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Fecteau RE, Koontz BF, Hoffman KE, Halabi S, Howard LE, Anand M, George DJ, Zhang T, Berry WR, Lee WR, Harrison MR, Corn PG, Armstrong AJ. Updated 5-year results for short course abiraterone acetate and LHRH agonist for unfavorable intermediate and favorable high-risk prostate cancer. Prostate Cancer Prostatic Dis 2024:10.1038/s41391-024-00811-5. [PMID: 38388778 DOI: 10.1038/s41391-024-00811-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Revised: 02/06/2024] [Accepted: 02/13/2024] [Indexed: 02/24/2024]
Abstract
Combined androgen deprivation therapy (ADT) and radiotherapy (RT) improves outcomes for intermediate and high-risk prostate cancer. Treatment intensification with abiraterone acetate/prednisone (AAP) provides additional benefit for high-risk disease. We previously reported 3-year outcomes of a single-arm prospective multicenter trial (AbiRT trial) of 33 patients with unfavorable intermediate risk (UIR) and favorable high risk (FHR) prostate cancer undergoing short course, combination therapy with ADT, AAP, and RT. Here we report the final analysis demonstrating a high rate of testosterone recovery (97%) and excellent biochemical progression-free survival (97%) at 5 years. These data support comparative prospective studies of shorter, more potent ADT courses in favorable high-risk prostate cancer.
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Affiliation(s)
- Ryan E Fecteau
- Department of Radiation Oncology, Duke University, Durham, NC, USA
- Duke Cancer Institute, Duke University School of Medicine, Durham, NC, USA
| | - Bridget F Koontz
- East Carolina University Brody School of Medicine, Greenville, NC, USA
| | - Karen E Hoffman
- Department of Genitourinary Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Susan Halabi
- Duke Cancer Institute, Duke University School of Medicine, Durham, NC, USA
| | - Lauren E Howard
- Duke Cancer Institute, Duke University School of Medicine, Durham, NC, USA
| | - Monika Anand
- Duke Cancer Institute, Duke University School of Medicine, Durham, NC, USA
| | - Daniel J George
- Duke Cancer Institute, Duke University School of Medicine, Durham, NC, USA
- Department of Medicine, Division of Medical Oncology, Duke University, Durham, NC, USA
| | - Tian Zhang
- Department of Internal Medicine, Division of Hematology/Oncology, UT Southwestern Medical Center, Dallas, TX, USA
| | - William R Berry
- Duke Cancer Institute, Duke University School of Medicine, Durham, NC, USA
- Department of Medicine, Division of Medical Oncology, Duke University, Durham, NC, USA
| | - W Robert Lee
- Department of Radiation Oncology, Duke University, Durham, NC, USA
| | - Michael R Harrison
- Duke Cancer Institute, Duke University School of Medicine, Durham, NC, USA
- Department of Medicine, Division of Medical Oncology, Duke University, Durham, NC, USA
| | - Paul G Corn
- Department of Genitourinary Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Andrew J Armstrong
- Duke Cancer Institute, Duke University School of Medicine, Durham, NC, USA.
- Department of Medicine, Division of Medical Oncology, Duke University, Durham, NC, USA.
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2
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Pra AD, Lyness J, Pollack A, Tran PT, Koontz BF, Abramowitz MC, Mahal BA, Martin AG, Michalski JM, Balogh A, Lukka H, Faria SL, Rodrigues G, Beauchemin MC, Lee RJ, Seaward SA, Coen SD, Allen AM, Pugh S, Feng FY. Impact of Testosterone Recovery on Clinical Outcomes of Patients Treated with Salvage Radiotherapy and Androgen Suppression: A Secondary Analysis of the NRG/RTOG 0534 Sport Phase 3 Trial. Int J Radiat Oncol Biol Phys 2023; 117:S82-S83. [PMID: 37784585 DOI: 10.1016/j.ijrobp.2023.06.403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) Testosterone (T) kinetics and its relationship with clinical outcomes has not been studied in trials using salvage radiotherapy and androgen deprivation therapy (ADT). We performed a secondary analysis of the NRG Oncology/RTOG 0534 SPPORT trial, which compared prostate bed radiotherapy (PBRT) (arm 1), PBRT + short-term androgen deprivation therapy (ADT) (arm 2), or PBRT + pelvic lymph node radiotherapy (PLNRT) + short-term ADT (arm 3). We assessed longitudinal serum T levels and the impact of testosterone recovery (TR) on clinical outcomes. MATERIALS/METHODS ADT was given for 4-6 months in arms 2 and 3, starting 2 months prior to radiotherapy. The trial excluded patients with baseline T < 40% of the lower limit of normal. TR was defined in 3 ways: 1) return to non-castrate level (>50 ng/dL), 2) return to normal level (>300 ng/dL), and 3) return to baseline level. Time to TR was estimated using cumulative incidence and death without an event considered a competing risk. Unadjusted and adjusted hazard ratios and 95% confidence intervals (CIs) were calculated using Cox proportional hazards model. Freedom from progression (FFP) was defined as biochemical failure according to the Phoenix definition (PSA ≥2 ng/mL over the nadir PSA), clinical failure (local, regional, or distant), or death from any cause. RESULTS A total of 1699 patients with T at baseline and at least 1 follow-up assessment were included. The median age was 64 years (IQR 59 - 69), 12.8% were black, 14.9% had diabetes, and 54.1% were former or current smokers. Median baseline T in arms 1, 2 and 3 was 320 ng/dL (IQR 239 - 424), 319 ng/dL (IQR 237 - 438) and 330 ng/dL (IQR 252 - 446), respectively. At 6 months, median T in arms 1, 2 and 3 was 290 ng/dL (IQR 210 - 390), 190.4 ng/dL (IQR 66 - 296) and 191 ng/dL (IQR 40.5 - 313). At 2 years, in arms 2 and 3, TR to non-castrate, normal and baseline levels were 95%, 55% and 23%, respectively. At 5 years, in arms 2 and 3, TR to non-castrate, normal and baseline levels were 98%, 73% and 42%, respectively. FFP was superior in arms 2 and 3 vs. arm 1 in patients with TR by all three definitions. In patients with recovered T to normal levels by 2 years (n = 904), the 5-year FFP rates were 71.8% (95% CI 66.9-76.6) in arm 1, 77.2% (72.1-82.2) in arm 2, and 86.3% (82.3-90.3) in arm 3 (arm 2 vs arm 1: HR 0.74, 95% CI 0.56-0.98, p = 0.034; arm 3 vs arm 1: HR 0.54, 95% CI 0.40-0.72, p<.0001). CONCLUSION This work represents the largest study of T kinetics in patients treated with salvage radiation and ADT. Approximately half of patients did not normalize their T levels by 2 years. Our data validate an incremental and meaningful FFP benefit of adding short-term ADT and PLNRT to PBRT independent of T recovery.
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Affiliation(s)
- A Dal Pra
- Department of Radiation Oncology, University of Miami/Sylvester Comprehensive Cancer Center, Miami, FL
| | - J Lyness
- NRG Oncology Statistics and Data Management Center, Philadelphia, PA
| | - A Pollack
- Department of Radiation Oncology, University of Miami/Sylvester Comprehensive Cancer Center, Miami, FL
| | - P T Tran
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD
| | | | - M C Abramowitz
- Department of Radiation Oncology, University of Miami/Sylvester Comprehensive Cancer Center, Miami, FL
| | - B A Mahal
- Department of Radiation Oncology, University of Miami/Sylvester Comprehensive Cancer Center, Miami, FL
| | - A G Martin
- Department of Radiation Oncology CHU de Québec-Université Laval, Québec, QC, Canada
| | - J M Michalski
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO
| | - A Balogh
- Tom Baker Cancer Centre, Calgary, AB, Canada
| | - H Lukka
- Juravinski Cancer Centre, Hamilton, ON, Canada
| | - S L Faria
- McGill University Health Centre, Montreal, QC, Canada
| | - G Rodrigues
- London Health Sciences Centre, London, ON, Canada
| | - M C Beauchemin
- Centre Hospitalier de l'Université de Montréal (CHUM), Montréal, QC, Canada
| | - R J Lee
- Intermountain Medical Center, Murray, UT
| | | | - S D Coen
- Southeast Clinical Oncology Research Consortium, Winston Salem, NC
| | - A M Allen
- Rabin Medical Center - Beilinson Hospital, Petah Tickva, Israel
| | - S Pugh
- NRG Oncology Statistics and Data Management Center, Philadelphia, PA
| | - F Y Feng
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA
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3
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Surasi DS, Eiber M, Maurer T, Preston MA, Helfand BT, Josephson D, Tewari AK, Somford DM, Rais-Bahrami S, Koontz BF, Bostrom PJ, Chau A, Davis P, Schuster DM, Chapin BF. Diagnostic Performance and Safety of Positron Emission Tomography with 18F-rhPSMA-7.3 in Patients with Newly Diagnosed Unfavourable Intermediate- to Very-high-risk Prostate Cancer: Results from a Phase 3, Prospective, Multicentre Study (LIGHTHOUSE). Eur Urol 2023; 84:361-370. [PMID: 37414702 DOI: 10.1016/j.eururo.2023.06.018] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 05/20/2023] [Accepted: 06/20/2023] [Indexed: 07/08/2023]
Abstract
BACKGROUND Radiohybrid (rh) 18F-rhPSMA-7.3 is a novel high-affinity prostate-specific membrane antigen (PSMA)-targeting radiopharmaceutical for prostate cancer (PCa) imaging. OBJECTIVE To evaluate the diagnostic performance and safety of 18F-rhPSMA-7.3 in newly diagnosed PCa patients planned for prostatectomy. DESIGN, SETTING, AND PARTICIPANTS Data on 18F-rhPSMA-7.3 were reported from the phase 3 prospective, multicentre LIGHTHOUSE study (NCT04186819). OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Patients underwent positron emission tomography/computed tomography (PET/CT) 50-70 min after an injection of 296 MBq 18F-rhPSMA-7.3. Images were interpreted locally and by three blinded independent readers. The coprimary endpoints were patient-level sensitivity and specificity for the detection of pelvic lymph node (PLN) metastases, validated using histopathology at PLN dissection. Prespecified statistical thresholds (lower bounds of 95% confidence interval [CI]) were set at 22.5% for sensitivity and 82.5% for specificity. RESULTS AND LIMITATIONS Of 372 patients screened, 352 had evaluable 18F-rhPSMA-7.3-PET/CT and 296 (99 [33%] with unfavourable intermediate-risk [UIR] and 197 [67%] with high-/very-high-risk [VHR] PCa) subsequently underwent surgery. As per the independent reads, 23-37 (7.8-13%) patients had 18F-rhPSMA-7.3-positive PLN. Seventy (24%) patients had one or more positive PLNs on histopathology. The sensitivity for PLN detection was 30% (95% CI, 19.6-42.1%) for reader 1, 27% (95% CI, 17.2-39.1%) for reader 2, and 23% (95% CI, 13.7-34.4%) for reader 3, not meeting the prespecified threshold. Specificity was 93% (95% CI, 88.8-95.9%), 94% (95% CI, 89.8-96.6%), and 97% (95% CI, 93.7-98.7%), respectively, exceeding the threshold for all readers. Specificity was high (≥92%) across both risk stratifications. Sensitivity was higher among high-risk/VHR (24-33%) than among UIR (16-21%) patients. Extrapelvic (M1) lesions were reported for 56-98/352 (16-28%) patients who underwent 18F-rhPSMA-7.3-PET/CT irrespective of surgery. Verification of these (predominantly by conventional imaging) gave a verified detection rate of 9.9-14% (positive predictive value, 51-63%). No serious adverse events were observed. CONCLUSIONS Across all risk stratifications, 18F-rhPSMA-7.3-PET/CT had high specificity, meeting the specificity endpoint. The sensitivity endpoint was not met, although higher sensitivity was noted among high-risk/VHR than among UIR patients. Overall, 18F-rhPSMA-7.3-PET/CT was well tolerated, and identified N1 and M1 disease prior to surgery in newly diagnosed PCa patients. PATIENT SUMMARY In order to select the most appropriate treatment for patients with prostate cancer, it is critical to diagnose the disease burden accurately at initial diagnosis. In this study, we investigated a new diagnostic imaging agent in a large population of men with primary prostate cancer. We found it to have an excellent safety profile and to provide clinically useful information regarding the presence of disease beyond the prostate.
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Affiliation(s)
- Devaki Shilpa Surasi
- Department of Nuclear Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | - Matthias Eiber
- Department of Nuclear Medicine, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Tobias Maurer
- Martini-Klinik, Hamburg, Germany; Department of Urology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | | | | | - David Josephson
- Tower Urology, Los Angeles, CA, USA; Cedars Sinai Medical Center, Los Angeles, CA, USA
| | | | - Diederik M Somford
- Department of Urology, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands; Prosper Prostate Cancer Clinics, Nijmegen/Eindhoven, The Netherlands
| | | | | | - Peter J Bostrom
- Turku University Central Hospital, Turku, Finland; University of Turku, Turku, Finland
| | | | - Phillip Davis
- Blue Earth Diagnostics Inc, Monroe Township, NJ, USA
| | - David M Schuster
- Division of Nuclear Medicine and Molecular Imaging, Department of Radiology and Imaging Sciences, Emory University, Atlanta, GA, USA
| | - Brian F Chapin
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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4
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Dick ET, Cavanaugh SX, Potrebko PS, Koontz BF, Curran WJ. Rapid Reinstatement of Cancer Care after Hurricane Ian. Int J Radiat Oncol Biol Phys 2023; 117:e376-e377. [PMID: 37785278 DOI: 10.1016/j.ijrobp.2023.06.2483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) Category 4 Hurricane Ian brought significant destruction and challenges to western Florida's healthcare facilities. A Radiation Oncology practice network serving the area minimized interruptions in care by implementing planned and improvised solutions. Examining actions that allowed rapid recovery of care could assist others in disaster response. MATERIALS/METHODS The National Hurricane Center issued a hurricane warning 36 hours prior to Ian's landfall. Center closures were based on evacuations and scheduled take down of the power grid. Computers were unplugged, elevated and wrapped in plastic. The LINAC was isolated from the power grid at the main breaker. Staff and patient contacts were printed. Communication techniques were agreed upon for post-storm scenarios with or without cellular service and internet. Hurricane Ian made landfall on September 28 with 150 mph sustained winds and gusts of 216 mph. Unsafe conditions prevented action on September 28. Facility assessment began on September 29. The majority of facilities were inaccessible due to impassible roads and entry hazards, or could not be safely occupied. Based on location and condition, one center from the network of facilities was selected for immediate operational restoration. After confirmation that the site's restored power would remain stable, the LINAC was powered on. An onsite engineering evaluation was done to assess machine functionality and vacuum integrity. Medical Physics then performed monthly QA and isocenter verification due to concern for building vibrations from extreme winds. Interfacing with patient charts in the Aria database was more complex than anticipated. Aria is a hub that uses relative paths to refer to plans, structure sets, images, and radiotherapy treatment records stored in remote servers. These Aria servers could not be accessed because the remote sites had no power. As the Aria servers could not be moved, teams went to retrieve the related Adaptivo servers to allow re-import of patient plans. When booted these servers had no common network and no graphical user interface. Using command line tools, the servers were added to the hub network and IP addresses were assigned. MS-DOS command Robocopy allowed a large-scale resumable transfer from Adaptivo patient folders to the Eclipse import directory. Plan validation and QA followed. Records could not be updated with delivered treatments, necessitating reconciliation of total dose when normal operations resumed. RESULTS Within 72 hours of Ian passing, treatment resumed for all patients within the cancer center network who were able to access the restored site. Within days, seven of the eight regional centers were operational and patients were redistributed. CONCLUSION The unexpected challenges posed by data and network access suggest that improving data location and back-up networks could facilitate center response and resiliency in future disasters.
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Sutera P, Deek MP, Jing Y, Pryor DI, Huynh MA, Koontz BF, Mercier C, Ost P, Kiess AP, Conde-Moreno AJ, Stish BJ, Bosetti DG, Siva S, Berlin A, Kroeze S, Corcoran N, Trock B, Gillessen S, Tran PT, Sweeney C. Multi-Institutional Analysis of Metastasis Directed Therapy with or without Androgen Deprivation Therapy in Oligometastatic Castration Sensitive Prostate Cancer. Int J Radiat Oncol Biol Phys 2023; 117:e442-e443. [PMID: 37785433 DOI: 10.1016/j.ijrobp.2023.06.1620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) Several prospective trials in oligometastatic castration sensitive prostate cancer (omCSPC) have shown metastasis-directed therapy (MDT) can delay time to progression and initiation of androgen deprivation therapy (ADT) compared to observation. However, the optimal integration of ADT with MDT remains unclear. Here we report a multi-national, multi-institutional retrospective cohort of omCSPC treated with MDT to characterize the long-term outcomes of patients treated with MDT alone or in combination with ADT. MATERIALS/METHODS Patients with a controlled primary site and omCSPC (defined as ≤ 5 lesions on conventional imaging) treated with MDT with or without concurrent ADT and with at least 36 months follow-up were retrospectively screened across 13 institutions. The primary endpoints included biochemical progression free survival (bPFS) and radiographic progression free survival (rPFS) calculated using Kaplan-Meier method and stratified by treatment group (MDT alone vs MDT + ADT). Multivariable Cox regression was performed adjusted for variables found to be prognostic on univariate analysis. RESULTS Among 414 patients screened, a total of 263 patients treated between 2003 and 2018 met inclusion criteria and included. Of these, 105 received MDT alone and 158 received MDT+ADT, with median follow-up of 49.5 and 54.5 months, respectively. The majority were metachronous (90%) and had bone lesions (60%). Median ADT duration was 21.3 months (IQR 12.0- 31.9). Patients who received ADT vs. no ADT had poorer prognostic features including 23% vs. 1% synchronous (p<0.001), and 55% vs 40% Gleason 8-10 (p = 0.012). ADT use was associated with a better 5-year bPFS 24% vs 11% (p<0.0001) and rPFS 41% vs 29% (p<0.001). On multivariable Cox regression adjusting for post-MDT PSA nadir and salvage therapy, ADT use maintained significance for both bPFS (HR 0.51 (0.36, 0.71), p<0.001) and rPFS (HR 0.67, 95% CI 0.46-0.96, p = 0.03). CONCLUSION Long-term outcomes with MDT alone suggest a small proportion of patients experience sustained disease control. The addition of ADT appears to improve rPFS, however prospective studies are needed in order to allow for personalization of care in patients with omCSPC.
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Affiliation(s)
- P Sutera
- Johns Hopkins University School of Medicine, Baltimore, MD
| | - M P Deek
- Rutgers Cancer Institute of New Jersey, Department of Radiation Oncology, New Brunswick, NJ
| | - Y Jing
- Johns Hopkins, Baltimore, MD
| | - D I Pryor
- Princess Alexandra Hospital, Brisbane, QLD, Australia
| | - M A Huynh
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA
| | | | - C Mercier
- Gasthuis Sisters, Antwerpen, Belgium
| | - P Ost
- Department of Radiation Oncology, Ghent University Hospital, Ghent, Belgium
| | - A P Kiess
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - B J Stish
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
| | - D G Bosetti
- Department of Radiation Oncology, Istituto Oncologico della Svizzera Italiana, Bellinzona, Switzerland
| | - S Siva
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, VIC, Australia
| | - A Berlin
- Department of Radiation Oncology, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada
| | - S Kroeze
- University Hospital Zurich, Zurich, Switzerland
| | - N Corcoran
- University of Melbourne, Melbourne, Australia
| | - B Trock
- Brady Urological Institute at Johns Hopkins Medical Institution, Baltimore, MD
| | - S Gillessen
- Istituto Oncologico della Svizzera Italiana, Bellinzona, Switzerland
| | - P T Tran
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD
| | - C Sweeney
- University of Adelaide, Adelaide, Australia
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Koontz BF, Kasibhatla MS. The use of positron emission tomography imaging to guide radiation therapy. Clin Adv Hematol Oncol 2023; 21:549-557. [PMID: 37948591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 11/12/2023]
Abstract
Positron emission tomography (PET)-based biologic radiation planning has the potential to improve tumor control by improving the accuracy of radiation delivery, allow for rational adaptive treatment, and decrease the likelihood of both acute and late side effects. 18F-fluorodeoxyglucose (FDG) PET is a widely used and effective diagnostic tool for many metabolically active tumors, including lymphoma and lung, head and neck, gastrointestinal, and gynecologic cancers. For these tumors, PET evidence has initially focused on more accurate staging but is evolving to allow for the escalation or deescalation of the radiotherapy dose depending on the PET-determined response to initial therapy. For gliomas and prostate cancer, novel tracers offer opportunities to improve tumor targeting of areas not well identified by traditional FDG PET. These tracers may also identify functional regions of healthy organs, allowing for more effective sparing of normal tissue.
