determine the feasibility of a focal boost defined with multiparametric magnetic resonance imaging (mpMRI) using stereotactic ablative body radiotherapy (SABR). MATERIALS AND METHODS Patients were included with newly diagnosed intermediate to high risk prostate cancer with at least one of: Gleason score 4 + 3, stage T3a, or PSA > 20 ng/ml. Visible disease on mpMRI was mandatory and up to 2 separate nodules were allowed. All patients received androgen deprivation. Patients received 36.25 Gy in 5 fractions using CyberKnife® and the DIL received a simultaneous boost to a maximum of 47.5 Gy, as allowed by OAR constraints. Genitourinary (GU) and gastrointestinal (GI) toxicity was reported using the RTOG scoring criteria. International Index of Erectile Function (IIEF) and EQ-5D global health scores were regularly captured. RESULTS An interim safety analysis was performed on the first 8 patients, recruited between July 2013 and December 2015. Median follow up was 56 months (range 50-74). Median D95 values for the prostate PTV and boost volume were 36.55 Gy (range 35.87-36.99) and 46.62 Gy (range 44.85-48.25) respectively. Of the dose constraints, 10/80 were not achieved but all were minor dose variations. Grade 2+ acute GU and GI toxicities were 37.5% respectively while grade 2+ late GU and GI toxicities were 12.5% and 0% respectively. IIEF and quality of life scores recovered over time and all patients remain in biochemical remission. CONCLUSION The first patients have been successfully treated with prostate SABR and focal boost on the SPARC trial, with excellent adherence to the planning protocol. Toxicity and efficacy results are promising and further recruitment is underway.
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Affiliation(s)
- Luke Nicholls
- Royal Marsden NHS Foundation Trust, 203 Fulham Road, London SW3 6JJ, UK
- School of Medicine, University of Queensland, Brisbane, Australia
| | - Yae-eun Suh
- Royal Marsden NHS Foundation Trust, 203 Fulham Road, London SW3 6JJ, UK
| | - Ewan Chapman
- Royal Marsden NHS Foundation Trust, 203 Fulham Road, London SW3 6JJ, UK
- The Institute of Cancer Research, 237 Fulham Road, Chelsea, London SW3 6JJ, UK
| | - Daniel Henderson
- University Hospitals Birmingham NHS Foundation Trust, Mindelsohn Way, Edgbaston, Birmingham, West Midlands B15 2GW, UK
| | - Caroline Jones
- Royal Marsden NHS Foundation Trust, 203 Fulham Road, London SW3 6JJ, UK
| | - Kirsty Morrison
- Royal Marsden NHS Foundation Trust, 203 Fulham Road, London SW3 6JJ, UK
| | - Aslam Sohaib
- Royal Marsden NHS Foundation Trust, 203 Fulham Road, London SW3 6JJ, UK
| | - Helen Taylor
- Royal Marsden NHS Foundation Trust, 203 Fulham Road, London SW3 6JJ, UK
| | - Alison Tree
- Royal Marsden NHS Foundation Trust, 203 Fulham Road, London SW3 6JJ, UK
- The Institute of Cancer Research, 237 Fulham Road, Chelsea, London SW3 6JJ, UK
| | - Nicholas van As
- Royal Marsden NHS Foundation Trust, 203 Fulham Road, London SW3 6JJ, UK
- The Institute of Cancer Research, 237 Fulham Road, Chelsea, London SW3 6JJ, UK
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Han JE, Chang J, Rosen L, Hartsell W, Tsai H, Chen J, Mishra MV, Krauss D, Isabelle Choi J, Simone CB, Hasan S. Treatment interruptions affect biochemical failure rates in prostate cancer patients treated with proton beam therapy: Report from the multi-institutional proton collaborative group registry. Clin Transl Radiat Oncol 2020; 25:94-101. [PMID: 33204857 PMCID: PMC7649394 DOI: 10.1016/j.ctro.2020.10.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 10/11/2020] [Accepted: 10/12/2020] [Indexed: 12/25/2022] Open
Abstract
INTRODUCTION To date, no studies examining the effect of treatment interruptions (TI) with proton beam therapy (PBT) have been published. The goal of our study was to determine the predictors of TI amongst patients with prostate cancer (PCa) treated with PBT and to determine whether TI are associated with biochemical failure (BF). We hypothesized that any correlation between TI and biochemical control would be more pronounced in high risk groups. METHODS Data for 4278 patients with PCa was obtained from the prospectively collected Proton Collaborative Group (PCG) data registry. Univariate and multivariate logistic regression analysis (MVA) was used to model possible predictors of BF. A subset analysis was performed for high risk patients treated with ADT and PBT. Finally, propensity score (PS) analysis was performed to account for any indication bias caused by lack of randomization. RESULTS Total treatment duration (OR, 1.05 [1.04-1.06]; p < 0.001) increased the likelihood of TI on MVA. TI did not have a statistically significant correlation with BF (OR, 1.44 [0.86-2.39]; p = 0.162) amongst PS matched patients. However, on subset analyses of high risk group patients with PS matching, there was a trend towards worse BF in patients with TI (OR 3.85; 95%CI (0.96-15.44); p = 0.057). CONCLUSION In the first analysis of its kind, the results suggest that TI in high risk PCa patients treated with PBT and ADT have worse BF rates. Interventions such as increased patient education, proper maintenance of proton facilities, and decreasing total treatment duration with alternative fractionation schedules may help avoid the unintended negative effects on tumor control due to TI. However, future analyses on a larger patient population is needed.
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Affiliation(s)
- James E. Han
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA, USA
| | - John Chang
- Department of Radiation Oncology, Oklahoma Proton Center, Oklahoma City, OK, USA
| | - Lane Rosen
- Department of Radiation Oncology, Willis Knighton Medical Center, Shreveport, LA, USA
| | - William Hartsell
- Department of Radiation Oncology, Northwestern University, Chicago, IL, USA
| | - Henry Tsai
- ProCure Proton Therapy Center, Somerset, NJ, USA
| | - Jonathan Chen
- Department of Radiation Oncology, University of Washington, Seattle, WA, USA
| | - Mark V. Mishra
- Department of Radiation Oncology, University of Maryland School of Medicine, MD, USA
| | - Daniel Krauss
- Department of Radiation Oncology, Beaumont Hospital, Royal Oak, MI, USA
| | - J. Isabelle Choi
- Department of Radiation Oncology, New York Proton Center, New York, NY, USA
| | - Charles B. Simone
- Department of Radiation Oncology, New York Proton Center, New York, NY, USA
| | - Shaakir Hasan
- Department of Radiation Oncology, New York Proton Center, New York, NY, USA
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Lehrer EJ, Kishan AU, Yu JB, Trifiletti DM, Showalter TN, Ellis R, Zaorsky NG. Ultrahypofractionated versus hypofractionated and conventionally fractionated radiation therapy for localized prostate cancer: A systematic review and meta-analysis of phase III randomized trials. Radiother Oncol 2020; 148:235-242. [DOI: 10.1016/j.radonc.2020.04.037] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 04/02/2020] [Accepted: 04/07/2020] [Indexed: 01/01/2023]
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Corkum MT, Mendez LC, Chin J, D’Souza D, Boldt RG, Bauman GS. A Novel Salvage Option for Local Failure in Prostate Cancer, Reirradiation Using External Beam or Stereotactic Radiation Therapy: Systematic Review and Meta-Analysis. Adv Radiat Oncol 2020; 5:965-977. [PMID: 33083660 PMCID: PMC7557139 DOI: 10.1016/j.adro.2020.04.022] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2019] [Revised: 03/11/2020] [Accepted: 04/25/2020] [Indexed: 02/07/2023] Open
Abstract
Purpose Reirradiation (re-RT) using external beam radiation therapy (EBRT) is a novel salvage strategy for local failure in prostate cancer. We performed a systematic review describing oncologic and toxicity outcomes for salvage EBRT/stereotactic radiation therapy (SBRT) re-RT. Methods and Materials A International Prospective Register of Systematic Reviews registered (#141466) systematic review, meta-analysis, and meta-regression was conducted using preferred reporting items for systematic reviews and meta-analyses guidelines. PubMed and EMBASE were searched from inception through September 2019. Outcome measures included local control (LC), biochemical relapse free survival (BRFS), and ≥grade 3 genitourinary (GU)/gastrointestinal (GI) toxicity. EBRT and SBRT data were collected separately. Meta-regression explored disease and toxicity outcomes as a function of equivalent dose in 2 Gy fractions (EQD2), length of follow-up, and partial versus whole prostate reirradiation. Results Nineteen studies representing 13 cohorts were included (428 patients). Weighted mean follow-up was 26.1 months. Median re-RT EQD2 was 77.1 Gy (α/β = 1.5), with 92% of patients receiving SBRT, 52.1% of patients receiving partial prostate re-RT, and 30.1% of patients receiving androgen deprivation therapy with re-RT. LC was 83.2% (95% confidence interval [CI], 75.5%-90.9%) and BRFS was 59.3% (47.9%-70.7%). Reported late toxicity ≥grade 3 was 3.4% (95% CI, 1.0%-5.8%) for GU and 2.0% (95% CI, 0.1%-4.0%) for GI. Meta-regression found higher LC, BRFS, and reported GU/GI toxicity with increasing EQD2, with partial prostate re-RT associated with less reported GU/GI toxicity and no detriment to LC and BRFS. Conclusions Salvage re-RT using EBRT, particularly with SBRT, is an emerging technique to treat isolated local failure of prostate cancer. With short-term follow-up, LC, BRFS, and reported toxicities appear reasonable, although further follow-up is required before definitive statements on late toxicities can be made. Our review is limited by incomplete reporting of androgen deprivation therapy use in the primary literature. Further prospective studies and longer follow-up are needed before considering re-RT as standard practice.
