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Halabi S, Roy A, Rydzewska L, Guo S, Godolphin P, Hussain M, Tangen C, Thompson I, Xie W, Carducci MA, Smith MR, Morris MJ, Gravis G, Dearnaley DP, Verhagen P, Goto T, James N, Buyse ME, Tierney JF, Sweeney C. Radiographic Progression-Free Survival and Clinical Progression-Free Survival as Potential Surrogates for Overall Survival in Men With Metastatic Hormone-Sensitive Prostate Cancer. J Clin Oncol 2024; 42:1044-1054. [PMID: 38181323 PMCID: PMC10950170 DOI: 10.1200/jco.23.01535] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 09/27/2023] [Accepted: 10/18/2023] [Indexed: 01/07/2024] Open
Abstract
PURPOSE Despite major increases in the longevity of men with metastatic hormone-sensitive prostate cancer (mHSPC), most men still die of prostate cancer. Phase III trials assessing new therapies in mHSPC with overall survival (OS) as the primary end point will take approximately a decade to complete. We investigated whether radiographic progression-free survival (rPFS) and clinical PFS (cPFS) are valid surrogates for OS in men with mHSPC and could potentially be used to expedite future phase III clinical trials. METHODS We obtained individual patient data (IPD) from 9 eligible randomized trials comparing treatment regimens (different androgen deprivation therapy [ADT] strategies or ADT plus docetaxel in the control or research arms) in mHSPC. rPFS was defined as the time from random assignment to radiographic progression or death from any cause whichever occurred first; cPFS was defined as the time from random assignment to the date of radiographic progression, symptoms, initiation of new treatment, or death, whichever occurred first. We implemented a two-stage meta-analytic validation model where conditions of patient-level and trial-level surrogacy had to be met. We then computed the surrogate threshold effect (STE). RESULTS IPD from 6,390 patients randomly assigned from 1994 to 2012 from 13 units were pooled for a stratified analysis. The median OS, rPFS, and cPFS were 4.3 (95% CI, 4.2 to 4.5), 2.4 (95% CI, 2.3 to 2.5), and 2.3 years (95% CI, 2.2 to 2.4), respectively. The STEs were 0.80 and 0.81 for rPFS and cPFS end points, respectively. CONCLUSION Both rPFS and cPFS appear to be promising surrogate end points for OS. The STE of 0.80 or higher makes it viable for either rPFS or cPFS to be used as the primary end point that is surrogate for OS in phase III mHSPC trials with testosterone suppression alone as the backbone therapy and would expedite trial conduct.
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Affiliation(s)
- Susan Halabi
- Duke University Medical Center, Duke University, Durham, NC
| | - Akash Roy
- Duke University Medical Center, Duke University, Durham, NC
| | - Larysa Rydzewska
- Medical Research Council Clinical Trials Unit at University College London, London, United Kingdom
| | - Siyuan Guo
- Duke University Medical Center, Duke University, Durham, NC
| | - Peter Godolphin
- Medical Research Council Clinical Trials Unit at University College London, London, United Kingdom
| | - Maha Hussain
- Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, IL
| | | | | | | | | | | | - Michael J. Morris
- Division of Solid Tumor Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Gwenaelle Gravis
- Institut Paoli-Calmettes Aix-Mareseille Université, Marseille, France
| | - David P. Dearnaley
- Institute of Cancer Research, The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | | | - Takayuki Goto
- Department of Urology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Nick James
- Institute of Cancer Research, The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Marc E. Buyse
- International Drug Development Institute, Louvain-La-Neuve, Belgium
| | - Jayne F. Tierney
- Institute of Cancer Research, The Royal Marsden NHS Foundation Trust, London, United Kingdom
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Kwak L, Ravi P, Armstrong JG, Beckendorf V, Chin JL, D'Amico AV, Dearnaley DP, Di Stasi SM, Gillessen S, Lukka H, Mottet N, Pommier P, Seiferheld W, Sydes MR, Tombal B, Zapatero A, Regan MM, Xie W, Sweeney CJ. Prognostic Impact of Prostate-Specific Antigen at 6 Months After Radiotherapy in Localized Prostate Cancer: An Individual Patient Data Analysis of Randomized Trials. J Clin Oncol 2024:JCO2300762. [PMID: 38471051 DOI: 10.1200/jco.23.00762] [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: 04/05/2023] [Revised: 10/30/2023] [Accepted: 01/22/2024] [Indexed: 03/14/2024] Open
Abstract
PURPOSE We sought to evaluate the prognostic impact of prostate-specific antigen (PSA) at 6 months after completion of radiotherapy (RT) in patients treated with RT alone, RT plus short-term (st; 3-6 months), and RT plus long-term (lt; 24-36 months) androgen-deprivation therapy (ADT). PATIENTS AND METHODS Individual patient data were obtained from 16 randomized trials evaluating RT ± ADT for localized prostate cancer (PCa) between 1987 and 2011. The lowest PSA recorded within 6 months after RT completion was identified and categorized as < or ≥0.1 ng/mL. The primary outcomes were metastasis-free survival (MFS), PCa-specific mortality (PCSM), and overall survival (OS), from 12 months after random assignment. RESULTS Ninety-eight percent (n = 2,339/2,376) of patients allocated to RT alone, 84% (n = 4,756/5,658) allocated to RT + stADT, and 77% (n = 1,258/1,626) allocated to RT + ltADT had PSA ≥0.1 ng/mL within 6 months after completing RT. PSA ≥0.1 ng/mL was associated with lower MFS and OS and higher PCSM among patients allocated to RT ± ADT (RT - MFS: hazard ratio [HR], 2.24 [95% CI, 1.21 to 4.16]; PCSM: subdistribution hazard ratio [sHR], 1.82 [0.51 to 6.49]; OS: HR, 1.72 [0.97 to 3.05]; RT + stADT - MFS: HR, 1.27 [1.12 to 1.44]; PCSM: sHR, 2.10 [1.52 to 2.92]; OS: HR, 1.26 [1.11 to 1.44]; RT + ltADT - MFS: HR, 1.58 [1.27 to 1.96]; PCSM: sHR, 1.97 [1.11 to 3.49]; OS: HR, 1.59 [1.27 to 1.99]). Five-year MFS rates among patients allocated to RT, RT + stADT, and RT + ltADT were 91% versus 79%, 83% versus 76%, and 87% versus 74%, respectively, based on PSA < or ≥0.1 ng/mL. CONCLUSION PSA ≥0.1 ng/mL within 6 months after RT completion was prognostic for lt outcomes in patients treated with RT ± ADT for localized PCa. This can be used to counsel patients treated with RT ± ADT and in guiding clinical trial design evaluating novel systemic therapies with RT + ADT as well as (de)intensification strategies.
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Affiliation(s)
- Lucia Kwak
- Department of Urology, Catholic University, Rome, Italy
| | - Praful Ravi
- Department of Urology, Catholic University, Rome, Italy
| | - John G Armstrong
- Oncology Institute of Southern Switzerland, EOC, Bellinzona, Switzerland
| | | | | | | | | | | | - Silke Gillessen
- Oncology Institute of Southern Switzerland, EOC, Bellinzona, Switzerland
| | - Himanshu Lukka
- McMaster University and Juravinski Cancer Centre, Hamilton, ON, Canada
| | | | | | | | | | | | - Almudena Zapatero
- Department of Radiation Oncology, La Princesa University Hospital, Health Research Institute, Madrid, Spain
| | | | - Wanling Xie
- Department of Urology, Catholic University, Rome, Italy
| | - Christopher J Sweeney
- 6South Australian Immunogenomics Cancer Institute, University of Adelaide, Adelaide, SA, Australia
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3
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Brand DH, Brüningk SC, Wilkins A, Naismith O, Gao A, Syndikus I, Dearnaley DP, Hall E, van As N, Tree AC, Gulliford S. Gastrointestinal Toxicity Prediction Not Influenced by Rectal Contour or Dose-Volume Histogram Definition. Int J Radiat Oncol Biol Phys 2023; 117:1163-1173. [PMID: 37433374 PMCID: PMC10680426 DOI: 10.1016/j.ijrobp.2023.07.002] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 06/01/2023] [Accepted: 07/03/2023] [Indexed: 07/13/2023]
Abstract
PURPOSE Rectal dose delivered during prostate radiation therapy is associated with gastrointestinal toxicity. Treatment plans are commonly optimized using rectal dose-volume constraints, often whole-rectum relative-volumes (%). We investigated whether improved rectal contouring, use of absolute-volumes (cc), or rectal truncation might improve toxicity prediction. METHODS AND MATERIALS Patients from the CHHiP trial (receiving 74 Gy/37 fractions [Fr] vs 60 Gy/20 Fr vs 57 Gy/19 Fr) were included if radiation therapy plans were available (2350/3216 patients), plus toxicity data for relevant analyses (2170/3216 patients). Whole solid rectum relative-volumes (%) dose-volume-histogram (DVH), as submitted by treating center (original contour), was assumed standard-of-care. Three investigational rectal DVHs were generated: (1) reviewed contour per CHHiP protocol; (2) original contour absolute volumes (cc); and (3) truncated original contour (2 versions; ±0 and ±2 cm from planning target volume [PTV]). Dose levels of interest (V30, 40, 50, 60, 70, 74 Gy) in 74 Gy arm were converted by equivalent-dose-in-2 Gy-Fr (EQD2α/β= 3 Gy) for 60 Gy/57 Gy arms. Bootstrapped logistic models predicting late toxicities (frequency G1+/G2+, bleeding G1+/G2+, proctitis G1+/G2+, sphincter control G1+, stricture/ulcer G1+) were compared by area-undercurve (AUC) between standard of care and the 3 investigational rectal definitions. RESULTS The alternative dose/volume parameters were compared with the original relative-volume (%) DVH of the whole rectal contour, itself fitted as a weak predictor of toxicity (AUC range, 0.57-0.65 across the 8 toxicity measures). There were no significant differences in toxicity prediction for: (1) original versus reviewed rectal contours (AUCs, 0.57-0.66; P = .21-.98); (2) relative- versus absolute-volumes (AUCs, 0.56-0.63; P = .07-.91); and (3) whole-rectum versus truncation at PTV ± 2 cm (AUCs, 0.57-0.65; P = .05-.99) or PTV ± 0 cm (AUCs, 0.57-0.66; P = .27-.98). CONCLUSIONS We used whole-rectum relative-volume DVH, submitted by the treating center, as the standard-of-care dosimetric predictor for rectal toxicity. There were no statistically significant differences in prediction performance when using central rectal contour review, with the use of absolute-volume dosimetry, or with rectal truncation relative to PTV. Whole-rectum relative-volumes were not improved upon for toxicity prediction and should remain standard-of-care.
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Affiliation(s)
- Douglas H Brand
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, United Kingdom; Department of Medical Physics and Biomedical Engineering, University College London, London, United Kingdom.
| | - Sarah C Brüningk
- Department of Health Science and Technology, ETH Zurich, Basel, Switzerland; Swiss Institute for Bioinformatics (SIB), Lausanne, Switzerland
| | - Anna Wilkins
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, United Kingdom; Urology Unit
| | - Olivia Naismith
- Radiotherapy Trials QA Group (RTTQA), Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Annie Gao
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, United Kingdom; Urology Unit
| | - Isabel Syndikus
- Radiotherapy Department, Clatterbridge Cancer Centre, Liverpool, United Kingdom
| | - David P Dearnaley
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, United Kingdom; Urology Unit
| | - Emma Hall
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, United Kingdom
| | - Nicholas van As
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, United Kingdom; Urology Unit
| | - Alison C Tree
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, United Kingdom; Urology Unit
| | - Sarah Gulliford
- Department of Medical Physics and Biomedical Engineering, University College London, London, United Kingdom; Department of Radiotherapy Physics, University College London Hospitals NHS Foundation Trust, London, United Kingdom
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4
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Roy S, Romero T, Michalski JM, Feng FY, Efstathiou JA, Lawton CA, Bolla M, Maingon P, de Reijke T, Joseph D, Ong WL, Sydes MR, Dearnaley DP, Tree AC, Carrier N, Nabid A, Souhami L, Incrocci L, Heemsbergen WD, Pos FJ, Zapatero A, Guerrero A, Alvarez A, San-Segundo CG, Maldonado X, Reiter RE, Rettig MB, Nickols NG, Steinberg ML, Valle LF, Ma TM, Farrell MJ, Neilsen BK, Juarez JE, Deng J, Vangala S, Avril N, Jia AY, Zaorsky NG, Sun Y, Spratt D, Kishan AU. Biochemical Recurrence Surrogacy for Clinical Outcomes After Radiotherapy for Adenocarcinoma of the Prostate. J Clin Oncol 2023; 41:5005-5014. [PMID: 37639648 PMCID: PMC10642893 DOI: 10.1200/jco.23.00617] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [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: 03/20/2023] [Revised: 05/30/2023] [Accepted: 07/12/2023] [Indexed: 08/31/2023] Open
Abstract
PURPOSE The surrogacy of biochemical recurrence (BCR) for overall survival (OS) in localized prostate cancer remains controversial. Herein, we evaluate the surrogacy of BCR using different surrogacy analytic methods. MATERIALS AND METHODS Individual patient data from 11 trials evaluating radiotherapy dose escalation, androgen deprivation therapy (ADT) use, and ADT prolongation were obtained. Surrogate candidacy was assessed using the Prentice criteria (including landmark analyses) and the two-stage meta-analytic approach (estimating Kendall's tau and the R2). Biochemical recurrence-free survival (BCRFS, time from random assignment to BCR or any death) and time to BCR (TTBCR, time from random assignment to BCR or cancer-specific deaths censoring for noncancer-related deaths) were assessed. RESULTS Overall, 10,741 patients were included. Dose escalation, addition of short-term ADT, and prolongation of ADT duration significantly improved BCR (hazard ratio [HR], 0.71 [95% CI, 0.63 to 0.79]; HR, 0.53 [95% CI, 0.48 to 0.59]; and HR, 0.54 [95% CI, 0.48 to 0.61], respectively). Adding short-term ADT (HR, 0.91 [95% CI, 0.84 to 0.99]) and prolonging ADT (HR, 0.86 [95% CI, 0.78 to 0.94]) significantly improved OS, whereas dose escalation did not (HR, 0.98 [95% CI, 0.87 to 1.11]). BCR at 48 months was associated with inferior OS in all three groups (HR, 2.46 [95% CI, 2.08 to 2.92]; HR, 1.51 [95% CI, 1.35 to 1.70]; and HR, 2.31 [95% CI, 2.04 to 2.61], respectively). However, after adjusting for BCR at 48 months, there was no significant treatment effect on OS (HR, 1.10 [95% CI, 0.96 to 1.27]; HR, 0.96 [95% CI, 0.87 to 1.06] and 1.00 [95% CI, 0.90 to 1.12], respectively). The patient-level correlation (Kendall's tau) for BCRFS and OS ranged between 0.59 and 0.69, and that for TTBCR and OS ranged between 0.23 and 0.41. The R2 values for trial-level correlation of the treatment effect on BCRFS and TTBCR with that on OS were 0.563 and 0.160, respectively. CONCLUSION BCRFS and TTBCR are prognostic but failed to satisfy all surrogacy criteria. Strength of correlation was greater when noncancer-related deaths were considered events.
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Affiliation(s)
- Soumyajit Roy
- Department of Radiation Oncology, Rush University Medical Center, Chicago, IL
| | - Tahmineh Romero
- Department of Medicine Statistics Core, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA
| | - Jeff M. Michalski
- Department of Radiation Oncology, Washington University, St Louis, MO
| | - Felix Y. Feng
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA
| | - Jason A. Efstathiou
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Colleen A.F. Lawton
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI
| | - Michel Bolla
- Radiotherapy Department, University Hospital, Grenoble, France
| | - Philippe Maingon
- Department of Oncology, Hematology, and Supportive Care, Sorbonne University, Paris, France
| | - Theo de Reijke
- Department of Urology, Prostate Cancer Network in the Netherlands, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - David Joseph
- Department of Medicine and Surgery, University of Western Australia, Perth, WA, Australia
| | - Wee Loon Ong
- Alfred Health Radiation Oncology, Monash University, Melbourne, VIC, Australia
| | - Matthew R. Sydes
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, University College London, London, United Kingdom
| | - David P. Dearnaley
- Division of Radiotherapy and Imaging, The Institute of Cancer Research and Department of Urology, The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Alison C. Tree
- Department of Radiation Oncology, University of Washington, Seattle, WA
| | - Nathalie Carrier
- Clinical Research Center, Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC, Canada
| | - Abdenour Nabid
- Department of Radiation Oncology, Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC, Canada
| | - Luis Souhami
- Department of Radiation Oncology, McGill University Health Centre, Montréal, QC, Canada
| | - Luca Incrocci
- Department of Radiation Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Wilma D. Heemsbergen
- Department of Radiation Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Floris J. Pos
- Department of Radiation Oncology, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, the Netherlands
| | | | | | - Ana Alvarez
- Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | | | | | - Robert E. Reiter
- Department of Urology, University of California Los Angeles, Los Angeles, CA
| | - Matthew B. Rettig
- Department of Medical Oncology, University of California Los Angeles, Los Angeles, CA
| | - Nicholas G. Nickols
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA
| | - Michael L. Steinberg
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA
| | - Luca F. Valle
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA
| | - T. Martin Ma
- Department of Radiation Oncology, University of Washington, Seattle, WA
| | - Matthew J. Farrell
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA
| | - Beth K. Neilsen
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA
| | - Jesus E. Juarez
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA
| | - Jie Deng
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA
| | - Sitaram Vangala
- Department of Medicine Statistics Core, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA
| | - Norbert Avril
- Department of Radiology, Division of Nuclear Medicine, Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland, OH
| | - Angela Y. Jia
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Nicholas G. Zaorsky
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Yilun Sun
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Case Western Reserve University School of Medicine, Cleveland, OH
- Department of Population Quantitative Health Sciences, Case Western Reserve University, Cleveland, OH
| | - Daniel Spratt
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Amar U. Kishan
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA
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5
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Naderi E, Aguado-Barrera ME, Schack LMH, Dorling L, Rattay T, Fachal L, Summersgill H, Martínez-Calvo L, Welsh C, Dudding T, Odding Y, Varela-Pazos A, Jena R, Thomson DJ, Steenbakkers RJHM, Dennis J, Lobato-Busto R, Alsner J, Ness A, Nutting C, Gómez-Caamaño A, Eriksen JG, Thomas SJ, Bates AM, Webb AJ, Choudhury A, Rosenstein BS, Taboada-Valladares B, Herskind C, Azria D, Dearnaley DP, de Ruysscher D, Sperk E, Hall E, Stobart H, Chang-Claude J, De Ruyck K, Veldeman L, Altabas M, De Santis MC, Farcy-Jacquet MP, Veldwijk MR, Sydes MR, Parliament M, Usmani N, Burnet NG, Seibold P, Symonds RP, Elliott RM, Bultijnck R, Gutiérrez-Enríquez S, Mollà M, Gulliford SL, Green S, Rancati T, Reyes V, Carballo A, Peleteiro P, Sosa-Fajardo P, Parker C, Fonteyne V, Johnson K, Lambrecht M, Vanneste B, Valdagni R, Giraldo A, Ramos M, Diergaarde B, Liu G, Leal SM, Chua MLK, Pring M, Overgaard J, Cascallar-Caneda LM, Duprez F, Talbot CJ, Barnett GC, Dunning AM, Vega A, Andreassen CN, Langendijk JA, West CML, Alizadeh BZ, Kerns SL. Large-scale meta-genome-wide association study reveals common genetic factors linked to radiation-induced acute toxicities across cancer types. JNCI Cancer Spectr 2023; 7:pkad088. [PMID: 37862240 PMCID: PMC10653584 DOI: 10.1093/jncics/pkad088] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 09/18/2023] [Accepted: 10/18/2023] [Indexed: 10/22/2023] Open
Abstract
BACKGROUND This study was designed to identify common genetic susceptibility and shared genetic variants associated with acute radiation-induced toxicity across 4 cancer types (prostate, head and neck, breast, and lung). METHODS A genome-wide association study meta-analysis was performed using 19 cohorts totaling 12 042 patients. Acute standardized total average toxicity (STATacute) was modelled using a generalized linear regression model for additive effect of genetic variants, adjusted for demographic and clinical covariates (rSTATacute). Linkage disequilibrium score regression estimated shared single-nucleotide variation (SNV-formerly SNP)-based heritability of rSTATacute in all patients and for each cancer type. RESULTS Shared SNV-based heritability of STATacute among all cancer types was estimated at 10% (SE = 0.02) and was higher for prostate (17%, SE = 0.07), head and neck (27%, SE = 0.09), and breast (16%, SE = 0.09) cancers. We identified 130 suggestive associated SNVs with rSTATacute (5.0 × 10‒8 < P < 1.0 × 10‒5) across 25 genomic regions. rs142667902 showed the strongest association (effect allele A; effect size ‒0.17; P = 1.7 × 10‒7), which is located near DPPA4, encoding a protein involved in pluripotency in stem cells, which are essential for repair of radiation-induced tissue injury. Gene-set enrichment analysis identified 'RNA splicing via endonucleolytic cleavage and ligation' (P = 5.1 × 10‒6, P = .079 corrected) as the top gene set associated with rSTATacute among all patients. In silico gene expression analysis showed that the genes associated with rSTATacute were statistically significantly up-regulated in skin (not sun exposed P = .004 corrected; sun exposed P = .026 corrected). CONCLUSIONS There is shared SNV-based heritability for acute radiation-induced toxicity across and within individual cancer sites. Future meta-genome-wide association studies among large radiation therapy patient cohorts are worthwhile to identify the common causal variants for acute radiotoxicity across cancer types.