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Affiliation(s)
- Bridget F Koontz
- Department of Radiation Oncology, Brody School of Medicine, East Carolina University, Greenville, North Carolina
| | - Mohit S Kasibhatla
- Department of Radiation Oncology, Brody School of Medicine, East Carolina University, Greenville, North Carolina
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Koontz BF, Karrison T, Pisansky TM, Posadas EM, Ballas LK, Berlin A, Hall WA, Tran PT, O'Daniel JC, Hope TA, Rodgers JP, Feng FY. NRG-GU011: A phase II double-blinded, placebo-controlled trial of prostate oligometastatic radiotherapy with or without androgen deprivation therapy in oligometastatic prostate cancer (NRG PROMETHEAN). J Clin Oncol 2023. [DOI: 10.1200/jco.2023.41.6_suppl.tps283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2023] Open
Abstract
TPS283 Background: There is no clear standard of care for biochemically recurrent prostate cancer (PCa) with positron emission tomography (PET)-detected oligometastases and normal conventional imaging (CIM). Phase II trials show that stereotactic ablative body radiotherapy (SABR) to oligometastases may delay cancer progression and initiation of androgen deprivation therapy (ADT) and its untoward effects. ADT with radiation prolongs survival in locally advanced PCa and in CIM metastatic PCa. However, there is a knowledge gap about timing and benefit vs toxicity of ADT with SABR in early oligometastatic PCa. NRG GU011 (PROMETHEAN) is a randomized phase II trial of SABR with or without relugolix for early PET-detected recurrent oligometastatic PCa. This study aims to evaluate the impact of relugolix, a novel oral gonadotropin-releasing hormone receptor antagonist, when combined with SABR to oligometastases. Relugolix allows for rapid testosterone recovery and is associated with fewer cardiovascular events when compared to leuprolide and is hypothesized to have low late ADT toxicity. GU011 will provide patients and their physicians data on the relative risks and benefits of early or delayed ADT in this setting. Methods: NRG-GU011 NCT# 05053152 is a randomized phase II double-blinded, placebo-controlled trial with randomization to SABR + 6 months placebo vs SABR + 6 months relugolix. Eligible patients have biochemical recurrence after prior curative intent radiation or surgery for localized PCa, PSA < 10 ng/mL, negative CIM and 1-5 PET-evident metastases (≥1 extrapelvic). SABR is delivered in 1-5 fractions to BED >100 Gy1.5, followed by placebo or relugolix 120mg daily for 6 months. Patients will then be followed with imaging at time of biochemical recurrence. The planned sample size of 260 patients (130 per arm) will provide 85% power to detect a hazard ratio of 0.65 for radiographic progression-free survival (rPFS), based on a one-sided test at alpha 0.10. Planned enrollment is predicted at 8 patients per month with an estimated study completion date of late 2026. The primary endpoint is CIM rPFS. Secondary endpoints include PET-based rPFS, sexual and hormonal quality of life (QoL) assessed by EPIC-26, other QoL measures from EQ5D-5L, EORTC QLQ-30 and PROMIS Fatigue, and between-group comparisons of time to salvage therapy, castration-resistance, local progression (SABR-targeted lesion), biochemical progression, distant metastases, prostate cancer-specific mortality, metastasis-free survival, and overall survival. We also aim to determine adverse event rates for both treatment arms and evaluate genomic and blood markers of treatment response. This study opened in December 2021. Clinical trial information: NCT05053152 .
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Affiliation(s)
| | - Theodore Karrison
- NRG Oncology Statistics and Data Management Center, Philadelphia, PA
| | | | | | | | - Alejandro Berlin
- Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | | | | | | | - Thomas A. Hope
- University of California, San Francisco, San Francisco, CA
| | - Joseph P. Rodgers
- NRG Oncology Statistics and Data Management Center, American College of Radiology, Philadelphia, PA
| | - Felix Y Feng
- University of California, San Francisco, San Francisco, CA
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8
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Vapiwala N, Chen YH, Cho SY, Duan F, Kyriakopoulos C, Morgans AK, Shevrin DH, Koontz BF, McKay RR, Yu EY, McConathy J, Liu G, Mankoff DA, Wong TZ, Carducci MA. Phase III study of local or systemic therapy intensification directed by PET in prostate cancer patients with post-prostatectomy biochemical recurrence (INDICATE): ECOG-ACRIN EA8191. J Clin Oncol 2023. [DOI: 10.1200/jco.2023.41.6_suppl.tps402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/15/2023] Open
Abstract
TPS402 Background: Salvage radiation therapy (sRT) to the prostate bed and pelvic nodes with short-term androgen deprivation therapy (STAD) is considered a standard of care (SOC) salvage therapy (ST) paradigm for prostate cancer (PC) patients (pts) with post-prostatectomy (RP) biochemical recurrence (BCR). PET imaging with recently FDA-approved agents in this setting (18F-Fluciclovine, 18F-DCFPyL and 68Ga-PSMA-11), have shown improved accuracy for detection of metastases not identified with conventional imaging (CIM). Given the greater sensitivity and specificity of PET, its findings are being increasingly but variably applied to justify modification or omission of SOC therapies without high-level evidence of clinical benefit. PET may help identify candidates for different treatment intensification approaches. In metastatic prostate cancer, metastasis-directed RT (MDT) has been used to avoid or delay systemic therapy in men with oligometastatic disease. Apalutamide (Apa) is an androgen receptor signaling inhibitor that has been shown to improve outcomes when added to ADT in mCSPC. This study will evaluate whether patients with PET-detected lesions outside the pelvis will benefit from addition of MDT to treatment intensification with STAD/Apa, and whether patients with no PET-detected lesions outside the pelvis will benefit from addition of Apa to standard sRT/STAD. Methods: PC pts with post-RP BCR (PSA>0.5ng/mL; >0.2ng/mL if first detectable within 12 mos of RP) and no extrapelvic metastases on CIM who are candidates for SOC ST (sRT to prostate bed and pelvic nodes with STAD) are eligible. Pts will undergo SOC baseline PET using a FDA-approved tracer. Based on institutional clinical interpretation of the SOC PET, pts will be placed in Cohort 1 (PET-negative) or 2 (PET-positive for extra-pelvic metastases). Cohort 1 will be randomized to SOC ST +/- Apa for 6 months and Cohort 2 will be randomized to SOC ST and Apa +/- MDT to PET-positive lesions. The primary endpoint is PFS, defined as time from randomization to radiographic progression on CIM, symptomatic disease or death, whichever occurs first. Primary objectives are to evaluate whether addition of Apa to SOC ST and addition of MDT to SOC ST and Apa could prolong PFS in Cohorts 1 and 2, respectively. For Cohort 1, 480 pts will be randomized with 85% power to distinguish a 5-year PFS rate of 90% (Apa arm) vs. 80% (SOC arm) using one-sided stratified logrank test with type I error of 0.025. For Cohort 2, 324 pts will be randomized with 85% power to distinguish a 5-year PFS rate of 76.5% in the experimental arm from 61.5% in the control arm. Secondary endpoints include overall and event-free survival, toxicity, PET progression and quality of life. Clinical trial information: NCT04423211 .
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Affiliation(s)
| | | | - Steve Y. Cho
- University of Wisconsin SMPH, Department of Radiology, University of Wisconsin Carbone Cancer Center, Madison, WI
| | - Fenghai Duan
- Brown University School of Public Health, Providence, RI
| | | | | | | | | | - Rana R. McKay
- Moores Cancer Center, University of California San Diego, La Jolla, CA
| | - Evan Y. Yu
- University of Washington School of Medicine, Seattle, WA
| | | | - Glenn Liu
- University of Wisconsin-Madison Carbone Cancer Center, Madison, WI
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9
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Koontz BF. Detection of true positive M1 lesions by 18F-rhPSMA-7.3 PET in newly diagnosed prostate cancer: Results from the phase 3 prospective LIGHTHOUSE study. J Clin Oncol 2023. [DOI: 10.1200/jco.2023.41.6_suppl.315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023] Open
Abstract
315 Background: Radiohybrid (rh) 18F-rhPSMA-7.3 is a novel high affinity prostate specific membrane antigen (PSMA)-targeting positron emission tomography (PET) radiopharmaceutical. The LIGHTHOUSE study (NCT04186819) evaluated the diagnostic performance of 18F-rhPSMA-7.3 in newly diagnosed prostate cancer. Here we report the 18F-rhPSMA-7.3 verified detection rate (VDR), defined as the proportion of patients with M1 lesions identified by blinded image evaluation (BIE) and subsequently confirmed true positive (TP) by biopsy or confirmatory imaging. Methods: Men with treatment-naïve, unfavorable intermediate to very high-risk prostate cancer who were scheduled to undergo radical prostatectomy underwent PET 50-70 min after IV administration of 296 MBq 18F-rhPSMA-7.3. Onsite readers interpreted the images before submission for BIE by 3 central readers.Ifthe onsite read indicated M1 disease, verification (by biopsy, surgery or additional imaging) of PET-positive M1 lesions was attempted prior to treatment. 18F-rhPSMA-7.3 M1 VDR was evaluated amongall study patients without major protocol deviations. Results: Of the 335 men analyzed (median [range] PSA, 8.89 [1.15-120] ng/mL), 58 (17%) had M1 lesions by majority read. In total, 34 (10%) had verified M1 lesions with individual readers’ M1 VDR ranging from 10-15%. By region, verified M1 lesions were most common in bone, ranging from 6.0-11% across readers (majority read, 6.6%). Similar data were shown among a subgroup who had negative baseline conventional imaging. In these patients, the VDR ranged from 8.9-13% across readers (majority read, 8.6%). Again, bone showed the highest regional VDR, ranging from 4.8-9.2% (majority read, 5.1%). Conclusions: Further to its clinically meaningful sensitivity and specificity for pelvic lymph node metastases (reported separately), here we show 18F-rhPSMA-7.3 PET to be a useful staging tool, as distant metastatic lesions were verified in 10-15% of newly diagnosed patients with unfavorable intermediate to very high-risk prostate cancer. Determining the presence of M1 disease prior to surgery may help guide treatment planning by identifying patients for whom surgery is the optimal approach, or those for whom alternatives such as radiation therapy and/or androgen deprivation may be more suitable. Clinical trial information: NCT04186819 . [Table: see text]
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10
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Wittmann D, Mehta A, McCaughan E, Faraday M, Duby A, Matthew A, Incrocci L, Burnett A, Nelson CJ, Elliott S, Koontz BF, Bober SL, McLeod D, Capogrosso P, Yap T, Higano C, Loeb S, Capellari E, Glodé M, Goltz H, Howell D, Kirby M, Bennett N, Trost L, Odiyo Ouma P, Wang R, Salter C, Skolarus TA, McPhail J, McPhail S, Brandon J, Northouse LL, Paich K, Pollack CE, Shifferd J, Erickson K, Mulhall JP. Guidelines for Sexual Health Care for Prostate Cancer Patients: Recommendations of an International Panel. J Sex Med 2022; 19:1655-1669. [PMID: 36192299 DOI: 10.1016/j.jsxm.2022.08.197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 07/18/2022] [Accepted: 08/29/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Patients with prostate cancer suffer significant sexual dysfunction after treatment which negatively affects them and their partners psychologically, and strain their relationships. AIM We convened an international panel with the aim of developing guidelines that will inform clinicians, patients and partners about the impact of prostate cancer therapies (PCT) on patients' and partners' sexual health, their relationships, and about biopsychosocial rehabilitation in prostate cancer (PC) survivorship. METHODS The guidelines panel included international expert researchers and clinicians, and a guideline methodologist. A systematic review of the literature, using the Ovid MEDLINE, Scopus, CINAHL, PsychINFO, LGBT Life, and Embase databases was conducted (1995-2022) according to the Cochrane Handbook for Systematic Reviews of Interventions. Study selection was based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Each statement was assigned an evidence strength (A-C) and a recommendation level (strong, moderate, conditional) based on benefit/risk assessment, according to the nomenclature of the American Urological Association (AUA). Data synthesis included meta-analyses of studies deemed of sufficient quality (3), using A Measurement Tool to Assess Systematic Reviews (AMSTAR). OUTCOMES Guidelines for sexual health care for patients with prostate cancer were developed, based on available evidence and the expertise of the international panel. RESULTS The guidelines account for patients' cultural, ethnic, and racial diversity. They attend to the unique needs of individuals with diverse sexual orientations and gender identities. The guidelines are based on literature review, a theoretical model of sexual recovery after PCT, and 6 principles that promote clinician-initiated discussion of realistic expectations of sexual outcomes and mitigation of sexual side-effects through biopsychosocial rehabilitation. Forty-seven statements address the psychosexual, relationship, and functional domains in addition to statements on lifestyle modification, assessment, provider education, and systemic challenges to providing sexual health care in PC survivorship. CLINICAL IMPLICATIONS The guidelines provide clinicians with a comprehensive approach to sexual health care for patients with prostate cancer. STRENGTHS & LIMITATIONS The strength of the study is the comprehensive evaluation of existing evidence on sexual dysfunction and rehabilitation in prostate cancer that can, along with available expert knowledge, best undergird clinical practice. Limitation is the variation in the evidence supporting interventions and the lack of research on issues facing patients with prostate cancer in low and middle-income countries. CONCLUSION The guidelines document the distressing sexual sequelae of PCT, provide evidence-based recommendations for sexual rehabilitation and outline areas for future research. Wittmann D, Mehta A, McCaughan E, et al. Guidelines for Sexual Health Care for Prostate Cancer Patients: Recommendations of an International Panel. J Sex Med 2022;19:1655-1669.
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Affiliation(s)
- Daniela Wittmann
- Department of Urology, University of Michigan, Ann Arbor, MI, USA.
| | - Akanksha Mehta
- Department of Urology, Emory University, Atlanta, GA, USA
| | - Eilis McCaughan
- In Memoriam, Ulster University School of Nursing, County Londonderry, Colraine, UK
| | | | - Ashley Duby
- Department of Urology, University of Michigan, Ann Arbor, MI, USA
| | - Andrew Matthew
- Adult Psychiatry and Health System, Princess Margaret Cancer Center, Toronto, ON, Canada
| | - Luca Incrocci
- Department of Radiation Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Arthur Burnett
- Department of Urology, Johns Hopkins University, Baltimore, MD, USA
| | - Christian J Nelson
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Stacy Elliott
- Departments of Psychiatry and Urologic Sciences, University of British Columbia, Vancouver, BC, Canada
| | | | - Sharon L Bober
- Department of Psychiatry, Dana Farber Cancer Institute and Harvard University, Boston, MA, USA
| | - Deborah McLeod
- School of Nursing, NS Health Authority and Dalhousie University, Halifax, NS, Canada
| | - Paolo Capogrosso
- Department of Urology, Ciircolo & Fondazione Macchi Hospital, University of Insubria, Varese, Lombardy, Italy
| | - Tet Yap
- Department of Urology, Guys & St Thomas' Hospital, City of London, London, UK
| | - Celestia Higano
- Department of Urologic Sciences, University of British Columbia, Vancouver, BC, Canada
| | - Stacy Loeb
- Department of Urology at NYU Grossman School of Medicine, New York, NY, USA
| | - Emily Capellari
- Taubman Health Sciences Library, University of Michigan, Ann Arbor, MI, USA
| | - Michael Glodé
- Department of Medical Oncology, University of Colorado Cancer Center, Aurora, CO, USA
| | - Heather Goltz
- School of Social Work, University of Houston-Downtown, Houston, TX, USA
| | - Doug Howell
- Patient with Lived Experience, Keaau, HI, USA
| | - Michael Kirby
- Faculty of the Health and Human Sciences, University of Hertfordshire, Hatfield, Hertfordshire, UK
| | - Nelson Bennett
- Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Landon Trost
- Department of Urology, Brigham Young University, Provo, UT, USA; Department of Urology, Mayo Clinic, Rochester, MN, USA
| | | | - Run Wang
- Department of Surgery-Urology, University of Texas McGovern Medical School, Houston, TX, USA; Department of Urology, MD Anderson Cancer Center, Houston, TX, USA
| | - Carolyn Salter
- Department of Urology, Madigan Army Medical Center, Tacoma, WA, USA
| | - Ted A Skolarus
- Department of Urology, University of Michigan, Ann Arbor, MI, USA; VA Health Services Research & Development, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - John McPhail
- Patient and Partner with Lived Experience, Okemos, MI, USA
| | - Susan McPhail
- Patient and Partner with Lived Experience, Okemos, MI, USA
| | - Jan Brandon
- Partner with Lived Experience, Nashville, TN, USA
| | | | - Kellie Paich
- Clinical Quality and Survivorship, Movember Foundation, Culver City, CA, USA
| | - Craig E Pollack
- Department of Health Policy Management, Johns Hopkins University, Baltimore, MD, USA
| | - Jen Shifferd
- Department of Physical Therapy and Rehabilitation Medicine, Michigan Medicine Therapy Services, Ann Arbor, MI, USA
| | - Kim Erickson
- Department of Physical Therapy and Rehabilitation Medicine, Michigan Medicine Therapy Services, Ann Arbor, MI, USA
| | - John P Mulhall
- Department of Sexual and Reproductive Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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11
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Randolph JT, Pak ES, McMains JC, Koontz BF, Hannan JL. Cocultured Schwann Cells Rescue Irradiated Pelvic Neuron Outgrowth and Increase Survival. J Sex Med 2022; 19:1333-1342. [DOI: 10.1016/j.jsxm.2022.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 05/13/2022] [Accepted: 06/11/2022] [Indexed: 10/17/2022]
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12
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Wittmann D, Mehta A, Bober SL, Zhu Z, Daignault-Newton S, Dunn RL, Braun TM, Carter C, Duby A, Northouse LL, Koontz BF, Glodé LM, Brandon J, Bangs R, McPhail J, McPhail S, Arab L, Paich K, Skolarus TA, An LC, Nelson CJ, Saigal CS, Chen RC, Mulhall JP, Hawley ST, Hearn JWD, Spratt DE, Pollack CE. TrueNTH Sexual Recovery Intervention for couples coping with prostate cancer: Randomized controlled trial results. Cancer 2022; 128:1513-1522. [PMID: 34985771 DOI: 10.1002/cncr.34076] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 11/22/2021] [Accepted: 11/30/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Despite significant sexual dysfunction and distress after localized prostate cancer treatment, patients typically receive only physiologic erectile dysfunction management. The authors performed a randomized controlled trial of an online intervention supporting couples' posttreatment recovery of sexual intimacy. METHODS Patients treated with surgery, radiation, or combined radiation and androgen deprivation therapy who had partners were recruited and randomized to an online intervention or a control group. The intervention, tailored to treatment type and sexual orientation, comprised 6 modules addressing expectations for sexual and emotional sequelae of treatment, rehabilitation, and guidance toward sexual intimacy recovery. Couples, recruited from 6 sites nationally, completed validated measures at the baseline and 3 and 6 months after treatment. Primary outcome group differences were assessed with t tests for individual outcomes. RESULTS Among 142 randomized couples, 105 patients (mostly surgery) and 87 partners completed the 6-month survey; this reflected challenges with recruitment and attrition. There were no differences between the intervention and control arms in Patient-Reported Outcomes Measurement Information System Global Satisfaction With Sex Life scores 6 months after treatment (the primary outcome). Three months after treatment, intervention patients and partners reported more engagement in penetrative and nonpenetrative sexual activities than controls. More than 73% of the intervention participants reported high or moderate satisfaction with module content; more than 85% would recommend the intervention to other couples. CONCLUSIONS Online psychosexual support for couples can help couples to connect and experience sexual pleasure early after treatment despite patients' sexual dysfunction. Participants' high endorsement of the intervention reflects the importance of sexual health support to couples after prostate cancer treatment. LAY SUMMARY This study tested a web-based program supporting couples' sexual recovery of sexual intimacy after prostate cancer treatment. One hundred forty-two couples were recruited and randomly assigned to the program (n = 60) or to a control group (n = 82). The program did not result in improvements in participants' satisfaction with their sex life 6 months after treatment, but couples in the intervention group engaged in sexual activity sooner after treatment than couples in the control group. Couples evaluated the program positively and would recommend it to others facing prostate cancer treatment.