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Affiliation(s)
- Mark T. Corkum
- Department of Radiation Oncology, London Health Sciences Centre, London, Canada
| | - Lucas C. Mendez
- Department of Radiation Oncology, London Health Sciences Centre, London, Canada
| | - Joseph Chin
- Department of Urology, London Health Sciences Centre, London, Canada
| | - David D’Souza
- Department of Radiation Oncology, London Health Sciences Centre, London, Canada
| | - R. Gabriel Boldt
- Department of Radiation Oncology, London Health Sciences Centre, London, Canada
| | - Glenn S. Bauman
- Department of Radiation Oncology, London Health Sciences Centre, London, Canada
- Corresponding author: Glenn S. Bauman, MD
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Migration of treatment planning system using existing commissioned planning system. JOURNAL OF RADIOTHERAPY IN PRACTICE 2020. [DOI: 10.1017/s1460396920000199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
AbstractIntroduction:Commissioning of a new planning system involves extensive data acquisition which can be onerous involving significant clinic downtime. This could be circumvented by extracting data from existing treatment planning system (TPS) to speed up the process.Material and methods:In this study, commissioning beam data was obtained from a clinically commissioned TPS (Pinnacle™) using Matlab™ generated Pinnacle™ executable scripts to commission an independent 3D dose verification TPS (Eclipse™). Profiles and output factors for commissioning as required by Eclipse™ were computed on a 50 × 50 × 50 cm3 water phantom at a dose grid resolution of 2 mm3. Verification doses were computed and compared to clinical TPS dose profiles based on TG-106 guidelines. Standard patient plans from Pinnacle™ including intensity modulated radiation therapy and volumetric modulated arc therapy were re-computed on Eclipse™ TPS while maintaining the same monitor units. Computed dose was exported back to Pinnacle for comparison with the original plans. This methodology enabled us to alleviate all ambiguities that arise in such studies.Results:Profile analysis using in-house software showed that for all field sizes including small multi-leaf collimator-generated fields, >95% of infield and penumbra data points of Eclipse™ match Pinnacle™ generated and measured profiles with 2%/2 mm gamma criteria. Excellent agreement was observed in the penumbra regions, with >95% of the data points passing distance to agreement criteria for complex C-shaped and S-shaped profiles. Dose volume histograms and isodose lines of patient plans agreed well to within a 0·5% for target coverage.Findings:Migration of TPS is possible without compromising accuracy or enduring the cumbersome measurement of commissioning data. Economising time for commissioning such a verification system or for migration of TPS can add great QA value and minimise downtime.
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Pettersson A, Alm D, Garmo H, Hjelm Eriksson M, Castellanos E, Åström L, Kindblom J, Widmark A, Gunnlaugsson A, Franck Lissbrant I, Nilsson P, Stattin P. Comparative Effectiveness of Different Radical Radiotherapy Treatment Regimens for Prostate Cancer: A Population-Based Cohort Study. JNCI Cancer Spectr 2020; 4:pkaa006. [PMID: 32373776 PMCID: PMC7192027 DOI: 10.1093/jncics/pkaa006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 01/09/2020] [Accepted: 02/07/2020] [Indexed: 02/07/2023] Open
Abstract
Background It is unclear which radiotherapy technique and dose fractionation scheme is most effective in decreasing the risk of prostate cancer death. Methods We conducted a population-based cohort study among 15 164 men in the Prostate Cancer database Sweden (version 4.0) treated with primary radical radiotherapy for prostate cancer in Sweden from 1998 to 2016. We calculated hazard ratios with 95% confidence intervals (CIs) of the association between the following exposure groups and outcome: conventionally fractionated external beam radiotherapy (EBRT) to 78 Gy (39 × 2 Gy), EBRT combined with high dose-rate brachytherapy (HDR-BT) (25 × 2 Gy + 2 × 10 Gy), conventionally fractionated EBRT to 70 Gy (35 × 2 Gy), and moderately hypofractionated (M-HF) dose-escalated EBRT (29 × 2.5 Gy or 22 × 3 Gy). Results Of the men, 7296 received conventionally fractionated EBRT to 78 Gy, 4657 EBRT combined with HDR-BT, 1672 conventionally fractionated EBRT to 70 Gy, and 1539 M-HF EBRT. Using EBRT to 78 Gy as the reference, the multivariable hazard ratios (95% CIs) of prostate cancer death was 0.64 (0.53 to 0.78) for EBRT combined with HDR-BT, 1.00 (0.80 to 1.27) for EBRT to 70 Gy, and 1.51 (0.99 to 2.32) for M-HF EBRT. The multivariable hazard ratios (95% CIs) for death from any cause were 0.79 (0.71 to 0.88), 0.99 (0.87 to 1.14), and 1.12 (0.88 to 1.42), respectively. The lower risk of prostate cancer death comparing EBRT combined with HDR-BT with conventionally fractionated EBRT to 78 Gy was more pronounced for men with high-risk or poorly differentiated tumors. Conclusions In this study, EBRT combined with HDR-BT was the most effective radiotherapy treatment regimen, especially for poorly differentiated tumors. Randomized trials comparing EBRT combined with HDR-BT with dose-escalated EBRT should be a priority.
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Affiliation(s)
- Andreas Pettersson
- Clinical Epidemiology Unit, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Daniel Alm
- Department of Radiation Oncology, Karolinska University Hospital, Stockholm, Sweden
| | - Hans Garmo
- Regional Cancer Centre Uppsala Örebro, Uppsala University Hospital, Uppsala, Sweden.,Cancer Epidemiology Group, Division of Cancer Studies, School of Medicine, King's College London, London, UK
| | | | | | - Lennart Åström
- Section of Clinical and Experimental Oncology, Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | - Jon Kindblom
- Department of Oncology, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Anders Widmark
- Department of Radiation Sciences, Oncology, Umeå University, Umeå, Sweden
| | - Adalsteinn Gunnlaugsson
- Department of Oncology and Radiation Physics, Skåne University Hospital, Lund University, Lund, Sweden
| | - Ingela Franck Lissbrant
- Department of Oncology, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Per Nilsson
- Department of Oncology and Radiation Physics, Skåne University Hospital, Lund University, Lund, Sweden
| | - Pär Stattin
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
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Fischer-Valuck BW, Gay HA, Patel S, Baumann BC, Michalski JM. A Brief Review of Low-Dose Rate (LDR) and High-Dose Rate (HDR) Brachytherapy Boost for High-Risk Prostate. Front Oncol 2019; 9:1378. [PMID: 31921640 PMCID: PMC6914687 DOI: 10.3389/fonc.2019.01378] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Accepted: 11/22/2019] [Indexed: 01/18/2023] Open
Abstract
For patients with unfavorable or high-risk prostate cancer, dose escalated radiation therapy leads to improved progression free survival but attempts to deliver increased dose by external beam radiation therapy (EBRT) alone can be limited by late toxicities to nearby genitourinary and gastrointestinal organs at risk. Brachytherapy is a method to deliver dose escalation in conjunction with EBRT with a potentially improved late toxicity profile and improved prostate cancer related outcomes. At least three randomized controlled trials have demonstrated improved biochemical control with the addition of either low-dose rate (LDR) or high-dose rate (HDR) brachytherapy to EBRT, although only ASCENDE-RT compared brachytherapy to dose-escalated EBRT but did report an over 50% improvement in biochemical failure with a LDR boost. Multiple single institution and comparative research series also support the use of a brachytherapy boost in the DE-EBRT era and demonstrate excellent prostate cancer specific outcomes. Despite improved oncologic outcomes with a brachytherapy boost in the high-risk setting, the utilization of both LDR, and HDR brachytherapy use is declining. The acute genitourinary toxicities when brachytherapy boost is combined with EBRT, particularly a LDR boost, are of concern in comparison to EBRT alone. HDR brachytherapy boost has many physical properties inherent to its rapid delivery of a large dose which may reduce acute toxicities and also appeal to the radiobiology of prostate cancer. We herein review the evidence for use of either LDR or HDR brachytherapy boost for high-risk prostate cancer and summarize comparisons between the two treatment modalities.
