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Ghafour H, Ali JS, Taher Ali R, Sirelkhatim E. A Comparison of Field-in-Field and Intensity Modulated Radiation Therapy in Delivering Hypofractionated Radiation Therapy for Prostate Cancer. Adv Radiat Oncol 2024; 9:101356. [PMID: 38405309 PMCID: PMC10885577 DOI: 10.1016/j.adro.2023.101356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 08/07/2023] [Indexed: 02/27/2024] Open
Abstract
Purpose This study compares the dosimetric performance of the field-in-field (FIF) technique with intensity modulated radiation therapy (IMRT) for delivering hypofractionated radiation therapy to prostate patients with cancer. The FIF technique uses 6 beams, whereas IMRT uses 9 beams. Methods and Materials This study was conducted on 15 patients with prostate cancer treated with step-and-shoot IMRT. The prescribed dose was 60 Gy in 20 fractions. The FIF plans contained 6 photon beams, and IMRT plans were designed using a 9-field step-and-shoot technique. Dose-volume histograms and dose distributions were evaluated to compare FIF and IMRT. Results The results of the planning target volume indices analysis showed a significant difference in the maximum dose, dose to 2% of volume, and homogeneity index in favor of FIF and in the mean dose, dose to 98% of volume, and D95 in favor of IMRT. The results of the organs-at-risk analysis showed significant differences in the volume of the rectum and bladder receiving 60 Gy in favor of FIF and the volume of the rectum and femoral heads receiving 30 Gy, as well as the mean dose to the rectum, in favor of IMRT. IMRT had a higher median number of monitor units (MUs) and segments (886 MU, 64 segments) compared to FIF (434 MUs, 6 segments). Conclusions The FIF technique and IMRT had comparable results in delivering hypofractionated radiation therapy for prostate cancer. The findings of this study may aid in decision-making for patients undergoing treatment.
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2
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Batumalai V, James M. Unwarranted variation in radiation therapy fractionation. J Med Imaging Radiat Oncol 2022; 66:233-241. [PMID: 35243787 DOI: 10.1111/1754-9485.13372] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 12/06/2021] [Indexed: 01/02/2023]
Abstract
The adoption of hypofractionation across multiple tumour sites has been slow despite robust evidence. There is considerable unwarranted variation in practice, both within and between jurisdictions. This has been attributed to inconsistencies in guidelines, physician preference, lack of technology and differing financial incentives. Unwarranted variation in the use of hypofractionation has a tremendous effect on cost to both patients and the healthcare system. This places an unnecessary burden on patients and poorly utilises scarce healthcare resources. A collaborative effort from clinicians, patients, healthcare providers and policymakers is needed to reduce unwarranted variation in practice. This will improve quality of care both for patients and at broader healthcare system level.
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Affiliation(s)
- Vikneswary Batumalai
- Collaboration for Cancer Outcomes, Research and Evaluation, Ingham Institute for Applied Medical Research, South Western Clinical School, University of New South Wales, Sydney, New South Wales, Australia.,GenesisCare, Sydney, New South Wales, Australia
| | - Melissa James
- Christchurch Oncology Service, Canterbury Regional Cancer and Haematology Centre, Christchurch, New Zealand.,Department of Medicine, Christchurch Hospital, University of Otago Christchurch, Christchurch, New Zealand
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3
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de Leon J, Crawford D, Moutrie Z, Alvares S, Hogan L, Pagulayan C, Jelen U, Loo C, Aylward JD, Condon K, Dunkerley N, Heinke MY, Sampaio S, Simon K, Twentyman T, Jameson MG. Early experience with MR-guided adaptive radiotherapy using a 1.5 T MR-Linac: First 6 months of operation using adapt to shape workflow. J Med Imaging Radiat Oncol 2021; 66:138-145. [PMID: 34643065 DOI: 10.1111/1754-9485.13336] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 09/17/2021] [Indexed: 11/26/2022]
Abstract
INTRODUCTION The magnetic resonance linear accelerator (MRL) offers improved soft tissue visualization to guide daily adaptive radiotherapy treatment. This manuscript aims to report initial experience using a 1.5 T MRL in the first 6 months of operation, including training, workflows, timings and dosimetric accuracy. METHODS All staff received training in MRI safety and MRL workflows. Initial sites chosen for treatment were stereotactic and hypofractionated prostate, thoraco-abdomino-pelvic metastasis, prostate bed and bladder. The Adapt To Shape (ATS) workflow was chosen to be the focus of treatment as it is the most robust solution for daily adaptive radiotherapy. A workflow was created addressing patient suitability, simulation, planning, treatment and peer review. Treatment times were recorded breaking down into the various stages of treatment. RESULTS A total of 37 patients were treated and 317 fractions delivered (of which 313 were delivered using an ATS workflow) in our initial 6 months. Average treatment times over the entire period were 50 and 38 min for stereotactic and non-stereotactic treatments respectively. Average treatment times reduced each month. The average difference between reference planned and ionization chamber measured dose was 0.0 ± 1.4%. CONCLUSION The MRL was successfully established in an Australian setting. A focus on training and creating a detailed workflow from patient selection, review and treatment are paramount to establishing new treatment programmes.