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Affiliation(s)
- Daniela Wittmann
- Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - Akanksha Mehta
- Department of Urology, Emory University, Atlanta, Georgia
| | - Sharon L Bober
- Sexual Health Program, Dana-Farber Cancer Institute, Boston, Massachusetts
- Department of Psychiatry, Harvard University, Boston, Massachusetts
| | - Ziwei Zhu
- Department of Urology, University of Michigan, Ann Arbor, Michigan
| | | | - Rodney L Dunn
- Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - Thomas M Braun
- Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - Caroline Carter
- Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - Ashley Duby
- Department of Urology, University of Michigan, Ann Arbor, Michigan
| | | | - Bridget F Koontz
- Department of Radiation Oncology, Duke University, Durham, North Carolina
| | - L Michael Glodé
- School of Medicine, Medical Oncology, University of Colorado, Aurora, Colorado
| | | | | | | | | | - Lenore Arab
- Department of Urology, University of California Los Angeles, Los Angeles, California
| | | | - Ted A Skolarus
- Department of Urology, University of Michigan, Ann Arbor, Michigan
- VA Health Services Research & Development, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Lawrence C An
- Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - Christian J Nelson
- Male Sexual and Reproductive Medicine Program, Memorial Sloan Kettering, New York, New York
- Psychiatry Service, New York, New York
| | - Christopher S Saigal
- Department of Urology, University of California Los Angeles, Los Angeles, California
| | - Ronald C Chen
- Department of Urology, University of California Los Angeles, Los Angeles, California
| | - John P Mulhall
- Center for Sexual and Reproductive Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Sarah T Hawley
- Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - Jason W D Hearn
- Department of Urology, University of Michigan, Ann Arbor, Michigan
- Department of Radiation Oncology, Duke University, Durham, North Carolina
| | - Daniel E Spratt
- Department of Urology, University of Michigan, Ann Arbor, Michigan
- Department of Radiation Oncology, Duke University, Durham, North Carolina
| | - Craig E Pollack
- Department of Health Policy and Management I School of Medicine, Johns Hopkins University, Baltimore, Maryland
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Barton DL, Pugh SL, Ganz PA, Plaxe SC, Koontz BF, Carter J, Greyz-Yusupov N, Page SJ, Rowland KM, Balcueva EP, Nabeel S, Basil JB, Hill ML, Muller CY, Bell MC, Deshmukh S, Kachnic LA. Randomized Controlled Phase II Evaluation of Two Dose Levels of Bupropion Versus Placebo for Sexual Desire in Female Cancer Survivors: NRG-CC004. J Clin Oncol 2022; 40:324-334. [PMID: 34882500 PMCID: PMC8797544 DOI: 10.1200/jco.21.01473] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
PURPOSE Because of the negative impact of cancer treatment on female sexual function, effective treatments are warranted. The purpose of this multisite study was to evaluate the ability of two dose levels of extended-release bupropion, a dopaminergic agent, to improve sexual desire more than placebo at 9 weeks, measured by the desire subscale of the Female Sexual Function Index (FSFI), and to evaluate associated toxicities. METHODS Postmenopausal women diagnosed with breast or gynecologic cancer and low baseline FSFI desire scores (< 3.3), who had completed definitive cancer therapy, were eligible. Women were randomly assigned to receive 150 mg or 300 mg once daily of extended-release bupropion or a matching placebo. t-tests were performed on the FSFI desire subscale to evaluate whether there was a significantly greater change from baseline to 9 weeks between placebo and each bupropion arm as the primary end point. Sixty-two patients per arm provided 80% power using a one-sided t-test. RESULTS Two hundred thirty women were randomly assigned from 72 institutions through the NRG Oncology NCORP network. At 9 weeks, there were no statistically significant differences in change of the desire subscale scores between groups; participants in all three arms reported improvement. The mean changes for each arm were placebo 0.62 (standard deviation [SD] = 1.18), 150-mg once daily bupropion 0.64 (SD = 0.95), and 300-mg once daily bupropion 0.60 (SD = 0.89). Total and subscale scores on the FSFI were low throughout the study, indicating dysfunction in all groups. CONCLUSION Bupropion was not more effective than placebo in improving the desire subscale of the FSFI. Subscale and total scores of the FSFI demonstrated dysfunction throughout the 9 weeks of the study. More research is needed to support sexual function in female cancer survivors.
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Affiliation(s)
- Debra L. Barton
- University of Michigan School of Nursing, Ann Arbor, MI,Debra L. Barton, RN, PhD, University of Michigan School of Nursing, 400 North Ingalls Building, Ann Arbor, MI 48109-5482; e-mail:
| | - Stephanie L. Pugh
- NRG Oncology Statistics and Data Management Center, American College of Radiology, Philadelphia, PA
| | | | | | | | - Jeanne Carter
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | | | | | - Ernie P. Balcueva
- Ascension Michigan St Marys Hospital, Saginaw, MI accrual under Michigan Cancer Research Consortium NCORP
| | - Sobia Nabeel
- University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Jack B. Basil
- Bethesda North Hospital, Cincinnati, OH accrual under Catholic Health Initiatives NCORP
| | - Matthew L. Hill
- Medical Oncology and Hematology Associates-Des Moines, Des Moines, IA accrual under Iowa-Wide Oncology Research Coalition NCORP
| | - Carolyn Y. Muller
- University of New Mexico Cancer Center, Albuquerque, NM accrual under New Mexico Minority Underserved NCORP
| | - Maria C. Bell
- Sanford Health, Sioux Falls, SD accrual under Sanford NCI Community Oncology Research Program of the North Central Plains
| | - Snehal Deshmukh
- NRG Oncology Statistics and Data Management Center, American College of Radiology, Philadelphia, PA
| | - Lisa A. Kachnic
- NYP-Columbia University Medical Center/Herbert Irving Comprehensive Cancer Center, New York, NY
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14
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Bitting RL, Healy P, George DJ, Anand M, Kim S, Mayer T, Winters C, Riggan C, Rasmussen J, Wilder R, Stein M, Frizzell B, Harrison MR, Zhang T, Lee WR, Wu Y, Koontz BF, Armstrong AJ. Phase II Trial of Enzalutamide and Androgen Deprivation Therapy with Salvage Radiation in Men with High-risk Prostate-specific Antigen Recurrent Prostate Cancer: The STREAM Trial. Eur Urol Oncol 2021; 4:948-954. [PMID: 32063492 DOI: 10.1016/j.euo.2020.01.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 01/10/2020] [Accepted: 01/30/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Salvage external beam radiotherapy (RT) with androgen deprivation therapy (ADT) improves survival over RT in men with prostate cancer (PC) and rising prostate-specific antigen (PSA) levels after radical prostatectomy (RP). OBJECTIVE To investigate the safety and efficacy of enzalutamide concurrent with salvage RT and ADT. DESIGN, SETTING, AND PARTICIPANTS This was a three-center prospective phase 2 single-arm trial (NCT02057939) of men with Gleason 7-10 PC and PSA recurrence within 4 yr of RP ranging from 0.2 to 4.0 ng/dl, no prior hormonal therapy, and no radiographic evidence of metastases. We enrolled 38 men; 37 completed therapy and were evaluable with testosterone recovery at 2 yr. INTERVENTION Six months of ADT with 160 mg/d enzalutamide and 66 Gy RT to the prostate bed. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS The primary endpoint was improved 2-yr progression-free survival (PFS) over historical controls. Secondary objectives included 3-yr PFS, safety, and patient-reported quality of life (QOL). RESULTS AND LIMITATIONS The primary endpoint of 2-yr PFS was 65% (95% confidence interval [CI]: 47, 78) versus 51% (95% CI: 33, 67) in a trial of men with similar eligibility treated with salvage RT and adjuvant docetaxel. The 3-yr PFS was 53%. Eleven (29%) men experienced G3 toxicities, and there were no G4-5 or unexpected toxicities. QOL data suggest modest worsening of bowel, bladder, and hormonal symptoms at 3 mo, with recovery by 24 mo in most men. CONCLUSIONS Salvage RT with enzalutamide and ADT following RP for men with PSA recurrent high-risk PC is safe and demonstrates encouraging efficacy, warranting prospective controlled phase 3 trials of ADT with or without potent androgen receptor inhibition in this curative-intent setting. PATIENT SUMMARY Addition of 6 mo of oral daily enzalutamide to standard salvage radiation and hormone therapy is safe and may improve prostate cancer remission rates at 2 and 3 yr.
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Affiliation(s)
- Rhonda L Bitting
- Comprehensive Cancer Center of Wake Forest University, Departments of Internal Medicine and Radiation Oncology, Winston-Salem NC USA
| | - Patrick Healy
- Department of Biostatistics, Duke Cancer Institute Center for Prostate and Urologic Cancers, Durham, NC, USA
| | - Daniel J George
- Department of Medicine, Duke Cancer Institute Center for Prostate and Urologic Cancers, Durham, NC, USA; Department of Surgery, Duke Cancer Institute Center for Prostate and Urologic Cancers, Durham, NC, USA; Department of Pharmacology, Duke Cancer Institute Center for Prostate and Urologic Cancers, Durham, NC, USA; Department of Cancer Biology, Duke Cancer Institute Center for Prostate and Urologic Cancers, Durham, NC, USA
| | - Monika Anand
- Duke Cancer Institute Center for Prostate and Urologic Cancers, Durham NC, USA
| | - Sung Kim
- Cancer Institute of New Jersey, Rutgers, NJ, USA
| | - Tina Mayer
- Cancer Institute of New Jersey, Rutgers, NJ, USA
| | - Carol Winters
- Duke Cancer Institute Center for Prostate and Urologic Cancers, Durham NC, USA
| | - Colleen Riggan
- Duke Cancer Institute Center for Prostate and Urologic Cancers, Durham NC, USA
| | - Julia Rasmussen
- Duke Cancer Institute Center for Prostate and Urologic Cancers, Durham NC, USA
| | - Rhonda Wilder
- Duke Cancer Institute Center for Prostate and Urologic Cancers, Durham NC, USA
| | - Mark Stein
- Cancer Institute of New Jersey, Rutgers, NJ, USA
| | - Bart Frizzell
- Comprehensive Cancer Center of Wake Forest University, Departments of Internal Medicine and Radiation Oncology, Winston-Salem NC USA
| | - Michael R Harrison
- Department of Medicine, Duke Cancer Institute Center for Prostate and Urologic Cancers, Durham, NC, USA; Department of Surgery, Duke Cancer Institute Center for Prostate and Urologic Cancers, Durham, NC, USA; Department of Pharmacology, Duke Cancer Institute Center for Prostate and Urologic Cancers, Durham, NC, USA; Department of Cancer Biology, Duke Cancer Institute Center for Prostate and Urologic Cancers, Durham, NC, USA
| | - Tian Zhang
- Department of Medicine, Duke Cancer Institute Center for Prostate and Urologic Cancers, Durham, NC, USA; Department of Surgery, Duke Cancer Institute Center for Prostate and Urologic Cancers, Durham, NC, USA; Department of Pharmacology, Duke Cancer Institute Center for Prostate and Urologic Cancers, Durham, NC, USA; Department of Cancer Biology, Duke Cancer Institute Center for Prostate and Urologic Cancers, Durham, NC, USA
| | - William R Lee
- Department of Radiation Oncology, Duke Cancer Institute Center for Prostate and Urologic Cancers, Durham, NC, USA
| | - Yuan Wu
- Department of Biostatistics, Duke Cancer Institute Center for Prostate and Urologic Cancers, Durham, NC, USA
| | - Bridget F Koontz
- Department of Radiation Oncology, Duke Cancer Institute Center for Prostate and Urologic Cancers, Durham, NC, USA
| | - Andrew J Armstrong
- Department of Medicine, Duke Cancer Institute Center for Prostate and Urologic Cancers, Durham, NC, USA; Department of Surgery, Duke Cancer Institute Center for Prostate and Urologic Cancers, Durham, NC, USA; Department of Pharmacology, Duke Cancer Institute Center for Prostate and Urologic Cancers, Durham, NC, USA; Department of Cancer Biology, Duke Cancer Institute Center for Prostate and Urologic Cancers, Durham, NC, USA.
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15
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Jadvar H, Calais J, Fanti S, Feng F, Greene KL, Gulley JL, Hofman M, Koontz BF, Lin DW, Morris MJ, Rowe SP, Royce TJ, Salami S, Savir-Baruch B, Srinivas S, Hope TA. Appropriate Use Criteria for Prostate-Specific Membrane Antigen PET Imaging. J Nucl Med 2021; 63:59-68. [PMID: 34593595 DOI: 10.2967/jnumed.121.263262] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 09/21/2021] [Indexed: 11/16/2022] Open
Affiliation(s)
- Hossein Jadvar
- Department of Radiology, University of Southern California, Los Angeles, California;
| | - Jeremie Calais
- Department of Molecular and Medical Pharmacology, University of California, Los Angeles, California
| | | | - Felix Feng
- Department of Radiation Oncology, University of California, San Francisco, California
| | - Kirsten L Greene
- Department of Urology, University of Virginia, Charlottesville, Virginia
| | | | - Michael Hofman
- Molecular Imaging and Therapeutic Nuclear Medicine, Peter MacCallum Cancer Center, Melbourne, Victoria, Australia and Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria Australia
| | - Bridget F Koontz
- Department of Radiation Oncology, Duke University, Durham, North Carolina
| | - Daniel W Lin
- Department of Urology, University of Washington, Seattle, Washington
| | - Michael J Morris
- Genitourinary Oncology Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Steve P Rowe
- Department of Radiological Sciences, Johns Hopkins University, Baltimore, Maryland
| | - Trevor J Royce
- Department of Radiation Oncology, University of North Carolina, Chapel Hill, North Carolina
| | - Simpa Salami
- Department of Urology, University of Michigan, Ann Arbor, Michigan
| | | | - Sandy Srinivas
- Department of Medicine (Oncology), Stanford University, California; and
| | - Thomas A Hope
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, California
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16
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Abstract
One of the most common side effects of urologic cancer and its treatment is sexual dysfunction. This negative consequence can occur because of changes in anatomy and/or the physiologic response to sexual stimuli, but also due to the psychological impact of those physical changes and the cancer experience. Sexual health is a key part of survivorship, but it is under-emphasized in training and can be overlooked in clinical practice. To support the sexual health of the urologic cancer survivor, the urologic oncologist should: 1) acknowledge and educate the patient about the potential effects, 2) be sensitive to identifying sexual issues as they arise, and 3) be aware of treatment strategies and be able to access the team members needed to provide these strategies. As sexual function requires a complex interplay of anatomy, physiology, and psychology, so does addressing sexual dysfunction resulting from cancer treatment. In this special Seminars issue, we review the sexual dysfunction consequences of urologic cancers in both men and women and strategies to maximize sexual health.
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Affiliation(s)
- Bridget F Koontz
- Department of Radiation Oncology, East Carolina University, Greenville, NC.
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17
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Koontz BF, Levine E, McSherry F, Niedzwiecki D, Sutton L, Dale T, Streicher M, Rushing C, Owen L, Kraus WE, Bennett G, Pollak KI. Increasing physical activity in Cancer Survivors through a Text-messaging Exercise motivation Program (ICanSTEP). Support Care Cancer 2021; 29:7339-7349. [PMID: 34050402 DOI: 10.1007/s00520-021-06281-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 05/05/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE Cancer survivors are often sedentary. Self-monitoring may promote physical activity through self-activation. We conducted a pilot trial to evaluate whether wearable activity tracker with personalized text message feedback would increase physical activity. METHODS We enrolled 30 patients with solid tumor cancers into a non-randomized prospective intervention trial (NCT02627079): 15 had completed treatment in the past year and 15 under active treatment. Each participant received an activity tracker and daily text messages personalized to their activity level. We assessed patient-reported outcomes and 6-min walk (6 MW) at baseline and 3 months. RESULTS Twenty-six participants completed the study. There was substantial variation in baseline activity. Overall, 39% of participants increased their steps taken by at least 20%, and 23% increased their 6 MW distance by 20% or more. More participants who had completed treatment strongly agreed (73%) that the intervention increased their exercise levels than those receiving active treatment (47%). At 3 months, there was a significant improvement in median Beck Depression Inventory-II and Godin Leisure Index composite scores. At 6 months, 72% still wore their activity tracker at least 4 days per week. CONCLUSION We found that the intervention was well-accepted with a high completion rate at 3 months and continued self-use at 6 months. In this pilot study of combined activity tracker and motivational messaging, we found a signal for increased physical activity over a 3-month period. Future research is needed to study this technique for its impact on activity and other physical and psychological measures of well-being. IMPLICATION FOR CANCER SURVIVORS Activity tracker with personalized motivational messaging may be useful in promoting physical activity in cancer survivors.
