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Ozyigit G, Kahvecioglu A, Cengiz M, Yedekci FY, Hurmuz P. The effect of incidental dose to pelvic nodes in bladder-only irradiation in the era of IMRT: a dosimetric study. Strahlenther Onkol 2024:10.1007/s00066-024-02246-2. [PMID: 38888741 DOI: 10.1007/s00066-024-02246-2] [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: 02/02/2024] [Accepted: 05/05/2024] [Indexed: 06/20/2024]
Abstract
PURPOSE While three-dimensional radiotherapy (RT) causes high incidental nodal doses in bladder-only irradiation for muscle-invasive bladder cancer (MIBC), the impact on pelvic lymphatics is unclear in the era of intensity-modulated RT (IMRT). This study evaluates incidental doses to pelvic lymphatics in MIBC patients treated with IMRT. METHODS The data of 40 MIBC patients treated with bladder-only IMRT and concurrent chemotherapy were retrospectively evaluated. The pelvic lymphatics were contoured on initial simulation images and incidental nodal doses were evaluated. The Statistical Package for the Social Sciences (SPSS) version 23.0 (IBM, Armonk, NY, USA) was used for statistics. RESULTS Median RT dose to the bladder was 60 Gy in 30 fractions. In dosimetric analysis, median values of mean dose (Dmean) of the obturator, presacral, external iliac, internal iliac, and distal common iliac lymphatics were 33 Gy (range 4-50 Gy), 3 Gy (range 1-28 Gy), 9.5 Gy (range 3-41 Gy), 7.5 Gy (range 2-14 Gy), and 1 Gy (range 0-15 Gy), respectively. The Dmean of the obturator lymphatics was significantly higher (p < 0.001) and the Dmean of the distal common iliac lymphatics was significantly lower (p < 0.001) than all remaining lymphatic stations. The Dmean of the external iliac lymphatics was significantly higher than that of the presacral lymphatics (p < 0.001), but the difference with the internal iliac lymphatics was not statistically significant (p = 0.563). CONCLUSION The incidental nodal doses with bladder-only IMRT are heterogeneous and remain below the generally accepted doses for microscopic disease eradication for bladder cancer.
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Affiliation(s)
- Gokhan Ozyigit
- Faculty of Medicine, Department of Radiation Oncology, Hacettepe University, Ankara, Turkey.
- Oncology Institute, Department of Radiation Oncology, Hacettepe University, 06100, Sıhhiye-Ankara, Turkey.
| | - Alper Kahvecioglu
- Faculty of Medicine, Department of Radiation Oncology, Hacettepe University, Ankara, Turkey
| | - Mustafa Cengiz
- Faculty of Medicine, Department of Radiation Oncology, Hacettepe University, Ankara, Turkey
| | - Fazli Yagiz Yedekci
- Faculty of Medicine, Department of Radiation Oncology, Hacettepe University, Ankara, Turkey
| | - Pervin Hurmuz
- Faculty of Medicine, Department of Radiation Oncology, Hacettepe University, Ankara, Turkey
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Riveros C, Ranganathan S, Haque W, Huang E, Xu J, Kulkarni GS, Geng M, Anis M, Muhammad T, Chan KS, Farach A, Teh BS, Miles BJ, Klaassen Z, Sonpavde GP, Wallis CJ, Satkunasivam R. Comparative real-world survival outcomes of muscle-invasive bladder cancer treated with bladder-only vs. whole-pelvis concurrent chemoradiation. Can Urol Assoc J 2024; 18:17-24. [PMID: 37931278 PMCID: PMC10841558 DOI: 10.5489/cuaj.8386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2023]
Abstract
INTRODUCTION Elective pelvic nodal irradiation for patients with muscle-invasive bladder cancer (MIBC) undergoing trimodal therapy (TMT ) is controversial. In patients with node-negative (N0) MIBC, the benefit of elective whole-pelvis concurrent chemoradiation (WP-CCR) compared to bladder-only (BO )-CCR has not been demonstrated. Using real-world data from the National Cancer Database (NCDB ), we sought to compare the overall survival (OS ) between BO-CCR and WP-CCR for MIBC. METHODS Using the 2020 NCDB Participant User File, we identified cases of MIBC diagnosed between 2017 and 2019. We selected patients with clinical T2-T4aN0M0 disease receiving CCR as first-line treatment. CCR was defined as transurethral resection of bladder tumor followed by ≥40 Gy radiation to the bladder with concurrent single- or multiple-agent chemotherapy. Based on elective nodal irradiation status, patients were stratified as having received BO-CCR vs. WP-CCR. OS analysis was performed using summary three-month conditional landmark, inverse probability treatment weighting (IPTW)-adjusted Kaplan-Meier estimates, and Cox regression. RESULTS A total of 604 patients receiving CCR for MIBC were identified: 367 (60.8%) BO-CCR and 237 (39.2%) WP-CCR. Before IPTW, the groups were imbalanced in terms of baseline characteristics. The median followup of the weighted population was 42.3 months (interquartile range 18.1-49.1 months). In IPTW-adjusted Cox proportional hazards regression analysis, WP-CCR was associated with a significant OS benefit compared to BO-CCR (adjusted hazard ratio 0.72, 95% confidence interval 0.54-0.96, p=0.026). CONCLUSIONS In the setting of CCR for N0 MIBC, this retrospective NCDB analysis revealed that WP-CCR was associated with a benefit in OS compared to BO-CCR.