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Affiliation(s)
- Elnaz Naderi
- Department of Epidemiology, University Medical Center Groningen, Groningen, The Netherlands
- Department of Radiation Oncology, University Medical Center Groningen, Groningen, The Netherlands
- Center for Statistical Genetics, Gertrude H. Sergievsky Center, and the Department of Neurology, Columbia University Medical Center, New York, NY, USA
| | - Miguel E Aguado-Barrera
- Fundación Pública Galega Medicina Xenómica, Santiago de Compostela, Spain
- Instituto de Investigación Sanitaria de Santiago de Compostela, Santiago de Compostela, Spain
| | - Line M H Schack
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Aarhus, Denmark
- Department of Oncology, Gødstrup Hospital, Herning, Denmark
- NIDO | Centre for Research and Education, Gødstrup Hospital, Herning, Denmark
| | - Leila Dorling
- Centre for Cancer Genetic Epidemiology, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Tim Rattay
- Leicester Cancer Research Centre, University of Leicester, Leicester, UK
| | - Laura Fachal
- Wellcome Sanger Institute, Wellcome Genome Campus, Hinxton, UK
- Centre for Cancer Genetic Epidemiology, Department of Oncology, University of Cambridge, Cambridge, UK
| | - Holly Summersgill
- Manchester Academic Health Science Centre, The Christie NHS Foundation Trust, Manchester, UK
| | - Laura Martínez-Calvo
- Fundación Pública Galega Medicina Xenómica, Santiago de Compostela, Spain
- Instituto de Investigación Sanitaria de Santiago de Compostela, Santiago de Compostela, Spain
| | - Ceilidh Welsh
- Department of Oncology, University of Cambridge, Cambridge, UK
| | - Tom Dudding
- Bristol Dental School, University of Bristol, Bristol, UK
- MRC Integrative Epidemiology Unit, University of Bristol, Bristol, UK
| | - Yasmin Odding
- Bristol Cancer Institute, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Ana Varela-Pazos
- Department of Radiation Oncology, Complexo Hospitalario Universitario de Santiago, SERGAS, Santiago de Compostela, Spain
| | - Rajesh Jena
- Department of Oncology, Addenbrooke’s Hospital, University of Cambridge, Cambridge, UK
| | - David J Thomson
- Division of Cancer Sciences, University of Manchester, Manchester, UK
- The Christie NHS Foundation Trust, Manchester, UK
| | - Roel J H M Steenbakkers
- Department of Radiation Oncology, University Medical Center Groningen, Groningen, The Netherlands
| | - Joe Dennis
- Centre for Cancer Genetic Epidemiology, Department of Oncology, University of Cambridge, Cambridge, UK
| | - Ramón Lobato-Busto
- Department of Medical Physics, Complexo Hospitalario Universitario de Santiago, SERGAS, Santiago de Compostela, Spain
| | - Jan Alsner
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Andy Ness
- Bristol Dental School, University of Bristol, Bristol, UK
| | - Chris Nutting
- Head and Neck Unit, The Royal Marsden Hospital, London, UK
| | - Antonio Gómez-Caamaño
- Instituto de Investigación Sanitaria de Santiago de Compostela, Santiago de Compostela, Spain
- Department of Radiation Oncology, Complexo Hospitalario Universitario de Santiago, SERGAS, Santiago de Compostela, Spain
| | - Jesper G Eriksen
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Steve J Thomas
- Bristol Dental School, University of Bristol, Bristol, UK
| | - Amy M Bates
- Department of Oncology, University of Cambridge, Cambridge, UK
| | - Adam J Webb
- Department of Genetics and Genome Biology, University of Leicester, Leicester, UK
| | - Ananya Choudhury
- Division of Cancer Sciences, University of Manchester, Manchester Academic Health Science Centre, Christie Hospital, Manchester, UK
| | - Barry S Rosenstein
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Begona Taboada-Valladares
- Instituto de Investigación Sanitaria de Santiago de Compostela, Santiago de Compostela, Spain
- Department of Radiation Oncology, Complexo Hospitalario Universitario de Santiago, SERGAS, Santiago de Compostela, Spain
| | - Carsten Herskind
- Department of Radiation Oncology, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - David Azria
- Fédération Universitaire d’Oncologie Radiothérapie d’Occitanie Méditérranée, Département d’Oncologie Radiothérapie, ICM Montpellier, INSERM U1194 IRCM, University of Montpellier, Montpellier, France
| | - David P Dearnaley
- Division of Radiotherapy and Imaging, The Institute of Cancer Research Department, The Royal Marsden NHS Foundation Trust, London, UK
| | - Dirk de Ruysscher
- MAASTRO Clinic, GROW School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, Netherlands
| | - Elena Sperk
- Department of Radiation Oncology, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Emma Hall
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, UK
| | - Hilary Stobart
- Patient Advocate, Independent Cancer Patients’ Voice, London, UK
| | - Jenny Chang-Claude
- Division of Cancer Epidemiology, German Cancer Research Center, Heidelberg, Germany
- University Cancer Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Kim De Ruyck
- Departments of Basic Medical Sciences and Radiotherapy, Ghent University Hospital, Ghent, Belgium
| | - Liv Veldeman
- Department of Human Structure and Repair, Ghent University, Ghent, Belgium
- Department of Radiation Oncology, Ghent University Hospital, Ghent, Belgium
| | - Manuel Altabas
- Radiation Oncology Department, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
| | | | - Marie-Pierre Farcy-Jacquet
- Fédération Universitaire d’Oncologie Radiothérapie d’Occitanie Méditérranée, Département d’Oncologie Radiothérapie, CHU Carémeau, Nîmes, France
| | - Marlon R Veldwijk
- Department of Radiation Oncology, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Matthew R Sydes
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, University College London, London, UK
| | - Matthew Parliament
- Division of Radiation Oncology, Department of Oncology, Cross Cancer Institute, University of Alberta, Edmonton, AB, Canada
| | - Nawaid Usmani
- Division of Radiation Oncology, Department of Oncology, Cross Cancer Institute, University of Alberta, Edmonton, AB, Canada
| | | | - Petra Seibold
- Division of Cancer Epidemiology, German Cancer Research Center, Heidelberg, Germany
| | - R Paul Symonds
- Cancer Research Centre, University of Leicester, Leicester, UK
| | - Rebecca M Elliott
- Division of Cancer Sciences, University of Manchester, Manchester Academic Health Science Centre, Christie Hospital, Manchester, UK
| | - Renée Bultijnck
- Department of Human Structure and Repair, Ghent University, Ghent, Belgium
- Department of Radiation Oncology, Ghent University Hospital, Ghent, Belgium
| | - Sara Gutiérrez-Enríquez
- Hereditary Cancer Genetics Group, Vall d’Hebron Institute of Oncology, Vall d’Hebron Hospital Campus, Barcelona, Spain
| | - Meritxell Mollà
- Radiation Oncology Department, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Sarah L Gulliford
- Department of Medical Physics and Biomedical Engineering, University College London, UK
| | - Sheryl Green
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Tiziana Rancati
- Data Science Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Victoria Reyes
- Radiation Oncology Department, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Ana Carballo
- Instituto de Investigación Sanitaria de Santiago de Compostela, Santiago de Compostela, Spain
- Department of Radiation Oncology, Complexo Hospitalario Universitario de Santiago, SERGAS, Santiago de Compostela, Spain
| | - Paula Peleteiro
- Instituto de Investigación Sanitaria de Santiago de Compostela, Santiago de Compostela, Spain
- Department of Radiation Oncology, Complexo Hospitalario Universitario de Santiago, SERGAS, Santiago de Compostela, Spain
| | - Paloma Sosa-Fajardo
- Instituto de Investigación Sanitaria de Santiago de Compostela, Santiago de Compostela, Spain
- Department of Radiation Oncology, Complexo Hospitalario Universitario de Santiago, SERGAS, Santiago de Compostela, Spain
| | - Chris Parker
- Department of Medical Physics and Biomedical Engineering, University College London, UK
| | - Valérie Fonteyne
- Department of Radiation Oncology, Ghent University Hospital, Ghent, Belgium
| | - Kerstie Johnson
- Leicester Cancer Research Centre, University of Leicester, Leicester, UK
| | | | - Ben Vanneste
- Department of Human Structure and Repair, Ghent University, Ghent, Belgium
- Department of Radiation Oncology, Ghent University Hospital, Ghent, Belgium
- Department of Radiation Oncology (Maastro Clinic), GROW School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Riccardo Valdagni
- Radiation Oncology, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
- Prostate Cancer Program, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Alexandra Giraldo
- Radiation Oncology Department, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Mónica Ramos
- Radiation Oncology Department, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Brenda Diergaarde
- Department of Human Genetics, School of Public Health, University of Pittsburgh, UPMC Hillman Cancer Center, Pittsburgh, PA, USA
| | - Geoffrey Liu
- Princess Margaret Cancer Centre, Temerty Faculty of Medicine, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Suzanne M Leal
- Center for Statistical Genetics, Gertrude H. Sergievsky Center, and the Department of Neurology, Columbia University Medical Center, New York, NY, USA
- Taub Institute for Alzheimer’s Disease and the Aging Brain, Columbia University Medical Center, New York, NY, USA
| | - Melvin L K Chua
- Division of Radiation Oncology, National Cancer Centre Singapore, Singapore
- Duke-NUS Medical School, Oncology Academic Clinical Programme, Singapore
| | - Miranda Pring
- Bristol Dental School, University of Bristol, Bristol, UK
| | - Jens Overgaard
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Luis M Cascallar-Caneda
- Department of Radiation Oncology, Complexo Hospitalario Universitario de Santiago, SERGAS, Santiago de Compostela, Spain
| | - Fréderic Duprez
- Department of Human Structure and Repair, Ghent University, Ghent, Belgium
- Department of Radiation Oncology, Ghent University Hospital, Ghent, Belgium
| | - Christopher J Talbot
- Department of Genetics and Genome Biology, University of Leicester, Leicester, UK
| | - Gillian C Barnett
- Department of Oncology, Addenbrooke’s Hospital, University of Cambridge, Cambridge, UK
| | - Alison M Dunning
- Centre for Cancer Genetic Epidemiology, Department of Oncology, University of Cambridge, Cambridge, UK
| | - Ana Vega
- Fundación Pública Galega Medicina Xenómica, Santiago de Compostela, Spain
- Instituto de Investigación Sanitaria de Santiago de Compostela, Santiago de Compostela, Spain
- Grupo de Medicina Xenómica, Centro de Investigación Biomédica en Red de Enfermedades Raras, Universidade de Santiago de Compostela, Santiago de Compostela, Spain
| | - Christian Nicolaj Andreassen
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Aarhus, Denmark
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Johannes A Langendijk
- Department of Radiation Oncology, University Medical Center Groningen, Groningen, The Netherlands
| | - Catharine M L West
- Translational Radiobiology Group, Division of Cancer Sciences, University of Manchester, Manchester Academic Health Science Centre, Christie NHS Foundation Trust Hospital, Manchester, UK
| | - Behrooz Z Alizadeh
- Department of Epidemiology, University Medical Center Groningen, Groningen, The Netherlands
| | - Sarah L Kerns
- Department of Radiation Oncology, The Medical College of Wisconsin, Milwaukee, WI, USA
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Attard G, Murphy L, Clarke NW, Sachdeva A, Jones C, Hoyle A, Cross W, Jones RJ, Parker CC, Gillessen S, Cook A, Brawley C, Gilson C, Rush H, Abdel-Aty H, Amos CL, Murphy C, Chowdhury S, Malik Z, Russell JM, Parkar N, Pugh C, Diaz-Montana C, Pezaro C, Grant W, Saxby H, Pedley I, O'Sullivan JM, Birtle A, Gale J, Srihari N, Thomas C, Tanguay J, Wagstaff J, Das P, Gray E, Alzouebi M, Parikh O, Robinson A, Montazeri AH, Wylie J, Zarkar A, Cathomas R, Brown MD, Jain Y, Dearnaley DP, Mason MD, Gilbert D, Langley RE, Millman R, Matheson D, Sydes MR, Brown LC, Parmar MKB, James ND. Abiraterone acetate plus prednisolone with or without enzalutamide for patients with metastatic prostate cancer starting androgen deprivation therapy: final results from two randomised phase 3 trials of the STAMPEDE platform protocol. Lancet Oncol 2023; 24:443-456. [PMID: 37142371 DOI: 10.1016/s1470-2045(23)00148-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 03/17/2023] [Accepted: 03/23/2023] [Indexed: 05/06/2023]
Abstract
BACKGROUND Abiraterone acetate plus prednisolone (herein referred to as abiraterone) or enzalutamide added at the start of androgen deprivation therapy improves outcomes for patients with metastatic prostate cancer. Here, we aimed to evaluate long-term outcomes and test whether combining enzalutamide with abiraterone and androgen deprivation therapy improves survival. METHODS We analysed two open-label, randomised, controlled, phase 3 trials of the STAMPEDE platform protocol, with no overlapping controls, conducted at 117 sites in the UK and Switzerland. Eligible patients (no age restriction) had metastatic, histologically-confirmed prostate adenocarcinoma; a WHO performance status of 0-2; and adequate haematological, renal, and liver function. Patients were randomly assigned (1:1) using a computerised algorithm and a minimisation technique to either standard of care (androgen deprivation therapy; docetaxel 75 mg/m2 intravenously for six cycles with prednisolone 10 mg orally once per day allowed from Dec 17, 2015) or standard of care plus abiraterone acetate 1000 mg and prednisolone 5 mg (in the abiraterone trial) orally or abiraterone acetate and prednisolone plus enzalutamide 160 mg orally once a day (in the abiraterone and enzalutamide trial). Patients were stratified by centre, age, WHO performance status, type of androgen deprivation therapy, use of aspirin or non-steroidal anti-inflammatory drugs, pelvic nodal status, planned radiotherapy, and planned docetaxel use. The primary outcome was overall survival assessed in the intention-to-treat population. Safety was assessed in all patients who started treatment. A fixed-effects meta-analysis of individual patient data was used to compare differences in survival between the two trials. STAMPEDE is registered with ClinicalTrials.gov (NCT00268476) and ISRCTN (ISRCTN78818544). FINDINGS Between Nov 15, 2011, and Jan 17, 2014, 1003 patients were randomly assigned to standard of care (n=502) or standard of care plus abiraterone (n=501) in the abiraterone trial. Between July 29, 2014, and March 31, 2016, 916 patients were randomly assigned to standard of care (n=454) or standard of care plus abiraterone and enzalutamide (n=462) in the abiraterone and enzalutamide trial. Median follow-up was 96 months (IQR 86-107) in the abiraterone trial and 72 months (61-74) in the abiraterone and enzalutamide trial. In the abiraterone trial, median overall survival was 76·6 months (95% CI 67·8-86·9) in the abiraterone group versus 45·7 months (41·6-52·0) in the standard of care group (hazard ratio [HR] 0·62 [95% CI 0·53-0·73]; p<0·0001). In the abiraterone and enzalutamide trial, median overall survival was 73·1 months (61·9-81·3) in the abiraterone and enzalutamide group versus 51·8 months (45·3-59·0) in the standard of care group (HR 0·65 [0·55-0·77]; p<0·0001). We found no difference in the treatment effect between these two trials (interaction HR 1·05 [0·83-1·32]; pinteraction=0·71) or between-trial heterogeneity (I2 p=0·70). In the first 5 years of treatment, grade 3-5 toxic effects were higher when abiraterone was added to standard of care (271 [54%] of 498 vs 192 [38%] of 502 with standard of care) and the highest toxic effects were seen when abiraterone and enzalutamide were added to standard of care (302 [68%] of 445 vs 204 [45%] of 454 with standard of care). Cardiac causes were the most common cause of death due to adverse events (five [1%] with standard of care plus abiraterone and enzalutamide [two attributed to treatment] and one (<1%) with standard of care in the abiraterone trial). INTERPRETATION Enzalutamide and abiraterone should not be combined for patients with prostate cancer starting long-term androgen deprivation therapy. Clinically important improvements in survival from addition of abiraterone to androgen deprivation therapy are maintained for longer than 7 years. FUNDING Cancer Research UK, UK Medical Research Council, Swiss Group for Clinical Cancer Research, Janssen, and Astellas.
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Affiliation(s)
- Gerhardt Attard
- Cancer Institute, University College London, London, UK; University College London Hospitals, London, UK.
| | - Laura Murphy
- Medical Research Council Clinical Trials Unit, University College London, London, UK
| | - Noel W Clarke
- Christie and Salford Royal NHS Foundation Trusts, Manchester, UK
| | - Ashwin Sachdeva
- Christie and Salford Royal NHS Foundation Trusts, Manchester, UK
| | - Craig Jones
- Christie and Salford Royal NHS Foundation Trusts, Manchester, UK
| | - Alex Hoyle
- Christie and Salford Royal NHS Foundation Trusts, Manchester, UK
| | | | - Robert J Jones
- Beatson West of Scotland Cancer Centre, University of Glasgow, Glasgow, UK
| | | | - Silke Gillessen
- Oncology Institute of Southern Switzerland, Bellinzona, Switzerland; CH and Universita della Svizzera Italiana, Lugano, Switzerland
| | - Adrian Cook
- Medical Research Council Clinical Trials Unit, University College London, London, UK
| | - Chris Brawley
- Medical Research Council Clinical Trials Unit, University College London, London, UK
| | - Clare Gilson
- Medical Research Council Clinical Trials Unit, University College London, London, UK
| | - Hannah Rush
- Medical Research Council Clinical Trials Unit, University College London, London, UK; Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Hoda Abdel-Aty
- Royal Marsden NHS Foundation Trust and Institute of Cancer Research, London, UK
| | - Claire L Amos
- Medical Research Council Clinical Trials Unit, University College London, London, UK
| | - Claire Murphy
- Medical Research Council Clinical Trials Unit, University College London, London, UK
| | | | - Zafar Malik
- Clatterbridge Cancer Centre NHS Foundation Trust, Wirral, UK
| | - J Martin Russell
- Institute of Cancer Sciences, University of Glasgow, Glasgow, UK
| | - Nazia Parkar
- Medical Research Council Clinical Trials Unit, University College London, London, UK
| | - Cheryl Pugh
- Medical Research Council Clinical Trials Unit, University College London, London, UK
| | - Carlos Diaz-Montana
- Medical Research Council Clinical Trials Unit, University College London, London, UK
| | | | | | - Helen Saxby
- Torbay and South Devon NHS Foundation Trust, Torbay, UK
| | - Ian Pedley
- Northern Centre for Cancer Care, Newcastle upon Tyne, UK
| | | | - Alison Birtle
- Rosemere Cancer Centre, Royal Preston Hospital, Preston, UK
| | | | | | | | | | | | | | - Emma Gray
- Yeovil District Hospital NHS Foundation Trust, Yeovil, UK
| | | | - Omi Parikh
- East Lancashire Hospitals NHS Trust, Preston, UK
| | | | | | - James Wylie
- Christie and Salford Royal NHS Foundation Trusts, Manchester, UK
| | - Anjali Zarkar
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Richard Cathomas
- Division of Oncology and Hematology, Cantonal Hospital Graubünden, Chur, Switzerland; Swiss Group for Clinical Cancer Research, Bern, Switzerland
| | - Michael D Brown
- Christie and Salford Royal NHS Foundation Trusts, Manchester, UK
| | - Yatin Jain
- Christie and Salford Royal NHS Foundation Trusts, Manchester, UK
| | - David P Dearnaley
- Royal Marsden NHS Foundation Trust and Institute of Cancer Research, London, UK
| | | | - Duncan Gilbert
- Medical Research Council Clinical Trials Unit, University College London, London, UK
| | - Ruth E Langley
- Medical Research Council Clinical Trials Unit, University College London, London, UK
| | - Robin Millman
- Medical Research Council Clinical Trials Unit, University College London, London, UK
| | - David Matheson
- Faculty of Education Health and Wellbeing, University of Wolverhampton, Walsall, UK
| | - Matthew R Sydes
- Medical Research Council Clinical Trials Unit, University College London, London, UK
| | - Louise C Brown
- Medical Research Council Clinical Trials Unit, University College London, London, UK
| | - Mahesh K B Parmar
- Medical Research Council Clinical Trials Unit, University College London, London, UK
| | - Nicholas D James
- Royal Marsden NHS Foundation Trust and Institute of Cancer Research, London, UK
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Ferreira MR, Andreyev JN, Wedlake L, Dearnaley DP. Comment on "Exploiting dietary fibre and the gut microbiota in pelvic radiotherapy patients". Br J Cancer 2023; 128:711-712. [PMID: 36717675 PMCID: PMC9977733 DOI: 10.1038/s41416-023-02163-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 12/05/2022] [Accepted: 01/13/2023] [Indexed: 01/31/2023] Open
Affiliation(s)
- Miguel R Ferreira
- Guys and St Thomas NHS Foundation Trust, London, UK.
- King's College London, London, UK.
| | | | | | - David P Dearnaley
- The Royal Marsden NHS Foundation Trust, London, UK
- The Institute of Cancer Research, London, UK
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8
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Roy S, Romero T, Steigler A, Denham JW, Joseph DJ, Michalski JM, Feng FY, Bolla M, de Reijke TM, Maingon P, Sydes MR, Dearnaley DP, Incrocci L, Heemsbergen W, Nabid A, Souhami L, Zapatero A, Sun Y, Spratt DE, Kishan AU. Biochemical recurrence (BCR) surrogacy for clinical outcomes after radiotherapy for adenocarcinoma of the prostate (BCRSCRAP): A meta-analysis from MARCAP Consortium. J Clin Oncol 2023. [DOI: 10.1200/jco.2023.41.6_suppl.391] [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: 03/17/2023] Open
Abstract
391 Background: Event-free survival, a PSA-driven endpoint, was shown to not be surrogate endpoint for overall survival (OS) in the ICECAP two-stage meta-analytic approach. However, time to biochemical recurrence (TTBCR) in NRG/RTOG 9202 met Prentice criteria for surrogacy. We performed an individual patient data (IPD) meta-analysis of 11 randomized controlled trials evaluating RT dose escalation, ADT use, and adjuvant ADT prolongation to evaluate the surrogacy of time to BCR (TTBCR), censoring for non-prostate cancer deaths, using both approaches to evaluate surrogacy. Methods: This individual patient level meta-analysis was performed using data from the MARCAP consortium, and 11 radiotherapy trials were included. TTBCR was defined as time to developing a BCR or experiencing prostate cancer-specific mortality (PCSM), with censoring at time of other-cause death or loss to follow-up. Landmark analyses were used to test the Prentice criteria for surrogacy. For patient level correlation between TTBCR and OS, we applied a bivariate Copula model to estimate the Kendall’s τ. For trial level correlation of the treatment effect on TTBCR and true endpoints, a weighted linear regression model was applied between the effects of treatment (natural log of hazard ratio [log-HR]) on OS versus TTBCR using a weightage that was inverse variance of BCR log-HR estimate. Results: Based on Prentice criteria, BCR at the landmark time point of 48 months was associated with increased risk of mortality in trials that compared treatment intensification with adjuvant ADT prolongation (HR 2.18 [95% CI 1.95-2.42]), the addition of ADT (HR 1.38 [1.25-1.54]), and RT dose escalation (HR 2.12 [1.83-2.46]) on uni- and multi-variable analyses. At the patient level, there was a low to moderate level correlation between BCR and OS with Kendall’s τ of 0.34 and a R2 of 0.55 for correlation of treatment effect on TTBCR and OS. At the trial level, there was a poor correlation between treatment effect on TTBCR and OS (R2=0.16). Conclusions: This IPD meta-analysis demonstrates that while BCR is prognostic, it is not a surrogate endpoint for OS in localized prostate cancer for patients treated with a diverse array of radiotherapeutic strategies. This highlights the importance of other cause mortality in prostate cancer. Our results highlight the differences in interpretability of Prentice criteria and the two-stage meta-analytic approach and suitability of endpoints for clinical trial design.
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Affiliation(s)
| | | | | | | | | | | | - Felix Y Feng
- University of California, San Francisco, San Francisco, CA
| | - Michel Bolla
- Grenoble Alpes University, Centre Hospitalier Universitaire de Grenoble, Grenoble, France
| | | | | | | | | | | | | | - Abdenour Nabid
- Centre Hospitalier de Sherbrooke, Sherbrooke, QC, Canada
| | - Luis Souhami
- McGill University Health Centre, Montréal, QC, Canada
| | | | - Yilun Sun
- Case Western Reserve University, Cleveland, OH
| | - Daniel Eidelberg Spratt
- University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH
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Syndikus I, Griffin C, Philipps L, Tree A, Khoo V, Birtle AJ, Choudhury A, Ferguson C, O'Sullivan JM, Panades M, Rimmer YL, Scrase CD, Staffurth J, Cruickshank C, Hassan S, Pugh J, Dearnaley DP, Hall E. 10-Year efficacy and co-morbidity outcomes of a phase III randomised trial of conventional vs. hypofractionated high dose intensity modulated radiotherapy for prostate cancer (CHHiP; CRUK/06/016). J Clin Oncol 2023. [DOI: 10.1200/jco.2023.41.6_suppl.304] [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
304 Background: Five-year results from the CHHiP trial indicated that moderate hypofractionation of 60 Gray (Gy)/20 fractions (f) was non-inferior to 74Gy/37f (Lancet Oncology, 2016). Reporting of long-term efficacy and side effects is essential in a patient population that remain at risk of recurrence years after treatment. Here we report specific co-morbidity data collected at 10 years and an update of efficacy. Methods: Between October 2002 and June 2011, 3216 men with node negative T1b-T3a localised prostate cancer with risk of seminal vesical involvement ≤30% were randomised (1:1:1 ratio) to 74Gy/37f (control), 60Gy/20f or 57Gy/19f. Patients received 3-6 months of androgen deprivation prior to radiotherapy. The primary endpoint was time to biochemical failure (Phoenix consensus guidelines) or clinical failure (BCF). The non-inferiority design specified a critical hazard ratio (HR) of 1.208 for each hypofractionated schedule compared to control. Data on specific radiotherapy related co-morbidities were collected at 10-year follow-up and are presented as frequency and percentages. Analysis was by intention-to-treat; HRs quoted are unadjusted. Results: With a median follow up of 12.1 years, 10-year BCF-free rates (95% CI) were 74Gy: 76.0% (73.1%, 78.6%); 60Gy: 79.8% (77.1%, 82.3%) and 57Gy: 73.4% (70.5%, 76.1%). For 60Gy/20f, non-inferiority was confirmed: HR60=0.84 (90% CI 0.72, 0.97) with borderline significance for superiority (HR=0.84 (95% CI 0.70, 1.00). As in the primary analysis, for 57Gy/19f, non-inferiority could not be declared: HR57=1.13 (90% CI 0.98, 1.30). 10-year overall survival (95% CI) was 78.5% (75.9%, 81.0%), 82.9% (80.4%, 85.0%) and 79.9% (77.3%, 82.2%) in the 74Gy, 60Gy and 57Gy groups. Bone fractures were reported in 2% (15/700), 2% (19/771) and 3% (22/719) of patients in the 74Gy, 60Gy and 57Gy groups respectively at 10 years. The most common intervention reported was a sigmoidoscopy with 12% (79/681), 8% (60/739) and 9% (65/702) in the 74Gy, 60Gy and 57Gy groups respectively. Of those patients who underwent a sigmoidoscopy it was due to symptoms for 81% (63/78) 81% (48/59) and 85% (55/65) of patients in the 74Gy, 60Gy and 57Gy group respectively. Frequencies of all other pre-specified co-morbidities or related interventions (ureteric obstruction, bowel strictures, trans-urethral resection of prostate, urethrotomy, urethral dilatation or long term catheterisation or treatment of proctopathy with steroid, sucralfate, formalin, laser coagulation or rectal diversion) were <1% in all groups. Conclusions: With a median follow-up of 12 years, oncological outcomes following 60Gy/20f continue to be non-inferior to those with 74Gy/37f. Late co-morbidities were very low across all treatment groups. These data support the long-term safety of moderate hypofractionation. Clinical trial information: 97182923 .