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Affiliation(s)
- Bridget F Koontz
- Department of Radiation Oncology,, Duke Cancer Institute, DUMC Box 3085, NC, 27710, Durham, USA.
| | - Erica Levine
- Arnhold Institute for Global Health, Icahn School of Medicine at Mount Sinai, NY, New York, USA.,Duke Digital Health Science Center, Duke Global Health Institute, Duke University, Durham, NC, 27710, USA
| | - Frances McSherry
- Duke Department of Biostatistics and Bioinformatics, Duke Cancer Institute Biostatistics, Durham, NC, 27710, USA
| | - Donna Niedzwiecki
- Duke Department of Biostatistics and Bioinformatics, Duke Cancer Institute Biostatistics, Durham, NC, 27710, USA
| | - Linda Sutton
- Department of Medicine, Duke School of Medicine, Durham, NC, 27710, USA.,Duke Cancer Network, Durham, NC, 27710, USA
| | - Tykeytra Dale
- Department of Radiation Oncology,, Duke Cancer Institute, DUMC Box 3085, NC, 27710, Durham, USA
| | - Martin Streicher
- Department of Population Health Sciences, Duke School of Medicine, Durham, NC, 27710, USA
| | - Christel Rushing
- Duke Department of Biostatistics and Bioinformatics, Duke Cancer Institute Biostatistics, Durham, NC, 27710, USA
| | - Lynda Owen
- Duke Cancer Network, Durham, NC, 27710, USA
| | - William E Kraus
- Department of Medicine, Duke School of Medicine, Durham, NC, 27710, USA.,Department of Population Health Sciences, Duke School of Medicine, Durham, NC, 27710, USA
| | - Gary Bennett
- Duke Digital Health Science Center, Duke Global Health Institute, Duke University, Durham, NC, 27710, USA.,Cancer Control and Population Sciences Program, Duke Cancer Institute, Durham, NC, 27710, USA
| | - Kathryn I Pollak
- Department of Population Health Sciences, Duke School of Medicine, Durham, NC, 27710, USA.,Cancer Control and Population Sciences Program, Duke Cancer Institute, Durham, NC, 27710, USA
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18
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Vapiwala N, Chen YH, Cho SY, Duan F, Kyriakopoulos C, Shevrin DH, McKay RR, Koontz BF, Yu EY, Beylergil V, Mankoff DA, McConathy J, Liu G, Wong TZ, Carducci MA. Phase III study of local or systemic therapy INtensification DIrected by PET in prostate CAncer patients with post-prostaTEctomy biochemical recurrence (INDICATE): ECOG-ACRIN EA8191. J Clin Oncol 2021. [DOI: 10.1200/jco.2021.39.15_suppl.tps5098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
TPS5098 Background: Radiation therapy (RT) to the prostate bed and pelvic nodes with short-term androgen deprivation therapy (STAD) is considered a standard of care (SOC) salvage therapy (ST) paradigm for prostate cancer (PC) patients (pts) with post-prostatectomy (RP) biochemical recurrence (BCR). Fluciclovine-PET/CT imaging is FDA-approved in this setting, with improved accuracy for detection of metastases not identified with conventional imaging (CIM). Given PET's greater sensitivity and specificity, its findings are increasingly but variably applied to justify modification or omission of SOC therapies without high-level evidence of clinical benefit. PET may help identify candidates for local or systemic treatment intensification of the otherwise non-tailored SOC approach. Improved systemic control and disease detection with molecular imaging have led to increasing use of focally ablative metastasis-directed RT, to delay or enhance systemic therapy through increased local control. There is also interest in earlier use of systemic therapy; apalutamide (Apa) is a nonsteroidal antiandrogen with established efficacy in improving overall and radiographic progression-free survival (PFS) for non-metastatic castration-resistant and metastatic castration-sensitive PC. This study will evaluate whether pts with PET-detected lesions benefit from such local or systemic treatment intensification approaches. Methods: PC pts with post-RP BCR (PSA>0.5ng/mL; >0.2ng/mL if within 12 mos of RP) and no metastases on CIM who are candidates for SOC ST (RT to prostate bed and pelvic nodes with STAD) are eligible. Prior to study registration, pts undergo SOC baseline PET (18F-fluciclovine but PSMA radiotracers permitted pending commercial availability). Based on institutional clinical interpretation of the SOC PET, pts will be placed in Cohort 1 (PET-negative) or 2 (PET-positive for extra-pelvic metastases). Cohort 1 will be randomized to SOC ST +/- Apa for 6 months and Cohort 2 will be randomized to SOC ST and Apa +/- metastasis-directed RT to PET-positive lesions. The primary endpoint is PFS, defined as time from randomization to radiographic progression on CIM, symptomatic disease or death. Primary objectives are to evaluate whether addition of Apa to SOC ST and addition of metastasis-directed RT to SOC ST and Apa could prolong PFS in Cohorts 1 and 2, respectively. For Cohort 1, 480 pts will be randomized with 85% power to distinguish 5-year PFS rate of 90% (Apa arm) vs. 80% (SOC arm) using one-sided stratified log-rank test with type I error of 0.025. For Cohort 2, 324 pts will be randomized with 85% power to distinguish 5-year PFS rate of 76.5% in the experimental arm from 61.5% in the control arm. Secondary endpoints include overall and event-free survival, toxicity, and PET progression. Clinical trial information: NCT04423211.
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Affiliation(s)
| | | | - Steve Y. Cho
- University of Wisconsin SMPH, Department of Radiology, University of Wisconsin Carbone Cancer Center, Madison, WI
| | | | | | | | - Rana R. McKay
- University of California San Diego, Moores Cancer Center, La Jolla, CA
| | | | - Evan Y. Yu
- Division of Oncology, Department of Medicine, University of Washington, Seattle, WA
| | | | | | | | - Glenn Liu
- University of Wisconsin Carbone Cancer Center, Madison, WI
| | - Terence Z. Wong
- Chief, Division of Nuclear Medicine and Radiotheranostics Professor of Radiology Professor in Medicine, Division of Medical Oncology Duke Cancer Institute Medical Physics Graduate Program Duke University Medical Center, Durham, NC
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19
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Turner AC, Powers SA, Odom MR, Pak ES, Ashcraft KA, Koontz BF, Hannan JL. Impact of prostatic radiation therapy on bladder contractility and innervation. Neurourol Urodyn 2021; 40:1470-1478. [PMID: 34015163 DOI: 10.1002/nau.24705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 05/03/2021] [Accepted: 05/06/2021] [Indexed: 11/10/2022]
Abstract
AIMS To determine the effect of prostatic radiation therapy (RT) on bladder contractility and morphology, and axon, or neuron profiles within the detrusor and major pelvic ganglia (MPG) in male rats. METHODS Male Sprague-Dawley rats (8 weeks) received a single dose of prostatic RT (0 or 22 Gy). Bladders and MPG were collected 2- and 10-weeks post-RT. Detrusor contractile responses to carbachol and electrical field stimulation (EFS) were measured. Bladders were stained with Masson's trichrome, and antibodies for nonspecific neuronal marker, cholinergic nerve marker choline acetyltransferase (ChAT), and alpha-smooth muscle actin. MPG gene expression was assessed by quantitative polymerase chain reaction for ubiquitin carboxy-terminal hydrolase L1 (Uchl1) and Chat. RESULTS At 2 weeks post-RT, bladder smooth muscle, detrusor cholinergic axon profiles, and MPG Chat gene expression were increased (p < .05), while carbachol and EFS-mediated contractions were decreased (p < .05). In contrast, at 10 weeks post-RT, nerve-mediated contractions were increased compared with control (p < .05), while bladder smooth muscle, detrusor cholinergic axon profiles, MPG Chat expression, and carbachol contractions had normalized. At both 2- and 10-weeks post-RT, there was no change in detrusor nonspecific axon profiles and MPG Uchl1 expression. CONCLUSION In a rat model, RT of the prostate and MPG was associated with early changes in MPG Chat gene expression, and bladder cholinergic axon profiles and smooth muscle content which resolved over time. After RT recovery, bladder contractility decreased early and increased by 10 weeks. Long-term changes to the MPG and increased bladder cholinergic axons may contribute to RT-induced bladder dysfunction in prostate cancer survivors.
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Affiliation(s)
- Alexander C Turner
- Department of Physiology, Brody School of Medicine, East Carolina University, Greenville, North Carolina, USA
| | - Shelby A Powers
- Department of Physiology, Brody School of Medicine, East Carolina University, Greenville, North Carolina, USA.,Department of Psychiatry & Behavioral Sciences, Duke University, Durham, North Carolina, USA
| | - Michael R Odom
- Department of Physiology, Brody School of Medicine, East Carolina University, Greenville, North Carolina, USA.,Division of Urology, Department of Surgery, Duke University, Durham, North Carolina, USA
| | - Elena S Pak
- Department of Physiology, Brody School of Medicine, East Carolina University, Greenville, North Carolina, USA
| | - Kathleen A Ashcraft
- Department of Radiation Oncology, Duke University, Durham, North Carolina, USA
| | - Bridget F Koontz
- Department of Radiation Oncology, Duke University, Durham, North Carolina, USA
| | - Johanna L Hannan
- Department of Physiology, Brody School of Medicine, East Carolina University, Greenville, North Carolina, USA
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20
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Jensen PJ, Zhang J, Koontz BF, Wu QJ. A Novel Machine Learning Model for Dose Prediction in Prostate Volumetric Modulated Arc Therapy Using Output Initialization and Optimization Priorities. Front Artif Intell 2021; 4:624038. [PMID: 33969289 PMCID: PMC8103207 DOI: 10.3389/frai.2021.624038] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 03/18/2021] [Indexed: 11/20/2022] Open
Abstract
Treatment planning for prostate volumetric modulated arc therapy (VMAT) can take 5–30 min per plan to optimize and calculate, limiting the number of plan options that can be explored before the final plan decision. Inspired by the speed and accuracy of modern machine learning models, such as residual networks, we hypothesized that it was possible to use a machine learning model to bypass the time-intensive dose optimization and dose calculation steps, arriving directly at an estimate of the resulting dose distribution for use in multi-criteria optimization (MCO). In this study, we present a novel machine learning model for predicting the dose distribution for a given patient with a given set of optimization priorities. Our model innovates upon the existing machine learning techniques by utilizing optimization priorities and our understanding of dose map shapes to initialize the dose distribution before dose refinement via a voxel-wise residual network. Each block of the residual network individually updates the initialized dose map before passing to the next block. Our model also utilizes contiguous and atrous patch sampling to effectively increase the receptive fields of each layer in the residual network, decreasing its number of layers, increasing model prediction and training speed, and discouraging overfitting without compromising on the accuracy. For analysis, 100 prostate VMAT cases were used to train and test the model. The model was evaluated by the training and testing errors produced by 50 iterations of 10-fold cross-validation, with 100 cases randomly shuffled into the subsets at each iteration. The error of the model is modest for this data, with average dose map root-mean-square errors (RMSEs) of 2.38 ± 0.47% of prescription dose overall patients and all optimization priority combinations in the patient testing sets. The model was also evaluated at iteratively smaller training set sizes, suggesting that the model requires between 60 and 90 patients for optimal performance. This model may be used for quickly estimating the Pareto set of feasible dose objectives, which may directly accelerate the treatment planning process and indirectly improve final plan quality by allowing more time for plan refinement.
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Affiliation(s)
- P James Jensen
- Department of Radiation Oncology, Duke Cancer Institute, Durham, NC, United States
| | - Jiahan Zhang
- Department of Radiation Oncology, Duke Cancer Institute, Durham, NC, United States
| | - Bridget F Koontz
- Department of Radiation Oncology, Duke Cancer Institute, Durham, NC, United States
| | - Q Jackie Wu
- Department of Radiation Oncology, Duke Cancer Institute, Durham, NC, United States
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21
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Affiliation(s)
- Bridget F Koontz
- Department of Radiation Oncology, Duke Cancer Institute, Duke University School of Medicine, Durham, North Carolina
| | - Thomas A Hope
- Department of Radiology and Biomedical Imaging, University of California, San Francisco
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22
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Vapiwala N, Chen YH, Cho SY, Duan F, Kyriakopoulos C, Shevrin DH, McKay RR, Koontz BF, Yu EY, Beylergil V, McConathy J, Liu G, Mankoff DA, Wong TZ, Carducci MA. PET-directed local or systemic therapy intensification in prostate cancer patients with post-prostatectomy biochemical recurrence: A trial of the ECOG-ACRIN Cancer Research Group (EA8191). J Clin Oncol 2021. [DOI: 10.1200/jco.2021.39.6_suppl.tps267] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
TPS267 Background: Radiation therapy (RT) to the prostate bed and pelvic nodes with short-term androgen deprivation therapy (STAD) is considered a standard of care (SOC) salvage therapy (ST) paradigm for prostate cancer (PC) patients (pts) with post-prostatectomy (RP) biochemical recurrence (BCR). Fluciclovine-PET/CT imaging is FDA-approved in this setting, with improved accuracy for detection of metastases (mets) not identified with conventional imaging (CIM). Given greater sensitivity and specificity of PET, its findings are being increasingly but variably applied to justify modification or omission of SOC therapies without high-level evidence of clinical benefit. PET may help identify candidates for local or systemic treatment intensification of otherwise non-tailored SOC. Earlier detection of mets with molecular imaging has led to increasing use of focally ablative met-directed RT, to delay or enhance systemic therapy through better local control. There is also interest in earlier use of advanced systemic therapy; apalutamide (Apa) is a nonsteroidal antiandrogen with established efficacy in improving overall and radiographic progression-free survival (PFS) for non-metastatic castrate-resistant and metastatic castration-sensitive PC, and potential activity for low-volume mets. This study will evaluate whether pts with PET-detected lesions benefit from such local or systemic treatment intensification approaches. Methods: PC pts with post-RP BCR (PSA>0.5ng/mL; >0.2 if RP within 12 mos), and negative CIM who are candidates for SOC ST (RT to prostate bed and pelvic nodes + STAD) and undergo SOC baseline PET are eligible. The study will initially use 18F-fluciclovine but permit additional radiotracers based on FDA approval and availability. Based on institutional clinical interpretation of the SOC PET, pts will be placed in Cohort 1 (PET-negative) or 2 (PET-positive for extra-pelvic mets). Cohort 1 will be randomized to SOC ST +/- Apa for 6 months and Cohort 2 will be randomized to SOC ST and Apa +/- met-directed RT to PET-positive lesions. The primary endpoint is PFS, defined as time from randomization to radiographic progression on CIM, symptomatic disease or death. Primary objectives are to evaluate whether addition of Apa to SOC ST and addition of met-directed RT to SOC ST and Apa could prolong PFS in Cohorts 1 and 2, respectively. For Cohort 1, 480 pts will be randomized with 85% power to distinguish 5-year PFS rate of 90% (Apa arm) vs. 80% (SOC arm) using one-sided stratified logrank test with type I error of 0.025. For Cohort 2, 324 pts will be randomized with 85% power to distinguish 5-year PFS rate of 76.5% in experimental arm from 61.5% in control arm. Secondary endpoints include overall and event-free survival, toxicity, and PET progression. Trial was activated on October 8, 2020; NCT04423211. Acknowledgement: This study was conducted by the ECOG-ACRIN Cancer Research Group (Peter J. O'Dwyer, MD and Mitchell D. Schnall, MD, PhD, Group Co-Chairs) and supported by the National Cancer Institute of the National Institutes of Health under the following award numbers: U10CA180794, U10CA180820, U10CA180868, U10CA180888, U10CA180821, UG1CA233196, UG1CA233253, UG1CA233277, UG1CA233328, and UG1CA233330. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Mention of trade names, commercial products, or organizations does not imply endorsement by the U.S. government. Clinical trial information: NCT 04423211.
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Affiliation(s)
| | | | - Steve Y. Cho
- University of Wisconsin SMPH, Department of Radiology, University of Wisconsin Carbone Cancer Center, Madison, WI
| | | | | | | | - Rana R. McKay
- University of California San Diego, Moores Cancer Center, La Jolla, CA
| | | | - Evan Y. Yu
- Division of Oncology, Department of Medicine, University of Washington, Seattle, WA
| | | | | | - Glenn Liu
- University of Wisconsin Carbone Cancer Center, Madison, WI
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23
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Zhang T, Koontz BF, Tagawa ST, Nagar H, Bitting RL, Frizzell B, Nordquist LT, Rasmussen J, Wilder R, Anand M, Winters C, Riggan C, Fernandez E, Healy P, Oyekunle T, Wu Y, McNamara MA, Harrison MR, George DJ, Armstrong AJ. Interim analysis of STARTAR: A phase II salvage trial of androgen receptor (AR) inhibition with androgen deprivation therapy (ADT) and apalutamide with radiation therapy (RT) followed by docetaxel in men with PSA recurrent prostate cancer (PC) after radical prostatectomy (RP). J Clin Oncol 2021. [DOI: 10.1200/jco.2021.39.6_suppl.90] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
90 Background: ADT with salvage RT improves survival for men with PSA recurrence after RP. Current standard duration of ADT for high risk PSA recurrence is up to 2 years with RT; therefore shortening but intensifying systemic therapy may improve outcomes. The STREAM trial showed 6 mo of enzalutamide added to ADT/RT had a 3-year progression free survival (PFS) of 53% in high risk patients including lymph node (LN) positive. Given that docetaxel improves survival in men with mHSPC, we evaluated the combination of salvage RT, ADT/apalutamide and docetaxel in this setting. Methods: STARTAR is a multicenter phase 2 trial for salvage treatment of PSA recurrent PC following RP conducted within the US Dept. of Defense Prostate Cancer Clinical Trials Consortium (DOD PCCTC). Key inclusion criteria included PC with Gleason 7 with T3/positive margin/1-4 positive LNs or Gleason 8-10 disease and PSA relapse within 4 years of RP (min PSA 0.2 ng/mL to max PSA 4 ng/mL). Men with up to 4 positive resected LNs were eligible. Men started ADT with apalutamide, continued with RT (66-74 Gy to the prostate bed +/- pelvic LNs over 6-8 weeks), and finally completed docetaxel 75mg/m2 IV q3 weeks for 6 cycles. Men were treated with ADT and apalutamide for approximately 9 months. The primary endpoint was PSA PFS at 36 months. This interim analysis evaluated secondary endpoints of 1-year PSA recurrence, testosterone recovery, and safety of this treatment sequence. Results: From 3/2018 to 12/2019, 39 men were enrolled at Duke, Wake Forest, Cornell, and the GU Research Network. With a data cutoff in 9/2020, median follow up from enrollment was 14 months. Baseline patient characteristics included Gleason 4+3 = 7 in 54% and Gleason 8-10 in 46%, and 23% LN positive; median PSA at the time of enrollment was 0.58 ng/mL (range 0.21-3.40) and the median time from RP to enrollment was 7 mo (range 2-98). At 1 year, there have been no progression events with 38% (12/31) of men with post-treatment testosterone recovery into normal range (recovery time median 10 mos [1-17 mos]). Common adverse events (AEs) of any-grade at least possibly related to the regimen were 98% hot flashes, 88% fatigue, 77% alopecia, 57% dysgeusia, and 53% rash (28% grade 1; 15% grade 2, 10% grade 3), with neutropenia as the most common grade 3/4 AE (27/39 men, 70%) with two grade 3 febrile neutropenia. Conclusions: In this first phase 2 trial of ADT, apalutamide, radiation, and 6 cycles docetaxel in the salvage setting for high risk PSA recurrence, short term outcomes are excellent with no recurrences at 12 months of follow-up. This salvage treatment was well tolerated in the majority of men with the exception of a high rate of drug rashes and neutropenia related to the course of treatment, in line with known safety profiles of the study agents. Clinical trial information: NCT03311555.