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Affiliation(s)
- Benjamin W. Fischer-Valuck
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, United States
| | - Hiram A. Gay
- Department of Radiation Oncology, Washington University School of Medicine in St. Louis, St. Louis, MO, United States
| | - Sagar Patel
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, United States
| | - Brian C. Baumann
- Department of Radiation Oncology, Washington University School of Medicine in St. Louis, St. Louis, MO, United States
| | - Jeff M. Michalski
- Department of Radiation Oncology, Washington University School of Medicine in St. Louis, St. Louis, MO, United States
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Dose Escalation in Stereotactic Body Radiation Therapy for Pancreatic Cancer: A Meta-Analysis. Am J Clin Oncol 2019; 42:46-55. [PMID: 29965809 DOI: 10.1097/coc.0000000000000472] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To determine whether increasing biologically effective dose (BED) with stereotactic body radiation therapy (SBRT) is associated with improved local control (LC) or toxicities in patients with locally advanced pancreatic cancer. METHODS A PICOS/PRISMA/MOOSE selection protocol was used to identify 15 studies across 12 institutions in 5 countries where patients received definitive SBRT for nonmetastatic disease. Biologically equivalent doses were calculated with an α/β of 10 (ie, BED10) for LC and acute toxicity and 3 (ie, BED3) for late toxicity. Fixed and random effects models were used to characterize LC and grade 3/4 toxicities by BED. RESULTS There were 508 patients included with a median follow-up time of 9.1 months. The median dose was 30 Gy, and the most common regimen was 30 Gy/5 fractions. There was no significant difference in LC rates at 1 year between the BED10<70 Gy versus ≥70 Gy groups, with an estimate of 0.60 (95% confidence interval [CI], 0.36-0.81) versus 0.83 (95% CI, 0.63-0.97), respectively. There was no significant difference in acute toxicity rates between the BED10<70 Gy versus ≥70 Gy groups, with an estimate of 0.02 (95% CI, 0.00-0.08) versus 0.05 (95% CI, 0.00-0.22), respectively. Given the dose distribution across studies, 3 intervals were used to characterize BED3. There were no significant differences in late toxicity among those receiving BED3<100, 100 to 200, or >200 Gy. CONCLUSIONS SBRT for pancreatic cancer results in LC rates of 60% to 83% and clinically significant toxicity of <7%. Increasing BED10 beyond 70 Gy was not associated with increased rates of 1-year LC or acute toxicity. Increasing BED3 beyond 100 Gy was not associated with increased rates of late toxicity.
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Long-Term Benefits of Dose-Escalation in Localized Prostate Cancer. Int J Radiat Oncol Biol Phys 2019; 104:798-800. [DOI: 10.1016/j.ijrobp.2019.04.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 03/18/2019] [Accepted: 04/05/2019] [Indexed: 02/07/2023]
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Lin D, Lehrer EJ, Rosenberg J, Trifiletti DM, Zaorsky NG. Toxicity after radiotherapy in patients with historically accepted contraindications to treatment (CONTRAD): An international systematic review and meta-analysis. Radiother Oncol 2019; 135:147-152. [DOI: 10.1016/j.radonc.2019.03.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 03/07/2019] [Accepted: 03/07/2019] [Indexed: 10/27/2022]
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Schörghofer A, Groher M, Karner J, Kopp A, Kametriser G, Kunit T, Holzinger J, Sedlmayer F, Wolf F. Risk-adapted moderate hypofractionation of prostate cancer : A prospective analysis of acute toxicity, QOL and outcome in 221 patients. Strahlenther Onkol 2019; 195:894-901. [PMID: 31139841 PMCID: PMC6763405 DOI: 10.1007/s00066-019-01477-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Accepted: 05/10/2019] [Indexed: 12/17/2022]
Abstract
Purpose Prostate cancer (PCA) is highly heterogeneous in terms of its oncologic outcome. We therefore aimed to tailor radiation treatment to the risk status by using three different hypofractionated radiation regimen differing in applied dose, use of rectum spacer, inclusion of pelvic lymph nodes (pLN) and use of androgen deprivation therapy (ADT). Here we report on acute toxicity, quality of life (QOL) and oncologic outcome at a median follow-up of 12 months. Methods A total of 221 consecutive PCA patients received hypofractionated intensity-modulated radiotherapy (IMRT). Low-risk (LR) patients were planned to receive 60 Gy in 20 fractions (EQD2α/β1.5 = 77.1 Gy), intermediate-risk (IR) patients 63 Gy in 21 fractions (EQD2α/β1.5 = 81 Gy), and high-risk (HR) patients 67.5 Gy in 25 fractions (EQD2α/β1.5 = 81 Gy) to the prostate and 50 Gy in 25 fractions to the pLN. Acute rectal toxicity was assessed by endoscopy. In addition, toxicity was scored using CTC-AE 4.0 and IPSS score, while QOL was assessed using QLQ-PR25 questionnaires. Results Acute CTC reactions were slightly higher in the HR regimen but reverted to baseline at 3 months. GI G2 toxicity was 4%, 0% and 12% for the LR, IR and HR regimen. Compared to IR patients, the increase in toxicity in HR patients was statistically significant (p = 0.002) and mainly caused by a higher incidence of diarrhea presumably due to pelvic EBRT. QOL scores of all domains were worse for the HR regimen (not significant). Conclusion Risk-adapted moderate hypofractionation is associated with low GI/GU toxicity. Given the higher rate of pelvic metastases in HR patients, slightly higher transient acute reactions should be outweighed by possible oncological benefits.
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Affiliation(s)
- Andreas Schörghofer
- Department of Radiotherapy and Radio-Oncology, LKH Salzburg, University Clinics, Paracelsus Medical University, Müllner Hauptstraße 48, 5020, Salzburg, Austria
| | - Michael Groher
- Department of Radiotherapy and Radio-Oncology, LKH Salzburg, University Clinics, Paracelsus Medical University, Müllner Hauptstraße 48, 5020, Salzburg, Austria
| | - Josef Karner
- Department of Radiotherapy and Radio-Oncology, LKH Salzburg, University Clinics, Paracelsus Medical University, Müllner Hauptstraße 48, 5020, Salzburg, Austria
| | - Andrea Kopp
- Department of Radiotherapy and Radio-Oncology, LKH Salzburg, University Clinics, Paracelsus Medical University, Müllner Hauptstraße 48, 5020, Salzburg, Austria
| | - Gerhard Kametriser
- Department of Radiotherapy and Radio-Oncology, LKH Salzburg, University Clinics, Paracelsus Medical University, Müllner Hauptstraße 48, 5020, Salzburg, Austria
| | - Thomas Kunit
- Department. of Urology, LKH Salzburg, University Clinics, Paracelsus Medical University, Müllner Hauptstraße 48, 5020, Salzburg, Austria
| | - Josef Holzinger
- Department of Surgery, LKH Salzburg, University Clinics, Paracelsus Medical University, Müllner Hauptstraße 48, 5020, Salzburg, Austria
| | - Felix Sedlmayer
- Department of Radiotherapy and Radio-Oncology, LKH Salzburg, University Clinics, Paracelsus Medical University, Müllner Hauptstraße 48, 5020, Salzburg, Austria
| | - Frank Wolf
- Department of Radiotherapy and Radio-Oncology, LKH Salzburg, University Clinics, Paracelsus Medical University, Müllner Hauptstraße 48, 5020, Salzburg, Austria.