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Affiliation(s)
| | | | - Zoë Moutrie
- GenesisCare, Sydney, New South Wales, Australia
| | | | | | | | | | - Conrad Loo
- GenesisCare, Sydney, New South Wales, Australia
| | - Jack D Aylward
- GenesisCare, Sydney, New South Wales, Australia.,Division of Cancer Sciences, Faculty of Biology Medicine and Health, The University of Manchester, Manchester, UK.,Christie Medical Physics and Engineering, The Christie NHS Foundation Trust, The University of Manchester, Manchester, UK
| | | | | | | | | | - Kathy Simon
- GenesisCare, Sydney, New South Wales, Australia
| | | | - Michael G Jameson
- GenesisCare, Sydney, New South Wales, Australia.,Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
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Nithiyananthan K, Creighton N, Currow D, Martin JM. Population-Level Uptake of Moderately Hypofractionated Definitive Radiation Therapy in the Treatment of Prostate Cancer. Int J Radiat Oncol Biol Phys 2021; 111:417-423. [PMID: 33974884 DOI: 10.1016/j.ijrobp.2021.04.033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 04/14/2021] [Accepted: 04/23/2021] [Indexed: 01/20/2023]
Abstract
PURPOSE Recent evidence shows the noninferiority of hypofractionated radiation therapy regimens compared with conventional regimens in the treatment of prostate cancer (PCa). Hypofractionation has benefits for both the patient and health care system, because of the shorter treatment duration. Despite this advantage, the uptake of hypofractionation can be slow. Here we investigate the factors influencing the changing use of moderate hypofractionation (HypoRT) for the treatment of PCa. METHODS AND MATERIALS We conducted a population-based, retrospective, consecutive cohort study using the 2014 to 2018 Outpatient Radiation Oncology Data from public and private treatment facilities in New South Wales, Australia. Included participants had a PCa diagnosis of any risk, and they completed curative-intent external beam radiation therapy without treatment to lymph nodes. Factors potentially affecting use of HypoRT were examined using a 3-level hierarchical logistic regression model. The effects were reported using adjusted, median, or interval odds ratios. RESULTS The study included 4915 patients. Of these, 4053 patients (82.5%) received conventional fractionation, and 862 patients (17.5%) received HypoRT. HypoRT utilization increased from 5.2% in 2014 to 40.3% in 2018. The treating radiation oncologist, treatment facility, and increasing distance to treatment centers had the greatest influence on HypoRT uptake. The main limitation was the lack of stratification by PCa risk categorization. CONCLUSIONS Although HypoRT uptake has considerably increased between 2014 and 2018, it remains variable among facilities and treating radiation oncologists. Strategies are being explored to reduce inter-clinician variability.
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Affiliation(s)
- Kajanan Nithiyananthan
- School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, Callaghan, Australia
| | | | | | - Jarad M Martin
- School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, Callaghan, Australia; Department of Radiation Oncology, Calvary Mater Newcastle, Waratah, Australia.