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Affiliation(s)
- Tian Zhang
- Duke Cancer Institute Center for Prostate and Urologic Cancers, Duke University, Durham, NC
| | | | | | - Himanshu Nagar
- New York-Presbyterian Hospital/Weill Cornell Medicine, New York, NY
| | - Rhonda L. Bitting
- Internal Medicine, Section on Hematology and Oncology, Winston Salem, NC
| | | | | | | | | | | | | | | | | | | | - Taofik Oyekunle
- Department of Biostatistics and Bioinformatics, Duke Cancer Institute, Durham, NC
| | - Yuan Wu
- Department of Biostatistics and Bioinformatics, Duke Cancer Institute, Durham, NC
| | | | - Michael Roger Harrison
- Duke Cancer Institute Center for Prostate and Urologic Cancers, Duke University, Durham, NC
| | - Daniel J. George
- Duke Cancer Institute Center for Prostate and Urologic Cancers, Duke University, Durham, NC
| | - Andrew J. Armstrong
- Duke Cancer Institute Center for Prostate and Urologic Cancers, Duke University, Durham, NC
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24
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Hall WA, Paulson E, Davis BJ, Spratt DE, Morgan TM, Dearnaley D, Tree AC, Efstathiou JA, Harisinghani M, Jani AB, Buyyounouski MK, Pisansky TM, Tran PT, Karnes RJ, Chen RC, Cury FL, Michalski JM, Rosenthal SA, Koontz BF, Wong AC, Nguyen PL, Hope TA, Feng F, Sandler HM, Lawton CAF. NRG Oncology Updated International Consensus Atlas on Pelvic Lymph Node Volumes for Intact and Postoperative Prostate Cancer. Int J Radiat Oncol Biol Phys 2021; 109:174-185. [PMID: 32861817 PMCID: PMC7736505 DOI: 10.1016/j.ijrobp.2020.08.034] [Citation(s) in RCA: 60] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 07/31/2020] [Accepted: 08/07/2020] [Indexed: 02/08/2023]
Abstract
PURPOSE In 2009, the Radiation Therapy Oncology Group (RTOG) genitourinary members published a consensus atlas for contouring prostate pelvic nodal clinical target volumes (CTVs). Data have emerged further informing nodal recurrence patterns. The objective of this study is to provide an updated prostate pelvic nodal consensus atlas. METHODS AND MATERIALS A literature review was performed abstracting data on nodal recurrence patterns. Data were presented to a panel of international experts, including radiation oncologists, radiologists, and urologists. After data review, participants contoured nodal CTVs on 3 cases: postoperative, intact node positive, and intact node negative. Radiation oncologist contours were analyzed qualitatively using count maps, which provided a visual assessment of controversial regions, and quantitatively analyzed using Sorensen-Dice similarity coefficients and Hausdorff distances compared with the 2009 RTOG atlas. Diagnostic radiologists generated a reference table outlining considerations for determining clinical node positivity. RESULTS Eighteen radiation oncologists' contours (54 CTVs) were included. Two urologists' volumes were examined in a separate analysis. The mean CTV for the postoperative case was 302 cm3, intact node positive case was 409 cm3, and intact node negative case was 342 cm3. Compared with the original RTOG consensus, the mean Sorensen-Dice similarity coefficient for the postoperative case was 0.63 (standard deviation [SD] 0.13), the intact node positive case was 0.68 (SD 0.13), and the intact node negative case was 0.66 (SD 0.18). The mean Hausdorff distance (in cm) for the postoperative case was 0.24 (SD 0.13), the intact node positive case was 0.23 (SD 0.09), and intact node negative case was 0.33 (SD 0.24). Four regions of CTV controversy were identified, and consensus for each of these areas was reached. CONCLUSIONS Discordance with the 2009 RTOG consensus atlas was seen in a group of experienced NRG Oncology and international genitourinary radiation oncologists. To address areas of variability and account for new data, an updated NRG Oncology consensus contour atlas was developed.
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Affiliation(s)
- William A Hall
- Medical College of Wisconsin, Department of Radiation Oncology, Milwaukee, Wisconsin.
| | - Eric Paulson
- Medical College of Wisconsin, Department of Radiation Oncology, Milwaukee, Wisconsin
| | - Brian J Davis
- Mayo Clinic, Department of Radiation Oncology, Rochester, Minnesota
| | - Daniel E Spratt
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Todd M Morgan
- Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - David Dearnaley
- The Royal Marsden NHS Foundation Trust and The Institute of Cancer Research, London, UK
| | - Alison C Tree
- The Royal Marsden NHS Foundation Trust and The Institute of Cancer Research, London, UK
| | - Jason A Efstathiou
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Mukesh Harisinghani
- Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Ashesh B Jani
- Department of Radiation Oncology, Emory University, Atlanta, Georgia
| | | | | | - Phuoc T Tran
- Department of Radiation Oncology, Johns Hopkins, Baltimore, Maryland
| | | | - Ronald C Chen
- Department of Radiation Oncology, University of Kansas, Kansas City, Kansas
| | - Fabio L Cury
- Department of Radiation Oncology, McGill University, Montreal, Canada
| | - Jeff M Michalski
- Department of Radiation Oncology, Washington University, St. Louis, Missouri
| | - Seth A Rosenthal
- Department of Radiation Oncology, Sutter Medical Group, Roseville, California
| | - Bridget F Koontz
- Department of Radiation Oncology, Duke Cancer Institute, Durham, North Carolina
| | - Anthony C Wong
- Department of Radiation Oncology, University of California San Francisco, San Francisco, California
| | - Paul L Nguyen
- Department of Radiation Oncology, Dana Farber Harvard Cancer Center, Boston, Massachusetts
| | - Thomas A Hope
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California
| | - Felix Feng
- Department of Radiation Oncology, University of California San Francisco, San Francisco, California
| | - Howard M Sandler
- Department of Radiation Oncology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Colleen A F Lawton
- Medical College of Wisconsin, Department of Radiation Oncology, Milwaukee, Wisconsin
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Koontz BF, Hoffman KE, Halabi S, Healy P, Anand M, George DJ, Harrison MR, Zhang T, Berry WR, Corn PG, Lee WR, Armstrong AJ. Combination of Radiation Therapy and Short-Term Androgen Blockade With Abiraterone Acetate Plus Prednisone for Men With High- and Intermediate-Risk Localized Prostate Cancer. Int J Radiat Oncol Biol Phys 2020; 109:1271-1278. [PMID: 33259932 DOI: 10.1016/j.ijrobp.2020.11.059] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 10/21/2020] [Accepted: 11/22/2020] [Indexed: 01/07/2023]
Abstract
PURPOSE Long-term androgen-deprivation therapy (ADT) is the standard of care in combination with radiation therapy (RT) in high-risk prostate cancer (PC), despite substantial toxicity from the resulting hypogonadism. We hypothesized that a combination of more potent but shorter-term androgen inhibition in men with intermediate- or high-risk localized PC would synergize with definitive RT to provide short-term testosterone recovery and improve disease control. METHODS AND MATERIALS This prospective phase 2 single-arm trial enrolled men with low-volume unfavorable intermediate or high-risk localized PC. Treatment included 6 months of ADT concurrent with abiraterone acetate plus prednisone (AAP) once daily and RT to prostate and seminal vesicles. The primary endpoint was the proportion of men with an undetectable prostate-specific antigen (PSA) at 12-months; secondary objectives included biochemical progression-free survival (PFS), testosterone recovery, toxicity, and sexual and hormonal quality of life. RESULTS We enrolled 37 men between January 2014 and August 2016, 45% of whom were high risk. All patients had T1-2 disease and PSA < 20 ng/mL. Median follow-up is 37 months (95% confidence interval [CI], 35.7-39.1). Treatment noted 32% grade 3 toxicities related to AAP, predominantly hypertension, with no toxicities ≥G4. The rate of undetectable PSA at 12 months was 55% (95% CI, 36%-72%). With 46 months of median follow-up, 2 of 37 patients developed PSA progression (36-month PFS = 96%; 95% CI, 76%-99%), and 81% of patients recovered testosterone with a median time to recovery of 9.2 months. Hormonal or sexual function declined at 6 months with subsequent improvement by 24 months. CONCLUSIONS The combination of RT and 6 months of ADT and AAP demonstrated acceptable toxicity and a high rate of testosterone recovery with restoration of quality of life and excellent disease control in men with low-volume, intermediate- or high-risk localized prostate cancer. Prospective comparative studies are justified.
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Affiliation(s)
- Bridget F Koontz
- Duke Cancer Institute Center for Prostate and Urologic Cancers, Durham, North Carolina; Department of Radiation Oncology, Duke University, Durham, North Carolina.
| | - Karen E Hoffman
- Department of Radiation Oncology, The University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Susan Halabi
- Duke Cancer Institute Center for Prostate and Urologic Cancers, Durham, North Carolina; Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina
| | - Patrick Healy
- Duke Cancer Institute Center for Prostate and Urologic Cancers, Durham, North Carolina; Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina
| | - Monika Anand
- Duke Cancer Institute Center for Prostate and Urologic Cancers, Durham, North Carolina
| | - Daniel J George
- Duke Cancer Institute Center for Prostate and Urologic Cancers, Durham, North Carolina; Department of Medicine, Division of Medical Oncology, Duke University, Durham, North Carolina; Department of Surgery, Division of Urology, Duke University, Durham, North Carolina
| | - Michael R Harrison
- Duke Cancer Institute Center for Prostate and Urologic Cancers, Durham, North Carolina; Department of Medicine, Division of Medical Oncology, Duke University, Durham, North Carolina
| | - Tian Zhang
- Duke Cancer Institute Center for Prostate and Urologic Cancers, Durham, North Carolina; Department of Medicine, Division of Medical Oncology, Duke University, Durham, North Carolina
| | - William R Berry
- Duke Cancer Institute Center for Prostate and Urologic Cancers, Durham, North Carolina; Department of Medicine, Division of Medical Oncology, Duke University, Durham, North Carolina
| | - Paul G Corn
- Department of Radiation Oncology, The University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - W Robert Lee
- Duke Cancer Institute Center for Prostate and Urologic Cancers, Durham, North Carolina; Department of Radiation Oncology, Duke University, Durham, North Carolina
| | - Andrew J Armstrong
- Duke Cancer Institute Center for Prostate and Urologic Cancers, Durham, North Carolina; Department of Medicine, Division of Medical Oncology, Duke University, Durham, North Carolina; Department of Surgery, Division of Urology, Duke University, Durham, North Carolina; Department of Pharmacology and Cancer Biology, Duke University, Durham, North Carolina
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26
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Koontz BF. The role of radiation treatment in metastatic prostate cancer. Clin Adv Hematol Oncol 2020; 18:707-709. [PMID: 33406062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
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Koontz BF. Through COVID-Colored Glasses: New Perspectives on Same Data. Int J Radiat Oncol Biol Phys 2020; 108:338. [PMID: 32890503 PMCID: PMC7462869 DOI: 10.1016/j.ijrobp.2020.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 07/04/2020] [Indexed: 10/31/2022]
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Nukala V, Incrocci L, Hunt AA, Ballas L, Koontz BF. Challenges in Reporting the Effect of Radiotherapy on Erectile Function. J Sex Med 2020; 17:1053-1059. [PMID: 32312661 DOI: 10.1016/j.jsxm.2020.03.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Revised: 03/10/2020] [Accepted: 03/11/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Erectile dysfunction (ED) is the most common side effect of prostate radiotherapy (RT), but reported rates over time and across modalities have varied widely. AIM To evaluate the published literature between 2002 and 2018 for high quality data utilizing prospectively gathered patient-reported ED, and to summarize the challenges in reporting of RT-induced ED (RIED). METHODS A PubMed search and literature review was performed to identify articles describing rates of ED before and after definitive external beam RT or brachytherapy without androgen deprivation. OUTCOMES Patient-reported ED, patient and treatment variables, and study follow-up constituted the main outcomes of this study. RESULTS 24 articles were identified, reporting RIED rates between 17% and 90%. Variables contributing to this range included patient, treatment, and study characteristics known to impact ED reporting. CLINICAL IMPLICATIONS For future studies, we recommend the use of validated patient-reported questionnaires and reporting of baseline function and comorbidities, RT type and dose, and use of androgen deprivation therapy and erectile aids at the time of ED measurement. With sufficient follow-up to understand the late nature of RIED, these recommendations will improve comparison of results between studies and the applicability of results to patients undergoing pretreatment counseling regarding the risks of RIED. STRENGTHS & LIMITATIONS The literature search and formulation of results were based on a broad understanding of the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines and the literature, but because of the focus on data reporting, a comprehensive systematic review of all RIED literature was not performed. CONCLUSION Reported rates of ED after RT vary widely due to differences in patients' baseline reported erectile function, age, comorbidities, and characteristics of the treatment delivered. The methodology of ED measurement has significant impact on the applicability and comparability of results to other studies and clinical practice. Nukala V, Incrocci L, Hunt AA, et al. Challenges in Reporting the Effect of Radiotherapy on Erectile Function. J Sex Med 2020;17:1053-1059.
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Affiliation(s)
- Varun Nukala
- Department of Neuroscience, Duke University, Durham, NC, USA
| | - Luca Incrocci
- Department of Radiation Oncology, Erasmus Medical Center, Rotterdam, The Netherlands
| | | | - Leslie Ballas
- Department of Radiation Oncology, University of Southern California, Los Angeles, CA, USA
| | - Bridget F Koontz
- Department of Neuroscience, Duke University, Durham, NC, USA; Department of Radiation Oncology, Duke Cancer Institute, Durham, NC, USA.
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Parikh NR, Chang EM, Nickols NG, Rettig M, Raldow AC, Steinberg ML, Koontz BF, Vapiwala N, Deville C, Feng FY, Spratt DE, Reiter RE, Phillips R, Tran PT, Kishan AU. Cost-effectiveness of upfront therapeutic options in low-volume de novo metastatic hormone-sensitive prostate cancer. J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.6_suppl.211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
211 Background: Low-volume de novo metastatic hormone-sensitive prostate cancer (mHSPC) has historically been treated with lifelong androgen deprivation therapy (ADT). Recently, however, the addition of several advanced therapeutic options – radiation therapy (RT) to the primary, advanced hormonal therapy agents such as abiraterone acetate/prednisone (AAP), and chemotherapy – to ADT have been shown to improve survival in low-volume mHSPC. The objective of this study was to compare the cost-effectiveness of treating low-volume mHSPC patients upfront with RT+ADT, AAP+ADT, or docetaxel+ADT. Methods: A Markov-based cost-effectiveness analysis was constructed comparing three treatment strategies for low-volume mHSPC patients: (1) upfront RT+ADT --> salvage AAP+ADT --> salvage docetaxel+ADT; (2) upfront AAP+ADT --> salvage docetaxel+ADT, and (3) upfront docetaxel+ADT --> salvage AAP+ADT. Transition probabilities were calculated using data from STAMPEDE arms C/G/H, COU-AA-301, COU-AA-302, and TAX-327. RT was delivered via five-fraction stereotactic body radiation therapy. The analysis utilized a 10-year time horizon, and a $100,000/quality adjusted life year (QALY) willingness-to-pay threshold. Utilities were extracted from the literature; costs were taken from Medicare fee schedules and VA oral drug contracts. Results: At 10 years, total cost was $140K, $259K, and $189K, with total QALYs of 4.66, 5.03, and 3.72 for strategies (1) upfront RT+ADT, (2) upfront AAP+ADT, and (3) upfront docetaxel+ADT, respectively. Compared to upfront RT+ADT, upfront AAP+ADT was not cost-effective (ICER: $321K/QALY). This result remained unchanged even after modification of various model inputs in 1-way sensitivity analysis. Upfront docetaxel+ADT was both more costly and less effective than upfront RT+ADT (ICER: -$53K/QALY). Conclusions: At 10 years, RT+ADT is cost-effective compared to other advanced systemic therapy options alone, and should be considered as a viable treatment strategy in all patients with a low-burden of metastatic disease. Additional studies are needed to determine whether any benefit exists in combining RT to the primary with upfront advanced systemic therapy.
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Affiliation(s)
| | - Eric M. Chang
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA
| | | | - Matthew Rettig
- UCLA Jonsson Comprehensive Cancer Center, Los Angeles, CA
| | - Ann C. Raldow
- University of California Los Angeles, Los Angeles, CA
| | | | | | | | | | - Felix Y Feng
- UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, CA
| | | | - Robert Evan Reiter
- Institute of Urologic Oncology, University of California, Los Angeles, Los Angeles, CA
| | - Ryan Phillips
- Department of Radiation Oncology and Molecular Radiation Sciences, The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD
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Koontz BF, Dal Pra A. Shifting the Curtain-Can We Make Sense of the Whole Pelvis Controversy? Int J Radiat Oncol Biol Phys 2020; 106:534-536. [PMID: 32014149 DOI: 10.1016/j.ijrobp.2019.11.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 11/04/2019] [Accepted: 11/10/2019] [Indexed: 11/25/2022]
Affiliation(s)
- Bridget F Koontz
- Department of Radiation Oncology, Duke Cancer Institute, Durham, North Carolina.
| | - Alan Dal Pra
- Department of Radiation Oncology, University of Miami Miller School of Medicine, Miami, Florida
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Price J, Koontz BF. Sexual Preservation With Radiotherapy: Think Target, Not Tool. J Sex Med 2019; 16:1871-1873. [DOI: 10.1016/j.jsxm.2019.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 09/16/2019] [Accepted: 09/19/2019] [Indexed: 11/26/2022]
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Rosett HA, Herring K, Ratliff W, Koontz BF, Zafar Y, LeBlanc TW. Integration of electronic patient-reported outcomes into clinical workflows within the Epic electronic medical record. J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.31_suppl.102] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
102 Background: Electronic patient-reported outcome measures (ePROs) offer a new strategy for symptom assessment that can improve quality of life and prolong survival in routine cancer care. However, ePRO systems are often separate from existing electronic medical records (EMRs) and not well integrated into oncology clinics. In this pilot project, we assessed the feasibility and utility of integrating ePROs into our existing EMR and clinical workflows. Methods: The 10-question Edmonton Symptom Assessment Scale (ESAS) was integrated into the Epic EMR at three outpatient clinics in the Duke Cancer Institute. Patients with active MyChart accounts were offered the ESAS survey prior to their visit, via the patient portal. ePRO data were routed to clinicians in tabular and graphical formats. A “SmartPhrase” facilitated easy data integration into clinical notes. We subsequently interviewed clinicians and optimized workflows. Several patient engagement strategies were used, including automated messages, phone call reminders, and electronic tablets, to increase response rate. Results: It was feasible to quickly customize and activate an ePRO in Epic. Over 10 months, 161 patients completed 208 ePRO surveys. Initially, 10-20% of eligible patients completed the MyChart questionnaire. Patient engagement strategies, including phone calls and personalized MyChart messages, had little effect. Ultimately, tablets were introduced in the clinic check-in process, increasing response rates to >90%. Clinicians reported positive regard for the system, and an impact on patient symptom management. Clinician workflow optimization resulted in minimal “clicks” in the EMR, and the SmartPhrase was used in 128 clinical notes. Conclusions: Integration of ePROs into the clinical setting poses three challenges: technical implementation, workflow optimization, and patient engagement. While technical implementation is important, it was the easiest to solve, with patient engagement as the greatest barrier. Clinicians value an integrated ePRO system that automatically routes data to the clinical note. The key to successful ePRO integration is in ease of use for both patients and clinicians.
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Affiliation(s)
| | - Kris Herring
- Duke Cancer Institute, Duke University Medical Center, Durham, NC
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Kelsey CR, Broadwater G, James O, Chino J, Diehl L, Beaven AW, Chang C, Koontz BF, Prosnitz LR. Phase 2 Study of Dose-Reduced Consolidation Radiation Therapy in Diffuse Large B-Cell Lymphoma. Int J Radiat Oncol Biol Phys 2019; 105:96-101. [PMID: 30858144 PMCID: PMC10171462 DOI: 10.1016/j.ijrobp.2019.02.055] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Revised: 02/04/2019] [Accepted: 02/26/2019] [Indexed: 01/19/2023]
Abstract
PURPOSE To evaluate the feasibility of reducing the dose of consolidation radiation therapy (RT) in diffuse large B-cell lymphoma. METHODS AND MATERIALS This phase 2 study enrolled patients with diffuse large B-cell lymphoma, not otherwise specified and primary mediastinal (thymic) large B-cell lymphoma in complete response on positron emission tomography-computed tomography imaging after ≥4 cycles of a rituximab/anthracycline-containing combination chemotherapy regimen. Consolidation RT used a dose of 19.5 to 20 Gy. The primary endpoint was 5-year freedom from local recurrence. RESULTS Sixty-two patients were enrolled between 2010 and 2016. Stage distribution was as follows: I to II (n = 49, 79%) and III to IV (n = 13, 21%). Bulky disease (defined as ≥7.5 cm or ≥10 cm) was present in 23 (40%) and 16 (28%) patients, respectively. Chemotherapy was R-CHOP (then list the drugs) in 58 (94%) and R-EPOCH (then list the drugs) in 4 (6%) with a median of 6 cycles. With a median follow-up of 51 months, 7 patients developed disease progression (6 outside the RT field, 1 within the RT field). Freedom from local recurrence at 5 years was 98% (90% lower confidence bound, 88%). Progression-free and overall survival at 5 years were 83% and 90%, respectively. CONCLUSIONS With more effective systemic therapy (e.g., addition of rituximab) and more refined chemotherapy response assessment (e.g., positron emission tomography-computed tomography), the dose of RT in combined modality treatment programs may potentially be reduced to 20 Gy. This achieves excellent local control with the potential to decrease acute and long-term side effects.