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Hatano K, Tohyama N, Kodama T, Okabe N, Sakai M, Konoeda K. Current status of intensity‐modulated radiation therapy for prostate cancer: History, clinical results and future directions. Int J Urol 2019; 26:775-784. [DOI: 10.1111/iju.14011] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Accepted: 04/07/2019] [Indexed: 01/05/2023]
Affiliation(s)
- Kazuo Hatano
- Division of Radiation Oncology Tokyo‐Bay Advanced Imaging & Radiation Oncology Clinic/Makuhari Chiba Japan
| | - Naoki Tohyama
- Division of Radiation Oncology Tokyo‐Bay Advanced Imaging & Radiation Oncology Clinic/Makuhari Chiba Japan
| | - Takashi Kodama
- Division of Radiation Oncology Tokyo‐Bay Advanced Imaging & Radiation Oncology Clinic/Makuhari Chiba Japan
| | - Naoyuki Okabe
- Division of Radiation Oncology Tokyo‐Bay Advanced Imaging & Radiation Oncology Clinic/Makuhari Chiba Japan
| | - Mitsuhiro Sakai
- Division of Radiation Oncology Tokyo‐Bay Advanced Imaging & Radiation Oncology Clinic/Makuhari Chiba Japan
| | - Koichi Konoeda
- Division of Radiation Oncology Tokyo‐Bay Advanced Imaging & Radiation Oncology Clinic/Makuhari Chiba Japan
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Roy S, Loblaw A, Cheung P, Chu W, Chung HT, Vesprini D, Ong A, Chowdhury A, Panjwani D, Pang G, Korol R, Davidson M, Ravi A, McCurdy B, Helou J, Zhang L, Mamedov A, Deabreu A, Quon HC. Prostate-specific Antigen Bounce After Stereotactic Body Radiotherapy for Prostate Cancer: A Pooled Analysis of Four Prospective Trials. Clin Oncol (R Coll Radiol) 2019; 31:621-629. [PMID: 31126725 DOI: 10.1016/j.clon.2019.05.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Revised: 03/05/2019] [Accepted: 04/01/2019] [Indexed: 12/21/2022]
Abstract
AIMS We conducted a pooled analysis of four prospective stereotactic body radiotherapy (SBRT) trials of low- and intermediate-risk prostate cancer to evaluate the incidence of prostate-specific antigen (PSA) bounce and its correlation with the time-dose-fraction schedule. The correlation between bounce with PSA response at 4 years (nadir PSA < 0.4 ng/ml) and biochemical failure-free survival (BFFS) was also explored. MATERIALS AND METHODS The study included four treatment groups: 35 Gy/five fractions once per week (QW) (TG-1; n = 84); 40 Gy/five fractions QW (TG-2; n = 100); 40 Gy/five fractions every other day (TG-3; n = 73); and 26 Gy/two fractions QW (TG-4; n = 30). PSA bounce was defined as a rise in PSA by 0.2 ng/ml (nadir + 0.2) or 2 ng/ml (nadir + 2.0) above nadir followed by a decrease back to nadir. Patients with fewer than three follow-up PSA tests were excluded from the pooled analysis. RESULTS In total, 287 patients were included, with a median follow-up of 5.0 years. The pooled 5-year cumulative incidence of bounce by nadir + 2.0 was 8%. The 2-year cumulative incidences of PSA bounce by nadir + 0.2 were 28.9, 21, 19.6 and 16.7% (P = 0.12) and by nadir + 2.0 were 7.2, 8, 2.7 and 6.7% (P = 0.32) for TG-1 to TG-4, respectively. Multivariable analysis revealed that for nadir + 2.0, pre-treatment PSA (odds ratio 0.49; 95% confidence interval 0.26-0.97) correlated with PSA bounce. Although PSA bounce by nadir + 0.2 (odds ratio 0.10; 95% confidence interval 0.04-0.24) and nadir + 2.0 (odds ratio 0.29; 95% confidence interval 0.09-0.93) was associated with a lower probability of PSA response at 4 years, there was no association between bounce by nadir + 0.2 (hazard ratio 0.36; 95% confidence interval 0.08-1.74) or nadir + 2 (hazard ratio 1.77; 95% confidence interval 0.28-11.07) with BFFS. CONCLUSION The incidence of PSA bounce was independent of time-dose-fraction schedule for prostate SBRT. One in 13 patients experienced a bounce high enough to be misinterpreted as biochemical failure, and clinicians should avoid early salvage interventions in these patients. There was no association between PSA bounce and BFFS.
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Affiliation(s)
- S Roy
- Tom Baker Cancer Center, Department of Oncology, University of Calgary, Calgary, Canada
| | - A Loblaw
- Odette Cancer Center, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Canada
| | - P Cheung
- Odette Cancer Center, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Canada
| | - W Chu
- Odette Cancer Center, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Canada
| | - H T Chung
- Odette Cancer Center, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Canada
| | - D Vesprini
- Odette Cancer Center, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Canada
| | - A Ong
- CancerCare Manitoba, University of Manitoba, Winnipeg, Canada
| | - A Chowdhury
- CancerCare Manitoba, University of Manitoba, Winnipeg, Canada
| | | | - G Pang
- Odette Cancer Center, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Canada
| | - R Korol
- Odette Cancer Center, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Canada
| | - M Davidson
- Odette Cancer Center, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Canada
| | - A Ravi
- Odette Cancer Center, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Canada
| | - B McCurdy
- CancerCare Manitoba, University of Manitoba, Winnipeg, Canada
| | - J Helou
- Princess Margaret Cancer Center, University of Toronto, Toronto, Canada
| | - L Zhang
- Odette Cancer Center, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Canada
| | - A Mamedov
- Odette Cancer Center, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Canada
| | - A Deabreu
- Odette Cancer Center, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Canada
| | - H C Quon
- Tom Baker Cancer Center, Department of Oncology, University of Calgary, Calgary, Canada.
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Evolution of definitive external beam radiation therapy in the treatment of prostate cancer. World J Urol 2019; 38:565-591. [PMID: 30850855 DOI: 10.1007/s00345-019-02661-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2018] [Accepted: 01/30/2019] [Indexed: 12/30/2022] Open
Abstract
PURPOSE Although the clinical significance of a diagnosis of prostate cancer for some men is debated, for many men it leads to significant morbidity and mortality. Radical treatment of clinically localized prostate cancer has been shown to improve survival in men with intermediate or high-risk disease. There is no high level evidence to support the superiority of radical prostatectomy, with or without adjuvant or salvage external beam radiotherapy in comparison to definitive radiotherapy with or without androgen deprivation, and the choice should be individualized. External beam radiation therapy practices are in constant evolution, and numerous strategies have been investigated to improve either efficacy or reduce toxicity, or both. METHODS Randomized controlled trials investigating strategies to improve efficacy, reduce toxicity, or both of external beam radiotherapy have been reviewed in men with prostate cancer without nodal or distant metastases. These strategies include the use of neo-adjuvant and adjuvant androgen deprivation, dose-escalation, hypofractionation, whole pelvic radiation therapy, incorporation of improved imaging, image- guided radiation therapy, and adjuvant systemic therapy. The evidence to date for these strategies is discussed, noting limitations in applying the results of reported trials to men treated in contemporary settings. RESULTS A number of strategies have shown improvements in biochemical control using external beam radiotherapy. To date, only with the use of androgen deprivation therapy has this translated into improvements in disease specific and overall survival. This may reflect the long natural history of prostate cancer and high incidence of competing risks. Technological advances have enabled dose escalation with reduced toxicity, of paramount importance given the long natural history. RESULTS The use of external beam radiation therapy in prostate cancer is evolving with numerous strategies incorporated to improve outcomes. The optimum dose and fractionation and use of androgen deprivation or systemic adjuvants for each man is unclear based on current evidence and prognostic and predictive parameters. Patient preferences play an important role in chosen therapy. It is hoped that future studies better capture all prostate cancer- and treatment- related morbidity to clarify the optimal therapy choices for each man with prostate cancer.