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5
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Zabel WJ, Conway JL, Gladwish A, Skliarenko J, Didiodato G, Goorts-Matthews L, Michalak A, Reistetter S, King J, Nakonechny K, Malkoske K, Tran MN, McVicar N. Clinical Evaluation of Deep Learning and Atlas-Based Auto-Contouring of Bladder and Rectum for Prostate Radiation Therapy. Pract Radiat Oncol 2020; 11:e80-e89. [PMID: 32599279 DOI: 10.1016/j.prro.2020.05.013] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 05/24/2020] [Accepted: 05/28/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE Auto-contouring may reduce workload, interobserver variation, and time associated with manual contouring of organs at risk. Manual contouring remains the standard due in part to uncertainty around the time and workload savings after accounting for the review and editing of auto-contours. This preliminary study compares a standard manual contouring workflow with 2 auto-contouring workflows (atlas and deep learning) for contouring the bladder and rectum in patients with prostate cancer. METHODS AND MATERIALS Three contouring workflows were defined based on the initial contour-generation method including manual (MAN), atlas-based auto-contour (ATLAS), and deep-learning auto-contour (DEEP). For each workflow, initial contour generation was retrospectively performed on 15 patients with prostate cancer. Then, radiation oncologists (ROs) edited each contour while blinded to the manner in which the initial contour was generated. Workflows were compared by time (both in initial contour generation and in RO editing), contour similarity, and dosimetric evaluation. RESULTS Mean durations for initial contour generation were 10.9 min, 1.4 min, and 1.2 min for MAN, DEEP, and ATLAS, respectively. Initial DEEP contours were more geometrically similar to initial MAN contours. Mean durations of the RO editing steps for MAN, DEEP, and ATLAS contours were 4.1 min, 4.7 min, and 10.2 min, respectively. The geometric extent of RO edits was consistently larger for ATLAS contours compared with MAN and DEEP. No differences in clinically relevant dose-volume metrics were observed between workflows. CONCLUSION Auto-contouring software affords time savings for initial contour generation; however, it is important to also quantify workload changes at the RO editing step. Using deep-learning auto-contouring for bladder and rectum contour generation reduced contouring time without negatively affecting RO editing times, contour geometry, or clinically relevant dose-volume metrics. This work contributes to growing evidence that deep-learning methods are a clinically viable solution for organ-at-risk contouring in radiation therapy.
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Affiliation(s)
- W Jeffrey Zabel
- Department of Physics and Astronomy, McMaster University, Hamilton, Ontario, Canada; Royal Victoria Regional Health Centre, Barrie, Ontario, Canada
| | - Jessica L Conway
- Royal Victoria Regional Health Centre, Barrie, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Adam Gladwish
- Royal Victoria Regional Health Centre, Barrie, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Julia Skliarenko
- Royal Victoria Regional Health Centre, Barrie, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | | | | | - Adam Michalak
- Royal Victoria Regional Health Centre, Barrie, Ontario, Canada
| | | | - Jenna King
- Royal Victoria Regional Health Centre, Barrie, Ontario, Canada
| | | | - Kyle Malkoske
- Royal Victoria Regional Health Centre, Barrie, Ontario, Canada
| | - Muoi N Tran
- Royal Victoria Regional Health Centre, Barrie, Ontario, Canada
| | - Nevin McVicar
- Royal Victoria Regional Health Centre, Barrie, Ontario, Canada.
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Mazonakis M, Kachris S, Damilakis J. Secondary bladder and rectal cancer risk estimates following standard fractionated and moderately hypofractionated VMAT for prostate carcinoma. Med Phys 2020; 47:2805-2813. [PMID: 32266979 DOI: 10.1002/mp.14169] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 03/25/2020] [Accepted: 03/28/2020] [Indexed: 12/17/2022] Open
Abstract
PURPOSE To estimate the risk for bladder and rectal cancer induction due to standard fractionated (SF) and moderately hypofractionated (HF) volumetric modulated arc therapy (VMAT) for prostate carcinoma. METHODS Twelve patients with low or intermediate-risk of prostate cancer referred for external-beam radiotherapy were included in this study. Three computed tomography-based VMAT plans were created for each study participant. The first plan was generated by assuming patient's irradiation with SF-VMAT (78 Gy in 39 fractions). The second and third plans were created on the basis of two different HF schedules (HF-VMAT1 : 70 Gy in 30 fractions, HF:VMAT2 : 60 Gy in 20 fractions). Data from differential dose-volume histograms obtained by the above treatment plans were employed to calculate the organ equivalent dose (OED) of the bladder and rectum with the aid of a nonlinear model accounting for fractionation and proliferation effects. The calculated OED values were used to estimate the average lifetime attributable risk (LARav ) for the appearance of radiotherapy-induced secondary bladder and rectal malignancies. The lifetime risk of radiation carcinogenesis was compared with the respective organ-, and age-dependent lifetime intrinsic risk (LIR) of cancer development for unexposed males. RESULTS The average OED of the rectum from SF-VMAT, HF-VMAT1 and HF-VMAT2 for prostate cancer was 972.0, 900.2, and 815.7 cGy, respectively. The corresponding values for bladder were 73.4, 72.3, and 71.0 cGy. The LARav for rectal cancer induction varied from 0.06% to 0.4% by the fractionation schedule used for irradiation and by the age of the patient at the time of treatment. The corresponding risk range related to the development of secondary bladder malignancies was 0.06-0.33%. The SF-VMAT, HF-VMAT1 and HF-VMAT2 led to an increase of the lifetime rectal cancer risk with respect to LIR by 2.2-9.8%, 2.0-9.1% and 1.8-8.2%, respectively, depending upon the patient's age. The corresponding elevation for bladder cancer induction was up to 8.0%, 7.9% and 7.7%. CONCLUSIONS The use of VMAT for prostate carcinoma leads to a noteworthy increase of the lifetime risk for bladder and rectal cancer induction compared to that of unexposed people irrespective of the patient's age at the time of treatment and the applied fractionation scheme. The cancer risk data presented in this study may be taken into account by radiation oncologists and medical physicists in the selection of the optimal radiation therapy plan.
