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Bittner NHJ, Cox BW, Davis B, King M, Lawton CAF, Merrick GS, Orio P, Ouhib Z, Rossi P, Showalter T, Small W, Schechter NR. ACR-ABS-ASTRO Practice Parameter for Transperineal Permanent Brachytherapy of Prostate Cancer. Am J Clin Oncol 2022; 45:249-257. [PMID: 35588224 DOI: 10.1097/coc.0000000000000915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
AIM/OBJECTIVES/BACKGROUND The American College of Radiology (ACR), American Brachytherapy Society (ABS), and American Society for Radiation Oncology (ASTRO) have jointly developed the following practice parameter for transperineal permanent brachytherapy of prostate cancer. Transperineal permanent brachytherapy of prostate cancer is the interstitial implantation of low-dose rate radioactive seeds into the prostate gland for the purpose of treating localized prostate cancer. METHODS This practice parameter was developed according to the process described under the heading The Process for Developing ACR Practice Parameters and Technical Standards on the ACR website (https://www.acr.org/Clinical-Resources/Practice-Parameters-and-Technical-Standards) by the Committee on Practice Parameters-Radiation Oncology of the Commission on Radiation Oncology, in collaboration with ABS and ASTRO. RESULTS This practice parameter provides a framework for the appropriate use of low-dose rate brachytherapy in the treatment of prostate cancer either as monotherapy or as part of a treatment regimen combined with external-beam radiation therapy. The practice parameter defines the qualifications and responsibilities of all involved radiation oncology personnel, including the radiation oncologist, medical physicist, dosimetrist, radiation therapist, and nursing staff. Patient selection criteria and the utilization of supplemental therapies such as external-beam radiation therapy and androgen deprivation therapy are discussed. The logistics of the implant procedure, postimplant dosimetry assessment, and best practices with regard to safety and quality control are presented. CONCLUSIONS Adherence to established standards can help to ensure that permanent prostate brachytherapy is delivered in a safe and efficacious manner.
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Affiliation(s)
| | | | | | - Martin King
- Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, MA
| | | | | | - Peter Orio
- Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, MA
| | - Zoubir Ouhib
- Boca Raton Regional Hospital, Lynn Cancer Institute, Boca Raton, FL
| | | | | | - William Small
- Keck Medical Center of USC, Norris Comprehensive Cancer, Center, University of Southern California, Los Angeles, CA
| | - Naomi R Schechter
- Keck Medical Center of USC, Norris Comprehensive Cancer, Center, University of Southern California, Los Angeles, CA
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Merrick GS. The narrow door of success. Brachytherapy 2020; 19:1-5. [DOI: 10.1016/j.brachy.2019.09.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Revised: 08/22/2019] [Accepted: 09/08/2019] [Indexed: 01/08/2023]
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Hagar Y, Dignam JJ, Dukic V. Flexible modeling of the hazard rate and treatment effects in long-term survival studies. Stat Methods Med Res 2017; 26:2455-2480. [PMID: 28150523 PMCID: PMC5651995 DOI: 10.1177/0962280216688034] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
The effects of predictors on time to failure may be difficult to assess in cancer studies with longer follow-up, as the commonly used assumption of proportionality of hazards holding over an extended period is often questionable. Motivated by a long-term prostate cancer clinical trial, we contrast and compare four powerful methods for estimation of the hazard rate. These four methods allow for varying degrees of smoothness as well as covariates with effects that vary over time. We pay particular attention to an extended multiresolution hazard estimator, which is a flexible, semi-parametric, Bayesian method for joint estimation of predictor effects and the hazard rate. We compare the results of the extended multiresolution hazard model to three other commonly used, comparable models: Aalen's additive model, Kooperberg's hazard regression model, and an extended Cox model. Through simulations and the analysis of a large-scale randomized prostate cancer clinical trial, we use the different methods to examine patterns of biochemical failure and to estimate the time-varying effects of androgen deprivation therapy treatment and other covariates.