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Affiliation(s)
- Isabel Syndikus
- Clatterbridge Cancer Centre, Department of Radiotherapy, Liverpool, United Kingdom
| | - Clare Griffin
- The Institute of Cancer Research, London, United Kingdom
| | - Lara Philipps
- The Institute of Cancer Research, London, United Kingdom
| | - Alison Tree
- The Royal Marsden NHS Foundation Trust and the Institute of Cancer Research, London, United Kingdom
| | - Vincent Khoo
- The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Alison Jane Birtle
- Rosemere Cancer Centre, Lancs Teaching Hospitals, & University of Manchester, University of Central Lancashire, Preston, United Kingdom
| | | | | | | | | | | | | | - John Staffurth
- Velindre Hospital, Cardiff University, Cardiff, United Kingdom
| | | | - Shama Hassan
- The Institute of Cancer Research, London, United Kingdom
| | - Julia Pugh
- The Institute of Cancer Research, London, United Kingdom
| | - David P. Dearnaley
- Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Emma Hall
- The Institute of Cancer Research, Clinical Trials and Statistics Unit, London, United Kingdom
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10
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Brand DH, Brüningk SC, Wilkins A, Naismith O, Gao A, Syndikus I, Dearnaley DP, van As N, Hall E, Gulliford S, Tree AC. The Fraction Size Sensitivity of Late Genitourinary Toxicity: Analysis of Alpha/Beta (α/β) Ratios in the CHHiP Trial. Int J Radiat Oncol Biol Phys 2023; 115:327-336. [PMID: 35985457 DOI: 10.1016/j.ijrobp.2022.08.030] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 08/04/2022] [Accepted: 08/06/2022] [Indexed: 01/14/2023]
Abstract
PURPOSE Moderately hypofractionated external beam intensity modulated radiation therapy (RT) for prostate cancer is now standard-of-care. Normal tissue toxicity responses to fraction size alteration are nonlinear: the linear-quadratic model is a widely used framework accounting for this, through the α/β ratio. Few α/β ratio estimates exist for human late genitourinary endpoints; here we provide estimates derived from a hypofractionation trial. METHODS AND MATERIALS The CHHiP trial randomized 3216 men with localized prostate cancer 1:1:1 between conventionally fractionated intensity modulated RT (74 Gy/37 fractions (Fr)) and 2 moderately hypofractionated regimens (60 Gy/20 Fr and 57 Gy/19 Fr). RT plan and suitable follow-up assessment was available for 2206 men. Three prospectively assessed clinician-reported toxicity scales were amalgamated for common genitourinary endpoints: dysuria, hematuria, incontinence, reduced flow/stricture, and urine frequency. Per endpoint, only patients with baseline zero toxicity were included. Three models for endpoint grade ≥1 (G1+) and G2+ toxicity were fitted: Lyman Kutcher-Burman (LKB) without equivalent dose in 2 Gy/Fr (EQD2) correction [LKB-NoEQD2]; LKB with EQD2-correction [LKB-EQD2]; LKB-EQD2 with dose-modifying-factor (DMF) inclusion [LKB-EQD2-DMF]. DMFs were age, diabetes, hypertension, pelvic surgery, prior transurethral resection of prostate (TURP), overall treatment time and acute genitourinary toxicity (G2+). Bootstrapping generated 95% confidence intervals and unbiased performance estimates. Models were compared by likelihood ratio test. RESULTS The LKB-EQD2 model significantly improved performance over LKB-NoEQD2 for just 3 endpoints: dysuria G1+ (α/β = 2.0 Gy; 95% confidence interval [CI], 1.2-3.2 Gy), hematuria G1+ (α/β = 0.9 Gy; 95% CI, 0.1-2.2 Gy) and hematuria G2+ (α/β = 0.6 Gy; 95% CI, 0.1-1.7 Gy). For these 3 endpoints, further incorporation of 2 DMFs improved on LKB-EQD2: acute genitourinary toxicity and prior TURP (hematuria G1+ only), but α/β ratio estimates remained stable. CONCLUSIONS Inclusion of EQD2-correction significantly improved model fitting for dysuria and hematuria endpoints, where fitted α/β ratio estimates were low: 0.6 to 2 Gy. This suggests therapeutic gain for clinician-reported GU toxicity, through hypofractionation, might be lower than expected by typical late α/β ratio assumptions of 3 to 5 Gy.
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Affiliation(s)
- Douglas H Brand
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, United Kingdom; Urology Unit, Royal Marsden NHS Foundation Trust, London, United Kingdom; Department of Medical Physics and Biomedical Engineering, University College London, London, United Kingdom.
| | - Sarah C Brüningk
- Department of Biosystems Science and Engineering, ETH Zurich, Basel, Switzerland; Swiss Institute for Bioinformatics (SIB), Lausanne, Switzerland
| | - Anna Wilkins
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, United Kingdom; Urology Unit, Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Olivia Naismith
- Radiotherapy Trials QA Group (RTTQA), Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Annie Gao
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, United Kingdom; Urology Unit, Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Isabel Syndikus
- Radiotherapy Department, Clatterbridge Cancer Centre, Liverpool, United Kingdom
| | - David P Dearnaley
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, United Kingdom; Urology Unit, Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Nicholas van As
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, United Kingdom; Urology Unit, Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Emma Hall
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, United Kingdom
| | - Sarah Gulliford
- Department of Medical Physics and Biomedical Engineering, University College London, London, United Kingdom; Department of Radiotherapy Physics, University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Alison C Tree
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, United Kingdom; Urology Unit, Royal Marsden NHS Foundation Trust, London, United Kingdom
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11
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Ma TM, Chu FI, Sandler H, Feng FY, Efstathiou JA, Jones CU, Roach M, Rosenthal SA, Pisansky T, Michalski JM, Bolla M, de Reijke TM, Maingon P, Neven A, Denham J, Steigler A, Joseph D, Nabid A, Souhami L, Carrier N, Incrocci L, Heemsbergen W, Pos FJ, Sydes MR, Dearnaley DP, Tree AC, Syndikus I, Hall E, Cruickshank C, Malone S, Roy S, Sun Y, Zaorsky NG, Nickols NG, Reiter RE, Rettig MB, Steinberg ML, Reddy VK, Xiang M, Romero T, Spratt DE, Kishan AU. Local Failure Events in Prostate Cancer Treated with Radiotherapy: A Pooled Analysis of 18 Randomized Trials from the Meta-analysis of Randomized Trials in Cancer of the Prostate Consortium (LEVIATHAN). Eur Urol 2022; 82:487-498. [PMID: 35934601 DOI: 10.1016/j.eururo.2022.07.011] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [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: 03/29/2022] [Revised: 07/03/2022] [Accepted: 07/14/2022] [Indexed: 02/07/2023]
Abstract
CONTEXT The prognostic importance of local failure after definitive radiotherapy (RT) in National Comprehensive Cancer Network intermediate- and high-risk prostate cancer (PCa) patients remains unclear. OBJECTIVE To evaluate the prognostic impact of local failure and the kinetics of distant metastasis following RT. EVIDENCE ACQUISITION A pooled analysis was performed on individual patient data of 12 533 PCa (6288 high-risk and 6245 intermediate-risk) patients enrolled in 18 randomized trials (conducted between 1985 and 2015) within the Meta-analysis of Randomized Trials in Cancer of the Prostate Consortium. Multivariable Cox proportional hazard (PH) models were developed to evaluate the relationship between overall survival (OS), PCa-specific survival (PCSS), distant metastasis-free survival (DMFS), and local failure as a time-dependent covariate. Markov PH models were developed to evaluate the impact of specific transition states. EVIDENCE SYNTHESIS The median follow-up was 11 yr. There were 795 (13%) local failure events and 1288 (21%) distant metastases for high-risk patients and 449 (7.2%) and 451 (7.2%) for intermediate-risk patients, respectively. For both groups, 81% of distant metastases developed from a clinically relapse-free state (cRF state). Local failure was significantly associated with OS (hazard ratio [HR] 1.17, 95% confidence interval [CI] 1.06-1.30), PCSS (HR 2.02, 95% CI 1.75-2.33), and DMFS (HR 1.94, 95% CI 1.75-2.15, p < 0.01 for all) in high-risk patients. Local failure was also significantly associated with DMFS (HR 1.57, 95% CI 1.36-1.81) but not with OS in intermediate-risk patients. Patients without local failure had a significantly lower HR of transitioning to a PCa-specific death state than those who had local failure (HR 0.32, 95% CI 0.21-0.50, p < 0.001). At later time points, more distant metastases emerged after a local failure event for both groups. CONCLUSIONS Local failure is an independent prognosticator of OS, PCSS, and DMFS in high-risk and of DMFS in intermediate-risk PCa. Distant metastasis predominantly developed from the cRF state, underscoring the importance of addressing occult microscopic disease. However a "second wave" of distant metastases occurs subsequent to local failure events, and optimization of local control may reduce the risk of distant metastasis. PATIENT SUMMARY Among men receiving definitive radiation therapy for high- and intermediate-risk prostate cancer, about 10% experience local recurrence, and they are at significantly increased risks of further disease progression. About 80% of patients who develop distant metastasis do not have a detectable local recurrence preceding it.
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Affiliation(s)
- Ting Martin Ma
- Depart of Radiation Oncology, University of California Los Angeles, Los Angeles, CA, USA
| | - Fang-I Chu
- Depart of Radiation Oncology, University of California Los Angeles, Los Angeles, CA, USA
| | - Howard Sandler
- Department of Radiation Oncology, Cedars Sinai, Los Angeles, CA, USA
| | - Felix Y Feng
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA, USA
| | - Jason A Efstathiou
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Mack Roach
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA, USA
| | - Seth A Rosenthal
- Department of Radiation Oncology, Sutter Medical Group, Roseville, CA, USA
| | - Thomas Pisansky
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | - Jeff M Michalski
- Department of Radiation Oncology, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Michel Bolla
- Department of Radiation Therapy, CHU Grenoble, Grenoble, France
| | - Theo M de Reijke
- Department of Urology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Philippe Maingon
- Department of Radiation Oncology, Centre Georges François Leclerc, University of Burgundy, Dijon, Burgundy, France
| | - Anouk Neven
- Luxembourg Institute of Health, Competence Center for Methodology and Statistics, Strassen, Luxembourg
| | - James Denham
- School of Medicine and Public Health, Faculty of Health and Medicine University of Newcastle, Newcastle, NSW, Australia
| | - Allison Steigler
- School of Medicine and Public Health, Faculty of Health and Medicine University of Newcastle, Newcastle, NSW, Australia
| | - David Joseph
- Department of Surgery, University of Western Australia
| | - Abdenour Nabid
- Department of Radiation Oncology, Centre Hospitaler Universitaire de Sherbrooke, Sherbrooke, QC, Canada
| | - Luis Souhami
- Department of Radiation Oncology, McGill University Health Centre, Montreal, QC, Canada
| | - Nathalie Carrier
- Centre de recherche clinique, Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC, Canada
| | - Luca Incrocci
- Department of Radiation Oncology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Wilma Heemsbergen
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Floris J Pos
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Matthew R Sydes
- MRC Clinical Trials Unit at UCL, University College London, London, UK
| | - David P Dearnaley
- Academic Urology Unit, Royal Marsden Hospital, London, UK; The Institute of Cancer Research, London, UK
| | - Alison C Tree
- The Institute of Cancer Research, London, UK; The Royal Marsden NHS Foundation Trust, London, UK
| | | | - Emma Hall
- The Institute of Cancer Research, London, UK
| | | | - Shawn Malone
- The Ottawa Hospital Cancer Centre, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Soumyajit Roy
- Department of Radiation Oncology, Rush University Medical Center, Chicago, IL, USA
| | - Yilun Sun
- Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, OH, USA; Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Nicholas G Zaorsky
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Nicholas G Nickols
- Depart of Radiation Oncology, University of California Los Angeles, Los Angeles, CA, USA
| | - Robert E Reiter
- Department of Urology, University of California Los Angeles, Los Angeles, CA, USA
| | - Matthew B Rettig
- Department of Urology, University of California Los Angeles, Los Angeles, CA, USA; Division of Hematology/Oncology, Department of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Michael L Steinberg
- Depart of Radiation Oncology, University of California Los Angeles, Los Angeles, CA, USA
| | - Vishruth K Reddy
- Depart of Radiation Oncology, University of California Los Angeles, Los Angeles, CA, USA
| | - Michael Xiang
- Depart of Radiation Oncology, University of California Los Angeles, Los Angeles, CA, USA
| | - Tahmineh Romero
- Department of Medicine Statistics Core, University of California Los Angeles, Los Angeles, CA, USA
| | - Daniel E Spratt
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Amar U Kishan
- Depart of Radiation Oncology, University of California Los Angeles, Los Angeles, CA, USA.
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12
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James ND, Clarke NW, Cook A, Ali A, Hoyle AP, Attard G, Brawley CD, Chowdhury S, Cross WR, Dearnaley DP, de Bono JS, Diaz‐Montana C, Gilbert D, Gillessen S, Gilson C, Jones RJ, Langley RE, Malik ZI, Matheson DJ, Millman R, Parker CC, Pugh C, Rush H, Russell JM, Berthold DR, Buckner ML, Mason MD, Ritchie AWS, Birtle AJ, Brock SJ, Das P, Ford D, Gale J, Grant W, Gray EK, Hoskin P, Khan MM, Manetta C, McPhail NJ, O'Sullivan JM, Parikh O, Perna C, Pezaro CJ, Protheroe AS, Robinson AJ, Rudman SM, Sheehan DJ, Srihari NN, Syndikus I, Tanguay JS, Thomas CW, Vengalil S, Wagstaff J, Wylie JP, Parmar MKB, Sydes MR. Abiraterone acetate plus prednisolone for metastatic patients starting hormone therapy: 5-year follow-up results from the STAMPEDE randomised trial (NCT00268476). Int J Cancer 2022; 151:422-434. [PMID: 35411939 PMCID: PMC9321995 DOI: 10.1002/ijc.34018] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 02/15/2022] [Accepted: 02/22/2022] [Indexed: 11/17/2022]
Abstract
Abiraterone acetate plus prednisolone (AAP) previously demonstrated improved survival in STAMPEDE, a multiarm, multistage platform trial in men starting long-term hormone therapy for prostate cancer. This long-term analysis in metastatic patients was planned for 3 years after the first results. Standard-of-care (SOC) was androgen deprivation therapy. The comparison randomised patients 1:1 to SOC-alone with or without daily abiraterone acetate 1000 mg + prednisolone 5 mg (SOC + AAP), continued until disease progression. The primary outcome measure was overall survival. Metastatic disease risk group was classified retrospectively using baseline CT and bone scans by central radiological review and pathology reports. Analyses used Cox proportional hazards and flexible parametric models, accounting for baseline stratification factors. One thousand and three patients were contemporaneously randomised (November 2011 to January 2014): median age 67 years; 94% newly-diagnosed; metastatic disease risk group: 48% high, 44% low, 8% unassessable; median PSA 97 ng/mL. At 6.1 years median follow-up, 329 SOC-alone deaths (118 low-risk, 178 high-risk) and 244 SOC + AAP deaths (75 low-risk, 145 high-risk) were reported. Adjusted HR = 0.60 (95% CI: 0.50-0.71; P = 0.31 × 10-9 ) favoured SOC + AAP, with 5-years survival improved from 41% SOC-alone to 60% SOC + AAP. This was similar in low-risk (HR = 0.55; 95% CI: 0.41-0.76) and high-risk (HR = 0.54; 95% CI: 0.43-0.69) patients. Median and current maximum time on SOC + AAP was 2.4 and 8.1 years. Toxicity at 4 years postrandomisation was similar, with 16% patients in each group reporting grade 3 or higher toxicity. A sustained and substantial improvement in overall survival of all metastatic prostate cancer patients was achieved with SOC + abiraterone acetate + prednisolone, irrespective of metastatic disease risk group.
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Affiliation(s)
| | - Noel W. Clarke
- The Departments of Surgery & UrologyThe Christie & Salford Royal HospitalsManchesterUK
| | - Adrian Cook
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials & Methodology, UCLLondonUK
| | - Adnan Ali
- The Christie NHS Foundation TrustManchesterUK
| | | | | | - Christopher D. Brawley
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials & Methodology, UCLLondonUK
| | - Simon Chowdhury
- Guy's, King's, & St. Thomas' Hospitals, and Sarah Cannon Research InstituteLondonUK
| | | | - David P. Dearnaley
- The Institute of Cancer Research and Royal Marsden NHS Foundation TrustLondonUK
| | | | - Carlos Diaz‐Montana
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials & Methodology, UCLLondonUK
| | - Duncan Gilbert
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials & Methodology, UCLLondonUK
| | - Silke Gillessen
- Istituto Oncologico della Svizzera ItalianaBellinzonaSwitzerland
| | - Clare Gilson
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials & Methodology, UCLLondonUK
- Royal Marsden HospitalLondonUK
| | - Rob J. Jones
- Beatson West of Scotland Cancer Centre, University of GlasgowGlasgowUK
| | - Ruth E. Langley
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials & Methodology, UCLLondonUK
| | - Zafar I. Malik
- Radiotherapy UnitThe Clatterbridge Cancer Centre NHS Foundation TrustLiverpoolLiverpoolL7 8YAUK
| | - David J. Matheson
- School of Allied Health and Midwifery, Faculty of Education, Health and WellbeingUniversity of WolverhamptonWolverhamptonWS1 3BDUK
| | | | - Chris C. Parker
- Uro‐Oncology UnitRoyal Marsden Hospital and Institute of Cancer ResearchSuttonUK
| | - Cheryl Pugh
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials & Methodology, UCLLondonUK
| | - Hannah Rush
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials & Methodology, UCLLondonUK
- Guys and St Thomas' NHS Foundation TrustLondonUK
| | - J. Martin Russell
- Institute of Cancer Sciences, University of GlasgowGlasgowUK
- Beatson West of Scotland Cancer CentreGlasgowUK
| | | | - Michelle L. Buckner
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials & Methodology, UCLLondonUK
| | | | | | - Alison J. Birtle
- Rosemere Cancer Centre, Lancashire Teaching Hospitals & University of Manchester, University of Central LancashireLancashireUK
| | | | - Prantik Das
- Department of OncologyUniversity Hospitals of Derby and Burton NHS Foundation TrustDerbyUK
| | - Dan Ford
- City Hospital, Cancer Centre at Queen Elizabeth HospitalBirminghamUK
| | - Joanna Gale
- Portsmouth Hospitals University TrustPortsmouthUK
| | - Warren Grant
- Gloucestershire Oncology Centre, Cheltenham General HospitalCheltenhamUK
| | | | | | - Mohammad M. Khan
- Department of Oncology Castle Hill HospitalHullUK
- Scarborough General HospitalScarboroughUK
| | | | | | - Joe M. O'Sullivan
- Patrick G Johnston Centre for Cancer Research, Queen's University BelfastBelfastUK
| | - Omi Parikh
- Rosemere Cancer Centre, Lancashire Teaching Hospitals NHS TrustPrestonUK
| | - Carla Perna
- Royal Surrey NHS Foundation TrustGuildfordUK
| | | | | | | | | | | | | | - Isabel Syndikus
- Radiotherapy UnitThe Clatterbridge Cancer Centre NHS Foundation TrustLiverpoolLiverpoolL7 8YAUK
| | | | | | - Salil Vengalil
- University Hospital North Midlands NHS TrustStaffordshireUK
| | - John Wagstaff
- Swansea University and the South West UK Cancer CentreSwanseaUK
| | | | - Mahesh K. B. Parmar
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials & Methodology, UCLLondonUK
| | - Matthew R. Sydes
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials & Methodology, UCLLondonUK
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13
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James ND, Ingleby FC, Clarke NW, Amos CL, Attard G, Brawley CD, Chowdhury S, Cross W, Dearnaley DP, Gilbert DC, Gillessen S, Jones RJ, Langley RE, Macnair A, Malik ZI, Mason MD, Matheson DJ, Millman R, Parker CC, Rush HL, Russell JM, Au C, Ritchie AWS, Mestre RP, Ahmed I, Birtle AJ, Brock SJ, Das P, Ford VA, Gray EK, Hughes RJ, Manetta CB, McLaren DB, Nikapota AD, O'Sullivan JM, Perna C, Peedell C, Protheroe AS, Sundar S, Tanguay JS, Tolan SP, Wagstaff J, Wallace JB, Wylie JP, Zarkar A, Parmar MKB, Sydes MR. Docetaxel for Nonmetastatic Prostate Cancer: Long-Term Survival Outcomes in the STAMPEDE Randomized Controlled Trial. JNCI Cancer Spectr 2022; 6:6649740. [PMID: 35877084 PMCID: PMC9338456 DOI: 10.1093/jncics/pkac043] [Citation(s) in RCA: 1] [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: 10/26/2021] [Revised: 12/02/2021] [Accepted: 02/24/2022] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND STAMPEDE previously reported adding upfront docetaxel improved overall survival for prostate cancer patients starting long-term androgen deprivation therapy. We report long-term results for non-metastatic patients using, as primary outcome, metastatic progression-free survival (mPFS), an externally demonstrated surrogate for overall survival. METHODS Standard of care (SOC) was androgen deprivation therapy with or without radical prostate radiotherapy. A total of 460 SOC and 230 SOC plus docetaxel were randomly assigned 2:1. Standard survival methods and intention to treat were used. Treatment effect estimates were summarized from adjusted Cox regression models, switching to restricted mean survival time if non-proportional hazards. mPFS (new metastases, skeletal-related events, or prostate cancer death) had 70% power (α = 0.05) for a hazard ratio (HR) of 0.70. Secondary outcome measures included overall survival, failure-free survival (FFS), and progression-free survival (PFS: mPFS, locoregional progression). RESULTS Median follow-up was 6.5 years with 142 mPFS events on SOC (3 year and 54% increases over previous report). There was no good evidence of an advantage to SOC plus docetaxel on mPFS (HR = 0.89, 95% confidence interval [CI] = 0.66 to 1.19; P = .43); with 5-year mPFS 82% (95% CI = 78% to 87%) SOC plus docetaxel vs 77% (95% CI = 73% to 81%) SOC. Secondary outcomes showed evidence SOC plus docetaxel improved FFS (HR = 0.70, 95% CI = 0.55 to 0.88; P = .002) and PFS (nonproportional P = .03, restricted mean survival time difference = 5.8 months, 95% CI = 0.5 to 11.2; P = .03) but no good evidence of overall survival benefit (125 SOC deaths; HR = 0.88, 95% CI = 0.64 to 1.21; P = .44). There was no evidence SOC plus docetaxel increased late toxicity: post 1 year, 29% SOC and 30% SOC plus docetaxel grade 3-5 toxicity. CONCLUSIONS There is robust evidence that SOC plus docetaxel improved FFS and PFS (previously shown to increase quality-adjusted life-years), without excess late toxicity, which did not translate into benefit for longer-term outcomes. This may influence patient management in individual cases.