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Affiliation(s)
- Michalis Mazonakis
- Department of Medical Physics, Faculty of Medicine, University of Crete, P.O. Box 2208, Iraklion, Crete, 71003, Greece
| | - Stefanos Kachris
- Department of Radiotherapy and Oncology, University Hospital of Iraklion, Iraklion, Crete, 71110, Greece
| | - John Damilakis
- Department of Medical Physics, Faculty of Medicine, University of Crete, P.O. Box 2208, Iraklion, Crete, 71003, Greece
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Shakespeare TP, Westhuyzen J, Lim Yew Fai T, Aherne NJ. Choosing between conventional and hypofractionated prostate cancer radiation therapy: Results from a study of shared decision-making. Rep Pract Oncol Radiother 2020; 25:193-199. [PMID: 32021576 PMCID: PMC6994273 DOI: 10.1016/j.rpor.2019.12.028] [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: 12/02/2019] [Accepted: 12/30/2019] [Indexed: 10/25/2022] Open
Abstract
AIM To evaluate patient choice of prostate cancer radiotherapy fractionation, using a decision aid. BACKGROUND Recent ASTRO guidelines recommend patients with localised prostate cancer be offered moderately hypofractionated radiation therapy after discussing increased acute toxicity and uncertainty of long-term results compared to conventional fractionation. MATERIALS AND METHODS A decision aid was designed to outline the benefits and potential downsides of conventionally and moderately hypofractionated radiation therapy. The aid incorporated the ASTRO guideline to outline risks and benefits. RESULTS In all, 124 patients with localised prostate cancer were seen from June-December 2018. Median age was 72 (range 50-90), 49.6 % were intermediate risk (50.4 % high risk). All except three patients made a choice using the aid; the three undecided patients were hypofractionated. In all, 33.9 % of patients chose hypofractionation: falling to 25.3 % for patients under 75 years, 24.3 % for patients living within 30 miles of the cancer centre, and 14.3 % for patients with baseline gastrointestinal symptoms. On multivariate analysis, younger age, proximity to the centre, and having baseline gastrointestinal symptoms significantly predicted for choosing conventional fractionation. Insurance status, attending clinician, baseline genitourinary symptoms, work/carer status, ECOG, cancer risk group and driving status did not impact choice. Reasons for choosing conventional fractionation were certainty of long-term results (84 %) and lower acute bowel toxicity (51 %). CONCLUSIONS Most patients declined the convenience of moderate hypofractionation due to potentially increased acute toxicity, and the uncertainty of long-term outcomes. We advocate that no patient should be offered hypofractionation without a thorough discussion of uncertainty and acute toxicity.