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Affiliation(s)
- Yolanda Hagar
- Department of Applied Mathematics, University of Colorado, CO, USA
| | - James J Dignam
- Department of Public Health Sciences, University of Chicago, IL, USA
| | - Vanja Dukic
- Department of Applied Mathematics, University of Colorado, CO, USA
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Biochemical control and toxicity for favorable- and intermediate-risk patients using real-time intraoperative inverse optimization prostate seed implant: Less is more! Brachytherapy 2017; 16:490-496. [DOI: 10.1016/j.brachy.2016.12.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Revised: 12/30/2016] [Accepted: 12/30/2016] [Indexed: 01/19/2023]
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The American College of Radiology and the American Brachytherapy Society practice parameter for transperineal permanent brachytherapy of prostate cancer. Brachytherapy 2017; 16:59-67. [DOI: 10.1016/j.brachy.2016.06.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Accepted: 06/02/2016] [Indexed: 01/04/2023]
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Focal prostate brachytherapy with 103 Pd seeds. Phys Med 2016; 32:459-64. [DOI: 10.1016/j.ejmp.2016.03.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Revised: 03/07/2016] [Accepted: 03/14/2016] [Indexed: 12/27/2022] Open
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Stratification of brachytherapy-treated intermediate-risk prostate cancer patients into favorable and unfavorable cohorts. J Contemp Brachytherapy 2015; 7:430-6. [PMID: 26816337 PMCID: PMC4716130 DOI: 10.5114/jcb.2015.56763] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2015] [Accepted: 12/18/2015] [Indexed: 01/11/2023] Open
Abstract
Purpose To evaluate biochemical failure (BF) and prostate cancer specific mortality (PCSM) in intermediate-risk (IR) brachytherapy patients stratified into favorable and unfavorable cohorts, and to compare those outcomes to patients with low (LR) and high-risk (HR) disease. Material and methods From March 1995 till February 2012, 2,502 consecutive patients underwent permanent interstitial brachytherapy for clinically localized prostate cancer. Patients were stratified into risk groups as per the NCCN guidelines with further stratification of the intermediate risk cohort into unfavorable (primary Gleason pattern 4, ≥ 50% positive biopsies or ≥ 2 IR features) and favorable cohorts. Median follow-up was 8.5 years. The brachytherapy prescription dose was prescribed to the prostate gland with generous periprostatic margins. Biochemical failure was defined as a PSA > 0.40 ng/ml after nadir. Patients with metastatic prostate cancer or non-metastatic castrate resistant disease who died of any cause were classified as dead of prostate cancer. Multiple parameters were evaluated for effect on outcomes. Results Fifteen year BF for LR, favorable IR, unfavorable IR, and HR were 1.4%, 2.2%, 7.1%, and 11.1% (p < 0.001), respectively. At 15 years, PCSM for LR, favorable IR, unfavorable IR, and HR was 0.3%, 0.6%, 2.2% and 4.6% (p < 0.001), respectively. In multivariate analysis, BF was best predicted by risk group, pre-implant PSA, percent positive biopsies, prostate volume, and ADT duration, while PCSM was most closely related to risk group, percent positive biopsies and prostate volume. Conclusions Patients with favorable IR disease have biochemical and PCSM outcomes comparable to those of patients with LR disease. Although unfavorable IR has greater than a 3-fold increased risk of BF and PCSM when compared to favorable IR, the outcomes remain superior to those men with HR disease.