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Discovery of Metabolic Biomarkers Predicting Radiation Therapy Late Effects in Prostate Cancer Patients. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2019; 1164:141-150. [PMID: 31576546 DOI: 10.1007/978-3-030-22254-3_11] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Patients presenting with prostate cancers undergo clinical staging evaluations to determine the extent of disease to guide therapeutic recommendations. Management options may include watchful waiting, surgery, or radiation therapy. Thus, initial risk stratification of prostate cancer patients is important for achieving optimal therapeutic results or cancer cure and preservation of quality of life. Predictive biomarkers for risks of complications or late effects of treatment are needed to inform clinical decisions for treatment selection. Here, we analyzed pre-treatment plasma metabolites in a cohort of prostate cancer patients (N = 99) treated with Stereotactic Body Radiation Therapy (SBRT) at Medstar-Georgetown University Hospital in a longitudinal, quality-of-life study to determine if individuals experiencing radiation toxicities can be identified by a molecular profile in plasma prior to treatment. We used a multiple reaction mass spectrometry-based molecular phenotyping of clinically annotated plasma samples in a retrospective outcome analysis to identify candidate biomarker panels correlating with adverse clinical outcomes following radiation therapy. We describe the discovery of candidate biomarkers, based on small molecule metabolite panels, showing high correlations (AUCs ≥ 95%) with radiation toxicities, suitable for validation studies in an expanded cohort of patients.
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Moschini M, Zaffuto E, Mattei A, Karakiewicz PI, Shariat SF. Reply to Nicholas G. Zaorsky, Daniel E. Spratt, and Pierre Blanchard's Letter to the Editor re: Marco Moschini, Emanuele Zaffuto, Pierre I. Karakiewicz, et al. External Beam Radiotherapy Increases the Risk of Bladder Cancer When Compared with Radical Prostatectomy in Patients Affected by Prostate Cancer: A Population-based Analysis. Eur Urol 2019;75:319-28. Eur Urol 2018; 75:e98-e99. [PMID: 30503180 DOI: 10.1016/j.eururo.2018.11.042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 11/21/2018] [Indexed: 10/27/2022]
Affiliation(s)
- Marco Moschini
- Department of Urology, Vienna General Hospital, Medical University of Vienna, Vienna, Austria; Department of Urology, Urological Research Institute, Vita-Salute University, San Raffaele Scientific Institute, Milan, Italy; Klinik für Urologie, Luzerner Kantonsspital, Lucerne, Switzerland.
| | - Emanuele Zaffuto
- Department of Urology, Urological Research Institute, Vita-Salute University, San Raffaele Scientific Institute, Milan, Italy; Department of Urology, University of Montreal, Montreal, Canada
| | - Agostino Mattei
- Klinik für Urologie, Luzerner Kantonsspital, Lucerne, Switzerland
| | | | - Shahrokh F Shariat
- Department of Urology, Vienna General Hospital, Medical University of Vienna, Vienna, Austria; Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX, USA; Department of Urology, Weill Cornell Medical College, New York, NY, USA; Karl Landsteiner Institute of Urology and Andrology, Vienna, Austria
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Zaorsky NG, Spratt DE, Blanchard P. Re: Marco Moschini, Emanuele Zaffuto, Pierre I. Karakiewicz, et al. External Beam Radiotherapy Increases the Risk of Bladder Cancer When Compared with Radical Prostatectomy in Patients Affected by Prostate Cancer: A Population-based Analysis. Eur Urol 2019;75:319-28. Eur Urol 2018; 75:e96-e97. [PMID: 30473434 DOI: 10.1016/j.eururo.2018.11.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Accepted: 11/12/2018] [Indexed: 11/19/2022]
Affiliation(s)
- Nicholas G Zaorsky
- Department of Radiation Oncology, Penn State Cancer Institute, Hershey, PA, USA; Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA, USA.
| | - Daniel E Spratt
- Department of Radiation Oncology, University of Michigan, Ann Arbon, MI, USA
| | - Pierre Blanchard
- Department of Radiation Oncology, Gustave Roussy, Paris Sud University, Villejuif, France
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Stish BJ, Davis BJ, Mynderse LA, McLaren RH, Deufel CL, Choo R. Low dose rate prostate brachytherapy. Transl Androl Urol 2018; 7:341-356. [PMID: 30050795 PMCID: PMC6043740 DOI: 10.21037/tau.2017.12.15] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Low dose rate (LDR) prostate brachytherapy is an evidence based radiation technique with excellent oncologic outcomes. By utilizing direct image guidance for radioactive source placement, LDR brachytherapy provides superior radiation dose escalation and conformality compared to external beam radiation therapy (EBRT). With this level of precision, late grade 3 or 4 genitourinary or gastrointestinal toxicity rates are typically between 1% and 4%. Furthermore, when performed as a same day surgical procedure, this technique provides a cost effective and convenient strategy. A large body of literature with robust follow-up has led multiple expert consensus groups to endorse the use of LDR brachytherapy as an appropriate management option for all risk groups of non-metastatic prostate cancer. LDR brachytherapy is often effective when delivered as a monotherapy, although for some patients with intermediate or high-risk disease, optimal outcome are achieved in combination with supplemental EBRT and/or androgen deprivation therapy (ADT). In addition to reviewing technical aspects and reported clinical outcomes of LDR prostate brachytherapy, this article will focus on the considerations related to appropriate patient selection and other aspects of its use in the treatment of prostate cancer.
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Affiliation(s)
- Bradley J Stish
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN 55905, USA
| | - Brian J Davis
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN 55905, USA
| | | | | | | | - Richard Choo
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN 55905, USA
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Zaorsky NG, Lee CT, Zhang E, Galloway TJ. Skin CanceR Brachytherapy vs External beam radiation therapy (SCRiBE) meta-analysis. Radiother Oncol 2018; 126:386-393. [PMID: 29370985 PMCID: PMC7548033 DOI: 10.1016/j.radonc.2017.12.029] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2017] [Revised: 12/26/2017] [Accepted: 12/27/2017] [Indexed: 01/13/2023]
Abstract
BACKGROUND AND PURPOSE To compare cosmesis and local recurrence (LR) of definitive external beam radiation therapy (EBRT) vs brachytherapy (BT) for indolent basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) of the skin. MATERIALS AND METHODS Studies including patients with T1-2 N0 SCCs/BCCs treated with definitive EBRT/BT and ≥10 months follow-up were analyzed. The primary endpoint was post-treatment cosmesis, categorized as "good," "fair," or "poor." The secondary endpoint was LR. Mixed effects regression models were used to estimate weighted linear relationships between biologically equivalent doses with α/β = 3 (BED3) and cosmetic outcomes. RESULTS A total of 9965 patients received EBRT and 553 received BT across 24 studies. Mean age was 73 years, median follow-up was 36 months, and median dose was 45 Gy/10 fractions at 4.4 Gy/fraction. At BED3 of 100 Gy, "good" cosmesis was more frequently observed in patients receiving BT, 95% (95% CI: 88-100%) vs 79% (95% CI: 60-82%), p < 0.05. Similar results were found for "good" cosmesis at BED3 >100 Gy. No difference in "poor" cosmesis was noted at any BED3. LR was <7% for both at one year. CONCLUSION BT has favorable cosmesis over EBRT for skin SCCs/BCCs at common fractionation regimens. Prospective studies comparing EBRT vs BT are warranted.
