1
|
Movsas B, Rodgers JP, Elshaikh MA, Martinez AA, Morton GC, Krauss DJ, Yan D, Citrin DE, Hershatter BW, Michalski JM, Ellis RJ, Kavadi VS, Gore EM, Gustafson GS, Schulz CA, Velker VM, Olson AC, Cury FL, Papagikos MA, Karrison TG, Sandler HM, Bruner DW. Dose-Escalated Radiation Alone or in Combination With Short-Term Total Androgen Suppression for Intermediate-Risk Prostate Cancer: Patient-Reported Outcomes From NRG/Radiation Therapy Oncology Group 0815 Randomized Trial. J Clin Oncol 2023:JCO2202389. [PMID: 37104723 DOI: 10.1200/jco.22.02389] [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: 04/29/2023] Open
Abstract
PURPOSE To report patient-reported outcomes (PROs) of a phase III trial evaluating total androgen suppression (TAS) combined with dose-escalated radiation therapy (RT) for patients with intermediate-risk prostate cancer. METHODS Patients with intermediate-risk prostate cancer were randomly assigned to dose-escalated RT alone (arm 1) or RT plus TAS (arm 2) consisting of luteinizing hormone-releasing hormone agonist/antagonist with oral antiandrogen for 6 months. The primary PRO was the validated Expanded Prostate Cancer Index Composite (EPIC-50). Secondary PROs included Patient-Reported Outcome Measurement Information System (PROMIS)-fatigue and EuroQOL five-dimensions scale questionnaire (EQ-5D). PRO change scores, calculated for each patient as the follow-up score minus baseline score (at the end of RT and at 6, 12, and 60 months), were compared between treatment arms using a two-sample t test. An effect size of 0.50 standard deviation was considered clinically meaningful. RESULTS For the primary PRO instrument (EPIC), the completion rates were ≥86% through the first year of follow-up and 70%-75% at 5 years. For the EPIC hormonal and sexual domains, there were clinically meaningful (P < .0001) deficits in the RT + TAS arm. However, there were no clinically meaningful differences by 1 year between arms. There were also no clinically meaningful differences at any time points between arms for PROMIS-fatigue, EQ-5D, and EPIC bowel/urinary scores. CONCLUSION Compared with dose-escalated RT alone, adding TAS demonstrated clinically meaningful declines only in EPIC hormonal and sexual domains. However, even these PRO differences were transient, and there were no clinically meaningful differences between arms by 1 year.
Collapse
Affiliation(s)
| | - Joseph P Rodgers
- NRG Oncology Statistics and Data Management Center, Philadelphia, PA
| | | | | | - Gerard C Morton
- Odette Cancer Centre-Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | | | - Di Yan
- William Beaumont Hospital, Royal Oak, MI
| | - Deborah E Citrin
- Center for Cancer Research, National Cancer Institute, Bethesda, MD
| | | | | | - Rodney J Ellis
- Penn State Milton Hershey Medical Center, Hershey, PA
- Case Western Reserve University, Cleveland, OH
| | | | - Elizabeth M Gore
- Froedtert and the Medical College of Wisconsin and Zablocki VAMC, Milwaukee, WI
| | | | - Craig A Schulz
- Columbia Saint Mary's Water Tower Medical Commons, Milwaukee, WI
| | | | - Adam C Olson
- University of Pittsburgh Cancer Institute, Pittsburgh, PA
| | - Fabio L Cury
- The Research Institute of the McGill University Health Centre (MUHC), Montreal, QC, Canada
| | - Michael A Papagikos
- Novant Health New Hanover Regional Medical Center-Zimmer Cancer Institute, Wilmington, NC
| | | | | | | |
Collapse
|
2
|
Dhere VR, Schuster DM, Goyal S, Schreibmann E, Hershatter BW, Rossi PJ, Shelton JW, Patel PR, Jani AB. Randomized Trial of Conventional Versus Conventional Plus Fluciclovine ( 18F) Positron Emission Tomography/Computed Tomography-Guided Postprostatectomy Radiation Therapy for Prostate Cancer: Volumetric and Patient-Reported Analyses of Toxic Effects. Int J Radiat Oncol Biol Phys 2022; 113:1003-1014. [PMID: 35417762 DOI: 10.1016/j.ijrobp.2022.04.005] [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] [Received: 01/19/2022] [Revised: 03/23/2022] [Accepted: 04/05/2022] [Indexed: 12/25/2022]
Abstract