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Merrick GS, Wallner KE, Galbreath RW, Butler WM, Adamovich E. Is supplemental external beam radiation therapy essential to maximize brachytherapy outcomes in patients with unfavorable intermediate-risk disease? Brachytherapy 2015; 15:79-84. [PMID: 26525214 DOI: 10.1016/j.brachy.2015.09.011] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Revised: 09/21/2015] [Accepted: 09/28/2015] [Indexed: 10/22/2022]
Abstract
PURPOSE To evaluate whether supplemental external beam radiotherapy (EBRT) is essential to maximize Pd-103 brachytherapy outcomes in patients with unfavorable intermediate-risk (IR) disease. METHODS AND MATERIALS A total of 630 patients were assessed from two prospective randomized brachytherapy trials evaluating the role of supplemental EBRT in patients with higher risk features. Patients were stratified into unfavorable IR (primary Gleason pattern 4, ≥50% positive biopsies, or ≥2 IR features), favorable IR, and high-risk (HR) cohorts. Median follow-up was 7.5 years. The brachytherapy prescription dose was prescribed to the prostate gland with generous periprostatic margins. Biochemical failure (BF) was defined as a prostate-specific antigen >0.40 ng/mL after nadir. Patients with metastatic prostate cancer or nonmetastatic castrate-resistant disease who died of any cause were classified as dead of prostate cancer. Multiple parameters were evaluated for effect on outcomes. RESULTS The 10-year BF for favorable IR, unfavorable IR, and HR was 1.7%, 6.6%, and 15.5% (p < 0.001). At 10 years, prostate cancer-specific mortality (PCSM) and overall mortality (OM) were 0% and 20.4%, 2.1% and 23.2%, and 4.3% and 42.4% for favorable IR, unfavorable IR, and HR. Although unfavorable IR patients had a greater incidence of BF, PCSM, and OM when compared with favorable IR, neither the addition nor dose of supplemental EBRT influenced outcome. CONCLUSIONS Outcomes for favorable IR were superior to those with unfavorable IR. Within the confines of this study, neither the addition nor dose of supplemental EBRT influenced BF, PCSM, or OM in patients with IR disease.
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Affiliation(s)
- Gregory S Merrick
- Department of Radiation Oncology, Schiffler Cancer Center, Wheeling Jesuit University, Wheeling, WV; Department of Urology, Wheeling Hospital, Wheeling, WV.
| | - Kent E Wallner
- Department of Radiation Oncology, Puget Sound Healthcare Corporation, Group Health Cooperative, University of Washington, Seattle, WA
| | - Robert W Galbreath
- Department of Radiation Oncology, Schiffler Cancer Center, Wheeling Jesuit University, Wheeling, WV; Ohio Univeristy Eastern, St. Clairsville, OH
| | - Wayne M Butler
- Department of Radiation Oncology, Schiffler Cancer Center, Wheeling Jesuit University, Wheeling, WV
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Merrick GS, Wallner KE, Galbreath RW, Butler WM, Fiano R, Orio PF, Adamovich E. Is supplemental external beam radiation therapy necessary for patients with higher risk prostate cancer treated with 103Pd? Results of two prospective randomized trials. Brachytherapy 2015; 14:677-85. [PMID: 26051802 DOI: 10.1016/j.brachy.2015.05.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Revised: 04/20/2015] [Accepted: 05/04/2015] [Indexed: 12/19/2022]
Abstract
PURPOSE To determine the necessity and/or dose of supplemental external beam radiotherapy (EBRT) in conjunction with palladium-103 ((103)Pd) brachytherapy for high-risk prostate cancer patients. METHODS AND MATERIALS Trial 44/20 randomized patients to 44 Gy plus 90 Gy (103)Pd vs. 20 Gy with 115 Gy (103)Pd, and the subsequent trial randomized patients to the 20 Gy arm vs. 125 Gy (103)Pd without EBRT (20/0 trial). Eligibility criteria included clinically organ-confined disease with Gleason scores 7-9 and/or a pretreatment prostate-specific antigen (PSA) 10-20 ng/mL. The brachytherapy prescription dose was prescribed to the prostate gland with generous periprostatic margins. Biochemical failure (BF) was defined as a PSA >0.40 ng/mL after nadir. Median Day 0 minimum dose covering 90% of the prostate volume (D90) was >121.0% of the prescription dose. Multiple parameters were evaluated for effect on outcomes. RESULTS In 44/20 trial, 13-year BF, prostate cancer-specific mortality (PCSM), and overall mortality (OM) were 8.2%, 4.0%, and 42.8% vs. 8.0%, 1.0%. and 40.3% for the 44 and 20 Gy arms. In 20/0 trial, 8-year BF, PCSM, and OM were 2.1%, 0%, and 14.4% vs. 3.6%, 0%, and 16.1% in the 20 vs. 0 Gy arms. When stratified by either pretreatment PSA or by Gleason score, supplemental EBRT dose did not impact BF, PCSM, or OM. In multivariate analysis, BF was most closely related to percent positive biopsies and prostate volume. In both trials, patients with biochemically controlled disease had a median PSA of <0.02 ng/mL. CONCLUSIONS With high-quality brachytherapy dose distributions, supplemental EBRT did not influence BF or PCSM for patients with intermediate-risk disease. The number of patients with Gleason score 8-9 was too small to determine the role of supplemental EBRT in that cohort.