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Affiliation(s)
- Nicholas D James
- Division of Radiotherapy and Imaging, The Institute of Cancer Research and Royal Marsden NHS Foundation Trust, London, UK
| | - Fiona C Ingleby
- MRC Clinical Trials Unit at University College London (UCL), Institute of Clinical Trials and Methodology, UCL, London, UK
| | - Noel W Clarke
- The Christie and Salford Royal Hospitals, Manchester, UK
| | - Claire L Amos
- MRC Clinical Trials Unit at University College London (UCL), Institute of Clinical Trials and Methodology, UCL, London, UK
| | | | - Christopher D Brawley
- MRC Clinical Trials Unit at University College London (UCL), Institute of Clinical Trials and Methodology, UCL, London, UK
| | - Simon Chowdhury
- Guy's and St. Thomas' NHS Foundation Trust, London, UK.,Sarah Cannon Research Institute, London, UK
| | | | - David P Dearnaley
- Division of Radiotherapy and Imaging, The Institute of Cancer Research and Royal Marsden NHS Foundation Trust, London, UK
| | - Duncan C Gilbert
- MRC Clinical Trials Unit at University College London (UCL), Institute of Clinical Trials and Methodology, UCL, London, UK
| | - Silke Gillessen
- Istituto Oncologico della Svizzera Italiana, Bellinzona, Switzerland
| | - Robert J Jones
- Institute of Cancer Sciences, University of Glasgow, Beatson West of Scotland Cancer Centre, Glasgow, UK
| | - Ruth E Langley
- MRC Clinical Trials Unit at University College London (UCL), Institute of Clinical Trials and Methodology, UCL, London, UK
| | - Archie Macnair
- MRC Clinical Trials Unit at University College London (UCL), Institute of Clinical Trials and Methodology, UCL, London, UK.,Guy's and St. Thomas' NHS Foundation Trust, London, UK
| | - Zafar I Malik
- The Clatterbridge Cancer Centre NHS Foundation Trust, Bebington, UK
| | | | - David J Matheson
- Faculty of Education, Health and Wellbeing, University of Wolverhampton, Wolverhampton, UK
| | - Robin Millman
- MRC Clinical Trials Unit at University College London (UCL), Institute of Clinical Trials and Methodology, UCL, London, UK
| | - Chris C Parker
- Division of Radiotherapy and Imaging, The Institute of Cancer Research and Royal Marsden NHS Foundation Trust, London, UK
| | - Hannah L Rush
- MRC Clinical Trials Unit at University College London (UCL), Institute of Clinical Trials and Methodology, UCL, London, UK.,Guy's and St. Thomas' NHS Foundation Trust, London, UK
| | - J Martin Russell
- Institute of Cancer Sciences, University of Glasgow, Beatson West of Scotland Cancer Centre, Glasgow, UK
| | - Carly Au
- MRC Clinical Trials Unit at University College London (UCL), Institute of Clinical Trials and Methodology, UCL, London, UK
| | - Alastair W S Ritchie
- Urology Department, Gloucestershire Royal NHS Foundation Trust, Gloucester, UK (retired)
| | - Ricardo Pereira Mestre
- Oncology Institute of Southern Switzerland, Bellinzona, Switzerland.,Institute of Oncology Research (IOR), Bellinzona, Switzerland
| | | | - Alison J Birtle
- Rosemere Cancer Centre Lancs Teaching Hospitals, Preston, UK.,University of Manchester, Manchester, UK.,University of Central Lancashire (UCLan), Lancaster, UK
| | | | - Prantik Das
- University Hospitals of Derby NHS Foundation Trust, Derby, UK
| | | | | | | | | | - Duncan B McLaren
- Edinburgh Cancer Centre, Western General Hospital, Edinburgh, UK
| | - Ashok D Nikapota
- Sussex Cancer Centre, University Hospitals Sussex, Brighton, UK.,Worthing and Southlands Hospital, Worthing, UK
| | - Joe M O'Sullivan
- Patrick G. Johnston Centre for Cancer Research, Queen's University Belfast, Belfast, UK
| | - Carla Perna
- Royal Surrey NHS Foundation Trust, Guildford, UK
| | | | | | | | | | - Shaun P Tolan
- The Clatterbridge Cancer Centre NHS Foundation Trust, Bebington, UK
| | - John Wagstaff
- Swansea University College of Medicine & The South West Wales Cancer Centre, Swansea, UK
| | | | | | | | - Mahesh K B Parmar
- MRC Clinical Trials Unit at University College London (UCL), Institute of Clinical Trials and Methodology, UCL, London, UK
| | - Matthew R Sydes
- MRC Clinical Trials Unit at University College London (UCL), Institute of Clinical Trials and Methodology, UCL, London, UK
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14
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Kishan AU, Wang X, Sun Y, Romero T, Michalski JM, Ma TM, Feng FY, Sandler HM, Bolla M, Maingon P, De Reijke T, Neven A, Steigler A, Denham JW, Joseph D, Nabid A, Carrier N, Souhami L, Sydes MR, Dearnaley DP, Syndikus I, Tree AC, Incrocci L, Heemsbergen WD, Pos FJ, Zapatero A, Efstathiou JA, Guerrero A, Alvarez A, San-Segundo CG, Maldonado X, Xiang M, Rettig MB, Reiter RE, Zaorsky NG, Ong WL, Dess RT, Steinberg ML, Nickols NG, Roy S, Garcia JA, Spratt DE. High-dose Radiotherapy or Androgen Deprivation Therapy (HEAT) as Treatment Intensification for Localized Prostate Cancer: An Individual Patient-data Network Meta-analysis from the MARCAP Consortium. Eur Urol 2022; 82:106-114. [PMID: 35469702 DOI: 10.1016/j.eururo.2022.04.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [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: 01/27/2022] [Revised: 03/22/2022] [Accepted: 04/04/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND The relative benefits of radiotherapy (RT) dose escalation and the addition of short-term or long-term androgen deprivation therapy (STADT or LTADT) in the treatment of prostate cancer are unknown. OBJECTIVE To perform a network meta-analysis (NMA) of relevant randomized trials to compare the relative benefits of RT dose escalation ± STADT or LTADT. DESIGN, SETTING, AND PARTICIPANTS An NMA of individual patient data from 13 multicenter randomized trials was carried out for a total of 11862 patients. Patients received one of the six permutations of low-dose RT (64 to <74 Gy) ± STADT or LTADT, high-dose RT (≥74 Gy), or high-dose RT ± STADT or LTADT. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSES Metastasis-free survival (MFS) was the primary endpoint. Frequentist and Bayesian NMAs were performed to rank the various treatment strategies by MFS and biochemical recurrence-free survival (BCRFS). RESULTS AND LIMITATIONS Median follow-up was 8.8 yr (interquartile range 5.7-11.5). The greatest relative improvement in outcomes was seen for addition of LTADT, irrespective of RT dose, followed by addition of STADT, irrespective of RT dose. RT dose escalation did not improve MFS either in the absence of ADT (hazard ratio [HR] 0.97, 95% confidence interval [CI] 0.80-1.18) or with STADT (HR 0.99, 95% CI 0.8-1.23) or LTADT (HR 0.94, 95% CI 0.65-1.37). According to P-score ranking and rankogram analysis, high-dose RT + LTADT was the optimal treatment strategy for both BCRFS and longer-term outcomes. CONCLUSIONS Conventionally escalated RT up to 79.2 Gy, alone or in the presence of ADT, does not improve MFS, while addition of STADT or LTADT to RT alone, regardless of RT dose, consistently improves MFS. RT dose escalation does provide a high probability of improving BCRFS and, provided it can be delivered without compromising quality of life, may represent the optimal treatment strategy when used in conjunction with ADT. PATIENT SUMMARY Using a higher radiotherapy dose when treating prostate cancer does not reduce the chance of developing metastases or death, but it does reduce the chance of having a rise in prostate-specific antigen (PSA) signifying recurrence of cancer. Androgen deprivation therapy improves all outcomes. A safe increase in radiotherapy dose in conjunction with androgen deprivation therapy may be the optimal treatment.
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Affiliation(s)
- Amar U Kishan
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA, USA; Department of Urology, University of California Los Angeles, Los Angeles, CA, USA.
| | - Xiaoyan Wang
- Division of General Internal Medicine and Health Services Research, University of California Los Angeles, Los Angeles, CA, USA
| | - Yilun Sun
- Department of Population Quantitative Health Sciences, Case Western Reserve University, Cleveland, OH, USA; Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Tahmineh Romero
- Division of General Internal Medicine and Health Services Research, University of California Los Angeles, Los Angeles, CA, USA
| | - Jeff M Michalski
- Department of Radiation Oncology, Washington University, St. Louis, MO, USA
| | - Ting Martin Ma
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA, USA
| | - Felix Y Feng
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA, USA
| | - Howard M Sandler
- Department of Radiation Oncology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Michel Bolla
- Radiotherapy Department, University Hospital, Grenoble, France
| | - Philippe Maingon
- Department of Oncology, Hematology, and Supportive Care, Sorbonne University, Paris, France
| | - Theo De Reijke
- Department of Urology, Prostate Cancer Network in the Netherlands, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Anouk Neven
- Statistics Department, European Organisation for Research and Treatment of Cancer Headquarters, Brussels, Belgium; Competence Center for Methodology and Statistics, Luxembourg Institute of Health, Strassen, Luxembourg
| | - Allison Steigler
- School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia
| | - James W Denham
- School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia
| | - David Joseph
- Department of Medicine and Surgery, University of Western Australia, Perth, WA, Australia
| | - Abdenour Nabid
- Department of Radiation Oncology, Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC, Canada
| | - Nathalie Carrier
- Clinical Research Center, Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC, Canada
| | - Luis Souhami
- Department of Radiation Oncology, McGill University Health Centre, Montréal, QC, Canada
| | - Matt R Sydes
- Medical Research Council Clinical Trials Unit, University College London, London, UK
| | | | | | | | - Luca Incrocci
- Department of Radiation Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Wilma D Heemsbergen
- Department of Radiation Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Floris J Pos
- Department of Radiation Oncology, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, the Netherlands
| | | | - Jason A Efstathiou
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA
| | | | - Ana Alvarez
- Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | | | | | - Michael Xiang
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA, USA
| | - Matthew B Rettig
- Department of Medical Oncology, University of California Los Angeles, Los Angeles, CA, USA
| | - Robert E Reiter
- Department of Urology, University of California Los Angeles, Los Angeles, CA, USA
| | - Nicholas G Zaorsky
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Wee Loon Ong
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Robert T Dess
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, USA
| | - Michael L Steinberg
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA, USA
| | - Nicholas G Nickols
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA, USA
| | - Soumyajit Roy
- Department of Radiation Oncology, Rush University, Chicago, IL, USA
| | - Jorge A Garcia
- Division of Oncology, Seidman Cancer Center, Cleveland, OH, USA
| | - Daniel E Spratt
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA
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15
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Sandler HM, Freedland SJ, Shore ND, Smith MR, Rosales RS, Brookman-May SD, Dearnaley DP, Dicker AP, McKenzie MR, Bossi A, Widmark A, Wiegel T, Martin JL, Miladinovic B, Whalen JA, Ciprotti M, McCarthy S, Mundle S, Tombal BF, Feng FY. Patient (pt) population and radiation therapy (RT) type in the long-term phase 3 double-blind, placebo (PBO)-controlled ATLAS study of apalutamide (APA) added to androgen deprivation therapy (ADT) in high-risk localized or locally advanced prostate cancer (HRLPC). J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.16_suppl.5084] [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
5084 Background: Current management of HRLPC includes long-term ADT with primary RT. Despite definitive primary treatment, these pts have a high risk of metastasis and death. The phase 3 ATLAS study (NCT02531516) is investigating whether treatment intensification with the addition of APA to neoadjuvant and adjuvant treatment with gonadotropin-releasing hormone agonist (GnRHa) and external beam radiation therapy (EBRT) will improve metastasis-free survival (MFS) in high-risk pts. Here we describe (1) the distribution of baseline characteristics in this high-risk pt population and (2) the application of different RT regimens reflecting recent international guidelines and clinical practice changes for pts with HRLPC. Methods: Eligible HRLPC pts (Gleason score [GS] ≥ 8 or 7 and prostate-specific antigen [PSA] ≥ 20 ng/mL and stage ≥ cT2c), with ECOG PS 0/1 and Charlson Comorbidity Index (CCI) ≤ 3 are stratified by GS, pelvic nodal status, use of brachytherapy boost, and region; pts are randomized 1:1 to APA or PBO plus GnRHa for 30 (28-d) treatment cycles. Study treatment is applied neoadjuvant/concurrent to RT with APA 240 mg/d vs bicalutamide 50 mg/d for 4 cycles; another 26 cycles are completed adjuvantly after RT with APA 240 mg/d vs PBO. Primary end point is MFS (time from randomization to first distant metastasis on CT/MRI/bone scan by independent central review blinded to treatment or death from any cause). Imaging is conducted at baseline and q6m from biochemical failure until MFS. The protocol has been amended to include PET imaging (PSMA, fluciclovine, or choline). Results: Pts (N = 1503) were randomized at 266 sites in 24 countries in North America, Latin America, Europe, and Asia. The study is fully enrolled, but ongoing. Baseline characteristics for the total population: median age, 67 yrs; ECOG PS 0/1; 89%/11%; tumor classification at study entry: high-risk, 66%/very high–risk, 34%; median PSA, 6.3 ng/mL; cT2, 44%/cT3, 50%; cN1, 13%. In 90% of ATLAS pts, RT used was standard EBRT to prostate/pelvis over 6-8 weeks (cumulative 78-81 Gy); in 10%, recent hypofractionation schedules (per CHHiP or NRG/RTOG 0415) were applied (20x3 Gy/d or 28x2.5 Gy/d). 5.6% of pts had EBRT combined with brachytherapy (per ASCENDE-RT). Conclusions: Baseline characteristics of the ATLAS study population are reflective of pts with high- and very high–risk features and pelvic nodal involvement undergoing primary RT in clinical practice. The RT schedules applied reflect recent evidence and guideline changes for the use of hypofractionation in this pt population. ATLAS is an example of how RT can be included in phase 3 trials of HRLPC, in combination with next-generation androgen receptor inhibitors (eg, APA). Clinical trial information: NCT02531516.
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Affiliation(s)
| | - Stephen J. Freedland
- Division of Urology, Department of Surgery, Cedars-Sinai Medical Center and Department of Surgery, Durham Veterans Affairs Health Care System, Durham, NC
| | | | | | | | - Sabine D. Brookman-May
- Janssen Research & Development, Los Angeles, CA and Ludwig-Maximilians-University, Munich, Germany
| | - David P. Dearnaley
- The Royal Marsden Hospital and The Institute of Cancer Research, London, United Kingdom
| | - Adam P. Dicker
- Sidney Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, PA
| | | | | | | | | | - Jason L. Martin
- Janssen Research & Development, High Wycombe, United Kingdom
| | | | | | | | | | | | - Bertrand F. Tombal
- Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Felix Y Feng
- Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, CA
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16
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Halabi S, Roy A, Rydzewska L, Godolphin P, Parmar MKB, Hussain MHA, Tangen C, Thompson I, Xie W, Carducci MA, Smith MR, Morris MJ, Gravis G, Dearnaley DP, Verhagen P, Goto T, James ND, Buyse ME, Tierney JF, Sweeney C. Assessing intermediate clinical endpoints (ICE) as potential surrogates for overall survival (OS) in men with metastatic hormone-sensitive prostate cancer (mHSPC). J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.16_suppl.5006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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
5006 Background: We hypothesized that radiographic progression free survival (rPFS) and clinical PFS (cPFS) are valid surrogates for OS in men with mHSPC and could potentially be used to expedite phase 3 clinical trials. This hypothesis was investigated by the STOPCAP M1 Collaboration. Methods: We obtained individual patient data (IPD) from 13/26 eligible randomized trials comparing treatment regimens (androgen deprivation therapy (ADT) or ADT + docetaxel in the control or research arms) in mHSPC. We evaluated the surrogacy of rPFS and cPFS as potential ICEs. rPFS was defined as time from randomization to radiographic progression (defined per protocol) or death from any cause whichever occurred first; cPFS was defined as time from randomization to date of radiographic progression, symptoms, initiation of new treatment, or death, whichever occurred first. OS was defined as time from randomization to death from any cause, if patients had not died they were censored at the date of last follow-up. We implemented a two-stage meta-analytic validation model where conditions of trial level and patient level surrogacy had to be met. We computed the surrogate threshold effect (STE), which is the minimum ICE treatment effect necessary to estimate a non-zero effect on OS. Results: IPD from 8592 patients randomized from 1994-2012 from 13 trials were pooled for a stratified analysis. There were 5377 deaths, of which 3971 (74%) were due to prostate cancer. The median follow-up for surviving patients was 75.6 months. In addition, there were 6227 rPFS and 6314 cPFS events. The median OS, rPFS and cPFS were 49.4, 26.8 and 25.2 months, respectively. The STE was 0.82 for rPFS and 0.84 for cPFS. Conclusions: Both rPFS and cPFS appear to be valid surrogate endpoints for OS. A surrogate threshold effect of 0.82 or higher makes it viable for either rPFS or cPFS to be used as the primary endpoint as a surrogate for OS in phase 3 mHSPC trials and would expedite trial conduct. Validation of these ICEs in trials with drugs having other mechanisms of action is planned. Clinical trial information: Several. [Table: see text]
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Affiliation(s)
| | | | | | | | | | - Maha H. A. Hussain
- Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, IL
| | | | | | | | | | | | - Michael J. Morris
- Division of Solid Tumor Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Gwenaelle Gravis
- Institut Paoli-Calmettes Aix-Mareseille Université, Marseille, France
| | - David P. Dearnaley
- Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | | | - Takayuki Goto
- Department of Urology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | | | - Marc E. Buyse
- International Drug Development Institute, Louvain-La-Neuve, Belgium
| | | | - Christopher Sweeney
- Lank Center for Genitourinary Oncology, Dana-Farber Cancer Institute, Boston, MA
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17
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Rush HL, Murphy L, Morgans AK, Clarke NW, Cook AD, Attard G, Macnair A, Dearnaley DP, Parker CC, Russell JM, Gillessen S, Matheson D, Millman R, Brawley CD, Pugh C, Tanguay JS, Jones RJ, Wagstaff J, Rudman S, O'Sullivan JM, Gale J, Birtle A, Protheroe A, Gray E, Perna C, Tolan S, McPhail N, Malik ZI, Vengalil S, Fackrell D, Hoskin P, Sydes MR, Chowdhury S, Gilbert DC, Parmar MKB, James ND, Langley RE. Quality of Life in Men With Prostate Cancer Randomly Allocated to Receive Docetaxel or Abiraterone in the STAMPEDE Trial. J Clin Oncol 2022; 40:825-836. [PMID: 34757812 PMCID: PMC7612717 DOI: 10.1200/jco.21.00728] [Citation(s) in RCA: 34] [Impact Index Per Article: 17.0] [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: 03/22/2021] [Revised: 08/09/2021] [Accepted: 10/01/2021] [Indexed: 12/13/2022] Open
Abstract
PURPOSE Docetaxel and abiraterone acetate plus prednisone or prednisolone (AAP) both improve survival when commenced alongside standard of care (SOC) androgen deprivation therapy in locally advanced or metastatic hormone-sensitive prostate cancer. Thus, patient-reported quality of life (QOL) data may guide treatment choices. METHODS A group of patients within the STAMPEDE trial were contemporaneously enrolled with the possibility of being randomly allocated to receive either docetaxel + SOC or AAP + SOC. A mixed-model assessed QOL in those who had completed at least one QLQ-C30 + PR25 questionnaire. The primary outcome measure was difference in global-QOL (QLQ-C30 Q29&30) between patients allocated to docetaxel + SOC or AAP + SOC over the 2 years after random assignment, with a predefined criterion for clinically meaningful difference of > 4.0 points. Secondary outcome measures included longitudinal comparison of functional domains, pain, and fatigue, plus global-QOL at defined timepoints. RESULTS Five hundred fifteen patients (173 docetaxel + SOC and 342 AAP + SOC) were included. Baseline characteristics, proportion of missing data, and mean baseline global-QOL scores (docetaxel + SOC 77.8 and AAP + SOC 78.0) were similar. Over the 2 years following random assignment, the mean modeled global-QOL score was +3.9 points (95% CI, +0.5 to +7.2; P = .022) higher in patients allocated to AAP + SOC. Global-QOL was higher for patients allocated to AAP + SOC over the first year (+5.7 points, 95% CI, +3.0 to +8.5; P < .001), particularly at 12 (+7.0 points, 95% CI, +3.0 to +11.0; P = .001) and 24 weeks (+8.3 points, 95% CI, +4.0 to +12.6; P < .001). CONCLUSION Patient-reported QOL was superior for patients allocated to receive AAP + SOC, compared with docetaxel + SOC over a 2-year period, narrowly missing the predefined value for clinical significance. Patients receiving AAP + SOC reported clinically meaningful higher global-QOL scores throughout the first year following random assignment.