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Affiliation(s)
- Carlos Riveros
- Department of Urology, Houston Methodist Hospital, Houston, TX, United States
| | - Sanjana Ranganathan
- Department of Urology, Houston Methodist Hospital, Houston, TX, United States
| | - Waqar Haque
- Department of Radiation Oncology, Houston Methodist Hospital, Houston, TX, United States
| | - Emily Huang
- Department of Urology, Houston Methodist Hospital, Houston, TX, United States
| | - Jiaqiong Xu
- Center for Health Data Science and Analytics, Houston Methodist Hospital, Houston, TX, United States
| | - Girish S. Kulkarni
- Division of Urology and Surgical Oncology, Department of Surgery, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, ON, Canada
- Division of Urology, University of Toronto, Toronto, ON, Canada
| | - Michael Geng
- School of Engineering Medicine, Texas A&M University, Houston, TX, United States
| | - Maryam Anis
- Department of Urology, Houston Methodist Hospital, Houston, TX, United States
| | - Taliah Muhammad
- Department of Urology, Houston Methodist Hospital, Houston, TX, United States
| | - Keith Syson Chan
- Department of Urology, Houston Methodist Hospital, Houston, TX, United States
- Center for TME Spatial Profiling in GU Oncology, Houston Methodist Research Institute, Houston, TX, United States
| | - Andrew Farach
- Department of Radiation Oncology, Houston Methodist Hospital, Houston, TX, United States
| | - Bin S. Teh
- Department of Radiation Oncology, Houston Methodist Hospital, Houston, TX, United States
| | - Brian J. Miles
- Department of Urology, Houston Methodist Hospital, Houston, TX, United States
| | - Zachary Klaassen
- Division of Urology, Medical College of Georgia, Augusta University, Augusta, GA, United States
| | - Guru P. Sonpavde
- Genitourinary Oncology Program, AdventHealth Cancer Institute, Orlando, FL, United States
| | - Christopher J.D. Wallis
- Division of Urology and Surgical Oncology, Department of Surgery, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, ON, Canada
- Division of Urology, University of Toronto, Toronto, ON, Canada
- Division of Urology, Mount Sinai Hospital, Toronto, ON, Canada
| | - Raj Satkunasivam
- Department of Urology, Houston Methodist Hospital, Houston, TX, United States
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De Hertogh O. [Bladder preservation treatments for bladder cancer: Trimodality therapy, an overview of clinical practices in 2023]. Cancer Radiother 2023; 27:562-567. [PMID: 37481342 DOI: 10.1016/j.canrad.2023.06.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 06/08/2023] [Accepted: 06/09/2023] [Indexed: 07/24/2023]
Abstract
Bladder cancer is the most frequent tumor of the urinary tract. Patients diagnosed at a stage when the tumor has spread into or through the muscle layer of the bladder wall are usually treated with cystectomy. The evolution of cancer treatments, related to the development of alternative treatment options to the historical surgical standard and to the implication of the patient as an actor in decision-making, trends towards organ and function preservation without sacrificing efficacy. Trimodality therapy, which is a maximal transurethral resection of the tumor followed by concurrent chemoradiation, is an interesting therapeutic alternative for patients unfit for surgery and for those wishing to benefit from organ preservation. Radiotherapy offers excellent treatment possibilities for muscle-invasive bladder cancer. In selected T2-stage patients fit for trimodality therapy, it has an equivalent oncological outcome compared to cystectomy while having less severe complications and offering organ preservation. It remains feasible in inoperable patients while offering significant perspectives of relapse-free survival. Finally, it also is an efficient palliative treatment in patients where mid-term local control and hemostasis are sought after.