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Affiliation(s)
- Thomas P. Shakespeare
- Department of Radiation Oncology, Mid-North Coast Cancer Institute, Coffs Harbour, New South Wales, Australia
| | - Justin Westhuyzen
- Department of Radiation Oncology, Mid-North Coast Cancer Institute, Coffs Harbour, New South Wales, Australia
| | - Tracy Lim Yew Fai
- Department of Radiation Oncology, North Coast Cancer Institute, Lismore, New South Wales, Australia
| | - Noel J. Aherne
- Department of Radiation Oncology, Mid-North Coast Cancer Institute, Coffs Harbour, New South Wales, Australia
- Faculty of Medicine, University of New South Wales, New South Wales, Australia
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8
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Sanguineti G, Faiella A, Farneti A, D'Urso P, Fuga V, Olivieri M, Giannarelli D, Marzi S, Iaccarino G, Landoni V. Refinement & validation of rectal wall dose volume objectives for prostate hypofractionation in 20 fractions. Clin Transl Radiat Oncol 2020; 21:91-97. [PMID: 32072030 PMCID: PMC7015822 DOI: 10.1016/j.ctro.2020.01.006] [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: 11/27/2019] [Revised: 01/25/2020] [Accepted: 01/29/2020] [Indexed: 02/07/2023] Open
Abstract
LRB was correlated to irradiation technique and several % rectal wall cut points. The predictive role of dosimetric variables relates to the irradiation technique. Dose volume objectives for patients treated with IMRT/VMAT are reported.
Background and purpose Dose-volume objectives for the rectum have been proposed to limit long term toxicity after moderately hypofractionated radiotherapy (MHRT) for localized prostate cancer. The purpose of the present study is to validate and possibly refine dose volume objective for the rectal wall after 20-fraction MHRT. Materials and methods All patients treated by 20-fraction MHRT at a single Institution were identified and relative rectal wall (%RW) DVH retrieved. The endpoint of the study is the development of grade 2+ late rectal bleeding (LRB) according to a modified RTOG scale. Clinical and dosimetric predictors of LRB were investigated at both uni- and multi-variable analysis. Results 293 patients were identified and analyzed. Of them, 35 (12%) developed the endpoint. At univariable analysis, antithrombotic drug usage (yes vs no), technique (3DCRT vs IMRT/VMAT) and several %RW DVH cut-points were significantly correlated with LRB. However, within patients treated by 3DCRT (N = 106), a bi-variable model including anti-thrombotic drug usage and selected %RW dose/volume metrics failed to identify independent dosimetric predictors of LRB. Conversely, within patients treated with intensity modulation (N = 187), the same model showed a progressively higher impact of the percent of RW receiving doses above 40 Gy. Based on this model, we were able to confirm (V32), refine (V60) and identify a novel (V50) cut-point for the %RW. Conclusion We recommend the following dose volume objectives for the %RW in order to minimize the risk of LRB after 20-fraction MHRT: V32 ≤ 50%; V50 ≤ 25.8% and V60 ≤ 10%.
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Affiliation(s)
- Giuseppe Sanguineti
- Departments of Radiation Oncology, IRCCS Regina Elena National Cancer Institute, Rome, Italy
- Corresponding author at: Department of Radiation Oncology, IRCCS Regina Elena National Cancer Institute, Via Elio Chianesi 53, 00144 Rome, Italy.
| | - Adriana Faiella
- Departments of Radiation Oncology, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Alessia Farneti
- Departments of Radiation Oncology, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Pasqualina D'Urso
- Departments of Radiation Oncology, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Valentina Fuga
- Departments of Radiation Oncology, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Michela Olivieri
- Departments of Radiation Oncology, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Diana Giannarelli
- Departments of Statistics, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Simona Marzi
- Departments of Physics, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Giuseppe Iaccarino
- Departments of Physics, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Valeria Landoni
- Departments of Physics, IRCCS Regina Elena National Cancer Institute, Rome, Italy
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9