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Affiliation(s)
- Hannah L. Rush
- MRC Clinical Trials Units at University College London, London, United Kingdom
| | - Laura Murphy
- MRC Clinical Trials Units at University College London, London, United Kingdom
| | | | - Noel W. Clarke
- The Christie and Salford Royal NHS Foundation Trusts, Manchester, United Kingdom
| | - Adrian D. Cook
- MRC Clinical Trials Units at University College London, London, United Kingdom
| | | | - Archie Macnair
- MRC Clinical Trials Units at University College London, London, United Kingdom
- Guys and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - David P. Dearnaley
- Royal Marsden NHS Foundation Trust and the Institute of Cancer Research, London, United Kingdom
| | - Christopher C. Parker
- Royal Marsden NHS Foundation Trust and the Institute of Cancer Research, London, United Kingdom
| | - J. Martin Russell
- Institute of Cancer Sciences, University of Glasgow, Beatson West of Scotland Cancer Centre, Glasgow, Scotland
| | - Silke Gillessen
- Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
| | - David Matheson
- University of Wolverhampton, Wolverhampton, United Kingdom
| | - Robin Millman
- MRC Clinical Trials Units at University College London, London, United Kingdom
| | | | - Cheryl Pugh
- MRC Clinical Trials Units at University College London, London, United Kingdom
| | | | - Robert J. Jones
- Institute of Cancer Sciences, University of Glasgow, Beatson West of Scotland Cancer Centre, Glasgow, Scotland
| | - John Wagstaff
- Swansea University College of Medicine, Swansea, United Kingdom
| | - Sarah Rudman
- Guys and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Joe M. O'Sullivan
- Patrick G. Johnston Centre for Cancer Research, Queen's University Belfast, United Kingdom
| | - Joanna Gale
- Portsmouth Hospital University Trust, Portsmouth, United Kingdom
| | - Alison Birtle
- Rosemere Cancer Centre, Lancs Teaching Hospitals, Preston, United Kingdom
- University of Manchester, Manchester, United Kingdom
| | - Andrew Protheroe
- Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Emma Gray
- Musgrove Park Hospital, Taunton, United Kingdom
| | - Carla Perna
- Royal Surrey Hospital Foundation Trust, Guildford, United Kingdom
| | - Shaun Tolan
- The Clatterbridge Cancer Centre NHS Foundation Trust, Liverpool, United Kingdom
| | | | - Zaf I. Malik
- The Clatterbridge Cancer Centre NHS Foundation Trust, Liverpool, United Kingdom
| | - Salil Vengalil
- University Hospital North Midlands NHS Trust, Stoke-on-Trent, United Kingdom
| | - David Fackrell
- University Hospital Birmingham, Birmingham, United Kingdom
| | - Peter Hoskin
- University of Manchester, Manchester, United Kingdom
- Mount Vernon Cancer Centre and University of Manchester, Manchester, United Kingdom
| | - Matthew R. Sydes
- MRC Clinical Trials Units at University College London, London, United Kingdom
| | - Simon Chowdhury
- Guys and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Duncan C. Gilbert
- MRC Clinical Trials Units at University College London, London, United Kingdom
| | - Mahesh K. B. Parmar
- MRC Clinical Trials Units at University College London, London, United Kingdom
| | - Nicholas D. James
- Royal Marsden NHS Foundation Trust and the Institute of Cancer Research, London, United Kingdom
| | - Ruth E. Langley
- MRC Clinical Trials Units at University College London, London, United Kingdom
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18
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Ebert MA, Marcello M, Kennedy A, Haworth A, Holloway LC, Greer P, Dowling JA, Jameson MG, Roach D, Joseph DJ, Gulliford SL, Sydes MR, Hall E, Dearnaley DP. In Regard to Shortall et al. Int J Radiat Oncol Biol Phys 2022; 112:831-833. [PMID: 35101196 DOI: 10.1016/j.ijrobp.2021.10.140] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 10/15/2021] [Indexed: 12/13/2022]
Affiliation(s)
- Martin A Ebert
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Nedlands, Australia; Department of Physics, University of Western Australia, Crawley, Australia; 5D Clinics, Claremont, Australia
| | - Marco Marcello
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Nedlands, Australia
| | - Angel Kennedy
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Nedlands, Australia
| | - Annette Haworth
- School of Physics, University of Sydney, Camperdown, Australia
| | - Lois C Holloway
- School of Physics, University of Sydney, Camperdown, Australia; Department of Medical Physics, Liverpool Cancer Centre, Liverpool, Australia; South Western Sydney Clinical School, University of New South Wales, Liverpool, Australia; Centre for Medical Radiation Physics, University of Wollongong, Wollongong, Australia
| | - Peter Greer
- School of Mathematical and Physical Sciences, University of Newcastle, Callaghan, Australia; Department of Radiation Oncology, Calvary Mater Newcastle, Waratah, Australia
| | - Jason A Dowling
- School of Physics, University of Sydney, Camperdown, Australia; South Western Sydney Clinical School, University of New South Wales, Liverpool, Australia; Centre for Medical Radiation Physics, University of Wollongong, Wollongong, Australia; School of Mathematical and Physical Sciences, University of Newcastle, Callaghan, Australia; CSIRO, Herston, Australia
| | - Michael G Jameson
- GenesisCare, Alexandria, Australia; St Vincent's Clinical School, University of New South Wales, Sydney, Australia
| | - Dale Roach
- South Western Sydney Clinical School, University of New South Wales, Liverpool, Australia
| | - David J Joseph
- 5D Clinics, Claremont, Australia; GenesisCare WA, Wembley, Australia; School of Surgery, University of Western Australia, Crawley, Australia
| | - Sarah L Gulliford
- Radiotherapy Department, University College London Hospitals NHS Foundation Trust, London, United Kingdom; Department of Medical Physics and Biomedical Engineering, University College London, London, United Kingdom
| | - Matthew R Sydes
- MRC Clinical Trials Unit, Institute of Clinical Trials and Methodology, University College London, London, United Kingdom
| | - Emma Hall
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, Sutton, United Kingdom
| | - David P Dearnaley
- Academic UroOncology Unit, The Institute of Cancer Research and the Royal Marsden NHS Trust, London, United Kingdom
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19
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Attard G, Murphy L, Clarke NW, Cross W, Jones RJ, Parker CC, Gillessen S, Cook A, Brawley C, Amos CL, Atako N, Pugh C, Buckner M, Chowdhury S, Malik Z, Russell JM, Gilson C, Rush H, Bowen J, Lydon A, Pedley I, O'Sullivan JM, Birtle A, Gale J, Srihari N, Thomas C, Tanguay J, Wagstaff J, Das P, Gray E, Alzoueb M, Parikh O, Robinson A, Syndikus I, Wylie J, Zarkar A, Thalmann G, de Bono JS, Dearnaley DP, Mason MD, Gilbert D, Langley RE, Millman R, Matheson D, Sydes MR, Brown LC, Parmar MKB, James ND. Abiraterone acetate and prednisolone with or without enzalutamide for high-risk non-metastatic prostate cancer: a meta-analysis of primary results from two randomised controlled phase 3 trials of the STAMPEDE platform protocol. Lancet 2022; 399:447-460. [PMID: 34953525 PMCID: PMC8811484 DOI: 10.1016/s0140-6736(21)02437-5] [Citation(s) in RCA: 157] [Impact Index Per Article: 78.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 11/02/2021] [Accepted: 11/03/2021] [Indexed: 01/05/2023]
Abstract
BACKGROUND Men with high-risk non-metastatic prostate cancer are treated with androgen-deprivation therapy (ADT) for 3 years, often combined with radiotherapy. We analysed new data from two randomised controlled phase 3 trials done in a multiarm, multistage platform protocol to assess the efficacy of adding abiraterone and prednisolone alone or with enzalutamide to ADT in this patient population. METHODS These open-label, phase 3 trials were done at 113 sites in the UK and Switzerland. Eligible patients (no age restrictions) had high-risk (defined as node positive or, if node negative, having at least two of the following: tumour stage T3 or T4, Gleason sum score of 8-10, and prostate-specific antigen [PSA] concentration ≥40 ng/mL) or relapsing with high-risk features (≤12 months of total ADT with an interval of ≥12 months without treatment and PSA concentration ≥4 ng/mL with a doubling time of <6 months, or a PSA concentration ≥20 ng/mL, or nodal relapse) non-metastatic prostate cancer, and a WHO performance status of 0-2. Local radiotherapy (as per local guidelines, 74 Gy in 37 fractions to the prostate and seminal vesicles or the equivalent using hypofractionated schedules) was mandated for node negative and encouraged for node positive disease. In both trials, patients were randomly assigned (1:1), by use of a computerised algorithm, to ADT alone (control group), which could include surgery and luteinising-hormone-releasing hormone agonists and antagonists, or with oral abiraterone acetate (1000 mg daily) and oral prednisolone (5 mg daily; combination-therapy group). In the second trial with no overlapping controls, the combination-therapy group also received enzalutamide (160 mg daily orally). ADT was given for 3 years and combination therapy for 2 years, except if local radiotherapy was omitted when treatment could be delivered until progression. In this primary analysis, we used meta-analysis methods to pool events from both trials. The primary endpoint of this meta-analysis was metastasis-free survival. Secondary endpoints were overall survival, prostate cancer-specific survival, biochemical failure-free survival, progression-free survival, and toxicity and adverse events. For 90% power and a one-sided type 1 error rate set to 1·25% to detect a target hazard ratio for improvement in metastasis-free survival of 0·75, approximately 315 metastasis-free survival events in the control groups was required. Efficacy was assessed in the intention-to-treat population and safety according to the treatment started within randomised allocation. STAMPEDE is registered with ClinicalTrials.gov, NCT00268476, and with the ISRCTN registry, ISRCTN78818544. FINDINGS Between Nov 15, 2011, and March 31, 2016, 1974 patients were randomly assigned to treatment. The first trial allocated 455 to the control group and 459 to combination therapy, and the second trial, which included enzalutamide, allocated 533 to the control group and 527 to combination therapy. Median age across all groups was 68 years (IQR 63-73) and median PSA 34 ng/ml (14·7-47); 774 (39%) of 1974 patients were node positive, and 1684 (85%) were planned to receive radiotherapy. With median follow-up of 72 months (60-84), there were 180 metastasis-free survival events in the combination-therapy groups and 306 in the control groups. Metastasis-free survival was significantly longer in the combination-therapy groups (median not reached, IQR not evaluable [NE]-NE) than in the control groups (not reached, 97-NE; hazard ratio [HR] 0·53, 95% CI 0·44-0·64, p<0·0001). 6-year metastasis-free survival was 82% (95% CI 79-85) in the combination-therapy group and 69% (66-72) in the control group. There was no evidence of a difference in metatasis-free survival when enzalutamide and abiraterone acetate were administered concurrently compared with abiraterone acetate alone (interaction HR 1·02, 0·70-1·50, p=0·91) and no evidence of between-trial heterogeneity (I2 p=0·90). Overall survival (median not reached [IQR NE-NE] in the combination-therapy groups vs not reached [103-NE] in the control groups; HR 0·60, 95% CI 0·48-0·73, p<0·0001), prostate cancer-specific survival (not reached [NE-NE] vs not reached [NE-NE]; 0·49, 0·37-0·65, p<0·0001), biochemical failure-free-survival (not reached [NE-NE] vs 86 months [83-NE]; 0·39, 0·33-0·47, p<0·0001), and progression-free-survival (not reached [NE-NE] vs not reached [103-NE]; 0·44, 0·36-0·54, p<0·0001) were also significantly longer in the combination-therapy groups than in the control groups. Adverse events grade 3 or higher during the first 24 months were, respectively, reported in 169 (37%) of 451 patients and 130 (29%) of 455 patients in the combination-therapy and control groups of the abiraterone trial, respectively, and 298 (58%) of 513 patients and 172 (32%) of 533 patients of the combination-therapy and control groups of the abiraterone and enzalutamide trial, respectively. The two most common events more frequent in the combination-therapy groups were hypertension (abiraterone trial: 23 (5%) in the combination-therapy group and six (1%) in control group; abiraterone and enzalutamide trial: 73 (14%) and eight (2%), respectively) and alanine transaminitis (abiraterone trial: 25 (6%) in the combination-therapy group and one (<1%) in control group; abiraterone and enzalutamide trial: 69 (13%) and four (1%), respectively). Seven grade 5 adverse events were reported: none in the control groups, three in the abiraterone acetate and prednisolone group (one event each of rectal adenocarcinoma, pulmonary haemorrhage, and a respiratory disorder), and four in the abiraterone acetate and prednisolone with enzalutamide group (two events each of septic shock and sudden death). INTERPRETATION Among men with high-risk non-metastatic prostate cancer, combination therapy is associated with significantly higher rates of metastasis-free survival compared with ADT alone. Abiraterone acetate with prednisolone should be considered a new standard treatment for this population. FUNDING Cancer Research UK, UK Medical Research Council, Swiss Group for Clinical Cancer Research, Janssen, and Astellas.
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Affiliation(s)
- Gerhardt Attard
- Cancer Institute, University College London, London, UK; University College London Hospitals, London, UK.
| | - Laura Murphy
- MRC Clinical Trials Unit at University College London, London, UK
| | - Noel W Clarke
- The Christie and Salford Royal NHS Foundation Trusts, Manchester, UK
| | | | | | | | - Silke Gillessen
- Oncology Institute of Southern Switzerland, Bellinzona, Switzerland; Universita della Svizzera Italiana, Lugano, Switzerland
| | - Adrian Cook
- MRC Clinical Trials Unit at University College London, London, UK
| | - Chris Brawley
- MRC Clinical Trials Unit at University College London, London, UK
| | - Claire L Amos
- MRC Clinical Trials Unit at University College London, London, UK
| | - Nafisah Atako
- MRC Clinical Trials Unit at University College London, London, UK
| | - Cheryl Pugh
- MRC Clinical Trials Unit at University College London, London, UK
| | - Michelle Buckner
- MRC Clinical Trials Unit at University College London, London, UK
| | | | - Zafar Malik
- Clatterbridge Cancer Centre NHS Foundation Trust, Wirral, UK
| | | | - Clare Gilson
- MRC Clinical Trials Unit at University College London, London, UK
| | - Hannah Rush
- MRC Clinical Trials Unit at University College London, London, UK
| | - Jo Bowen
- Cheltenham General Hospital, Cheltenham, UK
| | - Anna Lydon
- Torbay and South Devon NHS Foundation Trust, Torbay, UK
| | - Ian Pedley
- Northern Centre for Cancer Care, Newcastle upon Tyne, UK
| | | | | | | | | | | | | | | | | | - Emma Gray
- Yeovil District Hospital NHS Foundation Trust, Yeovil, UK; Musgrove Park Hospital, Taunton, UK
| | | | - Omi Parikh
- Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
| | | | - Isabel Syndikus
- Clatterbridge Cancer Centre NHS Foundation Trust, Wirral, UK
| | - James Wylie
- The Christie and Salford Royal NHS Foundation Trusts, Manchester, UK
| | - Anjali Zarkar
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | - Johann S de Bono
- Royal Marsden NHS Foundation Trust and Institute of Cancer Research, London, UK
| | - David P Dearnaley
- Royal Marsden NHS Foundation Trust and Institute of Cancer Research, London, UK
| | | | - Duncan Gilbert
- MRC Clinical Trials Unit at University College London, London, UK
| | - Ruth E Langley
- MRC Clinical Trials Unit at University College London, London, UK
| | - Robin Millman
- MRC Clinical Trials Unit at University College London, London, UK
| | - David Matheson
- Faculty of Education Health and Wellbeing, University of Wolverhampton, Walsall, UK
| | - Matthew R Sydes
- MRC Clinical Trials Unit at University College London, London, UK
| | - Louise C Brown
- MRC Clinical Trials Unit at University College London, London, UK
| | | | - Nicholas D James
- Royal Marsden NHS Foundation Trust and Institute of Cancer Research, London, UK
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20
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Clarke CS, Hunter RM, Gabrio A, Brawley CD, Ingleby FC, Dearnaley DP, Matheson D, Attard G, Rush HL, Jones RJ, Cross W, Parker C, Russell JM, Millman R, Gillessen S, Malik Z, Lester JF, Wylie J, Clarke NW, Parmar MKB, Sydes MR, James ND. Cost-utility analysis of adding abiraterone acetate plus prednisone/prednisolone to long-term hormone therapy in newly diagnosed advanced prostate cancer in England: Lifetime decision model based on STAMPEDE trial data. PLoS One 2022; 17:e0269192. [PMID: 35653395 PMCID: PMC9162346 DOI: 10.1371/journal.pone.0269192] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 05/14/2022] [Indexed: 01/27/2023] Open
Abstract
Adding abiraterone acetate (AA) plus prednisolone (P) to standard of care (SOC) improves survival in newly diagnosed advanced prostate cancer (PC) patients starting hormone therapy. Our objective was to determine the value for money to the English National Health Service (NHS) of adding AAP to SOC. We used a decision analytic model to evaluate cost-effectiveness of providing AAP in the English NHS. Between 2011-2014, the STAMPEDE trial recruited 1917 men with high-risk localised, locally advanced, recurrent or metastatic PC starting first-line androgen-deprivation therapy (ADT), and they were randomised to receive SOC plus AAP, or SOC alone. Lifetime costs and quality-adjusted life-years (QALYs) were estimated using STAMPEDE trial data supplemented with literature data where necessary, adjusting for baseline patient and disease characteristics. British National Formulary (BNF) prices (£98/day) were applied for AAP. Costs and outcomes were discounted at 3.5%/year. AAP was not cost-effective. The incremental cost-effectiveness ratio (ICER) was £149,748/QALY gained in the non-metastatic (M0) subgroup, with 2.4% probability of being cost-effective at NICE's £30,000/QALY threshold; and the metastatic (M1) subgroup had an ICER of £47,503/QALY gained, with 12.0% probability of being cost-effective. Scenario analysis suggested AAP could be cost-effective in M1 patients if priced below £62/day, or below £28/day in the M0 subgroup. AAP could dominate SOC in the M0 subgroup with price below £11/day. AAP is effective for non-metastatic and metastatic disease but is not cost-effective when using the BNF price. AAP currently only has UK approval for use in a subset of M1 patients. The actual price currently paid by the English NHS for abiraterone acetate is unknown. Broadening AAP's indication and having a daily cost below the thresholds described above is recommended, given AAP improves survival in both subgroups and its cost-saving potential in M0 subgroup.
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Affiliation(s)
- Caroline S. Clarke
- Research Department of Primary Care and Population Health, University College London, London, United Kingdom
- * E-mail:
| | - Rachael M. Hunter
- Research Department of Primary Care and Population Health, University College London, London, United Kingdom
| | - Andrea Gabrio
- Department of Methodology and Statistics, Faculty of Health Medicine and Life Sciences, Maastricht University, Maastricht, Netherlands
| | - Christopher D. Brawley
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, University College London, London, United Kingdom
| | - Fiona C. Ingleby
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, University College London, London, United Kingdom
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - David P. Dearnaley
- Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - David Matheson
- Patient Representative, University of Wolverhampton, Wolverhampton, United Kingdom
| | - Gerhardt Attard
- University College London Cancer Institute, London, United Kingdom
| | - Hannah L. Rush
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, University College London, London, United Kingdom
- Guys and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Rob J. Jones
- Beatson West of Scotland Cancer Centre, Glasgow, United Kingdom
- Institute of Cancer Sciences, University of Glasgow, Glasgow, United Kingdom
| | - William Cross
- Department of Urology, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Chris Parker
- Royal Marsden Hospital and Institute of Cancer Research, Sutton, United Kingdom
| | - J. Martin Russell
- Beatson West of Scotland Cancer Centre, Glasgow, United Kingdom
- Institute of Cancer Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Robin Millman
- Patient Representative, MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, University College London, London, United Kingdom
| | - Silke Gillessen
- Division of Cancer Sciences, University of Manchester, Manchester, United Kingdom
- Oncology Institute of Southern Switzerland, EOC, Bellinzona, Switzerland
- Università della Svizzera Italiana, Lugano, Switzerland
| | - Zafar Malik
- Clatterbridge Cancer Centre NHS Foundation Trust, Birkenhead, United Kingdom
| | - Jason F. Lester
- South West Wales Cancer Centre, Singleton Hospital, Swansea, United Kingdom
| | - James Wylie
- Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Noel W. Clarke
- Christie NHS Foundation Trust, Manchester, United Kingdom
- Salford Royal Hospital, Salford, United Kingdom
| | - Mahesh K. B. Parmar
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, University College London, London, United Kingdom
| | - Matthew R. Sydes
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, University College London, London, United Kingdom
| | - Nicholas D. James
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, University College London, London, United Kingdom
- Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, United Kingdom
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21
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Ferreira MR, Sands CJ, Li JV, Andreyev JN, Chekmeneva E, Gulliford S, Marchesi J, Lewis MR, Dearnaley DP. Impact of Pelvic Radiation Therapy for Prostate Cancer on Global Metabolic Profiles and Microbiota-Driven Gastrointestinal Late Side Effects: A Longitudinal Observational Study. Int J Radiat Oncol Biol Phys 2021; 111:1204-1213. [PMID: 34352290 PMCID: PMC8609156 DOI: 10.1016/j.ijrobp.2021.07.1713] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 07/17/2021] [Accepted: 07/26/2021] [Indexed: 12/18/2022]
Abstract
PURPOSE Radiation therapy to the prostate and pelvic lymph nodes (PLNRT) is part of the curative treatment of high-risk prostate cancer. Yet, the broader influence of radiation therapy on patient physiology is poorly understood. We conducted comprehensive global metabolomic profiling of urine, plasma, and stools sampled from patients undergoing PLNRT for high-risk prostate cancer. METHODS AND MATERIALS Samples were taken from 32 patients at 6 timepoints: baseline, 2 to 3 and 4 to 5 weeks of PLNRT; and 3, 6, and 12 months after PLNRT. We characterized the global metabolome of urine and plasma using 1H nuclear magnetic resonance spectroscopy and ultraperformance liquid chromatography-mass spectrometry, and of stools with nuclear magnetic resonance. Linear mixed-effects modeling was used to investigate metabolic changes between timepoints for each biofluid and assay and determine metabolites of interest. RESULTS Metabolites in urine, plasma and stools changed significantly after PLNRT initiation. Metabolic profiles did not return to baseline up to 1 year post-PLNRT in any biofluid. Molecules associated with cardiovascular risk were increased in plasma. Pre-PLNRT fecal butyrate levels directly associated with increasing gastrointestinal side effects, as did a sharper fall in those levels during and up to 1 year postradiation therapy, mirroring our previous results with metataxonomics. CONCLUSIONS We showed for the first time that an overall metabolic effect is observed in patients undergoing PLNRT up to 1 year posttreatment. These metabolic changes may effect on long-term morbidity after treatment, which warrants further investigation.
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Affiliation(s)
- Miguel R Ferreira
- Academic Radiotherapy Department, The Institute of Cancer Research, London, United Kingdom; Clinical Oncology Department, The Royal Marsden NHS Foundation Trust, London, United Kingdom; Clinical Oncology Department, Guys and St Thomas NHS Foundation Trust, London, United Kingdom; School of Cancer and Pharmaceutical Sciences, King's College London, London, United Kingdom.
| | - Caroline J Sands
- National Phenome Centre, Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Jia V Li
- Department of Metabolism, Digestion and Reproduction, Imperial College, London, United Kingdom
| | - Jervoise N Andreyev
- Gastroenterology Department, United Lincolnshire Hospitals NHS Trust, Lincolnshire, United Kingdom
| | - Elena Chekmeneva
- National Phenome Centre, Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Sarah Gulliford
- Academic Radiotherapy Department, The Institute of Cancer Research, London, United Kingdom; Radiotherapy Department, University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Julian Marchesi
- Department of Metabolism, Digestion and Reproduction, Imperial College, London, United Kingdom; School of Biosciences, Cardiff University, Cardiff, United Kingdom
| | - Matthew R Lewis
- National Phenome Centre, Faculty of Medicine, Imperial College London, London, United Kingdom
| | - David P Dearnaley
- Academic Radiotherapy Department, The Institute of Cancer Research, London, United Kingdom; Clinical Oncology Department, The Royal Marsden NHS Foundation Trust, London, United Kingdom
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22
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Abstract
Androgen deprivation therapy using gonadotropin-releasing hormone (GnRH) analogues is standard treatment for intermediate and advanced prostate cancer. GnRH agonist therapy results in an initial testosterone flare, and increased metabolic and cardiovascular risks. The GnRH antagonist relugolix is able to reduce serum testosterone levels in men with prostate cancer without inducing testosterone flare. In the HERO Phase III trial, relugolix was superior to leuprolide acetate at rapidly reducing testosterone and continuously suppressing testosterone, with faster post-treatment recovery of testosterone levels. Relugolix was associated with a 54% lower incidence of major adverse cardiovascular events than leuprolide acetate. As the first oral GnRH antagonist approved for the treatment of advanced prostate cancer, relugolix offers a new treatment option.
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Affiliation(s)
- Daniel J George
- Department of Medicine & Surgery, Duke Cancer Institute, Duke University, Durham, NC 27710, USA
| | - David P Dearnaley
- The Institute of Cancer Research & Royal Marsden NHS Foundation Trust, London, UK
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23
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Brand DH, Brüningk SC, Wilkins A, Fernandez K, Naismith O, Gao A, Syndikus I, Dearnaley DP, Tree AC, van As N, Hall E, Gulliford S. Estimates of Alpha/Beta (α/β) Ratios for Individual Late Rectal Toxicity Endpoints: An Analysis of the CHHiP Trial. Int J Radiat Oncol Biol Phys 2021; 110:596-608. [PMID: 33412260 PMCID: PMC8129972 DOI: 10.1016/j.ijrobp.2020.12.041] [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] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 12/10/2020] [Accepted: 12/24/2020] [Indexed: 12/04/2022]
Abstract
PURPOSE Changes in fraction size of external beam radiation therapy exert nonlinear effects on subsequent toxicity. Commonly described by the linear-quadratic model, fraction size sensitivity of normal tissues is expressed by the α/β ratio. We sought to study individual α/β ratios for different late rectal effects after prostate external beam radiation therapy. METHODS AND MATERIALS The CHHiP trial (ISRCTN97182923) randomized men with nonmetastatic prostate cancer 1:1:1 to 74 Gy/37 fractions (Fr), 60 Gy/20 Fr, or 57 Gy/19 Fr. Patients in the study had full dosimetric data and zero baseline toxicity. Toxicity scales were amalgamated to 6 bowel endpoints: bleeding, diarrhea, pain, proctitis, sphincter control, and stricture. Lyman-Kutcher-Burman models with or without equivalent dose in 2 Gy/Fr correction were log-likelihood fitted by endpoint, estimating α/β ratios. The α/β ratio estimate sensitivity was assessed using sequential inclusion of dose modifying factors (DMFs): age, diabetes, hypertension, inflammatory bowel or diverticular disease (IBD/diverticular), and hemorrhoids. 95% confidence intervals (CIs) were bootstrapped. Likelihood ratio testing of 632 estimator log-likelihoods compared the models. RESULTS Late rectal α/β ratio estimates (without DMF) ranged from bleeding (G1 + α/β = 1.6 Gy; 95% CI, 0.9-2.5 Gy) to sphincter control (G1 + α/β = 3.1 Gy; 95% CI, 1.4-9.1 Gy). Bowel pain modelled poorly (α/β, 3.6 Gy; 95% CI, 0.0-840 Gy). Inclusion of IBD/diverticular disease as a DMF significantly improved fits for stool frequency G2+ (P = .00041) and proctitis G1+ (P = .00046). However, the α/β ratios were similar in these no-DMF versus DMF models for both stool frequency G2+ (α/β 2.7 Gy vs 2.5 Gy) and proctitis G1+ (α/β 2.7 Gy vs 2.6 Gy). Frequency-weighted averaging of endpoint α/β ratios produced: G1 + α/β ratio = 2.4 Gy; G2 + α/β ratio = 2.3 Gy. CONCLUSIONS We estimated α/β ratios for several common late adverse effects of rectal radiation therapy. When comparing dose-fractionation schedules, we suggest using late a rectal α/β ratio ≤ 3 Gy.