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Affiliation(s)
- Chris R Kelsey
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina.
| | - Gloria Broadwater
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, North Carolina
| | - Olga James
- Department of Radiology, Division of Nuclear Medicine, Duke University Medical Center, Durham, North Carolina
| | - Junzo Chino
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - Louis Diehl
- Department of Medicine, Division of Hematologic Malignancies and Cellular Therapy, Duke University Medical Center, Durham, North Carolina
| | - Anne W Beaven
- Department of Medicine, Division of Medical Oncology, University of North Carolina Medical Center, Chapel Hill, North Carolina
| | - Catherine Chang
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - Bridget F Koontz
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - Leonard R Prosnitz
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
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Berkowitz CM, Zullig LL, Koontz BF, Smith SK. Prescribing an App? Oncology Providers' Views on Mobile Health Apps for Cancer Care. JCO Clin Cancer Inform 2019; 1:1-7. [PMID: 30657404 DOI: 10.1200/cci.17.00107] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
INTRODUCTION Although there are over 500 mobile health (mHealth) applications (apps) available for download in the field of oncology, little research has addressed their acceptability among health care providers. In addition, the providers' perspectives regarding patient app use has been largely unexamined. We conducted a qualitative study to explore opportunities and barriers for mHealth app use for oncology care. METHODS We developed a structured interview guide focusing on acceptability, appropriateness, feasibility, and sustainability of the use of apps in cancer care. We interviewed 15 oncology providers about their attitudes and preferences. De-identified audio recordings were transcribed and coded for emerging themes. RESULTS Providers interviewed included physicians (n = 8) and advanced practice (n = 3) and supportive services (n = 4) providers who care for a wide range of cancer types; ages ranged from 32 to 68 years. Interviews lasted approximately 30 minutes. Oncology providers reported limited exposure to mHealth apps in patient care, but were generally open to recommending or prescribing apps in the future. Key themes included opportunities for mobile app use (including general health promotion, tracking symptoms, and engaging patients) and barriers to implementation (including access to technology, responsibility, workflow, and the source of the app itself). CONCLUSION Our results show openness among oncology providers to using mHealth technology as part of patient care, but concerns regarding implementation. Designing acceptable apps may be challenging and require involvement of key stakeholders, partnering with trustworthy institutions, and outcome-based research.
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Affiliation(s)
- Callie M Berkowitz
- Callie M. Berkowitz, Leah L. Zullig, and Sophia K. Smith, Duke University; Leah L. Zullig, Durham Veterans Affairs Health Care System; and Bridget F. Koontz and Sophia K. Smith, Duke Cancer Institute, Durham, NC
| | - Leah L Zullig
- Callie M. Berkowitz, Leah L. Zullig, and Sophia K. Smith, Duke University; Leah L. Zullig, Durham Veterans Affairs Health Care System; and Bridget F. Koontz and Sophia K. Smith, Duke Cancer Institute, Durham, NC
| | - Bridget F Koontz
- Callie M. Berkowitz, Leah L. Zullig, and Sophia K. Smith, Duke University; Leah L. Zullig, Durham Veterans Affairs Health Care System; and Bridget F. Koontz and Sophia K. Smith, Duke Cancer Institute, Durham, NC
| | - Sophia K Smith
- Callie M. Berkowitz, Leah L. Zullig, and Sophia K. Smith, Duke University; Leah L. Zullig, Durham Veterans Affairs Health Care System; and Bridget F. Koontz and Sophia K. Smith, Duke Cancer Institute, Durham, NC
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Zullig LL, Ramos K, Berkowitz C, Miller JJ, Dolor RJ, Koontz BF, Yousuf Zafar S, Hutch Allen D, Tenhover JA, Bosworth HB. Assessing Key Stakeholders' Knowledge, Needs, and Preferences for Head and Neck Cancer Survivorship Care Plans. J Cancer Educ 2019; 34:584-591. [PMID: 29526021 PMCID: PMC8101022 DOI: 10.1007/s13187-018-1345-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/29/2023]
Abstract
Cancer survivorship care plans (SCPs) are endorsed to support quality care for cancer survivors, but uptake is slow. We assessed knowledge, needs, and preferences for SCP content and delivery from a wide variety of stakeholders. We focused SCP content for head and neck cancer as it is a disease prone to long-term side effects requiring management from multiple providers. We conducted telephone-based, qualitative interviews. We purposively sampled head and neck cancer survivors (n = 4), primary care physicians in the community (n = 5), and providers affiliated with a large academic medical center (n = 5) who treat head and neck cancer, cancer specialists (n = 6), and nurse practitioners/supportive care staff (n = 5). Interviews were recorded, transcribed, and analyzed using direct content analysis. Few participants reported personal experience with SCPs, but most supported the concept. Several key themes emerged: (1) perceived ambiguity regarding roles and responsibilities for SCPs, (2) a need to tailor the content and language based on the intended recipient, (3) documentation process should be as automated and streamlined as possible, (4) concerns about using the SCP to coordinate with outside providers, and (5) that SCPs would have added value as a "living document." We also report SCP-related issues that are unique to serving patients diagnosed with head and neck cancer. Effort is needed to tailor SCPs for different recipients and optimize their potential for successful implementation, impact on care outcomes, and sustainability. Many cancer survivors may not receive a SCP as part of routine care. Survivors could engage their health care team by requesting a SCP.
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Affiliation(s)
- Leah L Zullig
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Health Care Center, Durham, NC, 27705, USA.
- Department of Population Health Sciences, Duke University Medical Center, Durham, NC, 27710, USA.
- Duke Cancer Institute, Duke University Medical Center, Durham, NC, 27710, USA.
| | - Katherine Ramos
- Geriatric Research Education and Clinical Center, Durham Veterans Affairs Health Care Center, Durham, NC, 27705, USA
| | | | - Julie J Miller
- Department of Population Health Sciences, Duke University Medical Center, Durham, NC, 27710, USA
| | - Rowena J Dolor
- Division of General Internal Medicine, Duke University Medical Center, Durham, NC, 27710, USA
| | - Bridget F Koontz
- Duke Cancer Institute, Duke University Medical Center, Durham, NC, 27710, USA
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC, 27710, USA
| | - S Yousuf Zafar
- Duke Cancer Institute, Duke University Medical Center, Durham, NC, 27710, USA
- Department of Medical Oncology, Duke University Medical Center, Durham, NC, 27710, USA
| | - D Hutch Allen
- Duke Cancer Institute, Duke University Medical Center, Durham, NC, 27710, USA
| | - Jennifer A Tenhover
- Duke Cancer Institute, Duke University Medical Center, Durham, NC, 27710, USA
| | - Hayden B Bosworth
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Health Care Center, Durham, NC, 27705, USA
- Department of Population Health Sciences, Duke University Medical Center, Durham, NC, 27710, USA
- Duke Cancer Institute, Duke University Medical Center, Durham, NC, 27710, USA
- School of Nursing, Duke University Medical Center, Durham, NC, 27710, USA
- Department of Psychiatry and Behavioral Sciences, Duke University, Durham, NC, 27710, USA
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Zhang T, Koontz BF, Tagawa ST, Nagar H, Bitting RL, Frizzell B, Rasmussen J, Wilder R, Anand M, Winters C, Riggan C, Lee A, Healy P, Wu Y, McNamara MA, Harrison MR, George DJ, Armstrong AJ. A phase II Salvage Trial of AR Inhibition with ADT and Apalutamide with Radiation therapy followed by docetaxel in men with PSA recurrent prostate cancer (PC) after radical prostatectomy (STARTAR). J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.15_suppl.tps5097] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
TPS5097 Background: Androgen deprivation combined with salvage external beam radiation therapy (RT) have improved survival for patients (pts) with non-metastatic hormone naïve PC and PSA recurrence after radical prostatectomy (RP). Our recent STREAM trial showed addition of enzalutamide to RT and ADT had a 3-year progression free survival (PFS) of 53%. Adding effective PC treatments in this setting may further improve 3-year PFS. Methods: STARTAR is an investigator-initiated phase 2 trial for salvage treatment of biochemically recurrent PC following prostatectomy. Key inclusion criteria include histologic prostate adenocarcinoma, either Gleason 7 with T3/positive margin/1-4 positive lymph nodes or Gleason 8-10 disease, PSA relapse within 4 years of prostatectomy (minimum PSA 0.2 ng/mL to maximum PSA 4 ng/mL). Treatment involves ADT with apalutamide for 9 months, continue with with prostate bed +/- nodal RT at month 3, followed by 6 cycles of docetaxel 75mg/m2 IV every 3 weeks for 6 cycles. The primary endpoint of the study is 3-year PFS. With a one-sided alpha of 0.05 to improve 3-year PFS from 50% to 75%, we will have 92% power by enrolling 42 pts (including 10% dropout rate) based on the binomial test. Key secondary endpoints include 1, 2, and 3-year PSA recurrence rates with testosterone recovery, PSA PFS, PSA nadir, time to testosterone recovery, and safety of combination therapy. Quality of life will be assessed by EPIC questionnaire. As of February 2019, we have enrolled and treated 12 pts in this PCCTC trial. Accrual to the STARTAR trial is ongoing (NCT03311555). Clinical trial information: NCT03311555.
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Affiliation(s)
- Tian Zhang
- Duke University Medical Center, Durham, NC
| | | | | | - Himanshu Nagar
- New York-Presbyterian Hospital/Weill Cornell Medicine, New York, NY
| | - Rhonda L. Bitting
- Internal Medicine, Section on Hematology and Oncology, Winston Salem, NC
| | | | | | | | | | | | | | | | | | - Yuan Wu
- Department of Biostatistics and Bioinformatics, Duke Cancer Institute, Durham, NC
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Thor M, Deasy JO, Paulus R, Robert Lee W, Amin MB, Bruner DW, Low DA, Shah AB, Malone SC, Michalski JM, Dayes IS, Seaward SA, Gore EM, Albert M, Pisansky TM, Faria SL, Chen Y, Koontz BF, Swanson GP, Pugh SL, Sandler HM. Tolerance doses for late adverse events after hypofractionated radiotherapy for prostate cancer on trial NRG Oncology/RTOG 0415. Radiother Oncol 2019; 135:19-24. [PMID: 31015166 DOI: 10.1016/j.radonc.2019.02.014] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 02/13/2019] [Accepted: 02/17/2019] [Indexed: 12/23/2022]
Abstract
PURPOSE/OBJECTIVE Hypofractionated radiotherapy (HRT) regimens for prostate cancer are emerging, but tolerance doses for late adverse events are scarce. The purpose of this study is to define dose-volume predictors for late gastrointestinal and genitourinary (GI and GU) toxicities after HRT in the multi-center NRG Oncology/RTOG 0415 low-risk prostate cancer trial (N = 521). MATERIAL/METHODS Treatment in the studied HRT arm was delivered as 70 Gy at 2.5 Gy/fraction with 3D-CRT/IMRT (N = 108/413). At a median follow-up of 5.9 years, the crude late ≥Grade 2 GI and GU toxicities were 19% and 29%, respectively. For modeling, the complete HRT cohort was randomly split into training and validation (70% and 30%; preserved toxicity rates). Within training, dose-response modeling was based on dose-volume cut-points (EQD2Gy; bladder/rectum: α/β = 6 Gy/3Gy), age, acute ≥Grade 2 toxicity, and treatment technique using univariate and multivariate logistic regression on bootstrapping (UVA and MVA). Candidate predictors were determined at p ≤ 0.05, and the selected MVA models were explored on validation where model generalizability was judged if the area under the receiver-operating curve in validation (AUCvalidation) was within AUCtraining ± SD with p ≤ 0.05, and with an Hosmer-Lemeshow p-value (pHL) > 0.05. RESULTS Three candidate predictors were suggested for late GI toxicity: the minimum dose to the hottest 5% rectal volume (D5%[Gy]), the absolute rectal volume <35 Gy, and acute GI toxicity (AUC = 0.59-0.63; p = 0.02-0.04). The two generalizable MVA models, i.e., D5%[Gy] with or without acute GI toxicity (AUCvalidation = 0.64, 0.65; p = 0.01, 0.03; pHL = 0.45-0.56), suggest that reducing late GI toxicity from 20% to 10% would require reducing D5%[Gy] from ≤65 Gy to ≤62 Gy (logistic function argument: 17+(0.24D5%[Gy])). Acute GU toxicity showed only a trend to predict late GU toxicity (AUCtraining = 0.57; p = 0.07). CONCLUSION Late GI toxicity, following moderate HRT for low-risk prostate cancer, increases with higher doses to small rectal volumes. This work provides quantitative evidence that limiting small rectal dose 'hotspots' in clinical practice of such HRT regimens is likely to further reduce the associated rates of GI toxicity.
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Affiliation(s)
- Maria Thor
- Memorial Sloan Kettering Cancer Center, United States.
| | | | | | | | - Mahul B Amin
- University of Tennessee Health Science Center, United States
| | | | | | - Amit B Shah
- WellSpan Health-York Cancer Center (current) -Thomas Jefferson University Hospital (accrual), United States
| | | | | | | | - Samantha A Seaward
- Kaiser Permanente Northern California (current) University of California San Francisco (accruals), United States
| | - Elizabeth M Gore
- Medical College of Wisconsin and Zablocki Veterans Administration Medical Center, United States
| | - Michele Albert
- Saint Anne's Hospital (current) Massachusetts General Hospital (accruals), United States
| | | | | | | | | | | | - Stephanie L Pugh
- NRG Oncology Statistics and Data Management Center, United States
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Spiegel DY, Hong JC, Oyekunle T, Waters L, Lee WR, Salama JK, Koontz BF. A Nomogram for Testosterone Recovery After Combined Androgen Deprivation and Radiation Therapy for Prostate Cancer. Int J Radiat Oncol Biol Phys 2019; 103:834-842. [DOI: 10.1016/j.ijrobp.2018.11.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Revised: 10/08/2018] [Accepted: 11/02/2018] [Indexed: 10/27/2022]
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Armstrong AJ, Bitting RL, Healy P, George DJ, Kim S, Mayer TM, Winters C, Riggan C, Rasmussen J, Wilder R, Anand M, Stein MN, Frizzell B, Harrison MR, Zhang T, Lee WR, Wu Y, Koontz BF. Phase II trial enzalutamide and androgen deprivation therapy (ADT) with salvage radiation in men with high-risk PSA recurrent prostate cancer (PC): The STREAM trial. J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.7_suppl.29] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
29 Background: Salvage external beam radiotherapy (RT) and hormonal therapy improves survival over RT alone in men with non-metastatic hormone naïve PC and PSA recurrence after radical prostatectomy (RP). We investigated the safety/efficacy of enzalutamide with salvage RT and ADT in this setting. Methods: This was a 3 center prospective phase 2 single arm clinical trial in the Dept of Defense Prostate Cancer Clinical Trials Consortium. Eligibility: Gleason 7-10 PC and PSA recurrence within 4 years (yrs) of RP, PSA 0.2-4.0, no prior hormonal therapy, and no metastases on CT/Bone Scan imaging. Men received 6 months (mos) of ADT with 160 mg/d enzalutamide and 66 Gy RT to the prostate bed. Primary endpoint was 2 yr PFS with testosterone (T) recovery to >100 ng/dl. Secondary objectives included PSA nadir, 3 yr PFS, safety and patient reported quality-of-life over time. This trial was designed with 84% power to detect a 20% improvement in 2 yr PFS vs historic data and a 1-sided alpha of 0.05. Results: We enrolled 38 men (90% white, 8% black, 2% Asian); 37 (97%) completed therapy and were evaluable with T recovery at 2 yrs. Median age was 64 yrs; 47% Gleason 8-10, 79% T3/T4 disease, 21% had resected N+ PC; median PSA was 0.4 (0.19-4.19). Median follow-up is 29.5 mo. Treatment was well tolerated with 11 patients (29%) experiencing G3 toxicities (including 4 HTN, 2 urinary retention, 2 CV events); no G4-5 or unexpected toxicities were observed. T recovery occurred in 35 (95%) at 12 mos. The primary endpoint of 2 yr PFS was 65% (95% CI: 47%-78% vs. historic controls with 51% 2 yr PFS rate) among the 37 patients with T recovery. PSA remained at undetectable levels in 69% at 2 yrs. The 3 yr PFS was 53% (95% CI: 36%, 68%). QOL data over time suggest short term reductions in urinary and sexual function with recovery by 12-24 mo in most men. Conclusions: Salvage enzalutamide and ADT for 6 months with RT following RP for men with PSA recurrent high risk PC is safe, and demonstrates encouraging efficacy at 2 and 3 years. Most men have testosterone recovery at 1 year. These data warrant prospective controlled phase 3 trials to assess the impact of potent AR inhibition in this curative intent setting. Clinical trial information: NCT02057939.
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Affiliation(s)
- Andrew J. Armstrong
- Duke Cancer Institute and the Duke Prostate and Urologic Cancer Center, Durham, NC
| | - Rhonda L. Bitting
- Internal Medicine, Section on Hematology and Oncology, Winston Salem, NC
| | | | | | - Sung Kim
- Cancer Institute of New Jersey, New Brunswick, NJ
| | - Tina M. Mayer
- Rutgers Cancer Institute of New Jersey, New Brunswick, NJ
| | | | | | | | | | | | | | | | | | - Tian Zhang
- Duke University Medical Center, Durham, NC
| | | | - Yuan Wu
- Department of Biostatistics and Bioinformatics, Duke Cancer Institute, Durham, NC
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Powers SA, Odom MR, Pak ES, Moomaw MA, Ashcraft KA, Koontz BF, Hannan JL. Prostate-Confined Radiation Decreased Pelvic Ganglia Neuronal Survival and Outgrowth. J Sex Med 2019; 16:27-41. [DOI: 10.1016/j.jsxm.2018.11.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Revised: 10/10/2018] [Accepted: 11/16/2018] [Indexed: 12/15/2022]
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Matta R, Chapple CR, Fisch M, Heidenreich A, Herschorn S, Kodama RT, Koontz BF, Murphy DG, Nguyen PL, Nam RK. Pelvic Complications After Prostate Cancer Radiation Therapy and Their Management: An International Collaborative Narrative Review. Eur Urol 2018; 75:464-476. [PMID: 30573316 DOI: 10.1016/j.eururo.2018.12.003] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Accepted: 12/04/2018] [Indexed: 02/06/2023]
Abstract
CONTEXT Radiotherapy used for treating localized prostate cancer is effective at prolonging cancer-specific and overall survival. Still, acute and late pelvic toxicities are a concern, with gastrointestinal (GI) and genitourinary (GU) sequelae being most common as well as other pelvic complications. OBJECTIVE To present a critical review of the literature regarding the incidence and risk factors of pelvic toxicity following primary radiotherapy for prostate cancer and to provide a narrative review regarding its management. EVIDENCE ACQUISITION A collaborative narrative review of the literature from 2010 to present was conducted. EVIDENCE SYNTHESIS Regardless of the modality used, the incidence of acute high-grade pelvic toxicity is low following conventionally fractionated external beam radiotherapy (EBRT). After moderate hypofractionation, the crude cumulative incidences for late grade 3 or higher (G3+) GI and GU complications are as high as 6% and 7%, respectively. After extreme hypofractionation, the 5-yr incidences of G2+ GU and GI toxicities are 3-9% and 0-4%, respectively. Following brachytherapy monotherapy, crude rates of late G3+ GU toxicity range from 6% to 8%, while late GI toxicity is rare. With combination therapy (EBRT and brachytherapy), the cumulative incidence of late GU toxicity is high, between 18% and 31%; however, the prevalence is lower at 4-14%. Whole pelvic radiotherapy remains a controversial treatment option as there is increased G3+ GI toxicity compared with prostate-only treatment, with no overall survival benefit. Proton beam therapy appears to have similar toxicity to photon therapies currently in use. With respect to specific complications, urinary obstruction and urethral stricture are the most common severe urinary toxicities. Rectal and urinary bleeding can be recurrent long-term toxicities. The risk of hip fracture is also increased following prostate radiotherapy. The literature is mixed on the risk of in-field secondary pelvic malignancies following prostate radiotherapy. Urinary and GI fistulas are rare complications. Management of these toxicities may require invasive treatment and reconstructive surgery for refractory and severe symptoms. CONCLUSIONS There has been progress in the delivery of radiotherapy, enabling the administration of higher doses with minimal tradeoff in terms of slightly increased or equal toxicity. There is a need to focus future improvements in radiotherapy on sparing critical structures to reduce GU and GI morbidities. While complications such as fistulae, bone toxicity, and secondary malignancy are rare, there is a need for higher-quality studies assessing these outcomes and their management. PATIENT SUMMARY In this report, we review the literature regarding pelvic complications following modern primary prostate cancer radiotherapy and their management. Modern radiotherapy technologies have enabled the administration of higher doses with minimal increases in toxicity. Overall, high-grade long-term toxicity following prostate radiotherapy is uncommon. Management of late high-grade pelvic toxicities can be challenging, with patients often requiring invasive therapies for refractory cases.