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Martin J, Keall P, Siva S, Greer P, Christie D, Moore K, Dowling J, Pryor D, Chong P, McLeod N, Raman A, Lynam J, Smart J, Oldmeadow C, Tang CI, Murphy DG, Millar J, Tai KH, Holloway L, Reeves P, Hayden A, Lim T, Holt T, Sidhom M. TROG 18.01 phase III randomised clinical trial of the Novel Integration of New prostate radiation schedules with adJuvant Androgen deprivation: NINJA study protocol. BMJ Open 2019; 9:e030731. [PMID: 31434782 PMCID: PMC6707760 DOI: 10.1136/bmjopen-2019-030731] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
INTRODUCTION Stereotactic body radiotherapy (SBRT) is a non-invasive alternative to surgery for the treatment of non-metastatic prostate cancer (PC). The objectives of the Novel Integration of New prostate radiation schedules with adJuvant Androgen deprivation (NINJA) clinical trial are to compare two emerging SBRT regimens for efficacy with technical substudies focussing on MRI only planning and the use of knowledge-based planning (KBP) to assess radiotherapy plan quality. METHODS AND ANALYSIS Eligible patients must have biopsy-proven unfavourable intermediate or favourable high-risk PC, have an Eastern Collaborative Oncology Group (ECOG) performance status 0-1 and provide written informed consent. All patients will receive 6 months in total of androgen deprivation therapy. Patients will be randomised to one of two SBRT regimens. The first will be 40 Gy in five fractions given on alternating days (SBRT monotherapy). The second will be 20 Gy in two fractions given 1 week apart followed 2 weeks later by 36 Gy in 12 fractions given five times per week (virtual high-dose rate boost (HDRB)). The primary efficacy outcome will be biochemical clinical control at 5 years. Secondary endpoints for the initial portion of NINJA look at the transition of centres towards MRI only planning and the impact of KBP on real-time (RT) plan assessment. The first 150 men will demonstrate accrual feasibility as well as addressing the KBP and MRI planning aims, prior to proceeding with total accrual to 472 patients as a phase III randomised controlled trial. ETHICS AND DISSEMINATION NINJA is a multicentre cooperative clinical trial comparing two SBRT regimens for men with PC. It builds on promising results from several single-armed studies, and explores radiation dose escalation in the Virtual HDRB arm. The initial component includes novel technical elements, and will form an important platform set for a definitive phase III study. TRIAL REGISTRATION NUMBER ANZCTN 12615000223538.
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Affiliation(s)
- Jarad Martin
- Department of Radiation Oncology, Calvary Mater Newcastle, Newcastle, New South Wales, Australia
- School of Medicine and Public Health, University of Newcastle, Callaghan, New South Wales, Australia
| | - Paul Keall
- Radiation Physics Laboratory, University of Sydney, Sydney, New South Wales, Australia
| | - Shankar Siva
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia
| | - Peter Greer
- Department of Radiation Oncology, Calvary Mater Newcastle, Newcastle, New South Wales, Australia
- School of Mathematical and Physical Sciences, University of Newcastle, Callaghan, New South Wales, Australia
| | | | - Kevin Moore
- Department of Medical Physics, University of California San Diego, La Jolla, California, USA
| | - Jason Dowling
- The Australian e-Health Research Centre, CSIRO, Canberra, Australian Capital Territory, Australia
| | - David Pryor
- Department of Radiation Oncology, Princess Alexandra Hospital Health Service District, Woolloongabba, Queensland, Australia
| | - Peter Chong
- Department of Urology, John Hunter Hospital, New Lambton Heights, New South Wales, Australia
| | - Nicholas McLeod
- Department of Urology, John Hunter Hospital, New Lambton Heights, New South Wales, Australia
| | - Avi Raman
- Department of Urology, John Hunter Hospital, New Lambton Heights, New South Wales, Australia
| | - James Lynam
- School of Medicine and Public Health, University of Newcastle, Callaghan, New South Wales, Australia
| | - Joanne Smart
- Department of Radiation Oncology, Calvary Mater Newcastle, Newcastle, New South Wales, Australia
| | | | - Colin I Tang
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Declan G Murphy
- Urological Service Team, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Jeremy Millar
- Department of Radiation Oncology, Alfred Health, Melbourne, Victoria, Australia
| | - Keen Hun Tai
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia
| | - Lois Holloway
- Department of Radiation Oncology, Liverpool Hospital, Liverpool, New South Wales, Australia
| | - Penny Reeves
- School of Medicine and Public Health, University of Newcastle, Callaghan, New South Wales, Australia
- Department of Health Research Economics, University of Newcastle Hunter Medical Research Institute, New Lambton, New South Wales, Australia