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Affiliation(s)
- Douglas H Brand
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, United Kingdom; Urology Unit, Royal Marsden NHS Foundation Trust, London, United Kingdom.
| | - Sarah C Brüningk
- Department of Biosystems Science and Engineering, ETH Zurich, Basel, Switzerland
| | - Anna Wilkins
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, United Kingdom; Urology Unit, Royal Marsden NHS Foundation Trust, London, United Kingdom; Tumour Cell Biology Laboratory, The Francis Crick Institute, London, United Kingdom
| | - Katie Fernandez
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, United Kingdom
| | - Olivia Naismith
- Radiotherapy Trials QA Group, Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Annie Gao
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, United Kingdom; Urology Unit, Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Isabel Syndikus
- Radiotherapy Department, Clatterbridge Cancer Centre, United Kingdom
| | - David P Dearnaley
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, United Kingdom; Urology Unit, Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Alison C Tree
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, United Kingdom; Urology Unit, Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Nicholas van As
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, United Kingdom; Urology Unit, Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Emma Hall
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, United Kingdom
| | - Sarah Gulliford
- Department of Medical Physics and Biomedical Engineering, University College London, London, United Kingdom; Department of Radiotherapy Physics, University College London Hospitals NHS Foundation Trust, London, United Kingdom
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24
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Hamilton RJ, Ding K, Crook JM, O'Callaghan CJ, Higano CS, Dearnaley DP, Horwitz EM, Goldenberg SL, Gospodarowicz MK, Klotz L. The Association Between Statin Use and Outcomes in Patients Initiating Androgen Deprivation Therapy. Eur Urol 2021; 79:446-452. [PMID: 33390282 DOI: 10.1016/j.eururo.2020.12.031] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [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: 01/22/2020] [Accepted: 12/17/2020] [Indexed: 01/14/2023]
Abstract
BACKGROUND Studies have conflicting results regarding the association between statin use and biochemical recurrence for prostate cancer (PCa). A limited number of studies examining statins in advanced stages report positive results, with a few specifically examining statins and androgen deprivation therapy (ADT). OBJECTIVE To perform a post hoc secondary analysis of a randomised controlled trial (RCT) of men initiating ADT to examine the association between statin use and outcomes. DESIGN, SETTING, AND PARTICIPANTS Patients with prostate-specific antigen (PSA) >3 ng/ml >1 yr following primary/salvage radiotherapy were enrolled in an RCT of intermittent androgen deprivation (IAD) versus continuous ADT (NCT00003653). Baseline and on-study statin use was modelled as a time-dependent covariate. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS The primary endpoint was overall survival. Models were adjusted for age, time from radiotherapy to ADT, baseline PSA, and prior ADT. RESULTS AND LIMITATIONS Of 1364 patients, statin users (585; 43%) were younger (72.7 vs 73.8 yr, p = 0.001) and less likely to have PSA >15 ng/ml (20% vs 25%, p = 0.04). After a median follow-up of 6.9 yr, statin use was associated with reduced overall (hazard ratio [HR]: 0.64; 95% confidence interval [CI] 0.53-0.78, p < 0.001) and PCa-specific (HR: 0.65, 95% CI 0.48-0.87, p = 0.004) mortality. Statin users had 13% longer time to castration resistance, but this did not reach statistical significance (p = 0.15). As an exploratory endpoint, in the IAD arm, statin users had longer time off treatment (median: 0.85 vs 0.64 yr, p = 0.06). Limitations include potential for residual confounding between statin users and nonusers, and confounding by indication. CONCLUSIONS In men treated with ADT following primary or salvage radiotherapy, statin use was associated with improved overall and PCa-specific survival. In patients treated with IAD, statin use was associated with a trend towards longer time off treatment. A prospective trial of statins in men commencing ADT is warranted. PATIENT SUMMARY We found a favourable association between statin use and survival outcomes in patients initiating androgen deprivation therapy.
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Affiliation(s)
- Robert J Hamilton
- Department of Surgical Oncology, Princess Margaret Cancer Centre, Toronto, ON, Canada.
| | - Keyue Ding
- Canadian Cancer Trials Group (CCTG), Queen's University, Kingston, ON, Canada
| | - Juanita M Crook
- University of British Columbia, Kelowna, BC, Canada; British Columbia Cancer Agency, Kelowna, BC, Canada
| | | | - Celestia S Higano
- University of Washington and Fred Hutchinson Cancer Research Centre, Seattle, WA, USA
| | - David P Dearnaley
- The Institute for Cancer Research and Royal Marsden Hospital, London, UK
| | | | - S Larry Goldenberg
- Vancouver Prostate Centre, University of British Columbia, Vancouver, BC, Canada
| | - Mary K Gospodarowicz
- Department of Radiation Oncology, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Laurence Klotz
- Division of Urology, Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
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25
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Tree AC, Dearnaley DP, Hall E. Intermediate clinical endpoints in localised prostate cancer. Lancet Oncol 2021; 22:294-296. [PMID: 33662281 DOI: 10.1016/s1470-2045(21)00025-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Revised: 01/13/2021] [Accepted: 01/13/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Alison C Tree
- Urology Unit, The Royal Marsden NHS Foundation Trust, The Institute of Cancer Research, London SM2 5PT, UK; Division of Radiotherapy and Imaging, The Institute of Cancer Research, London SM2 5PT, UK
| | - David P Dearnaley
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London SM2 5PT, UK.
| | - Emma Hall
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London SM2 5PT, UK
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26
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Marcello M, Denham JW, Kennedy A, Haworth A, Steigler A, Greer PB, Holloway LC, Dowling JA, Jameson MG, Roach D, Joseph DJ, Gulliford SL, Dearnaley DP, Sydes MR, Hall E, Ebert MA. Reduced Dose Posterior to Prostate Correlates With Increased PSA Progression in Voxel-Based Analysis of 3 Randomized Phase 3 Trials. Int J Radiat Oncol Biol Phys 2020; 108:1304-1318. [PMID: 32739320 DOI: 10.1016/j.ijrobp.2020.07.030] [Citation(s) in RCA: 8] [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: 01/01/2020] [Revised: 07/13/2020] [Accepted: 07/20/2020] [Indexed: 02/07/2023]
Abstract
PURPOSE Reducing margins during treatment planning to decrease dose to healthy organs surrounding the prostate can risk inadequate treatment of subclinical disease. This study aimed to investigate whether lack of dose to subclinical disease is associated with increased disease progression by using high-quality prostate radiation therapy clinical trial data to identify anatomically localized regions where dose variation is associated with prostate-specific antigen progression (PSAP). METHODS AND MATERIALS Planned dose distributions for 683 patients of the Trans-Tasman Radiation Oncology Group 03.04 Randomized Androgen Deprivation and Radiotherapy (RADAR) trial were deformably registered onto a single exemplar computed tomography data set. These were divided into high-risk and intermediate-risk subgroups for analysis. Three independent voxel-based statistical tests, using permutation testing, Cox regression modeling, and least absolute shrinkage selection operator feature selection, were applied to identify regions where dose variation was associated with PSAP. Results from the intermediate-risk RADAR subgroup were externally validated by registering dose distributions from the RT01 (n = 388) and Conventional or Hypofractionated High Dose Intensity Modulated Radiotherapy for Prostate Cancer Trial (CHHiP) (n = 253) trials onto the same exemplar and repeating the tests on each of these data sets. RESULTS Voxel-based Cox regression revealed regions where reduced dose was correlated with increased prostate-specific androgen progression. Reduced dose in regions associated with coverage at the posterior prostate, in the immediate periphery of the posterior prostate, and in regions corresponding to the posterior oblique beams or posterior lateral beam boundary, was associated with increased PSAP for RADAR and RT01 patients, but not for CHHiP patients. Reduced dose to the seminal vesicle region was also associated with increased PSAP for RADAR intermediate-risk patients. CONCLUSIONS Ensuring adequate dose coverage at the posterior prostate and immediately surrounding posterior region (including the seminal vesicles), where aggressive cancer spread may be occurring, may improve tumor control. It is recommended that particular care be taken when defining margins at the prostate posterior, acknowledging the trade-off between quality of life due to rectal dose and the preferences of clinicians and patients.
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Affiliation(s)
- Marco Marcello
- Department of Physics, University of Western Australia, Perth, Western Australia, Australia; Department of Radiation Oncology, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia.
| | - James W Denham
- School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia
| | - Angel Kennedy
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Annette Haworth
- School of Physics, University of Sydney, Sydney, New South Wales, Australia
| | - Allison Steigler
- Prostate Cancer Trials Group, School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia
| | - Peter B Greer
- School of Mathematical and Physical Sciences, University of Newcastle, Newcastle, New South Wales, Australia; Department of Radiation Oncology, Calvary Mater Newcastle, Newcastle, New South Wales, Australia
| | - Lois C Holloway
- Department of Medical Physics, Liverpool Cancer Centre, Sydney, New South Wales, Australia; South Western Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia; Centre for Medical Radiation Physics, University of Wollongong, Wollongong, New South Wales, Australia
| | - Jason A Dowling
- School of Mathematical and Physical Sciences, University of Newcastle, Newcastle, New South Wales, Australia; CSIRO, Brisbane, Queensland, Australia
| | - Michael G Jameson
- Department of Medical Physics, Liverpool Cancer Centre, Sydney, New South Wales, Australia; South Western Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia; Centre for Medical Radiation Physics, University of Wollongong, Wollongong, New South Wales, Australia; Cancer Research Team, Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia
| | - Dale Roach
- Department of Medical Physics, Liverpool Cancer Centre, Sydney, New South Wales, Australia; South Western Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia; Cancer Research Team, Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia
| | - David J Joseph
- School of Surgery, University of Western Australia, Perth, Western Australia, Australia; 5D Clinics, Claremont, Perth, Western Australia, Australia; GenesisCare WA, Perth, Western Australia, Australia
| | - Sarah L Gulliford
- Radiotherapy Department, University College London Hospitals NHS Foundation Trust, London, United Kingdom; Department of Medical Physics and Biomedical Engineering, University College London, London, United Kingdom
| | - David P Dearnaley
- Academic UroOncology Unit, The Institute of Cancer Research and the Royal Marsden NHS Trust, London, United Kingdom
| | - Matthew R Sydes
- MRC Clinical Trials Unit, Institute of Clinical Trials and Methodology, University College London, London, United Kingdom
| | - Emma Hall
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, United Kingdom
| | - Martin A Ebert
- Department of Physics, University of Western Australia, Perth, Western Australia, Australia; Department of Radiation Oncology, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia; 5D Clinics, Claremont, Perth, Western Australia, Australia
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Marcello M, Denham JW, Kennedy A, Haworth A, Steigler A, Greer PB, Holloway LC, Dowling JA, Jameson MG, Roach D, Joseph DJ, Gulliford SL, Dearnaley DP, Sydes MR, Hall E, Ebert MA. Relationships between rectal and perirectal doses and rectal bleeding or tenesmus in pooled voxel-based analysis of 3 randomised phase III trials. Radiother Oncol 2020; 150:281-292. [PMID: 32745667 DOI: 10.1016/j.radonc.2020.07.048] [Citation(s) in RCA: 4] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 07/25/2020] [Accepted: 07/28/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND PURPOSE This study aimed to identify anatomically-localised regions where planned radiotherapy dose is associated with gastrointestinal toxicities in healthy tissues throughout the pelvic anatomy. MATERIALS AND METHODS Planned dose distributions for up to 657 patients of the Trans Tasman Radiation Oncology Group 03.04 RADAR trial were deformably registered onto a single exemplar computed tomography dataset. Voxel-based multiple comparison permutation dose difference testing, Cox regression modelling and LASSO feature selection were used to identify regions where dose-increase was associated with grade ≥2 rectal bleeding (RB) or tenesmus, according to the LENT/SOMA scale. This was externally validated by registering dose distributions from the RT01 (n = 388) and CHHiP (n = 241) trials onto the same exemplar and repeating the tests on each of these data sets, and on all three datasets combined. RESULTS Voxel-based Cox regression and permutation dose difference testing revealed regions where increased dose was correlated with gastrointestinal toxicity. Grade ≥2 RB was associated with posteriorly extended lateral beams that manifested high doses (>55 Gy) in a small rectal volume adjacent to the clinical target volume. A correlation was found between grade ≥2 tenesmus and increased low-intermediate dose (∼25 Gy) at the posterior beam region, including the posterior rectum and perirectal fat space (PRFS). CONCLUSIONS The serial response of the rectum with respect to RB has been demonstrated in patients with posteriorly extended lateral beams. Similarly, the parallel response of the PRFS with respect to tenesmus has been demonstrated in patients treated with the posterior beam.
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Affiliation(s)
- Marco Marcello
- Department of Physics, University of Western Australia, Crawley, Australia; Department of Radiation Oncology, Sir Charles Gairdner Hospital, Nedlands, Australia.
| | - James W Denham
- School of Medicine and Public Health, University of Newcastle, Callaghan, Australia
| | - Angel Kennedy
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Nedlands, Australia
| | - Annette Haworth
- School of Physics, University of Sydney, Camperdown, Australia
| | - Allison Steigler
- Prostate Cancer Trials Group, School of Medicine and Public Health, University of Newcastle, Callaghan, Australia
| | - Peter B Greer
- School of Mathematical and Physical Sciences, University of Newcastle, Callaghan, Australia; Department of Radiation Oncology, Calvary Mater Newcastle, Waratah, Australia
| | - Lois C Holloway
- Department of Medical Physics, Liverpool Cancer Centre, Australia; South Western Sydney Clinical School, University of New South Wales, Liverpool, Australia; Centre for Medical Radiation Physics, University of Wollongong, Australia
| | - Jason A Dowling
- School of Mathematical and Physical Sciences, University of Newcastle, Callaghan, Australia; CSIRO, Herston, Australia
| | - Michael G Jameson
- Department of Medical Physics, Liverpool Cancer Centre, Australia; South Western Sydney Clinical School, University of New South Wales, Liverpool, Australia; Centre for Medical Radiation Physics, University of Wollongong, Australia; Cancer Research Team, Ingham Institute for Applied Medical Research, Liverpool, Australia
| | - Dale Roach
- Department of Medical Physics, Liverpool Cancer Centre, Australia; South Western Sydney Clinical School, University of New South Wales, Liverpool, Australia; Cancer Research Team, Ingham Institute for Applied Medical Research, Liverpool, Australia
| | - David J Joseph
- School of Surgery, University of Western Australia, Crawley, Australia; 5D Clinics, Claremont, Australia; GenesisCare WA, Wembley, Australia
| | - Sarah L Gulliford
- Radiotherapy Department, University College London Hospitals NHS Foundation Trust, United Kingdom; Department of Medical Physics and Biomedical Engineering, University College London, United Kingdom
| | - David P Dearnaley
- Academic UroOncology Unit, The Institute of Cancer Research and the Royal Marsden NHS Trust, London, Australia
| | - Mathew R Sydes
- MRC Clinical Trials Unit, Institute of Clinical Trials and Methodology, University College, London, United Kingdom
| | - Emma Hall
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, Sutton, United Kingdom
| | - Martin A Ebert
- Department of Physics, University of Western Australia, Crawley, Australia; Department of Radiation Oncology, Sir Charles Gairdner Hospital, Nedlands, Australia; 5D Clinics, Claremont, Australia
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Dearnaley DP, Saltzstein DR, Sylvester JE, Karsh L, Mehlhaff BA, Pieczonka C, Bailen JL, Shi H, Ye Z, Faessel HM, Lin H, Zhu Y, Saad F, MacLean DB, Shore ND. The Oral Gonadotropin-releasing Hormone Receptor Antagonist Relugolix as Neoadjuvant/Adjuvant Androgen Deprivation Therapy to External Beam Radiotherapy in Patients with Localised Intermediate-risk Prostate Cancer: A Randomised, Open-label, Parallel-group Phase 2 Trial. Eur Urol 2020; 78:184-192. [PMID: 32273183 DOI: 10.1016/j.eururo.2020.03.001] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [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: 08/15/2019] [Accepted: 03/02/2020] [Indexed: 01/27/2023]
Abstract
BACKGROUND External beam radiotherapy (EBRT) with neoadjuvant/adjuvant androgen deprivation therapy (ADT) is an established treatment option to prolong survival for patients with intermediate- and high-risk prostate cancer (PCa). Relugolix, an oral gonadotropin-releasing hormone (GnRH) receptor antagonist, was evaluated in this clinical setting in comparison with degarelix, an injectable GnRH antagonist. OBJECTIVE To evaluate the safety and efficacy of relugolix to achieve and maintain castration. DESIGN, SETTING, AND PARTICIPANTS A phase 2 open-label study was conducted in 103 intermediate-risk PCa patients undergoing primary EBRT and neoadjuvant/adjuvant ADT between June 2014 and December 2015. INTERVENTION Patients randomly assigned (3:2) to 24-wk treatment with either daily oral relugolix or 4-wk subcutaneous depot degarelix (reference control). OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS The primary endpoint was the rate of effective castration (testosterone <1.73nmol/l) in relugolix patients between 4 and 24 wk of treatment. Secondary endpoints included rate of profound castration (testosterone <0.7nmol/l), prostate-specific antigen (PSA) levels, prostate volume, quality of life (QoL) assessed using the Aging Males' Symptoms scale, and the European Organization for Research and Treatment of Cancer (EORTC) Quality of Life (30-item EORTC core questionnaire [EORTC QLQ-C30] and 25-item EORTC prostate cancer module [EORTC QLQ-PR25]) questionnaires, and safety. No formal statistical comparisons with degarelix were planned. RESULTS AND LIMITATIONS Castration rates during treatment were 95% and 82% with relugolix and 89% and 68% with degarelix for 1.73 and 0.7nmol/l thresholds, respectively. Median time to castration in the relugolix arm was 4 d. During treatment, PSA levels and prostate volumes were reduced in both groups. Three months after discontinuing treatment, 52% of men on relugolix and 16% on degarelix experienced testosterone recovery (statistical significance of differences not tested). Mean and median QoL scores improved following treatment discontinuation. The most common adverse event was hot flush (relugolix 57%; degarelix 61%). Lack of blinding was a potential limitation. CONCLUSIONS Relugolix achieved testosterone suppression to castrate levels within days and maintained it over 24 wk with a safety profile consistent with its mechanism of action. PATIENT SUMMARY Oral once-daily relugolix may be a novel oral alternative to injectable androgen deprivation therapies.
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Affiliation(s)
- David P Dearnaley
- The Institute of Cancer Research and Royal Marsden Hospital, London, UK.
| | | | | | | | | | | | | | | | - Zhan Ye
- Millennium Pharmaceuticals, Inc., Cambridge, MA, USA(†)
| | | | - Huamao Lin
- Millennium Pharmaceuticals, Inc., Cambridge, MA, USA(†)
| | - Yanyan Zhu
- Millennium Pharmaceuticals, Inc., Cambridge, MA, USA(†)
| | - Fred Saad
- University of Montreal Hospital Center, Montreal, QC, Canada
| | | | - Neal D Shore
- Carolina Urologic Research Center, Myrtle Beach, SC, USA
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Lemanska A, Byford RC, Cruickshank C, Dearnaley DP, Ferreira F, Griffin C, Hall E, Hinton W, de Lusignan S, Sherlock J, Faithfull S. Linkage of the CHHiP randomised controlled trial with primary care data: a study investigating ways of supplementing cancer trials and improving evidence-based practice. BMC Med Res Methodol 2020; 20:198. [PMID: 32711460 PMCID: PMC7382082 DOI: 10.1186/s12874-020-01078-9] [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] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 07/08/2020] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Randomised controlled trials (RCTs) are the gold standard for evidence-based practice. However, RCTs can have limitations. For example, translation of findings into practice can be limited by design features, such as inclusion criteria, not accurately reflecting clinical populations. In addition, it is expensive to recruit and follow-up participants in RCTs. Linkage with routinely collected data could offer a cost-effective way to enhance the conduct and generalisability of RCTs. The aim of this study is to investigate how primary care data can support RCTs. METHODS Secondary analysis following linkage of two datasets: 1) multicentre CHHiP radiotherapy trial (ISRCTN97182923) and 2) primary care database from the Royal College of General Practitioners Research and Surveillance Centre. Comorbidities and medications recorded in CHHiP at baseline, and radiotherapy-related toxicity recorded in CHHiP over time were compared with primary care records. The association of comorbidities and medications with toxicity was analysed with mixed-effects logistic regression. RESULTS Primary care records were extracted for 106 out of 2811 CHHiP participants recruited from sites in England (median age 70, range 44 to 82). Complementary information included longitudinal body mass index, blood pressure and cholesterol, as well as baseline smoking and alcohol usage but was limited by the considerable missing data. In the linked sample, 9 (8%) participants were recorded in CHHiP as having a history of diabetes and 38 (36%) hypertension, whereas primary care records indicated incidence prior to trial entry of 11 (10%) and 40 (38%) respectively. Concomitant medications were not collected in CHHiP but available in primary care records. This indicated that 44 (41.5%) men took aspirin, 65 (61.3%) statins, 14 (13.2%) metformin and 46 (43.4%) phosphodiesterase-5-inhibitors at some point before or after trial entry. CONCLUSIONS We provide a set of recommendations on linkage and supplementation of trials. Data recorded in primary care are a rich resource and linkage could provide near real-time information to supplement trials and an efficient and cost-effective mechanism for long-term follow-up. In addition, standardised primary care data extracts could form part of RCT recruitment and conduct. However, this is at present limited by the variable quality and fragmentation of primary care data.
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Affiliation(s)
- Agnieszka Lemanska
- School of Health Sciences, Faculty of Health and Medical Sciences, University of Surrey, Guildford, GU2 7XH UK
- Data Science, National Physical Laboratory, Teddington, UK
| | - Rachel C. Byford
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Clare Cruickshank
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, UK
| | - David P. Dearnaley
- The Institute of Cancer Research and Royal Marsden NHS Trust, London, UK
| | - Filipa Ferreira
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Clare Griffin
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, UK
| | - Emma Hall
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, UK
| | - William Hinton
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Simon de Lusignan
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- Royal College of General Practitioners (RCGP) Research and Surveillance Centre (RSC), London, UK
- School of Biosciences and Medicine, Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK
| | - Julian Sherlock
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Sara Faithfull
- School of Health Sciences, Faculty of Health and Medical Sciences, University of Surrey, Guildford, GU2 7XH UK
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Marcello M, Denham JW, Kennedy A, Haworth A, Steigler A, Greer PB, Holloway LC, Dowling JA, Jameson MG, Roach D, Joseph DJ, Gulliford SL, Dearnaley DP, Sydes MR, Hall E, Ebert MA. Increased Dose to Organs in Urinary Tract Associates With Measures of Genitourinary Toxicity in Pooled Voxel-Based Analysis of 3 Randomized Phase III Trials. Front Oncol 2020; 10:1174. [PMID: 32793485 PMCID: PMC7387667 DOI: 10.3389/fonc.2020.01174] [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] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2020] [Accepted: 06/09/2020] [Indexed: 12/21/2022] Open
Abstract
Purpose: Dose information from organ sub-regions has been shown to be more predictive of genitourinary toxicity than whole organ dose volume histogram information. This study aimed to identify anatomically-localized regions where 3D dose is associated with genitourinary toxicities in healthy tissues throughout the pelvic anatomy. Methods and Materials: Dose distributions for up to 656 patients of the Trans-Tasman Radiation Oncology Group 03.04 RADAR trial were deformably registered onto a single exemplar CT dataset. Voxel- based multiple comparison permutation dose difference testing, Cox regression modeling and LASSO feature selection were used to identify regions where 3D dose-increase was associated with late grade ≥ 2 genitourinary dysuria, incontinence and frequency, and late grade ≥ 1 haematuria. This was externally validated by registering dose distributions from the RT01 (up to n = 388) and CHHiP (up to n = 247) trials onto the same exemplar and repeating the voxel-based tests on each of these data sets. All three datasets were then combined, and the tests repeated. Results: Voxel-based Cox regression and multiple comparison permutation dose difference testing revealed regions where increased dose was correlated with genitourinary toxicity. Increased dose in the vicinity of the membranous and spongy urethra was associated with dysuria for all datasets. Haematuria was similarly correlated with increased dose at the membranous and spongy urethra, for the RADAR, CHHiP, and combined datasets. Some evidence was found for the association between incontinence and increased dose at the internal and external urethral sphincter for RADAR and the internal sphincter alone for the combined dataset. Incontinence was also strongly correlated with dose from posterior oblique beams. Patients with fields extending inferiorly and posteriorly to the CTV, adjacent to the membranous and spongy urethra, were found to experience increased frequency. Conclusions: Anatomically-localized dose-toxicity relationships were determined for late genitourinary symptoms in the urethra and urinary sphincters. Low-intermediate doses to the extraprostatic urethra were associated with risk of late dysuria and haematuria, while dose to the urinary sphincters was associated with incontinence.