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Affiliation(s)
- Nicholas G Zaorsky
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, USA; Department of Radiation Oncology, Penn State Cancer Institute, Hershey, USA.
| | - Charles T Lee
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, USA
| | - Eddie Zhang
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, USA
| | - Thomas J Galloway
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, USA
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Dong Y, Zaorsky NG, Li T, Churilla TM, Viterbo R, Sobczak ML, Smaldone MC, Chen DY, Uzzo RG, Hallman MA, Horwitz EM. Effects of interruptions of external beam radiation therapy on outcomes in patients with prostate cancer. J Med Imaging Radiat Oncol 2017; 62:116-121. [PMID: 29030906 DOI: 10.1111/1754-9485.12675] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2017] [Accepted: 08/27/2017] [Indexed: 12/25/2022]
Abstract
INTRODUCTION To evaluate if interruptions of external beam radiation therapy impact outcomes in men with localized prostate cancer (PCa). METHODS We included men with localized PCa treated with three-dimensional conformal radiotherapy (3D-CRT) or intensity-modulated radiation therapy (IMRT) of escalated dose (≥74 Gy in 1.8 or 2 Gy fractions) between 1992 and 2013 at an NCI-designated cancer centre. Men receiving androgen deprivation therapy were excluded. The non-treatment day ratio (NTDR) was defined as the number of non-treatment days divided by the total elapsed days of therapy. NTDR was analysed for each National Comprehensive Cancer Network (NCCN) risk group. RESULTS There were 1728 men included (839 low-risk, 776 intermediate-risk and 113 high-risk), with a median follow up of 53.5 months (range 12-185.8). The median NTDR was 31% (range 23-71%), translating to approximately 2 breaks (each break represents a missed treatment that will be made up) for 8 weeks of RT with 5 treatments per week. The 75 percentile of NTDR was 33%, translating to approximately 4 breaks, which was used as the cutoff for analysis. There were no significant differences in freedom from biochemical failure, freedom from distant metastasis, cancer specific survival, or overall survival for men with NTDR ≥33% compared to NTDR<33% for each risk group. Multivariable analyses including NTDR, age, race, Gleason score, T stage, and PSA were performed using the proportional hazards regression procedure. NTDR≥33% was not significantly associated with increased hazard ratio for outcomes in each risk group compared to NTDR<33%. CONCLUSION Unintentional treatment breaks during dose escalated external beam radiation therapy for PCa did not cause a significant difference in outcomes, although duration of follow up limits the strength of this conclusion.
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Affiliation(s)
- Yanqun Dong
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania, USA
| | - Nicholas G Zaorsky
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania, USA.,Department of Radiation Oncology, Penn State Cancer Institute, Hershey, Pennsylvania, USA
| | - Tianyu Li
- Department of Biostatistics, Fox Chase Cancer Center, Philadelphia, Pennsylvania, USA
| | - Thomas M Churilla
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania, USA
| | - Rosalia Viterbo
- Department of Urologic Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania, USA
| | - Mark L Sobczak
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania, USA
| | - Marc C Smaldone
- Department of Urologic Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania, USA
| | - David Yt Chen
- Department of Urologic Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania, USA
| | - Robert G Uzzo
- Department of Urologic Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania, USA
| | - Mark A Hallman
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania, USA
| | - Eric M Horwitz
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania, USA
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Zaorsky NG, Lee CT, Zhang E, Keith SW, Galloway TJ. Hypofractionated radiation therapy for basal and squamous cell skin cancer: A meta-analysis. Radiother Oncol 2017; 125:13-20. [PMID: 28843727 PMCID: PMC7534946 DOI: 10.1016/j.radonc.2017.08.011] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2017] [Revised: 07/21/2017] [Accepted: 08/07/2017] [Indexed: 02/09/2023]
Abstract
PURPOSE To characterize the cosmetic outcomes and local recurrence (LR) rates of various hypofractionated radiation therapy (RT) regimens for skin basal and squamous cell cancers (BCCs/SCCs). METHODS A PICOS/PRISMA/MOOSE selection protocol was performed to identify 344 articles published between 1985-2016 evaluating patients with T1-2 N0 SCCs/BCCs treated with definitive RT. Biologically equivalent doses with α/β=3 (BED3s) were calculated. The primary endpoint was post-treatment cosmesis. Mixed effects regression models were used to estimate weighted linear relationships between BED3 and cosmetic outcomes. RESULTS A total of 21 studies were identified detailing the treatment of 9729 skin BCC/SCC patients, across seven countries, with external beam RT (n=9255) or brachytherapy (n=474). Median follow-up was 36months (range: 12-77). Median dose was 45Gy/11 fractions (interquartile range: 37.5Gy/6-55Gy/18) at 4Gy/fraction (interquartile range: 2.5-6Gy); most hypofractionated 18.75Gy/1. There was a trend to decreased "good" cosmesis with higher total dose: -3.4% "good" cosmesis/10Gy BED3, p=0.01. Similarly, there was a trend to increased "fair" cosmesis with higher dose: +3.8% "fair" cosmesis/10Gy BED3,p=0.006. At a BED3 of 100Gy, the expected rate of "good" cosmesis is 79% (95% confidence interval: 70%, 88%). Hypofractionated schedules produced similar cosmesis to conventionally fractionated schedules, at the same BED3. Fewer than 8% of patients experienced "poor" cosmesis, independent of dose or fractionation regimen. CONCLUSION Hypofractionated RT has favorable cosmesis for patients with skin BCCs/SCCs. We recommend clinicians consider these commonly-used regimens, which all have BED3 of ∼100Gy: 50Gy/15 fractions, 36.75Gy/7 fractions, or 35Gy/5 fractions, as they result in "good" cosmesis in 80% of patients.
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Affiliation(s)
- Nicholas G Zaorsky
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, USA; Department of Radiation Oncology, Penn State Cancer Institute, Hershey, USA.
| | - Charles T Lee
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, USA
| | - Eddie Zhang
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, USA
| | - Scott W Keith
- Department of Pharmacology and Experimental Therapeutics, Division of Biostatistics, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, USA
| | - Thomas J Galloway
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, USA.
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39
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Zaorsky NG, Davis BJ, Nguyen PL, Showalter TN, Hoskin PJ, Yoshioka Y, Morton GC, Horwitz EM. The evolution of brachytherapy for prostate cancer. Nat Rev Urol 2017; 14:415-439. [PMID: 28664931 PMCID: PMC7542347 DOI: 10.1038/nrurol.2017.76] [Citation(s) in RCA: 100] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Brachytherapy (BT), using low-dose-rate (LDR) permanent seed implantation or high-dose-rate (HDR) temporary source implantation, is an acceptable treatment option for select patients with prostate cancer of any risk group. The benefits of HDR-BT over LDR-BT include the ability to use the same source for other cancers, lower operator dependence, and - typically - fewer acute irritative symptoms. By contrast, the benefits of LDR-BT include more favourable scheduling logistics, lower initial capital equipment costs, no need for a shielded room, completion in a single implant, and more robust data from clinical trials. Prospective reports comparing HDR-BT and LDR-BT to each other or to other treatment options (such as external beam radiotherapy (EBRT) or surgery) suggest similar outcomes. The 5-year freedom from biochemical failure rates for patients with low-risk, intermediate-risk, and high-risk disease are >85%, 69-97%, and 63-80%, respectively. Brachytherapy with EBRT (versus brachytherapy alone) is an appropriate approach in select patients with intermediate-risk and high-risk disease. The 10-year rates of overall survival, distant metastasis, and cancer-specific mortality are >85%, <10%, and <5%, respectively. Grade 3-4 toxicities associated with HDR-BT and LDR-BT are rare, at <4% in most series, and quality of life is improved in patients who receive brachytherapy compared with those who undergo surgery.