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Affiliation(s)
- O De Hertogh
- Radiation oncology department, CHR Verviers East Belgium, 29, rue du Parc, 4800 Verviers, Belgique.
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de Ruiter BM, van de Kamp MW, van Steenbergen JP, Franckena M, Boormans JL, de Feijter JM, Bins AD, Hulshof MC, de Reijke TM, Schaake E, Oddens JR. A Multicenter Retrospective Cohort Series of Muscle-invasive Bladder Cancer Patients Treated with Definitive Concurrent Chemoradiotherapy in Daily Practice. EUR UROL SUPPL 2022; 39:7-13. [PMID: 35528785 PMCID: PMC9068732 DOI: 10.1016/j.euros.2022.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/22/2022] [Indexed: 11/06/2022] Open
Abstract
Background Concurrent chemoradiotherapy (CRT) as a definitive treatment option for patients with nonmetastatic muscle-invasive bladder carcinoma (MIBC) is increasingly being applied in clinical practice. Objective To assess the oncological and toxicity outcomes in a contemporary cohort of nonmetastatic MIBC patients treated with concurrent CRT in daily practice. Design, setting, and participants Patients with nonmetastatic MIBC (cT2-4aN0M0) who had received CRT with curative intent between January 2010 and April 2020 in three centers were retrospectively identified. The CRT consisted of 66 Gy (or biologically equivalent) plus either mitomycin C and fluorouracil/capecitabine or cisplatinum. Outcome measurements and statistical analysis The primary endpoint was the 2-yr locoregional disease-free survival (LDFS) estimate. Secondary endpoints were complete response, disease-specific survival (DSS), overall survival (OS), bladder intact event-free survival (BI-EFS), and severe adverse events (<90 d of starting CRT). Kaplan-Meier survival and Cox multivariable regression analyses were performed. Results and limitations We included data of 240 MIBC patients with a median age of 74 yr and a median follow-up of 27 mo (interquartile range 11–44). Complete response on first cystoscopy after CRT was seen in 209 cases (90%). The 2-yr LDFS was 76% (95% confidence interval [CI] 70–82%); the 5-yr OS and DSS were 50% (95% CI 42–59%) and 70% (95% CI 62–79%), respectively. On multivariable analysis, cT2 versus cT3–4 tumor stage was significantly associated with better DSS (hazard ratio 1.02, 95% CI 1–1.05, p = 0.024). The 2-yr BI-EFS was 75% (95% CI 69–82%). Forty-three (17%) patients experienced a severe adverse event (grade ≥3). Limitations include retrospective design and heterogeneous administration of CRT. Conclusions Concurrent CRT is a safe and effective treatment modality for nonmetastatic MIBC. Patient summary Chemoradiotherapy for the treatment of muscle-invasive bladder carcinoma is increasingly being applied. In this study, we reviewed the outcomes of this bladder-sparing treatment using a series of patients treated in three hospitals in daily practice. We found that administration of chemoradiotherapy can be safe and effective.