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Affiliation(s)
- Marco Marcello
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
- Department of Physics, University of Western Australia, Perth, WA, Australia
| | - James W. Denham
- School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, Australia
| | - Angel Kennedy
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
| | - Annette Haworth
- School of Physics, University of Sydney, Sydney, NSW, Australia
| | - Allison Steigler
- Prostate Cancer Trials Group, School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, Australia
| | - Peter B. Greer
- School of Mathematical and Physical Sciences, University of Newcastle, Callaghan, NSW, Australia
- Department of Radiation Oncology, Calvary Mater Newcastle, Waratah, NSW, Australia
| | - Lois C. Holloway
- Department of Medical Physics, Liverpool Cancer Centre, Liverpool, NSW, Australia
- South Western Sydney Clinical School, University of New South Wales, Kensington, NSW, Australia
- Centre for Medical Radiation Physics, University of Wollongong, Wollongong, NSW, Australia
| | - Jason A. Dowling
- School of Mathematical and Physical Sciences, University of Newcastle, Callaghan, NSW, Australia
- CSIRO, St Lucia, QLD, Australia
| | - Michael G. Jameson
- Department of Medical Physics, Liverpool Cancer Centre, Liverpool, NSW, Australia
- South Western Sydney Clinical School, University of New South Wales, Kensington, NSW, Australia
- Centre for Medical Radiation Physics, University of Wollongong, Wollongong, NSW, Australia
- Cancer Research Team, Ingham Institute for Applied Medical Research, Liverpool, NSW, Australia
| | - Dale Roach
- Department of Medical Physics, Liverpool Cancer Centre, Liverpool, NSW, Australia
- South Western Sydney Clinical School, University of New South Wales, Kensington, NSW, Australia
- Cancer Research Team, Ingham Institute for Applied Medical Research, Liverpool, NSW, Australia
| | - David J. Joseph
- School of Surgery, University of Western Australia, Perth, WA, Australia
- 5D Clinics, Claremont, WA, Australia
- GenesisCare WA, Wembley, WA, Australia
| | - Sarah L. Gulliford
- Radiotherapy Department, University College London Hospitals NHS Foundation Trust, London, United Kingdom
- Department of Medical Physics and Biomedical Engineering, University College London, London, United Kingdom
| | - David P. Dearnaley
- Academic UroOncology Unit, The Institute of Cancer Research and the Royal Marsden NHS Trust, London, United Kingdom
| | - Matthew R. Sydes
- MRC Clinical Trials Unit, Medical Research Council, London, United Kingdom
| | - Emma Hall
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, United Kingdom
| | - Martin A. Ebert
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
- Department of Physics, University of Western Australia, Perth, WA, Australia
- 5D Clinics, Claremont, WA, Australia
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Tree AC, Dearnaley DP. Seven or less Fractions is Not the Standard of Care for Intermediate-Risk Prostate Cancer. Clin Oncol (R Coll Radiol) 2020; 32:175-180. [PMID: 31711737 DOI: 10.1016/j.clon.2019.10.006] [Citation(s) in RCA: 4] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 09/20/2019] [Indexed: 01/09/2023]
Abstract
Evidence is accumulating for seven and less fractions in localised prostate cancer, including one large randomised trial. However, there is much more evidence yet to come and changing practice in advance of this may be premature. We review the reasons to persist with moderate hypofractionation for prostate cancer radiotherapy, until the results of further phase III studies are known.
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Affiliation(s)
- A C Tree
- The Royal Marsden NHS Foundation Trust, London, UK; The Institute of Cancer Research, London, UK.
| | - D P Dearnaley
- The Royal Marsden NHS Foundation Trust, London, UK; The Institute of Cancer Research, London, UK
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Clarke CS, Brawley CD, Ingleby FC, Gabrio A, Dearnaley DP, Matheson D, Attard G, Rush HL, Jones RJ, Clarke NW, Parmar MKB, Sydes MR, Hunter RM, James ND. Addition of abiraterone to first-line long-term hormone therapy in prostate cancer (STAMPEDE): Model to estimate long-term survival, quality-adjusted survival, and cost-effectiveness. J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.6_suppl.204] [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
204 Background: Results from randomised trials show adding abiraterone acetate plus prednisolone (AAP) to standard of care (SOC) improves disease-free and overall survival in men with prostate cancer (PC) starting long-term hormone therapy for first time. Formal assessment is required of whether funding AAP here shows appropriate use of resources. This cost-effectiveness decision model tests if giving AAP to these patients is cost-effective using costs from English National Health Service, the largest nation where STAMPEDE recruited. Methods: Health outcomes and costs were modelled using patient data from AAP comparison of STAMPEDE (recruitment 2011-14). This included 1917 men with high-risk, locally advanced metastatic or recurrent PC starting 1st-line hormone therapy. SOC was hormone therapy for ≥2 years with radiotherapy in pre-selected patients. If allocated to research group, AAP (AA 1000mg/day, P 5mg/day) was added to SOC. The model makes lifetime predictions of survival, costs and quality-adjusted lifeyears (QALYs), with costs and QALYs discounted at 3.5% annually. Sensitivity analyses were performed. Results: The model predicted AAP would extend survival (discounted quality-adjusted survival) by 2.68y (1.46 QALYs) for metastatic patients and 0.30y (0.29 QALYs) for non-metastatic. The cost of AAP means it is not currently cost-effective in this setting, including with Patient Access Scheme costs for AAP and enzalutamide and similar reductions for cabazitaxel and Ra. If AAP’s price reduces after patent expiry as expected (90% reduction on BNF cost), it would be cost-effective in both patient groups, with incremental cost-effectiveness ratios below £10,000 (US$12,665) per QALY. AAP could also dominate in non-metastatic patients (i.e. lower costs and higher QALYs than SOC alone). Conclusions: AAP could be cost-effective for patients with non-metastatic and metastatic disease with expected future pricing and may be cost-saving in the former. Policymakers should encourage license submissions and generic price reductions to facilitate use of AAP given cost-saving potential in addition to improving survival. Clinical trial information: NCT00268476.
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Affiliation(s)
| | | | | | | | - David P. Dearnaley
- Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | | | - Gerhardt Attard
- Institute of Cancer Research and The Royal Marsden Hospital, Sutton, United Kingdom
| | | | - Robert J. Jones
- University of Glasgow, Beatson West of Scotland Cancer Centre, Glasgow, United Kingdom
| | - Noel W. Clarke
- The Christie and Salford Royal Hospitals, Manchester, United Kingdom
| | - Mahesh K. B. Parmar
- Medical Research Center Clinical Trials Unit at University College London, London, United Kingdom
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33
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Rush HL, Cook AD, Brawley CD, Murphy L, Macnair A, Millman R, Attard G, Clarke N, Morgans AK, Chowdhury S, Gilbert DC, Dearnaley DP, Sydes MR, James ND, Langley RE, Parmar MKB. Comparative quality of life in patients randomized contemporaneously to docetaxel or abiraterone in the STAMPEDE trial. J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.6_suppl.14] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
14 Background: Docetaxel (DOC) and abiraterone (ABI) both improve overall survival (OS) in men with locally advanced or metastatic hormone-sensitive prostate cancer (HSPC) but no head to head trials compare the 2 agents. STAMPEDE, a multi-arm multi-stage platform trial, recruited patients (pts) to treatments including DOC or ABI between Nov-11 and Mar-13. There was no evidence OS differed between DOC or ABI, thus quality of life (QOL) may increasingly inform treatment options. Methods: QOL scores were analysed in pts contemporaneously randomised to receive DOC or ABI, in addition to standard of care treatment. Self-assessment QOL questionnaires EORTC QLQ C30 and PR25 were completed during treatment and follow-up. These analyses focus on average global QOL over the first 2 years after randomisation, using repeated measures analysis, plus cross-sectional analyses at 3, 6, 12 and 24 months. A score difference of ≥4 points was pre-defined as clinically meaningful. Results: 173 men randomised to DOC and 342 men randomised to ABI participated in the QOL sub-study and contributed to this analysis. Baseline characteristics and proportion of missing data were similar between groups. Baseline global QOL scores were similar (mean (sd): DOC 77.8 (20) and ABI 78.0 (19.3)). Average global QOL over 2 years was higher in pts randomised to ABI than DOC, although the difference was statistically significant it did not meet the pre-defined clinical parameter (+3.9, 95%CI 0.6 to 7.1, p=0.021). Cross-sectional analyses showed clinically meaningful superior QOL in the ABI group at 3 and 6 months (+6.6, 95%CI 2.6 to 10.7, p=0.001; +8.0, 95%CI 3.6 to 12.3, p<0.001), but not at 1 or 2 years (+1.3, 95%CI -3.0 to 5.6, p=0.545; +4.5, 95%CI -0.25 to 9.2, p=0.063). An exploratory analysis indicated average QOL for pts with metastatic disease (n=207) was better in the ABI group (+4.44, 95%CI 0.2 to 8.6, p=0.036). Conclusion: Global QOL was significantly higher in the first 2 years of treatment for the ABI group compared to the DOC group, though did not meet the pre-defined clinically meaningful threshold. The majority of difference was seen in the first year of treatment. This should be considered when discussing treatment options with pts. Clinical trial information: NCT00268476.
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Affiliation(s)
| | | | | | - Laura Murphy
- MRC Clinical Trials Unit at UCL, London, United Kingdom
| | | | | | - Gerhardt Attard
- Institute of Cancer Research and The Royal Marsden Hospital, Sutton, United Kingdom
| | - Noel Clarke
- The Christie and Salford Royal NHS Foundation Trusts, Manchester, United Kingdom
| | | | - Simon Chowdhury
- Guy’s, King’s and St. Thomas’ Hospitals, and Sarah Cannon Research Institute, London, United Kingdom
| | | | - David P. Dearnaley
- Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | | | | | | | - Mahesh K. B. Parmar
- Medical Research Center Clinical Trials Unit at University College London, London, United Kingdom
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Dearnaley DP, Griffin C, Syndikus I, Khoo V, Birtle AJ, Choudhury A, Ferguson C, Graham J, O'Sullivan J, Panades M, Rimmer YL, Scrase CD, Staffurth J, Cruickshank C, Hassan S, Pugh J, Hall E. Eight-year outcomes of a phase III randomized trial of conventional versus hypofractionated high-dose intensity modulated radiotherapy for prostate cancer (CRUK/06/016): Update from the CHHiP Trial. J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.6_suppl.325] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [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
325 Background: CHHiP is a non-inferiority trial to determine efficacy and safety of hypofractionated radiotherapy for localised prostate cancer (PCa). Five year results indicated that moderate hypofractionation of 60 Gray (Gy)/20 fractions (f) was non-inferior to 74Gy/37f (Lancet Oncology, 2016). Moderate hypofractionation is now an international standard of care but with patients remaining at risk of recurrence for many years, information on long-term outcomes is important. Here we report pre-planned analysis of 8 year outcomes. Methods: Between October 2002 and June 2011, 3216 men with node negative T1b-T3a localised PCa with risk of seminal vesical involvement ≤30% were randomised (1:1:1 ratio) to 74Gy/37f (control), 60Gy/20f or 57Gy/19f. Androgen deprivation began at least 3 months prior to radiotherapy (RT) and continued until end of RT. The primary endpoint was time to biochemical failure (Phoenix consensus guidelines) or clinical failure (BCF). The non-inferiority design specified a critical hazard ratio (HR) of 1.208 for each hypofractionated schedule compared to 74Gy/37f. Late toxicity was assessed at 5 years by RTOG and LENT-SOM scales. Analysis was by intention-to-treat. Results: With a median follow up of 9.2 years, 8 year BCF-free rates (95% CI) were 74Gy: 80.6% (77.9%, 83.0%); 60Gy: 83.7% (81.2%, 85.9%) and 57Gy: 78.5% (75.8%, 81.0%). For 60Gy/20f, non-inferiority was confirmed: HR60=0.84 (90% CI 0.71, 0.99). For 57Gy/19f, non-inferiority could not be declared: HR57=1.17 (90% CI 1.00, 1.37). Clinician assessments of late toxicity were similar across groups. At 5 years, RTOG grade≥2 (G2+) bowel toxicity was observed in 14/879 (1.6%), 18/908 (2.0%) and 17/904 (1.9%) of the 74Gy, 60Gy and 57Gy groups respectively. RTOG G2+ bladder toxicity was observed in 17/879 (1.9%), 14/908 (1.5%) and 17/904 (1.9%) of the 74Gy, 60Gy and 57Gy groups respectively. Conclusions: With BCF rates over 80%, long-term follow-up confirms that 60Gy/20f is non-inferior to 74Gy/37f. Late side effects were very low across all groups. These results support the continued use of 60Gy/20f as standard of care for men with localised PCa. Clinical trial information: 97182923.
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Affiliation(s)
- David P. Dearnaley
- Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Clare Griffin
- The Institute of Cancer Research, London, United Kingdom
| | | | - Vincent Khoo
- Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | | | - Ananya Choudhury
- The Christie NHS Foundation Trust and University of Manchester, Manchester, United Kingdom
| | - Catherine Ferguson
- Sheffield Teaching Hospitals Foundation Trust, Sheffield, United Kingdom
| | - John Graham
- Musgrove Park Hospital, Taunton, United Kingdom
| | | | | | - Yvonne L. Rimmer
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | | | - John Staffurth
- Velindre Hospital, Cardiff University, Cardiff, United Kingdom
| | | | - Shama Hassan
- The Institute of Cancer Research, London, United Kingdom
| | - Julia Pugh
- The Institute of Cancer Research, London, United Kingdom
| | - Emma Hall
- The Institute of Cancer Research, London, United Kingdom
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Bauman G, Ding K, Chin J, Iaboni A, Klotz L, Dearnaley DP, Horwitz EM, Crook JM, O'Callaghan CJ. Comparative efficacy of local versus systemic salvage therapies for recurrent prostate cancer after primary radiotherapy. J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.6_suppl.221] [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
221 Background: We sought to compare two common salvage strategies for radio-recurrent prostate cancer: androgen deprivation therapy (ADT: PR7 RCT NCT00003653) or local salvage ablation using cryotherapy (CRYO: single institution study Williams, Eur Urol. 2011;60(3):405). Methods: Pre-salvage therapy prognostic variables common to the two datasets (Gleason score at initial treatment, time from original RT, use of ADT at time of original RT, PSA at time of salvage, patient age) were used for propensity matching between patients from previously published ADT (1) and CRYO (2) datasets. Progression free survival (PFS, defined as time from initial treatment to development of castrate resistance or death); Disease Specific Survival (DSS, defined as time from salvage to prostate cancer related death) and Overall Survival (OS, defined as time from salvage to death from any cause) were compared between the propensity matched cohorts using Log-Rank and Cox PH regression statistics. Raw linear propensity scores included in the PH model to account for residual variability. A planned subset analysis examined the effect of neoadjuvant ADT among the CRYO cohort (no CRYO patients had adjuvant ADT). Results: Overall, 1119/1386 (ADT) and 172/187 (CRYO) patients were included in the propensity matched analysis. Median follow up was 6.7 yrs (ADT) and 18.7 yrs (CRYO). Median PFS (95% CI) was 10.7 yrs (9.5, 12.3) for CRYO vs. 7.0 yrs (6.1, 10.0) for ADT (HR 0.63 (0.44, 0.89), p = 0.009). Median OS was also longer for CRYO vs. ADT: 12.3 (11.0, 13.8) vs. 10.2 (9.4, not reached) yrs (HR 0.69; p = 0.02). 10 year DSS event rate was 16.5% CRYO vs. 18.5% ADT but was not statistically different. Neoadjuvant ADT did not affect outcomes in CRYO. Conclusions: A 3-year PFS and 2-year OS benefit was noted for the CRYO vs. ADT cohorts while no difference was noted in DSS. Potential explanations include residual bias not corrected for in the propensity scoring, variable follow-up duration, adverse effects from differing cumulative exposure to ADT or a combination of these factors. Prospective comparisons are required to control for these potential biases and compare other important outcomes such as side effects and quality of life.
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Affiliation(s)
- Glenn Bauman
- Western University, London Regional Cancer Program, London, ON, Canada
| | - Keyue Ding
- Canadian Cancer Trials Group, Kingston, ON, Canada
| | - Joseph Chin
- London Health Sciences Centre, London, ON, Canada
| | | | - Laurence Klotz
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - David P. Dearnaley
- Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, United Kingdom
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Abstract
316 Background: CHHiP (CRUK/06/016) is a multicentre randomised controlled trial which investigated the use of moderately hypofractionated radiotherapy (RT) dose schedules for treatment of localised prostate cancer. 97% of participants (pts) had concurrent androgen deprivation therapy (ADT). Luteinising Hormone Releasing Hormone analogues (LHRHa) and bicalutamide 150mg (BIC) daily were permitted. This exploratory analysis investigates whether both ADT regimens show similar efficacy and whether BIC has the propensity to preserve erectile function. Methods: In CHHiP, 2700 pts received LHRH and 403 BIC, median duration 5.6 months. The primary endpoint was biochemical or clinical failure (BCF). ADT groups were compared with Cox regression adjusted forage, NCCN risk group, Gleason score,T-stage and stratified by RT dose. A key secondary endpoint was erectile function assessed by clinicians (LENTSOM subjective erectile function for vaginal penetration score) and pts (single items within UCLA-PCI and EPIC-50 questionnaires) at 2 years. 195/875 (22%) pts were excluded from this toxicity analysis as they had erectile dysfunction pre-ADT (grade (G) 3/4 LENTSOM). A chi square trend test compared ADT regimens. Results: Baseline demographics were similar except BIC pts were significantly younger (median 67 years BIC, 69 years LHRHa). With a median follow-up of 9.2 years, there was no evidence of a difference in BCF with an adjusted hazard ratio 0.95 (95% CI 0.75-1.20), p = 0.657. Eight year BCF rates were 80.7% (95%CI 79.0-82.2) and 80.3% (95%CI 75.8-84.0) for LHRHa and BIC pts respectively. At two years, LENTSOM erectile function was significantly worse (p < 0.0001) for LHRHa pts with 93/585 (16%), 95/585 (16%) and 125/585 (21%) G2, G3 and G4, compared to 3/68 (4%), 5/68 (7%) and 9/68 (13%) in BIC. At 2 years, the ability to have an erection, as reported by pts, was graded poor and very poor in 73/278 (26%) and 57/278 (21%) LHRHa pts and 5/23 (22%) and 4/23 (17%) in BIC pts (p = 0.584). Conclusions: There was no evidence of a difference in efficacy according to ADT received. BIC preserved clinician assessed (LENTSOM) erectile function at 2 years but patient reported outcomes did not show statistically significant differences with type of ADT. Clinical trial information: 97182923.
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Affiliation(s)
- Alison Tree
- The Royal Marsden Hospital and The Institute of Cancer Research, London, United Kingdom
| | - Clare Griffin
- The Institute of Cancer Research, London, United Kingdom
| | - Emma Hall
- The Institute of Cancer Research, London, United Kingdom
| | - David P. Dearnaley
- Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, United Kingdom
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Kerns SL, Fachal L, Dorling L, Barnett GC, Baran A, Peterson DR, Hollenberg M, Hao K, Narzo AD, Ahsen ME, Pandey G, Bentzen SM, Janelsins M, Elliott RM, Pharoah PDP, Burnet NG, Dearnaley DP, Gulliford SL, Hall E, Sydes MR, Aguado-Barrera ME, Gómez-Caamaño A, Carballo AM, Peleteiro P, Lobato-Busto R, Stock R, Stone NN, Ostrer H, Usmani N, Singhal S, Tsuji H, Imai T, Saito S, Eeles R, DeRuyck K, Parliament M, Dunning AM, Vega A, Rosenstein BS, West CML. Radiogenomics Consortium Genome-Wide Association Study Meta-Analysis of Late Toxicity After Prostate Cancer Radiotherapy. J Natl Cancer Inst 2020; 112:179-190. [PMID: 31095341 PMCID: PMC7019089 DOI: 10.1093/jnci/djz075] [Citation(s) in RCA: 62] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Revised: 03/20/2019] [Accepted: 04/29/2019] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND A total of 10%-20% of patients develop long-term toxicity following radiotherapy for prostate cancer. Identification of common genetic variants associated with susceptibility to radiotoxicity might improve risk prediction and inform functional mechanistic studies. METHODS We conducted an individual patient data meta-analysis of six genome-wide association studies (n = 3871) in men of European ancestry who underwent radiotherapy for prostate cancer. Radiotoxicities (increased urinary frequency, decreased urinary stream, hematuria, rectal bleeding) were graded prospectively. We used grouped relative risk models to test associations with approximately 6 million genotyped or imputed variants (time to first grade 2 or higher toxicity event). Variants with two-sided Pmeta less than 5 × 10-8 were considered statistically significant. Bayesian false discovery probability provided an additional measure of confidence. Statistically significant variants were evaluated in three Japanese cohorts (n = 962). All statistical tests were two-sided. RESULTS Meta-analysis of the European ancestry cohorts identified three genomic signals: single nucleotide polymorphism rs17055178 with rectal bleeding (Pmeta = 6.2 × 10-10), rs10969913 with decreased urinary stream (Pmeta = 2.9 × 10-10), and rs11122573 with hematuria (Pmeta = 1.8 × 10-8). Fine-scale mapping of these three regions was used to identify another independent signal (rs147121532) associated with hematuria (Pconditional = 4.7 × 10-6). Credible causal variants at these four signals lie in gene-regulatory regions, some modulating expression of nearby genes. Previously identified variants showed consistent associations (rs17599026 with increased urinary frequency, rs7720298 with decreased urinary stream, rs1801516 with overall toxicity) in new cohorts. rs10969913 and rs17599026 had similar effects in the photon-treated Japanese cohorts. CONCLUSIONS This study increases the understanding of the architecture of common genetic variants affecting radiotoxicity, points to novel radio-pathogenic mechanisms, and develops risk models for testing in clinical studies. Further multinational radiogenomics studies in larger cohorts are worthwhile.