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Affiliation(s)
- Nicholas G Zaorsky
- Department of Radiation Oncology, Fox Chase Cancer Center, 333 Cottman Avenue, Philadelphia, Pennsylvania 19111-2497, USA
| | - Brian J Davis
- Department of Radiation Oncology, Mayo Clinic, 200 First St SW, Charlton Bldg/Desk R - SL, Rochester, Minnesota 5590, USA
| | - Paul L Nguyen
- Department of Radiation Oncology, Brigham and Women's Hospital, 75 Francis St BWH. Radiation Oncology, Boston, Massachusetts 02115, USA
| | - Timothy N Showalter
- Department of Radiation Oncology, University of Virginia, 1240 Lee St, Charlottesville, Virginia 22908, USA
| | - Peter J Hoskin
- Mount Vernon Cancer Centre, Rickmansworth Road, Northwood, Middlesex HA6 2RN, UK
| | - Yasuo Yoshioka
- Department of Radiation Oncology, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo 135-8550, Japan
| | - Gerard C Morton
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, 2075 Bayview Ave, Toronto, Ontario M4N 3M5, Canada
| | - Eric M Horwitz
- Department of Radiation Oncology, Fox Chase Cancer Center, 333 Cottman Avenue, Philadelphia, Pennsylvania 19111-2497, USA
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40
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Wallis CJD, Glaser A, Hu JC, Huland H, Lawrentschuk N, Moon D, Murphy DG, Nguyen PL, Resnick MJ, Nam RK. Survival and Complications Following Surgery and Radiation for Localized Prostate Cancer: An International Collaborative Review. Eur Urol 2017; 73:11-20. [PMID: 28610779 DOI: 10.1016/j.eururo.2017.05.055] [Citation(s) in RCA: 64] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Accepted: 05/30/2017] [Indexed: 10/24/2022]
Abstract
BACKGROUND Evaluation of treatment options for localized prostate cancer (PCa) remains among the highest priorities for comparative effectiveness research. Surgery and radiotherapy (RT) are the two interventions most commonly used. OBJECTIVE To provide a critical narrative review of evidence of the comparative effectiveness and harms of surgery and RT in the treatment of localized PCa. EVIDENCE ACQUISITION A collaborative critical narrative review of the literature was conducted. EVIDENCE SYNTHESIS Evidence to clearly guide treatment choice in PCa remains insufficient. Randomized trials are underpowered for clinically meaningful endpoints and have demonstrated no difference in overall or PCa-specific survival. Observational studies have consistently demonstrated an absolute survival benefit for men treated with radical prostatectomy, but are limited by selection bias and residual confounding errors. Surgery and RT are associated with comparable health-related quality of life following treatment in three randomized trials. Randomized data regarding urinary, erectile, and bowel function show few long-term (>5 yr) differences, although short-term continence and erectile function were worse following surgery and short-term urinary bother and bowel function were worse following RT. There has been recent recognition of other complications that may significantly affect the life trajectory of those undergoing PCa treatment. Of these, hospitalization, the need for urologic, rectoanal, and other major surgical procedures, and secondary cancers are more common among men treated with RT. Androgen deprivation therapy, frequently co-administered with RT, may additionally contribute to treatment-related morbidity. Technological innovations in surgery and RT have shown inconsistent oncologic and functional benefits. CONCLUSIONS Owing to underpowered randomized control studies and the selection biases inherent in observational studies, the question of which treatment provides better PCa control cannot be definitively answered now or in the near future. Complications following PCa treatment are relatively common regardless of treatment approach. These include the commonly identified issues of urinary incontinence and erectile dysfunction, and others including hospitalization and invasive procedures to manage complications and secondary malignancies. Population-based outcome studies, rather than clinical trial data, will be necessary for a comprehensive understanding of the relative benefits and risks of each therapeutic approach. PATIENT SUMMARY Surgery and radiotherapy are the most common interventions for men diagnosed with prostate cancer. Comparisons of survival after these treatments are limited by various flaws in the relevant studies. Complications are common regardless of the treatment approach.
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Affiliation(s)
- Christopher J D Wallis
- Division of Urology, Department of Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management, & Evaluation, University of Toronto, Toronto, ON, Canada
| | - Adam Glaser
- Leeds Institute of Cancer and Pathology, University of Leeds, Leeds, UK
| | - Jim C Hu
- Department of Urology, Weill Cornell Medicine, New York, NY, USA
| | - Hartwig Huland
- Martini-Klinik Prostate Cancer Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Nathan Lawrentschuk
- Department of Surgery, University of Melbourne, Austin Health, Melbourne, Australia; Olivia Newton-John Cancer Research Institute, Austin Health, Melbourne, Australia; Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Daniel Moon
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Australia; Central Clinical School, Monash University, Clayton, Australia; The Epworth Prostate Centre, Epworth Hospital, Richmond, Australia
| | - Declan G Murphy
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Australia; The Epworth Prostate Centre, Epworth Hospital, Richmond, Australia
| | - Paul L Nguyen
- Department of Radiation Oncology, Dana-Farber/Brigham and Women's Cancer Center, Harvard Medical School, Boston, MA, USA
| | - Matthew J Resnick
- Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA; Geriatric Research, Education, and Clinical Center, Tennessee Valley VA Health Care System, Nashville, TN, USA
| | - Robert K Nam
- Division of Urology, Department of Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management, & Evaluation, University of Toronto, Toronto, ON, Canada.
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Zaorsky NG, Williams GR, Barta SK, Esnaola NF, Kropf PL, Hayes SB, Meyer JE. Splenic irradiation for splenomegaly: A systematic review. Cancer Treat Rev 2017; 53:47-52. [PMID: 28063304 PMCID: PMC7537354 DOI: 10.1016/j.ctrv.2016.11.016] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Revised: 11/19/2016] [Accepted: 11/29/2016] [Indexed: 10/20/2022]
Abstract
Splenic irradiation (SI) is a palliative treatment option for symptomatic splenomegaly (i.e. for pain, early satiety, pancytopenia from sequestration) secondary to hematologic malignancies and disorders. The purpose of the current article is to review the literature on SI for hematologic malignancies and disorders, including: (1) patient selection and optimal technique; (2) efficacy of SI; and (3) toxicities of SI. PICOS/PRISMA methods are used to select 27 articles including 766 courses of SI for 486 patients from 1960 to 2016. The most common cancers treated included chronic lymphocytic leukemia and myeloproliferative disorders; the most common regimen was 10Gy in 1Gy fractions over two weeks, and 27% of patients received retreatment. A partial or complete response (for symptoms, lab abnormalities) was obtained in 85-90% of treated patients, and 30% were retreated within 6-12months. There was no correlation between biologically equivalent dose of radiation therapy and response duration, pain relief, spleen reduction, or cytopenia improvement (r2 all <0.4); therefore, lower doses (e.g. 5Gy in 5 fractions) may be as effective as higher doses. Grade 3-4 toxicity (typically leukopenia, infection) was noted in 22% of courses, with grade 5 toxicity in 0.7% of courses. All grade 5 toxicities were due to either thrombocytopenia with hemorrhage or leukopenia with sepsis (or a combination of both); they were sequelae of cancer and not directly caused by SI. In summary, SI is generally a safe and efficacious method for treating patients with symptomatic splenomegaly.
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Affiliation(s)
- Nicholas G Zaorsky
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA.
| | - Graeme R Williams
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Stefan K Barta
- Department of Medical Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Nestor F Esnaola
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Patricia L Kropf
- Department of Medical Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Shelly B Hayes
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Joshua E Meyer
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA.
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Zaorsky NG, Churilla TM, Ruth K, Hayes SB, Sobczak ML, Hallman MA, Smaldone MC, Chen DY, Horwitz EM. Men's health supplement use and outcomes in men receiving definitive intensity-modulated radiation therapy for localized prostate cancer. Am J Clin Nutr 2016; 104:1583-1593. [PMID: 27797706 PMCID: PMC5118729 DOI: 10.3945/ajcn.115.119958] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2015] [Accepted: 09/19/2016] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Approximately 50% of newly diagnosed cancer patients start taking dietary supplements. Men's health supplements (MHSs), which we define as supplements that are specifically marketed with the terms men's health and prostate health (or similar permutations), are often mislabeled as having potential anticancer benefits. OBJECTIVE We evaluated the effects of MHSs on patient outcomes and toxicities in patients who were undergoing definitive intensity-modulated radiation therapy (IMRT) for localized prostate cancer. DESIGN This retrospective analysis included patients who were being treated at a National Cancer Institute-designated comprehensive cancer center and consented to have information stored in a prospective database. MHSs were queried online. Outcome measures were freedom from biochemical failure (FFBF) (biochemical failure was defined with the use of the prostate-specific antigen nadir + 2-ng/mL definition), freedom from distant metastasis (FFDM), cancer-specific survival (CSS), and overall survival (OS) as well as toxicities. Kaplan-Meier analysis, log-rank tests, Fine and Gray competing-risk regression (to adjust for patient and lifestyle factors), and Cox models were used. RESULTS From 2001 to 2012, 2207 patients were treated with IMRT with a median dose of 78 Gy, and a median follow-up of 46 mo. Of these patients, 43% were low risk, 37% were intermediate risk, and 20% were high risk; 10% used MHSs. MHSs contained a median of 3 identifiable ingredients (range: 0-78 ingredients). Patients who were taking an MHS compared with those who were not had improved 5-y OS (97% compared with 92%, respectively; P = 0.01), but there were no differences in the FFBF (94% compared with 89%, respectively; P = 0.12), FFDM (96% compared with 97%, respectively; P = 0.32), or CSS (100% compared with 99%, respectively; P = 0.22). The unadjusted association between MHS use and improved OS was attenuated after adjustment for patient lifestyle factors and comorbidities. There was no difference in toxicities between the 2 groups (late-grade 3-4 genitourinary <3%; gastrointestinal <4%). CONCLUSION The use of MHSs is not associated with outcomes or toxicities.