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Affiliation(s)
- Rano Matta
- Division of Urology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada; Institute for Health Policy, Management & Evaluation, University of Toronto, Toronto, Ontario, Canada
| | | | - Margit Fisch
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Axel Heidenreich
- Department of Urology, Uro-Oncology, Robot-Assisted and Reconstructive Surgery, University of Cologne, Cologne, Germany
| | - Sender Herschorn
- Division of Urology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Ronald T Kodama
- Division of Urology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Bridget F Koontz
- Department of Radiation Oncology, Duke Prostate and Urologic Cancers Center, Duke University Medical Center, Durham, NC, USA
| | - Declan G Murphy
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Australia; Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia
| | - Paul L Nguyen
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Robert K Nam
- Division of Urology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada; Institute for Health Policy, Management & Evaluation, University of Toronto, Toronto, Ontario, Canada.
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Ashcraft KA, Hannan JL, Eichenbaum G, Zhang X, Pak ES, Faught AM, Patel P, Dewhirst MW, Koontz BF. Clarifying the Relative Impacts of Vascular and Nerve Injury That Culminate in Erectile Dysfunction in a Pilot Study Using a Rat Model of Prostate Irradiation and a Thrombopoietin Mimetic. Int J Radiat Oncol Biol Phys 2018; 103:1212-1220. [PMID: 30529374 DOI: 10.1016/j.ijrobp.2018.11.064] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Revised: 11/27/2018] [Accepted: 11/29/2018] [Indexed: 12/24/2022]
Abstract
PURPOSE Radiation therapy (RT) offers an important and curative approach to treating prostate cancer, but it is associated with a high incidence of erectile dysfunction (ED). It is not clear whether the etiology of radiation-induced ED (RI-ED) is driven by RT-mediated injury to the vasculature, the nerves, or both. This pilot study sought to distinguish the effects of vascular and nerve injury in RI-ED by applying a vascular radioprotectant in a rat model of prostate RT. METHODS A single dose of the thrombopoietin mimetic (TPOm; RWJ-800088), previously shown to mitigate radiation-induced vascular injury, was administered 10 minutes after single-fraction conformal prostate RT. Nine weeks after RT, rats were assessed for erectile and arterial function. Nerve markers were quantified with reverse transcriptase polymerase chain reaction. Immunofluorescent microscopy further characterized vascular effects of RT and TPOm. RESULTS Sham animals and animals that received RT and TPOm showed significant arterial vasodilation in response to systemic hydralazine (24.1% ± 7.3% increase; P = .03 in paired t test). However, animals that received RT and vehicle were unable to mount a vasodilatory response (-7.4% ± 9.9% increase; P = .44 in paired t test). TPOm prevented RT-induced change in the penile artery cross-sectional area (P = .036), but it did not ameliorate cavernous nerve injury as evaluated by gene expression of neuronal injury markers. Despite significant structural and functional vascular protective effects and some trends for differences in nerve injury/recovery markers, TPOm did not prevent RI-ED at 9 weeks, as assessed by intracavernous pressure monitoring after cavernous nerve stimulation. CONCLUSIONS These data suggest that vascular protection alone is not sufficient to prevent RI-ED and that cavernous nerve injury plays a key role in RI-ED. Further research is required to delineate the multifactorial nature of RI-ED and to determine if TPOm with modified dosing regimens can mitigate against nerve injury either through direct or vascular protective effects.
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Affiliation(s)
- Kathleen A Ashcraft
- Duke University School of Medicine, Department of Radiation Oncology, Durham, North Carolina
| | - Johanna L Hannan
- Department of Physiology, Brody School of Medicine, East Carolina University, Greenville, North Carolina
| | - Gary Eichenbaum
- Johnson & Johnson, Office of the Chief Medical Officer, New Brunswick, New Jersey
| | - Xiaojie Zhang
- Duke University School of Medicine, Department of Radiation Oncology, Durham, North Carolina
| | - Elena S Pak
- Department of Physiology, Brody School of Medicine, East Carolina University, Greenville, North Carolina
| | - Austin M Faught
- Duke University School of Medicine, Department of Radiation Oncology, Durham, North Carolina
| | - Pranalee Patel
- Duke University School of Medicine, Department of Radiation Oncology, Durham, North Carolina
| | - Mark W Dewhirst
- Duke University School of Medicine, Department of Radiation Oncology, Durham, North Carolina
| | - Bridget F Koontz
- Duke University School of Medicine, Department of Radiation Oncology, Durham, North Carolina.
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Berkowitz C, Allen DH, Tenhover J, Zullig LL, Ragsdale J, Fischer JE, Pollak KI, Koontz BF. Knowledge and Preferences of Primary Care Providers in Delivering Head and Neck Cancer Survivorship Care. J Cancer Educ 2018; 33:1323-1327. [PMID: 28707205 DOI: 10.1007/s13187-017-1250-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
Long-term care for head and neck cancer (HNC) survivors is complex and requires coordination among multiple providers. Clinical practice guidelines highlight the role of primary care providers (PCPs) in screening for secondary cancer/recurrence, assessment of late/long-term side effects, and referrals for appropriate specialty management of toxicity. However, these responsibilities may be difficult to meet within the scope of primary care practice. We conducted this study to explore preferences, comfort, and knowledge of PCPs in the care of HNC survivors. We piloted a 40-item web-based survey developed with oncologist and PCP input targeted for family medicine and internal medicine providers. Responses were collected within a single university health system over 2 months. PCPs (n = 28; RR = 11.3%) were interested in learning about health promotion after cancer treatment (89%) and generally agree that their current practice patterns address healthy lifestyle behaviors (82%). However, only 32% of PCPs felt confident they could manage late/long-term side effects of chemotherapy, radiation, or surgery. Only 29% felt confident they could provide appropriate cancer screening. Looking at shared care responsibilities with oncology providers, PCPs perceived being responsible for 30% of care in the first year after treatment and 81% of care after 5 years. Seventy-one percent of PCPs agreed that oncologists provided them necessary information, yet 32% of PCPs found it difficult to coordinate with cancer providers. While these PCPs perceive increased care responsibility for long-term survivors, most are uncomfortable screening for recurrence and managing late/long-term side effects. Education and mutual coordination between PCPs and oncology providers may improve survivor care.
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Affiliation(s)
| | - Deborah H Allen
- Duke Cancer Institute, Box 3085 DUMC, Durham, NC, 27710, USA
- Duke University Health System, Durham, NC, USA
| | | | - Leah L Zullig
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, NC, USA
- Division of General Internal Medicine, Department of Medicine, Duke University, Durham, NC, USA
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Morgan SC, Hoffman K, Loblaw DA, Buyyounouski MK, Patton C, Barocas D, Bentzen S, Chang M, Efstathiou J, Greany P, Halvorsen P, Koontz BF, Lawton C, Leyrer CM, Lin D, Ray M, Sandler H. Hypofractionated Radiation Therapy for Localized Prostate Cancer: Executive Summary of an ASTRO, ASCO, and AUA Evidence-Based Guideline. Pract Radiat Oncol 2018; 8:354-360. [DOI: 10.1016/j.prro.2018.08.002] [Citation(s) in RCA: 111] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Accepted: 08/01/2018] [Indexed: 11/25/2022]
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Morgan SC, Hoffman K, Loblaw DA, Buyyounouski MK, Patton C, Barocas D, Bentzen S, Chang M, Efstathiou J, Greany P, Halvorsen P, Koontz BF, Lawton C, Leyrer CM, Lin D, Ray M, Sandler H. Hypofractionated Radiation Therapy for Localized Prostate Cancer: An ASTRO, ASCO, and AUA Evidence-Based Guideline. J Clin Oncol 2018; 36:JCO1801097. [PMID: 30307776 PMCID: PMC6269129 DOI: 10.1200/jco.18.01097] [Citation(s) in RCA: 98] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Affiliation(s)
- Scott C. Morgan
- Scott C. Morgan, The Ottawa Hospital and University of Ottawa, Ottawa; D. Andrew Loblaw, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Karen Hoffman, MD Anderson Cancer Center, Houston, TX; Mark K. Buyyounouski, Stanford University, Stanford; Palto Alto VA Health System, Palo Alto, CA; Caroline Patton, American Society for Radiation Oncology, Arlington, VA; Daniel Barocas, Vanderbilt University Medical Center, Nashville, TN; Soren Bentzen, University of Maryland School of Medicine, Baltimore, MD; Michael Chang, Hunter Holmes McGuire VA Medical Center and Virginia Commonwealth University, Richmond, VA; Jason Efstathiou, Massachusetts General Hospital, Boston MA; Patrick Greany, Patient representative, Tallahassee, FL; Per Halvorsen, Lahey Hospital and Medical Center, Burlington, MA; Bridget F. Koontz, Duke University Medical Center, Durham, NC; Colleen Lawton, Medical College of Wisconsin, Milwaukee, WI; C. Marc Leyrer, Wake Forest University, Winston-Salem, NC; Daniel Lin, University of Washington, Seattle, WA; Michael Ray, Radiology Associates of Appleton, ThedaCare Regional Cancer Center, Appleton, WI; and Howard Sandler, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Karen Hoffman
- Scott C. Morgan, The Ottawa Hospital and University of Ottawa, Ottawa; D. Andrew Loblaw, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Karen Hoffman, MD Anderson Cancer Center, Houston, TX; Mark K. Buyyounouski, Stanford University, Stanford; Palto Alto VA Health System, Palo Alto, CA; Caroline Patton, American Society for Radiation Oncology, Arlington, VA; Daniel Barocas, Vanderbilt University Medical Center, Nashville, TN; Soren Bentzen, University of Maryland School of Medicine, Baltimore, MD; Michael Chang, Hunter Holmes McGuire VA Medical Center and Virginia Commonwealth University, Richmond, VA; Jason Efstathiou, Massachusetts General Hospital, Boston MA; Patrick Greany, Patient representative, Tallahassee, FL; Per Halvorsen, Lahey Hospital and Medical Center, Burlington, MA; Bridget F. Koontz, Duke University Medical Center, Durham, NC; Colleen Lawton, Medical College of Wisconsin, Milwaukee, WI; C. Marc Leyrer, Wake Forest University, Winston-Salem, NC; Daniel Lin, University of Washington, Seattle, WA; Michael Ray, Radiology Associates of Appleton, ThedaCare Regional Cancer Center, Appleton, WI; and Howard Sandler, Cedars-Sinai Medical Center, Los Angeles, CA
| | - D. Andrew Loblaw
- Scott C. Morgan, The Ottawa Hospital and University of Ottawa, Ottawa; D. Andrew Loblaw, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Karen Hoffman, MD Anderson Cancer Center, Houston, TX; Mark K. Buyyounouski, Stanford University, Stanford; Palto Alto VA Health System, Palo Alto, CA; Caroline Patton, American Society for Radiation Oncology, Arlington, VA; Daniel Barocas, Vanderbilt University Medical Center, Nashville, TN; Soren Bentzen, University of Maryland School of Medicine, Baltimore, MD; Michael Chang, Hunter Holmes McGuire VA Medical Center and Virginia Commonwealth University, Richmond, VA; Jason Efstathiou, Massachusetts General Hospital, Boston MA; Patrick Greany, Patient representative, Tallahassee, FL; Per Halvorsen, Lahey Hospital and Medical Center, Burlington, MA; Bridget F. Koontz, Duke University Medical Center, Durham, NC; Colleen Lawton, Medical College of Wisconsin, Milwaukee, WI; C. Marc Leyrer, Wake Forest University, Winston-Salem, NC; Daniel Lin, University of Washington, Seattle, WA; Michael Ray, Radiology Associates of Appleton, ThedaCare Regional Cancer Center, Appleton, WI; and Howard Sandler, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Mark K. Buyyounouski
- Scott C. Morgan, The Ottawa Hospital and University of Ottawa, Ottawa; D. Andrew Loblaw, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Karen Hoffman, MD Anderson Cancer Center, Houston, TX; Mark K. Buyyounouski, Stanford University, Stanford; Palto Alto VA Health System, Palo Alto, CA; Caroline Patton, American Society for Radiation Oncology, Arlington, VA; Daniel Barocas, Vanderbilt University Medical Center, Nashville, TN; Soren Bentzen, University of Maryland School of Medicine, Baltimore, MD; Michael Chang, Hunter Holmes McGuire VA Medical Center and Virginia Commonwealth University, Richmond, VA; Jason Efstathiou, Massachusetts General Hospital, Boston MA; Patrick Greany, Patient representative, Tallahassee, FL; Per Halvorsen, Lahey Hospital and Medical Center, Burlington, MA; Bridget F. Koontz, Duke University Medical Center, Durham, NC; Colleen Lawton, Medical College of Wisconsin, Milwaukee, WI; C. Marc Leyrer, Wake Forest University, Winston-Salem, NC; Daniel Lin, University of Washington, Seattle, WA; Michael Ray, Radiology Associates of Appleton, ThedaCare Regional Cancer Center, Appleton, WI; and Howard Sandler, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Caroline Patton
- Scott C. Morgan, The Ottawa Hospital and University of Ottawa, Ottawa; D. Andrew Loblaw, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Karen Hoffman, MD Anderson Cancer Center, Houston, TX; Mark K. Buyyounouski, Stanford University, Stanford; Palto Alto VA Health System, Palo Alto, CA; Caroline Patton, American Society for Radiation Oncology, Arlington, VA; Daniel Barocas, Vanderbilt University Medical Center, Nashville, TN; Soren Bentzen, University of Maryland School of Medicine, Baltimore, MD; Michael Chang, Hunter Holmes McGuire VA Medical Center and Virginia Commonwealth University, Richmond, VA; Jason Efstathiou, Massachusetts General Hospital, Boston MA; Patrick Greany, Patient representative, Tallahassee, FL; Per Halvorsen, Lahey Hospital and Medical Center, Burlington, MA; Bridget F. Koontz, Duke University Medical Center, Durham, NC; Colleen Lawton, Medical College of Wisconsin, Milwaukee, WI; C. Marc Leyrer, Wake Forest University, Winston-Salem, NC; Daniel Lin, University of Washington, Seattle, WA; Michael Ray, Radiology Associates of Appleton, ThedaCare Regional Cancer Center, Appleton, WI; and Howard Sandler, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Daniel Barocas
- Scott C. Morgan, The Ottawa Hospital and University of Ottawa, Ottawa; D. Andrew Loblaw, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Karen Hoffman, MD Anderson Cancer Center, Houston, TX; Mark K. Buyyounouski, Stanford University, Stanford; Palto Alto VA Health System, Palo Alto, CA; Caroline Patton, American Society for Radiation Oncology, Arlington, VA; Daniel Barocas, Vanderbilt University Medical Center, Nashville, TN; Soren Bentzen, University of Maryland School of Medicine, Baltimore, MD; Michael Chang, Hunter Holmes McGuire VA Medical Center and Virginia Commonwealth University, Richmond, VA; Jason Efstathiou, Massachusetts General Hospital, Boston MA; Patrick Greany, Patient representative, Tallahassee, FL; Per Halvorsen, Lahey Hospital and Medical Center, Burlington, MA; Bridget F. Koontz, Duke University Medical Center, Durham, NC; Colleen Lawton, Medical College of Wisconsin, Milwaukee, WI; C. Marc Leyrer, Wake Forest University, Winston-Salem, NC; Daniel Lin, University of Washington, Seattle, WA; Michael Ray, Radiology Associates of Appleton, ThedaCare Regional Cancer Center, Appleton, WI; and Howard Sandler, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Soren Bentzen
- Scott C. Morgan, The Ottawa Hospital and University of Ottawa, Ottawa; D. Andrew Loblaw, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Karen Hoffman, MD Anderson Cancer Center, Houston, TX; Mark K. Buyyounouski, Stanford University, Stanford; Palto Alto VA Health System, Palo Alto, CA; Caroline Patton, American Society for Radiation Oncology, Arlington, VA; Daniel Barocas, Vanderbilt University Medical Center, Nashville, TN; Soren Bentzen, University of Maryland School of Medicine, Baltimore, MD; Michael Chang, Hunter Holmes McGuire VA Medical Center and Virginia Commonwealth University, Richmond, VA; Jason Efstathiou, Massachusetts General Hospital, Boston MA; Patrick Greany, Patient representative, Tallahassee, FL; Per Halvorsen, Lahey Hospital and Medical Center, Burlington, MA; Bridget F. Koontz, Duke University Medical Center, Durham, NC; Colleen Lawton, Medical College of Wisconsin, Milwaukee, WI; C. Marc Leyrer, Wake Forest University, Winston-Salem, NC; Daniel Lin, University of Washington, Seattle, WA; Michael Ray, Radiology Associates of Appleton, ThedaCare Regional Cancer Center, Appleton, WI; and Howard Sandler, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Michael Chang
- Scott C. Morgan, The Ottawa Hospital and University of Ottawa, Ottawa; D. Andrew Loblaw, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Karen Hoffman, MD Anderson Cancer Center, Houston, TX; Mark K. Buyyounouski, Stanford University, Stanford; Palto Alto VA Health System, Palo Alto, CA; Caroline Patton, American Society for Radiation Oncology, Arlington, VA; Daniel Barocas, Vanderbilt University Medical Center, Nashville, TN; Soren Bentzen, University of Maryland School of Medicine, Baltimore, MD; Michael Chang, Hunter Holmes McGuire VA Medical Center and Virginia Commonwealth University, Richmond, VA; Jason Efstathiou, Massachusetts General Hospital, Boston MA; Patrick Greany, Patient representative, Tallahassee, FL; Per Halvorsen, Lahey Hospital and Medical Center, Burlington, MA; Bridget F. Koontz, Duke University Medical Center, Durham, NC; Colleen Lawton, Medical College of Wisconsin, Milwaukee, WI; C. Marc Leyrer, Wake Forest University, Winston-Salem, NC; Daniel Lin, University of Washington, Seattle, WA; Michael Ray, Radiology Associates of Appleton, ThedaCare Regional Cancer Center, Appleton, WI; and Howard Sandler, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Jason Efstathiou
- Scott C. Morgan, The Ottawa Hospital and University of Ottawa, Ottawa; D. Andrew Loblaw, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Karen Hoffman, MD Anderson Cancer Center, Houston, TX; Mark K. Buyyounouski, Stanford University, Stanford; Palto Alto VA Health System, Palo Alto, CA; Caroline Patton, American Society for Radiation Oncology, Arlington, VA; Daniel Barocas, Vanderbilt University Medical Center, Nashville, TN; Soren Bentzen, University of Maryland School of Medicine, Baltimore, MD; Michael Chang, Hunter Holmes McGuire VA Medical Center and Virginia Commonwealth University, Richmond, VA; Jason Efstathiou, Massachusetts General Hospital, Boston MA; Patrick Greany, Patient representative, Tallahassee, FL; Per Halvorsen, Lahey Hospital and Medical Center, Burlington, MA; Bridget F. Koontz, Duke University Medical Center, Durham, NC; Colleen Lawton, Medical College of Wisconsin, Milwaukee, WI; C. Marc Leyrer, Wake Forest University, Winston-Salem, NC; Daniel Lin, University of Washington, Seattle, WA; Michael Ray, Radiology Associates of Appleton, ThedaCare Regional Cancer Center, Appleton, WI; and Howard Sandler, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Patrick Greany