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Affiliation(s)
- Gregory S Merrick
- Schiffler Cancer Center, Department of Radiation Oncology, Wheeling Jesuit University, Wheeling, WV; Department of Urology, Wheeling Hospital, Wheeling, WV.
| | - Kent E Wallner
- Puget Sound Health Care System, Department of Radiation Oncology, Seattle, WA
| | - Robert W Galbreath
- Schiffler Cancer Center, Department of Radiation Oncology, Wheeling Jesuit University, Wheeling, WV; Ohio University Eastern, St. Clairsville, OH
| | - Wayne M Butler
- Schiffler Cancer Center, Department of Radiation Oncology, Wheeling Jesuit University, Wheeling, WV
| | - Ryan Fiano
- Schiffler Cancer Center, Department of Radiation Oncology, Wheeling Jesuit University, Wheeling, WV
| | - Peter F Orio
- Department of Radiation Oncology, Dana-Farber/Brigham and Women's Hospital, Harvard Medical School, Boston, MA
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Musunuru HB, Cheung P, Loblaw A. Evolution of hypofractionated accelerated radiotherapy for prostate cancer - the sunnybrook experience. Front Oncol 2014; 4:313. [PMID: 25452934 PMCID: PMC4231839 DOI: 10.3389/fonc.2014.00313] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2014] [Accepted: 10/20/2014] [Indexed: 11/13/2022] Open
Abstract
Stereotactic ablative body radiotherapy (SABR) is a newer method of ultra hypo fractionated radiotherapy that uses combination of image-guided radiotherapy (IGRT) and intensity-modulated radiotherapy (IMRT) or volumetric modulated arc therapy (VMAT), to deliver high doses of radiation in a few fractions to a target, at the same time sparing the surrounding organs at risk (OAR). SABR is ideal for treating small volumes of disease and has been introduced in a number of disease sites including brain, lung, liver, spine, and prostate. Given the radiobiological advantages of treating prostate cancer with high doses per fraction, SABR is becoming a standard of care for low and intermediate-risk prostate cancer patients based upon the results from Sunnybrook and also the US-based prostate SABR consortium. This review examines the development of moderate and ultra hypo-fractionation schedules at the Odette Cancer centre, Sunnybrook Health Sciences. Moderate hypo-fractionation protocol was first developed in 2001 for intermediate-risk prostate cancer and from there on different treatment schedules including SABR evolved for all risk groups.
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Affiliation(s)
- Hima Bindu Musunuru
- Odette Cancer Centre, Sunnybrook Health Sciences Centre , Toronto, ON , Canada ; Department of Radiation Oncology, University of Toronto , Toronto, ON , Canada
| | - Patrick Cheung
- Odette Cancer Centre, Sunnybrook Health Sciences Centre , Toronto, ON , Canada ; Department of Radiation Oncology, University of Toronto , Toronto, ON , Canada
| | - Andrew Loblaw
- Odette Cancer Centre, Sunnybrook Health Sciences Centre , Toronto, ON , Canada ; Department of Radiation Oncology, University of Toronto , Toronto, ON , Canada ; Department of Health Policy, Measurement and Evaluation, University of Toronto , Toronto, ON , Canada
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