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Bladder-Sparing Chemoradiotherapy Combined with Immune Checkpoint Inhibition for Locally Advanced Urothelial Bladder Cancer-A Review. Cancers (Basel) 2021; 14:cancers14010038. [PMID: 35008202 PMCID: PMC8750609 DOI: 10.3390/cancers14010038] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Revised: 12/17/2021] [Accepted: 12/20/2021] [Indexed: 01/22/2023] Open
Abstract
Simple Summary Immunotherapy with immune checkpoint inhibition (ICI) has provided durable treatment responses in advanced, metastatic, bladder cancer patients. The first trials using checkpoint inhibitors before surgery, when the cancer is still confined to the pelvis, without signs of metastasis, have reported promising results. We reviewed the literature to identify clinical trials combining ICI with bladder-sparing chemoradiotherapy (CRT). Radiotherapy stimulates the immune system, thereby possibly inducing an additive effect in combination with checkpoint inhibition. Currently, twelve trials are treating patients with this immunochemoradiotherapy (iCRT) combination treatment. Several combinations with different chemotherapeutics and ICI added to CRT appear safe and feasible. Further research and comparative trials are needed to prove whether iCRT has additional clinical value for bladder cancer patients. Abstract Despite current treatment strategies, the 5-year overall survival of muscle-invasive bladder cancer (MIBC) is approximately 50%. Historically, radical cystectomy (RC) with neoadjuvant chemotherapy has been the first-choice treatment for this patient group. Recently, several studies have reported encouraging results of using immune checkpoint inhibitors (ICI) prior to RC. However, in recent years, bladder-sparing alternatives such as CRT have gained popularity. The effect of radiotherapy on the tumor microenvironment is an important rationale for combining CRT with ICI therapy. Worldwide, twelve immunochemoradiotherapy (iCRT) trials are ongoing. Each study employs a different chemotherapy and radiotherapy regimen and varies the timing of ICI administration concurrent to radiotherapy, adjuvant, or both. Five studies have presented (preliminary) results showing promising safety and short-term survival data. The first peer-reviewed publications are expected in the near future. The preclinical evidence and preliminary patient data demonstrate the potential of iCRT bladder-sparing treatment for bladder cancer.
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Portner R, Bajaj A, Elumalai T, Huddart R, Murthy V, Nightingale H, Patel K, Sargos P, Song Y, Hoskin P, Choudhury A. A practical approach to bladder preservation with hypofractionated radiotherapy for localised muscle-invasive bladder cancer. Clin Transl Radiat Oncol 2021; 31:1-7. [PMID: 34466667 PMCID: PMC8385113 DOI: 10.1016/j.ctro.2021.08.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 07/27/2021] [Accepted: 08/03/2021] [Indexed: 02/06/2023] Open
Abstract
Bladder preservation with trimodality treatment (TMT) is an alternative strategy to radical cystectomy (RC) for the management of localised muscle invasive bladder cancer (MIBC). TMT comprises of transurethral resection of the bladder tumour (TURBT) followed by radiotherapy with concurrent radiosensitisation. TMT studies have shown neo-adjuvant chemotherapy with cisplatin-based regimens is often given to further improve survival outcomes. A hypofractionated radiotherapy regimen is preferable due to its non-inferiority in local control and late toxicities. Radiosensitisation can comprise concurrent chemotherapy (with gemcitabine, cisplatin or combination fluorouracil and mitomycin), CON (carbogen and nicotinomide) or hyperthermic treatment. Radiotherapy techniques are continuously improving and becoming more personalised. As the bladder is a mobile structure subject to volumetric changes from filling, an adaptive approach can optimise bladder coverage and reduce dose to normal tissue. Adaptive radiotherapy (ART) is an evolving field that aims to overcome this. Improved knowledge of tumour biology and advances in imaging techniques aims to further optimise and personalise treatment.