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Affiliation(s)
| | | | - Karen Ruth
- Biostatistics and Bioinformatics Facility, and
| | | | | | | | - Marc C Smaldone
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA
| | - David Yt Chen
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA
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Zaorsky NG, Shaikh T, Ruth K, Sharda P, Hayes SB, Sobczak ML, Hallman MA, Smaldone MC, Chen DYT, Horwitz EM. Prostate Cancer Patients With Unmanaged Diabetes or Receiving Insulin Experience Inferior Outcomes and Toxicities After Treatment With Radiation Therapy. Clin Genitourin Cancer 2016; 15:326-335.e3. [PMID: 27789181 DOI: 10.1016/j.clgc.2016.08.020] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Revised: 08/22/2016] [Accepted: 08/26/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND The purpose of the study was to determine the effect of type 2 diabetes mellitus (T2DM) on outcomes and toxicities among men with localized prostate cancer receiving definitive radiation therapy. PATIENTS AND METHODS We performed a retrospective review of 3217 patients, from 1998 to 2013, subdivided into 5 subgroups: (I) no T2DM; (II) T2DM receiving oral antihyperglycemic agent that contains metformin, no insulin; (III) T2DM receiving nonmetformin oral agent alone, no insulin; (IV) T2DM receiving any insulin; and (V) T2DM not receiving medication. Outcome measures were overall survival, freedom from biochemical failure (BF), freedom from distant metastasis, cancer-specific survival, and toxicities. Kaplan-Meier analysis, log rank tests, Fine and Gray competing risk regression (to adjust for patient and lifestyle factors), Cox models, and subdistribution hazard ratios (sHRs) were used. RESULTS Of the 3217 patients, 1295 (40%) were low-risk, 1192 (37%) were intermediate-risk, and 652 (20%) were high risk. The group I to V distribution was 81%, 8%, 5%, 3%, and 4%. The median dose was 78 Gy, and the median follow-up time was 50 (range, 1-190) months. Group V had increased mortality (sHR, 2.1; 95% confidence interval [CI], 0.66-1.54), BF (sHR, 2.14; 0.88-1.83), and cause-specific mortality (sHR, 3.87; 95% CI, 1.31-11). Acute toxicities were higher in group IV versus group I (genitourinary: 38% vs. 26%; P = .01; gastrointestinal: 21% vs. 5%; P = 001). Late toxicities were higher in groups IV and V versus group I (12%-14% vs. 2%-6%; P < .01). CONCLUSION Men with T2DM not receiving medication and men with T2DM receiving insulin had worse outcomes and toxicities compared to other patients.
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Affiliation(s)
- Nicholas G Zaorsky
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA.
| | - Talha Shaikh
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA
| | - Karen Ruth
- Biostatistics and Bioinformatics Facility, Fox Chase Cancer Center, Philadelphia, PA
| | - Pankaj Sharda
- Department of Endocrinology, Fox Chase Cancer Center, Philadelphia, PA
| | - Shelly B Hayes
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA
| | - Mark L Sobczak
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA
| | - Mark A Hallman
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA
| | - Marc C Smaldone
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA
| | - David Y T Chen
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA
| | - Eric M Horwitz
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA
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Avkshtol V, Dong Y, Hayes SB, Hallman MA, Price RA, Sobczak ML, Horwitz EM, Zaorsky NG. A comparison of robotic arm versus gantry linear accelerator stereotactic body radiation therapy for prostate cancer. Res Rep Urol 2016; 8:145-58. [PMID: 27574585 PMCID: PMC4993397 DOI: 10.2147/rru.s58262] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Prostate cancer is the most prevalent cancer diagnosed in men in the United States besides skin cancer. Stereotactic body radiation therapy (SBRT; 6–15 Gy per fraction, up to 45 minutes per fraction, delivered in five fractions or less, over the course of approximately 2 weeks) is emerging as a popular treatment option for prostate cancer. The American Society for Radiation Oncology now recognizes SBRT for select low- and intermediate-risk prostate cancer patients. SBRT grew from the notion that high doses of radiation typical of brachytherapy could be delivered noninvasively using modern external-beam radiation therapy planning and delivery methods. SBRT is most commonly delivered using either a traditional gantry-mounted linear accelerator or a robotic arm-mounted linear accelerator. In this systematic review article, we compare and contrast the current clinical evidence supporting a gantry vs robotic arm SBRT for prostate cancer. The data for SBRT show encouraging and comparable results in terms of freedom from biochemical failure (>90% for low and intermediate risk at 5–7 years) and acute and late toxicity (<6% grade 3–4 late toxicities). Other outcomes (eg, overall and cancer-specific mortality) cannot be compared, given the indolent course of low-risk prostate cancer. At this time, neither SBRT device is recommended over the other for all patients; however, gantry-based SBRT machines have the abilities of treating larger volumes with conventional fractionation, shorter treatment time per fraction (~15 minutes for gantry vs ~45 minutes for robotic arm), and the ability to achieve better plans among obese patients (since they are able to use energies >6 MV). Finally, SBRT (particularly on a gantry) may also be more cost-effective than conventionally fractionated external-beam radiation therapy. Randomized controlled trials of SBRT using both technologies are underway.
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Affiliation(s)
- Vladimir Avkshtol
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Yanqun Dong
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Shelly B Hayes
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Mark A Hallman
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Robert A Price
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Mark L Sobczak
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Eric M Horwitz
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Nicholas G Zaorsky
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
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45
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Zaorsky NG, Shaikh T, Murphy CT, Hallman MA, Hayes SB, Sobczak ML, Horwitz EM. Comparison of outcomes and toxicities among radiation therapy treatment options for prostate cancer. Cancer Treat Rev 2016; 48:50-60. [PMID: 27347670 DOI: 10.1016/j.ctrv.2016.06.006] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2016] [Revised: 06/07/2016] [Accepted: 06/08/2016] [Indexed: 01/13/2023]
Abstract
We review radiation therapy (RT) options available for prostate cancer, including external beam (EBRT; with conventional fractionation, hypofractionation, stereotactic body RT [SBRT]) and brachytherapy (BT), with an emphasis on the outcomes, toxicities, and contraindications for therapies. PICOS/PRISMA methods were used to identify published English-language comparative studies on PubMed (from 1980 to 2015) that included men treated on prospective studies with a primary endpoint of patient outcomes, with ⩾70 patients, and ⩾5year median follow up. Twenty-six studies met inclusion criteria; of these, 16 used EBRT, and 10 used BT. Long-term freedom from biochemical failure (FFBF) rates were roughly equivalent between conventional and hypofractionated RT with intensity modulation (evidence level 1B), with 10-year FFBF rates of 45-90%, 40-60%, and 20-50% (for low-, intermediate-, and high-risk groups, respectively). SBRT had promising rates of BF, with shorter follow-up (5-year FFBF of >90% for low-risk patients). Similarly, BT (5-year FFBF for low-, intermediate-, and high-risk patients have generally been >85%, 69-97%, 63-80%, respectively) and BT+EBRT were appropriate in select patients (evidence level 1B). Differences in overall survival, distant metastasis, and cancer specific mortality (5-year rates: 82-97%, 1-14%, 0-8%, respectively) have not been detected in randomized trials of dose escalation or in studies comparing RT modalities. Studies did not use patient-reported outcomes, through Grade 3-4 toxicities were rare (<5%) among all modalities. There was limited evidence available to compare proton therapy to other modalities. The treatment decision for a man is usually based on his risk group, ability to tolerate the procedure, convenience for the patient, and the anticipated impact on quality of life. To further personalize therapy, future trials should report (1) race; (2) medical comorbidities; (3) psychiatric comorbidities; (4) insurance status; (5) education status; (6) marital status; (7) income; (8) sexual orientation; and (9) facility-related characteristics.
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Affiliation(s)
- Nicholas G Zaorsky
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA.
| | - Talha Shaikh
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Colin T Murphy
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Mark A Hallman
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Shelly B Hayes
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Mark L Sobczak
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Eric M Horwitz
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
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