- Scott C. Morgan, The Ottawa Hospital and University of Ottawa, Ottawa; D. Andrew Loblaw, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Karen Hoffman, MD Anderson Cancer Center, Houston, TX; Mark K. Buyyounouski, Stanford University, Stanford; Palto Alto VA Health System, Palo Alto, CA; Caroline Patton, American Society for Radiation Oncology, Arlington, VA; Daniel Barocas, Vanderbilt University Medical Center, Nashville, TN; Soren Bentzen, University of Maryland School of Medicine, Baltimore, MD; Michael Chang, Hunter Holmes McGuire VA Medical Center and Virginia Commonwealth University, Richmond, VA; Jason Efstathiou, Massachusetts General Hospital, Boston MA; Patrick Greany, Patient representative, Tallahassee, FL; Per Halvorsen, Lahey Hospital and Medical Center, Burlington, MA; Bridget F. Koontz, Duke University Medical Center, Durham, NC; Colleen Lawton, Medical College of Wisconsin, Milwaukee, WI; C. Marc Leyrer, Wake Forest University, Winston-Salem, NC; Daniel Lin, University of Washington, Seattle, WA; Michael Ray, Radiology Associates of Appleton, ThedaCare Regional Cancer Center, Appleton, WI; and Howard Sandler, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Per Halvorsen
- Scott C. Morgan, The Ottawa Hospital and University of Ottawa, Ottawa; D. Andrew Loblaw, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Karen Hoffman, MD Anderson Cancer Center, Houston, TX; Mark K. Buyyounouski, Stanford University, Stanford; Palto Alto VA Health System, Palo Alto, CA; Caroline Patton, American Society for Radiation Oncology, Arlington, VA; Daniel Barocas, Vanderbilt University Medical Center, Nashville, TN; Soren Bentzen, University of Maryland School of Medicine, Baltimore, MD; Michael Chang, Hunter Holmes McGuire VA Medical Center and Virginia Commonwealth University, Richmond, VA; Jason Efstathiou, Massachusetts General Hospital, Boston MA; Patrick Greany, Patient representative, Tallahassee, FL; Per Halvorsen, Lahey Hospital and Medical Center, Burlington, MA; Bridget F. Koontz, Duke University Medical Center, Durham, NC; Colleen Lawton, Medical College of Wisconsin, Milwaukee, WI; C. Marc Leyrer, Wake Forest University, Winston-Salem, NC; Daniel Lin, University of Washington, Seattle, WA; Michael Ray, Radiology Associates of Appleton, ThedaCare Regional Cancer Center, Appleton, WI; and Howard Sandler, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Bridget F. Koontz
- Scott C. Morgan, The Ottawa Hospital and University of Ottawa, Ottawa; D. Andrew Loblaw, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Karen Hoffman, MD Anderson Cancer Center, Houston, TX; Mark K. Buyyounouski, Stanford University, Stanford; Palto Alto VA Health System, Palo Alto, CA; Caroline Patton, American Society for Radiation Oncology, Arlington, VA; Daniel Barocas, Vanderbilt University Medical Center, Nashville, TN; Soren Bentzen, University of Maryland School of Medicine, Baltimore, MD; Michael Chang, Hunter Holmes McGuire VA Medical Center and Virginia Commonwealth University, Richmond, VA; Jason Efstathiou, Massachusetts General Hospital, Boston MA; Patrick Greany, Patient representative, Tallahassee, FL; Per Halvorsen, Lahey Hospital and Medical Center, Burlington, MA; Bridget F. Koontz, Duke University Medical Center, Durham, NC; Colleen Lawton, Medical College of Wisconsin, Milwaukee, WI; C. Marc Leyrer, Wake Forest University, Winston-Salem, NC; Daniel Lin, University of Washington, Seattle, WA; Michael Ray, Radiology Associates of Appleton, ThedaCare Regional Cancer Center, Appleton, WI; and Howard Sandler, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Colleen Lawton
- Scott C. Morgan, The Ottawa Hospital and University of Ottawa, Ottawa; D. Andrew Loblaw, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Karen Hoffman, MD Anderson Cancer Center, Houston, TX; Mark K. Buyyounouski, Stanford University, Stanford; Palto Alto VA Health System, Palo Alto, CA; Caroline Patton, American Society for Radiation Oncology, Arlington, VA; Daniel Barocas, Vanderbilt University Medical Center, Nashville, TN; Soren Bentzen, University of Maryland School of Medicine, Baltimore, MD; Michael Chang, Hunter Holmes McGuire VA Medical Center and Virginia Commonwealth University, Richmond, VA; Jason Efstathiou, Massachusetts General Hospital, Boston MA; Patrick Greany, Patient representative, Tallahassee, FL; Per Halvorsen, Lahey Hospital and Medical Center, Burlington, MA; Bridget F. Koontz, Duke University Medical Center, Durham, NC; Colleen Lawton, Medical College of Wisconsin, Milwaukee, WI; C. Marc Leyrer, Wake Forest University, Winston-Salem, NC; Daniel Lin, University of Washington, Seattle, WA; Michael Ray, Radiology Associates of Appleton, ThedaCare Regional Cancer Center, Appleton, WI; and Howard Sandler, Cedars-Sinai Medical Center, Los Angeles, CA
| | - C. Marc Leyrer
- Scott C. Morgan, The Ottawa Hospital and University of Ottawa, Ottawa; D. Andrew Loblaw, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Karen Hoffman, MD Anderson Cancer Center, Houston, TX; Mark K. Buyyounouski, Stanford University, Stanford; Palto Alto VA Health System, Palo Alto, CA; Caroline Patton, American Society for Radiation Oncology, Arlington, VA; Daniel Barocas, Vanderbilt University Medical Center, Nashville, TN; Soren Bentzen, University of Maryland School of Medicine, Baltimore, MD; Michael Chang, Hunter Holmes McGuire VA Medical Center and Virginia Commonwealth University, Richmond, VA; Jason Efstathiou, Massachusetts General Hospital, Boston MA; Patrick Greany, Patient representative, Tallahassee, FL; Per Halvorsen, Lahey Hospital and Medical Center, Burlington, MA; Bridget F. Koontz, Duke University Medical Center, Durham, NC; Colleen Lawton, Medical College of Wisconsin, Milwaukee, WI; C. Marc Leyrer, Wake Forest University, Winston-Salem, NC; Daniel Lin, University of Washington, Seattle, WA; Michael Ray, Radiology Associates of Appleton, ThedaCare Regional Cancer Center, Appleton, WI; and Howard Sandler, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Daniel Lin
- Scott C. Morgan, The Ottawa Hospital and University of Ottawa, Ottawa; D. Andrew Loblaw, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Karen Hoffman, MD Anderson Cancer Center, Houston, TX; Mark K. Buyyounouski, Stanford University, Stanford; Palto Alto VA Health System, Palo Alto, CA; Caroline Patton, American Society for Radiation Oncology, Arlington, VA; Daniel Barocas, Vanderbilt University Medical Center, Nashville, TN; Soren Bentzen, University of Maryland School of Medicine, Baltimore, MD; Michael Chang, Hunter Holmes McGuire VA Medical Center and Virginia Commonwealth University, Richmond, VA; Jason Efstathiou, Massachusetts General Hospital, Boston MA; Patrick Greany, Patient representative, Tallahassee, FL; Per Halvorsen, Lahey Hospital and Medical Center, Burlington, MA; Bridget F. Koontz, Duke University Medical Center, Durham, NC; Colleen Lawton, Medical College of Wisconsin, Milwaukee, WI; C. Marc Leyrer, Wake Forest University, Winston-Salem, NC; Daniel Lin, University of Washington, Seattle, WA; Michael Ray, Radiology Associates of Appleton, ThedaCare Regional Cancer Center, Appleton, WI; and Howard Sandler, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Michael Ray
- Scott C. Morgan, The Ottawa Hospital and University of Ottawa, Ottawa; D. Andrew Loblaw, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Karen Hoffman, MD Anderson Cancer Center, Houston, TX; Mark K. Buyyounouski, Stanford University, Stanford; Palto Alto VA Health System, Palo Alto, CA; Caroline Patton, American Society for Radiation Oncology, Arlington, VA; Daniel Barocas, Vanderbilt University Medical Center, Nashville, TN; Soren Bentzen, University of Maryland School of Medicine, Baltimore, MD; Michael Chang, Hunter Holmes McGuire VA Medical Center and Virginia Commonwealth University, Richmond, VA; Jason Efstathiou, Massachusetts General Hospital, Boston MA; Patrick Greany, Patient representative, Tallahassee, FL; Per Halvorsen, Lahey Hospital and Medical Center, Burlington, MA; Bridget F. Koontz, Duke University Medical Center, Durham, NC; Colleen Lawton, Medical College of Wisconsin, Milwaukee, WI; C. Marc Leyrer, Wake Forest University, Winston-Salem, NC; Daniel Lin, University of Washington, Seattle, WA; Michael Ray, Radiology Associates of Appleton, ThedaCare Regional Cancer Center, Appleton, WI; and Howard Sandler, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Howard Sandler
- Scott C. Morgan, The Ottawa Hospital and University of Ottawa, Ottawa; D. Andrew Loblaw, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Karen Hoffman, MD Anderson Cancer Center, Houston, TX; Mark K. Buyyounouski, Stanford University, Stanford; Palto Alto VA Health System, Palo Alto, CA; Caroline Patton, American Society for Radiation Oncology, Arlington, VA; Daniel Barocas, Vanderbilt University Medical Center, Nashville, TN; Soren Bentzen, University of Maryland School of Medicine, Baltimore, MD; Michael Chang, Hunter Holmes McGuire VA Medical Center and Virginia Commonwealth University, Richmond, VA; Jason Efstathiou, Massachusetts General Hospital, Boston MA; Patrick Greany, Patient representative, Tallahassee, FL; Per Halvorsen, Lahey Hospital and Medical Center, Burlington, MA; Bridget F. Koontz, Duke University Medical Center, Durham, NC; Colleen Lawton, Medical College of Wisconsin, Milwaukee, WI; C. Marc Leyrer, Wake Forest University, Winston-Salem, NC; Daniel Lin, University of Washington, Seattle, WA; Michael Ray, Radiology Associates of Appleton, ThedaCare Regional Cancer Center, Appleton, WI; and Howard Sandler, Cedars-Sinai Medical Center, Los Angeles, CA
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Morgan SC, Hoffman K, Loblaw DA, Buyyounouski MK, Patton C, Barocas D, Bentzen S, Chang M, Efstathiou J, Greany P, Halvorsen P, Koontz BF, Lawton C, Leyrer CM, Lin D, Ray M, Sandler H. Hypofractionated Radiation Therapy for Localized Prostate Cancer: An ASTRO, ASCO, and AUA Evidence-Based Guideline. J Urol 2018:S0022-5347(18)43963-8. [PMID: 30316897 DOI: 10.1016/j.juro.2018.10.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/01/2018] [Indexed: 11/24/2022]
Abstract
PURPOSE The aim of this guideline is to present recommendations regarding moderately hypofractionated (240-340 cGy per fraction) and ultrahypofractionated (500 cGy or more per fraction) radiation therapy for localized prostate cancer. METHODS AND MATERIALS The American Society for Radiation Oncology convened a task force to address 8 key questions on appropriate indications and dose-fractionation for moderately and ultrahypofractionated radiation therapy, as well as technical issues, including normal tissue dose constraints, treatment volumes, and use of image guided and intensity modulated radiation therapy. Recommendations were based on a systematic literature review and created using a predefined consensus-building methodology and Society-approved tools for grading evidence quality and recommendation strength. RESULTS Based on high-quality evidence, strong consensus was reached for offering moderate hypofractionation across risk groups to patients choosing external beam radiation therapy. The task force conditionally recommends ultrahypofractionated radiation may be offered for low- and intermediate-risk prostate cancer but strongly encourages treatment of intermediate-risk patients on a clinical trial or multi-institutional registry. For high-risk patients, the task force conditionally recommends against routine use of ultrahypofractionated external beam radiation therapy. With any hypofractionated approach, the task force strongly recommends image guided radiation therapy and avoidance of nonmodulated 3-dimensional conformal techniques. CONCLUSIONS Hypofractionated radiation therapy provides important potential advantages in cost and convenience for patients, and these recommendations are intended to provide guidance on moderate hypofractionation and ultrahypofractionation for localized prostate cancer. The limits in the current evidentiary base-especially for ultrahypofractionation-highlight the imperative to support large-scale randomized clinical trials and underscore the importance of shared decision making between clinicians and patients.
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Affiliation(s)
- Scott C Morgan
- The Ottawa Hospital and University of Ottawa, Ottawa, ON, Canada, Division of RadiationOncology
| | - Karen Hoffman
- MD Anderson Cancer Center, Houston, TX, Department of Radiation Oncology
| | - D Andrew Loblaw
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada, Department ofRadiation Oncology
| | - Mark K Buyyounouski
- Stanford University, Stanford, CA and Palto Alto VA Health System, Department of RadiationOncology
| | | | - Daniel Barocas
- Vanderbilt University Medical Center, Nashville, TN, Department of Urologic Surgery
| | - Soren Bentzen
- University of Maryland School of Medicine, Baltimore, MD, Division of Biostatistics andBioinformatics
| | - Michael Chang
- Hunter Holmes McGuire VA Medical Center and Virginia Commonwealth University, Richmond, VA,Department of Radiation Oncology
| | - Jason Efstathiou
- Massachusetts General Hospital, Boston MA, Department of Radiation Oncology
| | | | - Per Halvorsen
- Lahey Hospital and Medical Center, Burlington, MA, Department of Radiation Oncology
| | - Bridget F Koontz
- Duke University Medical Center, Durham, NC, Department of Radiation Oncology
| | - Colleen Lawton
- Medical College of Wisconsin, Milwaukee, WI, Department of Radiation Oncology
| | - C Marc Leyrer
- Wake Forest University, Winston-Salem, NC, Department of Radiation Oncology
| | - Daniel Lin
- University of Washington, Seattle, WA, Department of Urology
| | - Michael Ray
- Radiology Associates of Appleton, ThedaCare Regional Cancer Center, Appleton, WI
| | - Howard Sandler
- Cedars-Sinai Medical Center, Los Angeles, CA, Department of Radiation Oncology.
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Denis F, Koontz BF, Letellier C. Application and Benefits of Web-Mediated Symptom Reporting for Patients Undergoing Immunotherapy: A Clinical Example. Case Rep Oncol 2018; 11:763-768. [PMID: 30627090 PMCID: PMC6323363 DOI: 10.1159/000494829] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Accepted: 10/23/2018] [Indexed: 12/21/2022] Open
Abstract
Two randomized studies of symptom monitoring during chemotherapy or during second line treatment and follow-up via web-based patient-reported outcomes (PROs) was previously demonstrated to lengthen survival. We are presenting here a patient with advanced and recurrent lung cancer who was followed for 4 years by PROs for relapse and adverse events detection. We report how the web-mediated follow-up helped to detect dangerous pulmonary embolism, relapse and pseudo-progression to immunotherapy by self-reported symptom tracking and specific algorithms triggering notifications to medical team, allowing early management of events. We particularly describe how a discordance between objective clinical improvement under immunotherapy assessed by the application allowed to detect pseudo-progression on imaging and allowed maintenance of the treatment during more than 1-year, although imaging report could have led to stop an effective therapy. The progression observed in the routine imaging was indeed in clear contradiction with improvements in patient's global status as assessed by the reduced PRO-score computed from patient self-reported symptoms. The ability of e-health tools based on symptoms reporting for tumor response assessment should be assessed in trials to help physician in decision of stopping or continuing therapy.
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Affiliation(s)
- Fabrice Denis
- Institut Inter-régional de Cancérologie Jean Bernard, 9 rue Beauverger, Le Mans, France
- Normandie Université - CORIA, Campus Universitaire du Madrillet, Saint-Etienne du Rouvray, France
| | - Bridget F. Koontz
- Department of Radiation Oncology, Duke Cancer Institute, Durham, North Carolina, USA
| | - Christophe Letellier
- Normandie Université - CORIA, Campus Universitaire du Madrillet, Saint-Etienne du Rouvray, France
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48
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Ashcraft KA, Miles D, Sunday ME, Choudhury KR, Young KH, Palmer GM, Patel P, Woska EC, Zhang R, Oldham M, Dewhirst MW, Koontz BF. Development and Preliminary Evaluation of a Murine Model of Chronic Radiation-Induced Proctitis. Int J Radiat Oncol Biol Phys 2018; 101:1194-1201. [DOI: 10.1016/j.ijrobp.2018.04.061] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Revised: 02/24/2018] [Accepted: 04/23/2018] [Indexed: 01/28/2023]
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49
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Ramey SJ, Agrawal S, Abramowitz MC, Moghanaki D, Pisansky TM, Efstathiou JA, Michalski JM, Spratt DE, Hearn JW, Koontz BF, Liauw SL, Pollack A, Anscher MS, Den RB, Stephans KL, Zietman AL, Lee WR, Stephenson AJ, Tendulkar RD. Multi-institutional Evaluation of Elective Nodal Irradiation and/or Androgen Deprivation Therapy with Postprostatectomy Salvage Radiotherapy for Prostate Cancer. Eur Urol 2018; 74:99-106. [DOI: 10.1016/j.eururo.2017.10.009] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Accepted: 10/14/2017] [Indexed: 11/26/2022]
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50
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Abstract
The biologic effects of changing the daily radiation dose (fractionation) have been studied for more than a century. The fractionation question in the treatment of prostate cancer came into stark relief in 1999 with the publication of a provocative report suggesting that hypofractionated regimens could maintain the therapeutic ratio with logistic and financial advantages. In the last two decades medical evidence, weak and strong, has accumulated on the efficacy and toxicity of hypofractionated regimens in the radiotherapeutic treatment of prostate cancer. This brief review will focus on the results of randomized trials that compare moderate hypofractionation (HF) to conventional fractionation (CF). Extreme HF is covered in a separate review within this issue.
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Affiliation(s)
- W Robert Lee
- Department of Radiation Oncology, Duke University School of Medicine, Durham, NC 27710, USA
| | - Bridget F Koontz
- Department of Radiation Oncology, Duke University School of Medicine, Durham, NC 27710, USA
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