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Affiliation(s)
- R. Portner
- The Christie NHS Foundation Trust, Manchester, UK
| | - A. Bajaj
- Department of Radiation Oncology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Feinberg School of Medicine, Chicago, IL, USA
| | - T. Elumalai
- The Christie NHS Foundation Trust, Manchester, UK
| | - R. Huddart
- Royal Marsden NHS Foundation Trust, London, UK
- Institute of Cancer Research, UK
| | - V. Murthy
- Department of Radiation Oncology, ACTREC and Tata Memorial Hospital, Homi Bhabha National University, Mumbai, India
| | | | - K. Patel
- The Christie NHS Foundation Trust, Manchester, UK
| | - P. Sargos
- Department of Radiation Oncology, Institut Bergonié, F-33076 Bordeaux Cedex, France
| | - Y. Song
- The Christie NHS Foundation Trust, Manchester, UK
| | - P. Hoskin
- Mount Vernon Cancer Centre, Northwood, UK
- Division of Cancer Sciences, University of Manchester, Manchester, UK
| | - A. Choudhury
- The Christie NHS Foundation Trust, Manchester, UK
- Division of Cancer Sciences, University of Manchester, Manchester, UK
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Tholomier C, Souhami L, Kassouf W. Bladder-sparing protocols in the treatment of muscle-invasive bladder cancer. Transl Androl Urol 2020; 9:2920-2937. [PMID: 33457265 PMCID: PMC7807363 DOI: 10.21037/tau.2020.02.10] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2019] [Accepted: 11/29/2019] [Indexed: 01/06/2023] Open
Abstract
Bladder-sparing protocols (BSP) have been gaining widespread popularity as an attractive alternative to radical cystectomy (RC) for muscle-invasive bladder cancer. Unimodal therapies are inferior to multimodal regimens. The most promising regimen is trimodal therapy (TMT), which is a combination of maximal transurethral resection of bladder tumor (TURBT), radiotherapy, and chemotherapy. In appropriately selected patients (low volume unifocal T2 disease, complete TURBT, no hydronephrosis and no carcinoma-in-situ), comparable oncological outcomes to RC have been reported in large retrospective studies, with a potential improvement in overall quality of life (QOL). TMT also offers the possibility for definitive therapy for patients who are not surgically fit to undergo RC. Routine biopsy of previous tumor resection is recommended to assess response. Prompt salvage RC is required in non-responders and for recurrent muscle-invasive disease, while non-muscle-invasive recurrence can be managed conservatively with TURBT +/- intravesical BCG. Long-term follow-up consisting of routine cystoscopy, urine cytology, and cross-section imaging is required. Further studies are warranted to better define the role of neoadjuvant or adjuvant chemotherapy in the setting of TMT. Finally, future research on predictive markers of response to TMT and on the integration of immunotherapy in bladder sparing protocols is ongoing and is highly promising.
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Affiliation(s)
- Côme Tholomier
- Department of Surgery, Division of Urology, McGill University, McGill University Health Centre, Montréal, Québec, Canada
| | - Luis Souhami
- Department of Radiation Oncology, McGill University, McGill University Health Centre, Montréal, Québec, Canada
| | - Wassim Kassouf
- Department of Surgery, Division of Urology, McGill University, McGill University Health Centre, Montréal, Québec, Canada
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8
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Cardoso M, Choudhury A, Christie D, Eade T, Foroudi F, Hayden A, Holt T, Kneebone A, Sasso G, Shakespeare TP, Sidhom M. FROGG patterns of practice survey and consensus recommendations on radiation therapy for MIBC. J Med Imaging Radiat Oncol 2020; 64:882-893. [DOI: 10.1111/1754-9485.13120] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 09/17/2020] [Accepted: 09/29/2020] [Indexed: 12/29/2022]
Affiliation(s)
- Michael Cardoso
- Cancer Therapy Centre Liverpool Hospital New South Wales Australia
- Centre for Medical Radiation Physics University of Wollongong Wollongong New South Wales Australia
- South Western Sydney Clinical School University of New South Wales New South Wales Australia
| | - Ananya Choudhury
- Division of Cancer Sciences University of Manchester Manchester UK
- The Christie NHS Foundation Trust Manchester UK
| | - David Christie
- Genesis Cancer Care Queensland Australia
- Department of Health Sciences and Medicine Bond University Gold Coast Queensland Australia