| | - Amy Hayden
- Department of Radiation Oncology, Westmead Hospital, Westmead, New South Wales, Australia
| | - Tee Lim
- Genesis Care, Perth, Western Australia, Australia
| | - Tanya Holt
- Radiation Oncology Princess Alexandra Raymond Terrace, Brisbane, Queensland, Australia
| | - Mark Sidhom
- Department of Radiation Oncology, Liverpool Hospital, Liverpool, New South Wales, Australia
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10
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Pryor D, Sidhom M, Arumugam S, Bucci J, Gallagher S, Smart J, Grand M, Greer P, Keats S, Wilton L, Martin J. Phase 2 Multicenter Study of Gantry-Based Stereotactic Radiotherapy Boost for Intermediate and High Risk Prostate Cancer (PROMETHEUS). Front Oncol 2019; 9:217. [PMID: 31001481 PMCID: PMC6454110 DOI: 10.3389/fonc.2019.00217] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Accepted: 03/12/2019] [Indexed: 12/17/2022] Open
Abstract
Objectives: To report feasibility, early toxicity, and PSA kinetics following gantry-based, stereotactic radiotherapy (SBRT) boost within a prospective, phase 2, multicenter study (PROMETHEUS: ACTRN12615000223538). Methods: Patients were treated with gantry-based SBRT, 19–20 Gy in two fractions delivered 1 week apart, followed by conventionally fractionated IMRT (46 Gy in 23 fractions). The study mandated MRI fusion for RT planning, rectal displacement, and intrafraction image guidance. Toxicity was prospectively graded using the Common Terminology Criteria for Adverse Events version 4.0 (CTCAE v4). Results: Between March 2014 and July 2018, 135 patients (76% intermediate, 24% high-risk) with a median age of 70 years (range 53–81) were treated across five centers. Short course (≤6 months) androgen deprivation therapy (ADT) was used in 36% and long course in 18%. Rectal displacement method was SpaceOAR in 59% and Rectafix in 41%. Forty-two and ninety-three patients were treated at the 19 Gy and 20 Gy dose levels, respectively. Median follow-up was 24 months. Acute grade 2 gastrointestinal (GI) and urinary toxicity occurred in 4.4 and 26.6% with no acute grade 3 toxicity. At 6, 12, 18, 24, and 36 months post-treatment the prevalence of late grade ≥2 gastrointestinal toxicity was 1.6, 3.7, 2.2, 0, and 0%, respectively, and the prevalence of late grade ≥2 urinary toxicity was 0.8, 11, 12, 7.1, and 6.3%, respectively. Three patients experienced grade 3 late toxicity at 12 to 18 months which subsequently resolved to grade 2 or less. For patients not receiving ADT the median PSA value pre-treatment was 7.6 ug/L (1.1–20) and at 12, 24, and 36 months post-treatment was 0.86, 0.36, and 0.20 ug/L. Conclusions: Delivery of a gantry-based SBRT boost is feasible in a multicenter setting, is well-tolerated with low rates of early toxicity and is associated with promising PSA responses. A second transient peak in urinary toxicity was observed at 18 months which subsequently resolved. Follow-up is ongoing to document late toxicity, long-term patient reported outcomes, and tumor control with this approach.
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Affiliation(s)
- David Pryor
- Princess Alexandra Hospital, Brisbane, QLD, Australia.,Queensland University of Technology, Brisbane, QLD, Australia
| | - Mark Sidhom
- Liverpool and Macarthur Cancer Therapy Centres, Sydney, NSW, Australia.,University of New South Wales, Sydney, NSW, Australia
| | - Sankar Arumugam
- Liverpool and Macarthur Cancer Therapy Centres, Sydney, NSW, Australia.,University of New South Wales, Sydney, NSW, Australia.,Ingham Institute, Sydney, NSW, Australia
| | - Joseph Bucci
- University of New South Wales, Sydney, NSW, Australia.,St George Hospital, Cancer Care Centre, Sydney, NSW, Australia
| | - Sarah Gallagher
- Department of Radiation Oncology, Calvary Mater Newcastle Hospital, Newcastle, NSW, Australia
| | - Joanne Smart
- Department of Radiation Oncology, Calvary Mater Newcastle Hospital, Newcastle, NSW, Australia
| | - Melissa Grand
- Liverpool and Macarthur Cancer Therapy Centres, Sydney, NSW, Australia.,Ingham Institute, Sydney, NSW, Australia
| | - Peter Greer
- Department of Radiation Oncology, Calvary Mater Newcastle Hospital, Newcastle, NSW, Australia.,University of Newcastle, Newcastle, NSW, Australia
| | - Sarah Keats
- Liverpool and Macarthur Cancer Therapy Centres, Sydney, NSW, Australia
| | - Lee Wilton
- Department of Radiation Oncology, Calvary Mater Newcastle Hospital, Newcastle, NSW, Australia
| | - Jarad Martin
- Department of Radiation Oncology, Calvary Mater Newcastle Hospital, Newcastle, NSW, Australia.,University of Newcastle, Newcastle, NSW, Australia
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