PURPOSE Postprostatectomy radiation therapy planning with fluciclovine (18F) positron emission tomography (PET)/computed tomography has demonstrated improved disease-free survival over conventional only (computed tomography- or magnetic resonance imaging-based) treatment planning. We hypothesized that incorporating PET would result in larger clinical target volumes (CTVs) without increasing patient-reported toxic effects. METHODS AND MATERIALS From 2012 to 2019, 165 postprostatectomy patients with detectable prostate-specific antigen were randomized (arm 1 [no PET]: 82; arm 2 [PET]: 83). Prostate bed target volumes with (CTV1: 45.0-50.4 Gy/1.8 Gy) or without (CTV2/CTV: 64.8-70.2 Gy/1.8 Gy) pelvic nodes, as well as organ-at-risk doses, were compared pre- versus post-PET (arm 2) using the paired t test and between arms using the t test. Patient-reported outcomes used International Prostate Symptom Score and Expanded Prostate Cancer Index Composite for Clinical Practice (EPIC-CP). Univariate and multivariable analyses were performed and linear mixed models were fitted. RESULTS Median follow-up of the whole cohort was 3.52 years. All patients had baseline patient-reported outcomes, 1 patient in arm 1 and 3 patients in arm 2 withdrew, and 4 arm 2 patients had extrapelvic uptake on PET with radiotherapy aborted, leaving 81 (arm 1) and 76 patients (arm 2) for analysis of toxic effects. Mean CTV1 (427.6 vs 452.2 mL; P = .462, arm 1 vs arm 2) and CTV2/CTV (137.18 vs 134.2 mL; P = .669) were similar before PET incorporation. CTV1 (454.57 vs 461.33 mL; P = .003) and CTV2/CTV (134.14 vs 135.61 mL; P < .001) were modestly larger after PET incorporation. Although V40 Gy (P = .402 and P = .522 for rectum and bladder, respectively) and V65 Gy (P = .157 and P = .182 for rectum and bladder, respectively) were not significantly different pre- versus post-PET, penile bulb dose significantly increased post-PET (P < .001 for both V40 Gy and V65 Gy). On univariate and multivariable analyses, arm was not significant for any EPIC-CP subdomain. International Prostate Symptom Score and EPIC-CP linear mixed models were not significantly different between arms. CONCLUSIONS Despite larger CTVs after incorporation of fluciclovine (18F) PET, we found no significant difference in patient-reported toxic effects with long-term follow-up.
Collapse
Affiliation(s)
- Vishal R Dhere
- Departments of Radiation Oncology, Winship Cancer Institute.
| | | | - Subir Goyal
- Biostatistics and Bioinformatics, Emory University, Atlanta, Georgia
| | | | | | - Peter J Rossi
- Departments of Radiation Oncology, Winship Cancer Institute
| | | | | | - Ashesh B Jani
- Departments of Radiation Oncology, Winship Cancer Institute
| |
Collapse
|
3
|
Dhere VR, Fischer-Valuck BW, Goyal S, Liu Y, Morgan TM, Ghavidel E, Moghanaki DM, Hershatter BW, Patel PR, Jani AB, Godette KD, Rossi PJ, Patel SA. Patient-reported outcomes after Low-dose-rate versus High-dose-rate brachytherapy boost in combination with external beam radiation for intermediate and high risk prostate cancer. Brachytherapy 2021; 20:1130-1138. [PMID: 34417136 DOI: 10.1016/j.brachy.2021.07.005] [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: 05/10/2021] [Revised: 06/24/2021] [Accepted: 07/14/2021] [Indexed: 02/07/2023]
Abstract
PURPOSE Addition of a brachytherapy boost to external beam radiation therapy (EBRT) reduces prostate cancer (PCa) recurrence at the expense of genitourinary (GU) toxicity. Whether brachytherapy boost technique, specifically low-dose-rate (LDR-BT) versus high-dose-rate (HDR-BT), impacts treatment-related toxicity is unclear. METHODS Between 2012-2018, 106 men with intermediate/high risk PCa underwent EBRT (37.5-45 Gy in 1.8-2.5 Gy/fraction) plus brachytherapy boost, either with LDR-BT (110 Gy I-125 or 100 Gy Pd-103; n = 51) or HDR-BT (15 Gy x1 Ir-192; n = 55). Patient-reported outcomes (PRO) were assessed by International Prostate Symptom Score (IPSS) and Expanded Prostate Cancer Index Composite (EPIC-CP) surveys at 3-6-month intervals for up to three years following treatment, with higher scores indicating more severe toxicity. Provider-reported GU and gastrointestinal (GI) toxicity was graded per CTCAE v5.0 at each follow-up. Linear mixed models comparing PROs between LDR-BT versus HDR-BT were fitted. Stepwise multivariable analysis (MVA) was performed to account for age, gland size, androgen deprivation therapy use, and alpha-blocker medication use. Incidence rates of grade 2+ GU/GI toxicity was compared using Fisher's exact test. RESULTS Use of LDR-BT was associated with greater change in IPSS (p=0.003) and EPIC-CP urinary irritative score (p = 0.002) compared with HDR-BT, but effect size diminished over time (LDR-BT versus HDR-BT: baseline to 6-/24-month mean IPSS change, +6.4/+1.4 versus +2.7/-3.0, respectively; mean EPIC-CP irritative/obstructive change, +2.5/+0.1 versus +0.9/+0.1, respectively). Results remained significant on MVA. Post-treatment grade 2+ GU toxicity was significantly higher in the LDR-BT group (67.5% versus 42.9% for LDR-BT and HDR-BT, respectively; p <0.001). There were no differences between groups in incontinence, bowel function, and erectile function, or grade 2+ GI toxicity. CONCLUSION Compared with LDR-BT, HDR-BT was associated with lower acute patient- and provider-reported GU toxicity.