| | - Thomas Eade
- Northern Sydney Cancer CentreRoyal North Shore Hospital New South Wales Australia
- Northern Medical School University of Sydney Sydney New South Wales Australia
| | - Farshad Foroudi
- Department of Radiation Oncology Newton‐John Cancer Wellness and Research CentreAustin Health Heidelberg Victoria Australia
- Latrobe University Melbourne Victoria Australia
| | - Amy Hayden
- Sydney West Radiation Oncology Westmead Hospital Sydney New South Wales Australia
| | - Tanya Holt
- Princess Alexandra Hospital‐ROPART Brisbane Queensland Australia
- University of Queensland Queensland Australia
| | - Andrew Kneebone
- Northern Sydney Cancer CentreRoyal North Shore Hospital New South Wales Australia
- Northern Medical School University of Sydney Sydney New South Wales Australia
- Central Coast Cancer Centre Gosford Hospital Gosford New South Wales Australia
- Genesis Cancer Care New South Wales Australia
| | - Giuseppe Sasso
- Radiation Oncology Department Auckland District Health Board Auckland New Zealand
- Faculty of Medical and Health Sciences University of Auckland Auckland New Zealand
| | - Thomas P. Shakespeare
- Department of Radiation Oncology Mid North Coast Cancer Institute Coffs Harbour New South Wales Australia
- University of New South Wales Rural Clinical School Coffs Harbour Australia
| | - Mark Sidhom
- Cancer Therapy Centre Liverpool Hospital New South Wales Australia
- South Western Sydney Clinical School University of New South Wales New South Wales Australia
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Murali-Krishnan S, Pang KH, Greco F, Fiori C, Catto JW, Vavassori VL, Esperto F. Bladder-sparing treatment in MIBC: where do we stand? MINERVA UROL NEFROL 2019; 71:101-112. [DOI: 10.23736/s0393-2249.19.03317-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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10
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Lawrie TA, Green JT, Beresford M, Wedlake L, Burden S, Davidson SE, Lal S, Henson CC, Andreyev HJN. Interventions to reduce acute and late adverse gastrointestinal effects of pelvic radiotherapy for primary pelvic cancers. Cochrane Database Syst Rev 2018; 1:CD012529. [PMID: 29360138 PMCID: PMC6491191 DOI: 10.1002/14651858.cd012529.pub2] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND An increasing number of people survive cancer but a significant proportion have gastrointestinal side effects as a result of radiotherapy (RT), which impairs their quality of life (QoL). OBJECTIVES To determine which prophylactic interventions reduce the incidence, severity or both of adverse gastrointestinal effects among adults receiving radiotherapy to treat primary pelvic cancers. SEARCH METHODS We conducted searches of CENTRAL, MEDLINE, and Embase in September 2016 and updated them on 2 November 2017. We also searched clinical trial registries. SELECTION CRITERIA We included randomised controlled trials (RCTs) of interventions to prevent adverse gastrointestinal effects of pelvic radiotherapy among adults receiving radiotherapy to treat primary pelvic cancers, including radiotherapy techniques, other aspects of radiotherapy delivery, pharmacological interventions and non-pharmacological interventions. Studies needed a sample size of 20 or more participants and needed to evaluate gastrointestinal toxicity outcomes. We excluded studies that evaluated dosimetric parameters only. We also excluded trials of interventions to treat acute gastrointestinal symptoms, trials of altered fractionation and dose escalation schedules, and trials of pre- versus postoperative radiotherapy regimens, to restrict the vast scope of the review. DATA COLLECTION AND ANALYSIS We used standard Cochrane methodology. We used the random-effects statistical model for all meta-analyses, and the GRADE system to rate the certainty of the evidence. MAIN RESULTS We included 92 RCTs involving more than 10,000 men and women undergoing pelvic radiotherapy. Trials involved 44 different interventions, including radiotherapy techniques (11 trials, 4 interventions/comparisons), other aspects of radiotherapy delivery (14 trials, 10 interventions), pharmacological interventions (38 trials, 16 interventions), and non-pharmacological interventions (29 trials, 13 interventions). Most studies (79/92) had design limitations. Thirteen studies had a low risk of bias, 50 studies had an unclear risk of bias and 29 studies had a high risk of bias. Main findings include the following:Radiotherapy techniques: Intensity-modulated radiotherapy (IMRT) versus 3D conformal RT (3DCRT) may reduce acute (risk ratio (RR) 0.48, 95% confidence interval (CI) 0.26 to 0.88; participants = 444; studies = 4; I2 = 77%; low-certainty evidence) and late gastrointestinal (GI) toxicity grade 2+ (RR 0.37, 95% CI 0.21 to 0.65; participants = 332; studies = 2; I2 = 0%; low-certainty evidence). Conformal RT (3DCRT or IMRT) versus conventional RT reduces acute GI toxicity grade 2+ (RR 0.57, 95% CI 0.40 to 0.82; participants = 307; studies = 2; I2 = 0%; high-certainty evidence) and probably leads to less late GI toxicity grade 2+ (RR 0.49, 95% CI 0.22 to 1.09; participants = 517; studies = 3; I2 = 44%; moderate-certainty evidence). When brachytherapy (BT) is used instead of external beam radiotherapy (EBRT) in early endometrial cancer, evidence indicates that it reduces acute GI toxicity (grade 2+) (RR 0.02, 95% CI 0.00 to 0.18; participants = 423; studies = 1; high-certainty evidence).Other aspects of radiotherapy delivery: There is probably little or no difference in acute GI toxicity grade 2+ with reduced radiation dose volume (RR 1.21, 95% CI 0.81 to 1.81; participants = 211; studies = 1; moderate-certainty evidence) and maybe no difference in late GI toxicity grade 2+ (RR 1.02, 95% CI 0.15 to 6.97; participants = 107; studies = 1; low-certainty evidence). Evening delivery of RT may reduce acute GI toxicity (diarrhoea) grade 2+ during RT compared with morning delivery of RT (RR 0.51, 95% CI 0.34 to 0.76; participants = 294; studies = 2; I2 = 0%; low-certainty evidence). There may be no difference in acute (RR 2.22, 95% CI 0.62 to 7.93, participants = 110; studies = 1) and late GI toxicity grade 2+ (RR 0.44, 95% CI 0.12 to 1.65; participants = 81; studies = 1) between a bladder volume preparation of 1080 mls and that of 540 mls (low-certainty evidence). Low-certainty evidence on balloon and hydrogel spacers suggests that these interventions for prostate cancer RT may make little or no difference to GI outcomes.Pharmacological interventions: Evidence for any beneficial effects of aminosalicylates, sucralfate, amifostine, corticosteroid enemas, bile acid sequestrants, famotidine and selenium is of a low or very low certainty. However, evidence on certain aminosalicylates (mesalazine, olsalazine), misoprostol suppositories, oral magnesium oxide and octreotide injections suggests that these agents may worsen GI symptoms, such as diarrhoea or rectal bleeding.Non-pharmacological interventions: Low-certainty evidence suggests that protein supplements (RR 0.23, 95% CI 0.07 to 0.74; participants = 74; studies = 1), dietary counselling (RR 0.04, 95% CI 0.00 to 0.60; participants = 74; studies = 1) and probiotics (RR 0.43, 95% CI 0.22 to 0.82; participants = 923; studies = 5; I2 = 91%) may reduce acute RT-related diarrhoea (grade 2+). Dietary counselling may also reduce diarrhoeal symptoms in the long term (at five years, RR 0.05, 95% CI 0.00 to 0.78; participants = 61; studies = 1). Low-certainty evidence from one study (108 participants) suggests that a high-fibre diet may have a beneficial effect on GI symptoms (mean difference (MD) 6.10, 95% CI 1.71 to 10.49) and quality of life (MD 20.50, 95% CI 9.97 to 31.03) at one year. High-certainty evidence indicates that glutamine supplements do not prevent RT-induced diarrhoea. Evidence on various other non-pharmacological interventions, such as green tea tablets, is lacking.Quality of life was rarely and inconsistently reported across included studies, and the available data were seldom adequate for meta-analysis. AUTHORS' CONCLUSIONS Conformal radiotherapy techniques are an improvement on older radiotherapy techniques. IMRT may be better than 3DCRT in terms of GI toxicity, but the evidence to support this is uncertain. There is no high-quality evidence to support the use of any other prophylactic intervention evaluated. However, evidence on some potential interventions shows that they probably have no role to play in reducing RT-related GI toxicity. More RCTs are needed for interventions with limited evidence suggesting potential benefits.
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Affiliation(s)
- Theresa A Lawrie
- Cochrane Gynaecological, Neuro-oncology and Orphan Cancer Group, 1st Floor Education Centre, Royal United Hospital, Combe Park, Bath, UK, BA1 3NG
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