Collapse
Affiliation(s)
- Vishal R Dhere
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta GA
| | | | - Subir Goyal
- Department of Biostatistics and Bioinformatics, Emory University, Atlanta GA
| | - Yuan Liu
- Department of Biostatistics and Bioinformatics, Emory University, Atlanta GA
| | | | - Elizabeth Ghavidel
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta GA
| | - Drew M Moghanaki
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta GA
| | - Bruce W Hershatter
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta GA
| | - Pretesh R Patel
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta GA
| | - Ashesh B Jani
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta GA
| | - Karen D Godette
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta GA
| | - Peter J Rossi
- Calaway Young Cancer Center, Valley View Hospital, Glenwood Springs CO
| | - Sagar A Patel
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta GA.
| |
Collapse
|
4
|
Edelman S, Butler J, Hershatter BW, Khan MK. The effects of androgen deprivation therapy on cardiac function and heart failure: implications for management of prostate cancer. Clin Genitourin Cancer 2014; 12:399-407. [PMID: 25193364 DOI: 10.1016/j.clgc.2014.07.009] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [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: 05/27/2014] [Revised: 07/28/2014] [Accepted: 07/29/2014] [Indexed: 11/19/2022]
Abstract
Conflicting clinical evidence regarding the possible association between androgen deprivation therapy (ADT) with heart failure in men with prostate cancer is reviewed, including 2 population-based registries showing such an association, and 1 showing no association. Studies of the effects of androgens on cardiomyocyte contractility at the molecular level, the effects of testosterone on the cardiovascular system, particularly cardiac function, and the beneficial effects of testosterone therapy for patients with heart failure might help illuminate this controversy. Future studies are needed to evaluate the effect of ADT on end points of heart failure. The authors weigh the possible adverse effects of ADT on cardiac function and heart failure against its known benefits to cancer outcomes, defined according to published, randomized trials, in a discussion of the implications of the preclinical and clinical literature on the management of prostate cancer in men at risk for heart failure. In the absence of conclusive evidence that ADT causes heart failure, the authors discuss clinical situations in which ADT may be delayed, given on a short-term or intermittent basis, or withheld from treatment with the goal of reducing the risks of heart failure without compromising prostate cancer outcomes.
Collapse
Affiliation(s)
- Scott Edelman
- Department of Radiation Oncology, Emory University, Atlanta, GA; Winship Cancer Institute, Emory University, Atlanta, GA.
| | - Javed Butler
- Division of Cardiology, Emory University, Atlanta, GA
| | - Bruce W Hershatter
- Department of Radiation Oncology, Emory University, Atlanta, GA; Winship Cancer Institute, Emory University, Atlanta, GA
| | - Mohammad K Khan
- Department of Radiation Oncology, Emory University, Atlanta, GA; Winship Cancer Institute, Emory University, Atlanta, GA
| |
Collapse
|
5
|
Abstract
We have reviewed the clinical experience in the treatment of medulloblastoma with radiotherapy at Duke University Medical Center. One hundred and twenty-seven patients treated between January 1, 1940 and December 31, 1983 were evaluated. The irradiation technique was reviewed and all irradiation doses were recalculated as minimum tumor doses in Gray (Gy). The mean follow-up was 24.4 years and the median follow-up was 26.5 years. The energy of the treatment machine was known in 102 cases. Sixty patients were treated with orthovoltage equipment and 42 patients were treated with megavoltage equipment. As a gross assessment of the impact of the details of radiotherapy treatment upon outcome, patients were grouped into excellent, good, fair, and poor treatment groups. Patients undergoing cranio-spinal axis (CSA) irradiation and receiving greater than or equal to 52 Gy to the posterior fossa and greater than or equal to 30 Gy to the clinically uninvolved remainder of the CSA were classified as having "excellent" technique. Patients undergoing CSA irradiation and receiving 40 to 52 Gy to the posterior fossa and greater than or equal to 20 Gy to the remainder of the CSA were classified as "good." Patients receiving 20 to 40 Gy to the posterior fossa and greater than or equal to 10 Gy to the spinal axis with or without prophylactic cranial irradiation were designated "fair." Any patient not fulfilling the above minimum criteria was categorized as "poor." The actuarial 5-year survival for the entire population was 33%. The 10-year survival was 21%. In 93 patients for whom records were detailed enough to allow categorization of treatment technique, 5-year actuarial survivals were: Excellent 37% (n = 17), Good 55% (n = 13), Fair 35% (n = 23), Poor 20% (n = 40). A complete surgical resection was not correlated with improved disease-free survival (DFS) in the excellent and good groups, but was correlated with an improved DFS in the fair and poor groups. The posterior fossa accounted for 62% of the failures in the 55 patients completing irradiation where the initial site of failure was known. An examination of patterns of failure in the spinal canal failed to demonstrate a dose response relationship above 10 Gy for spinal canal prophylactic irradiation. No patient developed recurrence beyond their period of risk as defined by "Collins' Law."(ABSTRACT TRUNCATED AT 400 WORDS)
Collapse
|
6
|
|