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Affiliation(s)
- Sarah L Kerns
- Departments of Radiation Oncology and Surgery, University of Rochester Medical Center, Rochester, NY
| | | | | | - Gillian C Barnett
- Department of Public Health and Primary Care
- Centre for Cancer Genetic Epidemiology, Strangeways Research Laboratory, University of Cambridge, Cambridge, UK; Department of Oncology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Andrea Baran
- Department of Biostatistics and Computational Biology, University of Rochester Medical Center, Rochester, NY
| | - Derick R Peterson
- Department of Biostatistics and Computational Biology, University of Rochester Medical Center, Rochester, NY
| | | | - Ke Hao
- Department of Genetics and Genomic Sciences and Icahn Institute for Data Science and Genomic Technology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Antonio Di Narzo
- Department of Genetics and Genomic Sciences and Icahn Institute for Data Science and Genomic Technology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Mehmet Eren Ahsen
- Department of Genetics and Genomic Sciences and Icahn Institute for Data Science and Genomic Technology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Gaurav Pandey
- Department of Genetics and Genomic Sciences and Icahn Institute for Data Science and Genomic Technology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Søren M Bentzen
- Division of Biostatistics and Bioinformatics, Department of Epidemiology and Public Health, University of Maryland Greenebaum Cancer Center, School of Medicine, University of Maryland, Baltimore
| | - Michelle Janelsins
- Departments of Radiation Oncology and Surgery, University of Rochester Medical Center, Rochester, NY
| | - Rebecca M Elliott
- Division of Cancer Sciences, the University of Manchester, Manchester Academic Health Science Centre, Christie Hospital, Manchester, UK
| | - Paul D P Pharoah
- Centre for Cancer Genetic Epidemiology, Strangeways Research Laboratory, University of Cambridge, Cambridge, UK; Department of Oncology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Neil G Burnet
- Division of Cancer Sciences, the University of Manchester, Manchester Academic Health Science Centre, Christie Hospital, Manchester, UK
| | - David P Dearnaley
- Academic Urooncology Unit, The Institute of Cancer Research and Royal Marsden NHS Foundation Trust, London, UK
| | - Sarah L Gulliford
- Academic Urooncology Unit, The Institute of Cancer Research and Royal Marsden NHS Foundation Trust, London, UK
| | - Emma Hall
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, UK
| | - Matthew R Sydes
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, University College London, London, UK
| | - Miguel E Aguado-Barrera
- Fundación Pública Galega de Medicina Xenómica-Servizo Galego de Saude (SERGAS & Instituto de Investigación Sanitaria de Santiago de Compostela (IDIS), Santiago de Compostela, Spain
| | | | | | | | | | - Richard Stock
- Complexo Hospitalario Universitario de Santiago, SERGAS, Santiago de Compostela, Spain; Department of Radiation Oncology
| | | | - Harry Ostrer
- Icahn School of Medicine at Mount Sinai, New York, NY; Departments of Pathology and Genetics, Albert Einstein College of Medicine, Bronx, NY
| | - Nawaid Usmani
- Division of Radiation Oncology, Department of Oncology, Cross Cancer Institute, University of Alberta, Edmonton, Canada
| | - Sandeep Singhal
- Department of Pathology and Cell Biology, Columbia University, New York, NY
| | - Hiroshi Tsuji
- National Institute of Radiological Science, National Institutes for Quantum and Radiological Science and Technology, Chiba, Japan
| | - Takashi Imai
- National Institute of Radiological Science, National Institutes for Quantum and Radiological Science and Technology, Chiba, Japan
| | - Shiro Saito
- Department of Urology, National Tokyo Medical Center, Tokyo, Japan
| | - Rosalind Eeles
- Division of Genetics and Epidemiology, Institute of Cancer Research and Royal Marsden NHS Foundation Trust, London, UK
| | - Kim DeRuyck
- Departments of Basic Medical Sciences and Radiotherapy, Ghent University Hospital, Ghent, Belgium
| | - Matthew Parliament
- Division of Radiation Oncology, Department of Oncology, Cross Cancer Institute, University of Alberta, Edmonton, Canada
| | | | - Ana Vega
- Fundación Pública Galega de Medicina Xenómica-Servizo Galego de Saude (SERGAS & Instituto de Investigación Sanitaria de Santiago de Compostela (IDIS), Santiago de Compostela, Spain
- Grupo de Medicina Xenómica, Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Universidade de Santiago de Compostela, Santiago de Compostela, Spain
| | - Barry S Rosenstein
- Departments of Radiation Oncology & Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Catharine M L West
- Division of Cancer Sciences, the University of Manchester, Manchester Academic Health Science Centre, Christie Hospital, Manchester, UK
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Clarke NW, Ali A, Ingleby FC, Hoyle A, Amos CL, Attard G, Brawley CD, Calvert J, Chowdhury S, Cook A, Cross W, Dearnaley DP, Douis H, Gilbert D, Gillessen S, Jones RJ, Langley RE, MacNair A, Malik Z, Mason MD, Matheson D, Millman R, Parker CC, Ritchie AWS, Rush H, Russell JM, Brown J, Beesley S, Birtle A, Capaldi L, Gale J, Gibbs S, Lydon A, Nikapota A, Omlin A, O'Sullivan JM, Parikh O, Protheroe A, Rudman S, Srihari NN, Simms M, Tanguay JS, Tolan S, Wagstaff J, Wallace J, Wylie J, Zarkar A, Sydes MR, Parmar MKB, James ND. Corrigendum to Addition of docetaxel to hormonal therapy in low- and high-burden metastatic hormone sensitive prostate cancer: long-term survival results from the STAMPEDE trial: Ann Oncol 2019; 30: 1992-2003. Ann Oncol 2020; 31:442. [PMID: 32067690 PMCID: PMC8929236 DOI: 10.1016/j.annonc.2020.01.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Affiliation(s)
- N W Clarke
- Department of Urology, The Christie and Salford Royal NHS Foundation Trusts, Manchester.
| | - A Ali
- Genito-Urinary Cancer Research Group, Division of Cancer Sciences, The University of Manchester, Manchester
| | - F C Ingleby
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, UCL, London; London School of Hygiene and Tropical Medicine, London
| | - A Hoyle
- Department of Urology, The Christie and Salford Royal NHS Foundation Trusts, Manchester
| | - C L Amos
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, UCL, London
| | | | - C D Brawley
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, UCL, London
| | - J Calvert
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, UCL, London
| | - S Chowdhury
- Guy's and Saint Thomas' NHS Foundation Trust, London
| | - A Cook
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, UCL, London
| | - W Cross
- St James University Hospital, Leeds
| | | | - H Douis
- Department of Radiology, University Hospitals Birmingham NHS Foundation Trust, Birmingham
| | - D Gilbert
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, UCL, London
| | - S Gillessen
- Division of Cancer Sciences, The University of Manchester, Manchester
| | - R J Jones
- Beatson West of Scotland Cancer Centre, University of Glasgow, Glasgow
| | - R E Langley
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, UCL, London
| | - A MacNair
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, UCL, London
| | - Z Malik
- The Clatterbridge Cancer Centre NHS Foundation Trust, Liverpool
| | | | - D Matheson
- Faculty of Education Health and Wellbeing, University of Wolverhampton, Wolverhampton
| | - R Millman
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, UCL, London
| | - C C Parker
- Institute of Cancer Research, Sutton-London; RoyalMarsden NHS Foundation Trust, London
| | - A W S Ritchie
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, UCL, London
| | - H Rush
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, UCL, London
| | - J M Russell
- Institute of Cancer Sciences, Beatson West of Scotland Cancer Centre, Glasgow
| | - J Brown
- University of Sheffield, Sheffield
| | | | - A Birtle
- Lancashire Teaching Hospitals NHS Foundation Trust, Preston
| | - L Capaldi
- Worcestershire Acute Hospitals NHS Trust, Worcester
| | - J Gale
- Portsmouth Oncology Centre, Queen Alexandra Hospital, Portsmouth
| | | | - A Lydon
- Torbay and South Devon NHS Foundation Trust, Torbay
| | | | - A Omlin
- Department of Oncology and Haematology, Kantonsspital, St Gallen, Switzerland
| | - J M O'Sullivan
- Centre for Cancer Research and Cell Biology, Queen's University Belfast, Belfast, UK
| | - O Parikh
- East Lancashire Hospitals NHS Trust, Blackburn, UK
| | - A Protheroe
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - S Rudman
- Guy's and Saint Thomas' NHS Foundation Trust, London
| | - N N Srihari
- Shrewsbury and Telford Hospital NHS Trust, Shrewsbury, UK
| | - M Simms
- Hull and East Yorkshire Hospitals NHS Trust, Hull, UK
| | | | - S Tolan
- The Clatterbridge Cancer Centre NHS Foundation Trust, Liverpool
| | - J Wagstaff
- Swansea University College of Medicine, Swansea, UK
| | - J Wallace
- Beatson West of Scotland Cancer Centre, University of Glasgow, Glasgow
| | - J Wylie
- The Christie NHS Foundation Trust, Manchester, UK
| | - A Zarkar
- Heartlands Hospital, Birmingham, UK
| | - M R Sydes
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, UCL, London
| | - M K B Parmar
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, UCL, London
| | - N D James
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
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Hoyle AP, Ali A, James ND, Cook A, Parker CC, de Bono JS, Attard G, Chowdhury S, Cross WR, Dearnaley DP, Brawley CD, Gilson C, Ingleby F, Gillessen S, Aebersold DM, Jones RJ, Matheson D, Millman R, Mason MD, Ritchie AWS, Russell M, Douis H, Parmar MKB, Sydes MR, Clarke NW. Abiraterone in "High-" and "Low-risk" Metastatic Hormone-sensitive Prostate Cancer. Eur Urol 2019; 76:719-728. [PMID: 31447077 DOI: 10.1016/j.eururo.2019.08.006] [Citation(s) in RCA: 127] [Impact Index Per Article: 25.4] [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: 04/16/2019] [Accepted: 08/07/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND Abiraterone acetate received licencing for use in only "high-risk" metastatic hormone-naïve prostate cancer (mHNPC) following the LATITUDE trial findings. However, a "risk"-related effect was not seen in the STAMPEDE trial. There remains uncertainty as to whether men with LATITUDE "low-risk" M1 disease benefit from androgen deprivation therapy (ADT) combined with abiraterone acetate and prednisolone (AAP). OBJECTIVE Evaluation of heterogeneity of effect between LATITUDE high- and low-risk M1 prostate cancer patients receiving ADT + AAP in the STAMPEDE trial. DESIGN, SETTING, AND PARTICIPANTS A post hoc subgroup analysis of the 2017 STAMPEDE "abiraterone comparison". Staging scans for M1 patients contemporaneously randomised to ADT or ADT + AAP within the STAMPEDE trial were evaluated centrally and blind to treatment assignment. Stratification was by risk according to the criteria set out in the LATITUDE trial. Exploratory subgroup stratification incorporated the CHAARTED criteria. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS The primary outcome measure was overall survival (OS) and the secondary outcome measure was failure-free survival (FFS). Further exploratory analysis evaluated clinical skeletal-related events, progression-free survival (PFS), and prostate cancer-specific death. Standard Cox-regression and Kaplan-Meier survival estimates were employed for analysis. RESULTS AND LIMITATIONS A total of 901 M1 STAMPEDE patients were evaluated after exclusions. Of the patients, 428 (48%) were identified as having a low risk and 473 (52%) a high risk. Patients receiving ADT + AAP had significantly improved OS (low-risk hazard ratio [HR]: 0.66, 95% confidence interval or CI [0.44-0.98]) and FFS (low-risk HR: 0.24, 95% CI [0.17-0.33]) compared with ADT alone. Heterogeneity of effect was not seen between low- and high-risk groups for OS or FFS. For OS benefit in low risk, the number needed to treat was four times greater than that for high risk. However, this was not observed for the other measured endpoints. CONCLUSIONS Men with mHNPC gain treatment benefit from ADT + AAP irrespective of risk stratification for "risk" or "volume". PATIENT SUMMARY Coadministration of abiraterone acetate and prednisolone with androgen deprivation therapy (ADT) is associated with prolonged overall survival and disease control, compared with ADT alone, in all men with metastatic disease starting hormone therapy for the first time.
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Affiliation(s)
- Alex P Hoyle
- The Christie and Royal Salford Hospitals, Manchester, UK; Genito Urinary Cancer Research Group and the FASTMAN Centre of Excellence, Division of Cancer Sciences, The University of Manchester, Manchester, UK
| | - Adnan Ali
- The Christie and Royal Salford Hospitals, Manchester, UK
| | - Nicholas D James
- Institute of Cancer and Genomic Sciences, University of Birmingham, Edgbaston, Birmingham, UK
| | - Adrian Cook
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, UCL, London, UK
| | | | | | | | | | | | | | - Christopher D Brawley
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, UCL, London, UK
| | - Clare Gilson
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, UCL, London, UK
| | | | - Silke Gillessen
- Division of Oncology and Haematology, Kantonsspital St. Gallen, St. Gallen, Switzerland; Christie Hospital, Manchester, UK; University of Manchester, Manchester, UK; Swiss Group for Cancer Clinical Research (SAKK), Bern, Switzerland
| | | | - Rob J Jones
- Institute of Cancer Sciences, University of Glasgow, Glasgow, UK; Beatson West of Scotland Cancer Centre, University of Glasgow, Glasgow, UK
| | | | | | | | | | - Martin Russell
- Institute of Cancer Sciences, University of Glasgow, Glasgow, UK; Beatson West of Scotland Cancer Centre, University of Glasgow, Glasgow, UK
| | - Hassan Douis
- Institute of Cancer and Genomic Sciences, University of Birmingham, Edgbaston, Birmingham, UK
| | - Mahesh K B Parmar
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, UCL, London, UK
| | - Matthew R Sydes
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, UCL, London, UK
| | - Noel W Clarke
- The Christie and Royal Salford Hospitals, Manchester, UK; Genito Urinary Cancer Research Group and the FASTMAN Centre of Excellence, Division of Cancer Sciences, The University of Manchester, Manchester, UK.
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Brand DH, Parker JI, Dearnaley DP, Eeles R, Huddart R, Khoo V, Murray J, Suh YE, Tree AC, van As N, Parker C. Patterns of recurrence after prostate bed radiotherapy. Radiother Oncol 2019; 141:174-180. [PMID: 31563410 DOI: 10.1016/j.radonc.2019.09.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [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: 07/31/2019] [Revised: 09/04/2019] [Accepted: 09/05/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND PURPOSE Prostate bed radiotherapy is a standard treatment after radical prostatectomy. Recent evidence suggests that, for patients with a PSA > 0.34 ng/ml, the radiotherapy treatment volume should include not only the prostate bed but also the pelvic lymph nodes. We describe the patterns of failure after prostate bed radiotherapy, focussing on the proportion of patients with radiologically confirmed pelvic nodal failure only, in the absence of distant disease. MATERIALS AND METHODS Patients included were men receiving prostate bed radiotherapy at the Royal Marsden Hospital between 1997 and 2013. The key outcome of interest was the pattern of radiologic failure after prostate bed radiotherapy. Baseline characteristics of patients experiencing pelvic nodal failure without distant disease were compared versus all other relapse patterns. Comparisons were by Chi-square test, with multiple testing adjusted p < 0.005 significant. RESULTS 140 of 322 patients developed biochemical failure after salvage RT. Radiologic failure occurred in 89 patients. 35 of the 89 patients (39%) with radiologic failure had pelvic nodal failure without distant disease, with no significant differences in baseline characteristics when compared to all other patients. The rate of pelvic nodal failure was the same for patients with PSA above or below 0.34 ng/ml (16/149, 95% CI = 6-17% vs 19/171, 95% CI = 7-17%). CONCLUSIONS Pelvic lymph node disease, without more distant disease, is a common site of failure in men receiving radiotherapy to the prostate bed, including those with PSA < 0.34 ng/ml. This observation informs the case for including the pelvic lymph nodes in the radiotherapy treatment volume.
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Affiliation(s)
- Douglas H Brand
- Urological Oncology Department, Royal Marsden Hospital, London & Sutton, UK; Radiotherapy and Imaging Division, Institute of Cancer Research, London & Sutton, UK
| | - Joanna I Parker
- Radiotherapy and Imaging Division, Institute of Cancer Research, London & Sutton, UK
| | - David P Dearnaley
- Urological Oncology Department, Royal Marsden Hospital, London & Sutton, UK; Radiotherapy and Imaging Division, Institute of Cancer Research, London & Sutton, UK
| | - Rosalind Eeles
- Urological Oncology Department, Royal Marsden Hospital, London & Sutton, UK; Radiotherapy and Imaging Division, Institute of Cancer Research, London & Sutton, UK
| | - Robert Huddart
- Urological Oncology Department, Royal Marsden Hospital, London & Sutton, UK; Radiotherapy and Imaging Division, Institute of Cancer Research, London & Sutton, UK
| | - Vincent Khoo
- Urological Oncology Department, Royal Marsden Hospital, London & Sutton, UK; Radiotherapy and Imaging Division, Institute of Cancer Research, London & Sutton, UK
| | - Julia Murray
- Urological Oncology Department, Royal Marsden Hospital, London & Sutton, UK; Radiotherapy and Imaging Division, Institute of Cancer Research, London & Sutton, UK
| | - Yae-Eun Suh
- Urological Oncology Department, Royal Marsden Hospital, London & Sutton, UK; Radiotherapy and Imaging Division, Institute of Cancer Research, London & Sutton, UK
| | - Alison C Tree
- Urological Oncology Department, Royal Marsden Hospital, London & Sutton, UK; Radiotherapy and Imaging Division, Institute of Cancer Research, London & Sutton, UK
| | - Nicholas van As
- Urological Oncology Department, Royal Marsden Hospital, London & Sutton, UK; Radiotherapy and Imaging Division, Institute of Cancer Research, London & Sutton, UK
| | - Chris Parker
- Urological Oncology Department, Royal Marsden Hospital, London & Sutton, UK; Radiotherapy and Imaging Division, Institute of Cancer Research, London & Sutton, UK.
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Alexander EJ, Murray JR, Morgan VA, Giles SL, Riches SF, Hazell S, Thomas K, Sohaib SA, Thompson A, Gao A, Dearnaley DP, DeSouza NM. Validation of T2- and diffusion-weighted magnetic resonance imaging for mapping intra-prostatic tumour prior to focal boost dose-escalation using intensity-modulated radiotherapy (IMRT). Radiother Oncol 2019; 141:181-187. [PMID: 31493904 PMCID: PMC6908966 DOI: 10.1016/j.radonc.2019.07.030] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 07/22/2019] [Accepted: 07/25/2019] [Indexed: 01/28/2023]
Abstract
BACKGROUND AND PURPOSE To assess the diagnostic accuracy and inter-observer agreement of T2-weighted (T2W) and diffusion-weighted (DW) magnetic resonance imaging (MRI) for mapping intra-prostatic tumour lesions (IPLs) for the purpose of focal dose-escalation in prostate cancer radiotherapy. MATERIALS AND METHODS Twenty-six men selected for radical treatment with radiotherapy were recruited prospectively and underwent pre-treatment T2W+DW-MRI and 5 mm spaced transperineal template-guided mapping prostate biopsies (TTMPB). A 'traffic-light' system was used to score both data sets. Radiologically suspicious lesions measuring ≥0.5 cm3 were classified as red; suspicious lesions 0.2-0.5 cm3 or larger lesions equivocal for tumour were classified as amber. The histopathology assessment combined pathological grade and tumour length on biopsy (red = ≥4 mm primary Gleason grade 4/5 or ≥6 mm primary Gleason grade 3). Two radiologists assessed the MRI data and inter-observer agreement was measured with Cohens' Kappa co-efficient. RESULTS Twenty-five of 26 men had red image-defined IPLs by both readers, 24 had red pathology-defined lesions. There was a good correlation between lesions ≥0.5 cm3 classified "red" on imaging and "red" histopathology in biopsies (Reader 1: r = 0.61, p < 0.0001, Reader 2: r = 0.44, p = 0.03). Diagnostic accuracy for both readers for red image-defined lesions was sensitivity 85-86%, specificity 93-98%, positive predictive value (PPV) 79-92% and negative predictive value (NPV) 96%. Inter-observer agreement was good (Cohen's Kappa 0.61). CONCLUSIONS MRI is accurate for mapping clinically significant prostate cancer; diffusion-restricted lesions ≥0.5 cm3 can be confidently identified for radiation dose boosting.
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Affiliation(s)
- E J Alexander
- The Royal Marsden NHS Foundation Trust, Sutton, UK; The Institute of Cancer Research, Sutton, UK.
| | - J R Murray
- The Royal Marsden NHS Foundation Trust, Sutton, UK; The Institute of Cancer Research, Sutton, UK.
| | - V A Morgan
- The Institute of Cancer Research, Sutton, UK.
| | - S L Giles
- The Institute of Cancer Research, Sutton, UK.
| | - S F Riches
- The Institute of Cancer Research, Sutton, UK.
| | - S Hazell
- The Royal Marsden NHS Foundation Trust, Sutton, UK.
| | - K Thomas
- The Royal Marsden NHS Foundation Trust, Sutton, UK
| | - S A Sohaib
- The Royal Marsden NHS Foundation Trust, Sutton, UK.
| | - A Thompson
- The Royal Marsden NHS Foundation Trust, Sutton, UK.
| | - A Gao
- The Royal Marsden NHS Foundation Trust, Sutton, UK; The Institute of Cancer Research, Sutton, UK.
| | - D P Dearnaley
- The Royal Marsden NHS Foundation Trust, Sutton, UK; The Institute of Cancer Research, Sutton, UK.
| | - N M DeSouza
- The Royal Marsden NHS Foundation Trust, Sutton, UK; The Institute of Cancer Research, Sutton, UK.
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Clarke NW, Ali A, Ingleby FC, Hoyle A, Amos CL, Attard G, Brawley CD, Calvert J, Chowdhury S, Cook A, Cross W, Dearnaley DP, Douis H, Gilbert D, Gillessen S, Jones RJ, Langley RE, MacNair A, Malik Z, Mason MD, Matheson D, Millman R, Parker CC, Ritchie AWS, Rush H, Russell JM, Brown J, Beesley S, Birtle A, Capaldi L, Gale J, Gibbs S, Lydon A, Nikapota A, Omlin A, O'Sullivan JM, Parikh O, Protheroe A, Rudman S, Srihari NN, Simms M, Tanguay JS, Tolan S, Wagstaff J, Wallace J, Wylie J, Zarkar A, Sydes MR, Parmar MKB, James ND. Addition of docetaxel to hormonal therapy in low- and high-burden metastatic hormone sensitive prostate cancer: long-term survival results from the STAMPEDE trial. Ann Oncol 2019; 30:1992-2003. [PMID: 31560068 PMCID: PMC6938598 DOI: 10.1093/annonc/mdz396] [Citation(s) in RCA: 222] [Impact Index Per Article: 44.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND STAMPEDE has previously reported that the use of upfront docetaxel improved overall survival (OS) for metastatic hormone naïve prostate cancer patients starting long-term androgen deprivation therapy. We report on long-term outcomes stratified by metastatic burden for M1 patients. METHODS We randomly allocated patients in 2 : 1 ratio to standard-of-care (SOC; control group) or SOC + docetaxel. Metastatic disease burden was categorised using retrospectively-collected baseline staging scans where available. Analysis used Cox regression models, adjusted for stratification factors, with emphasis on restricted mean survival time where hazards were non-proportional. RESULTS Between 05 October 2005 and 31 March 2013, 1086 M1 patients were randomised to receive SOC (n = 724) or SOC + docetaxel (n = 362). Metastatic burden was assessable for 830/1086 (76%) patients; 362 (44%) had low and 468 (56%) high metastatic burden. Median follow-up was 78.2 months. There were 494 deaths on SOC (41% more than the previous report). There was good evidence of benefit of docetaxel over SOC on OS (HR = 0.81, 95% CI 0.69-0.95, P = 0.009) with no evidence of heterogeneity of docetaxel effect between metastatic burden sub-groups (interaction P = 0.827). Analysis of other outcomes found evidence of benefit for docetaxel over SOC in failure-free survival (HR = 0.66, 95% CI 0.57-0.76, P < 0.001) and progression-free survival (HR = 0.69, 95% CI 0.59-0.81, P < 0.001) with no evidence of heterogeneity of docetaxel effect between metastatic burden sub-groups (interaction P > 0.5 in each case). There was no evidence that docetaxel resulted in late toxicity compared with SOC: after 1 year, G3-5 toxicity was reported for 28% SOC and 27% docetaxel (in patients still on follow-up at 1 year without prior progression). CONCLUSIONS The clinically significant benefit in survival for upfront docetaxel persists at longer follow-up, with no evidence that benefit differed by metastatic burden. We advocate that upfront docetaxel is considered for metastatic hormone naïve prostate cancer patients regardless of metastatic burden.
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Affiliation(s)
- N W Clarke
- Department of Urology, The Christie and Salford Royal NHS Foundation Trusts, Manchester.
| | - A Ali
- Genito-Urinary Cancer Research Group, Division of Cancer Sciences, The University of Manchester, Manchester
| | - F C Ingleby
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, UCL, London; London School of Hygiene and Tropical Medicine, London
| | - A Hoyle
- Department of Urology, The Christie and Salford Royal NHS Foundation Trusts, Manchester
| | - C L Amos
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, UCL, London
| | | | - C D Brawley
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, UCL, London
| | - J Calvert
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, UCL, London
| | - S Chowdhury
- Guy's and Saint Thomas' NHS Foundation Trust, London
| | - A Cook
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, UCL, London
| | - W Cross
- St James University Hospital, Leeds
| | | | - H Douis
- Department of Radiology, University Hospitals Birmingham NHS Foundation Trust, Birmingham
| | - D Gilbert
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, UCL, London
| | - S Gillessen
- Division of Cancer Sciences, The University of Manchester, Manchester
| | - R J Jones
- Beatson West of Scotland Cancer Centre, University of Glasgow, Glasgow
| | - R E Langley
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, UCL, London
| | - A MacNair
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, UCL, London
| | - Z Malik
- The Clatterbridge Cancer Centre NHS Foundation Trust, Liverpool
| | | | - D Matheson
- Faculty of Education Health and Wellbeing, University of Wolverhampton, Wolverhampton
| | - R Millman
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, UCL, London
| | - C C Parker
- Institute of Cancer Research, Sutton-London; Royal Marsden NHS Foundation Trust, London
| | - A W S Ritchie
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, UCL, London
| | - H Rush
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, UCL, London
| | - J M Russell
- Institute of Cancer Sciences, Beatson West of Scotland Cancer Centre, Glasgow
| | - J Brown
- University of Sheffield, Sheffield
| | | | - A Birtle
- Lancashire Teaching Hospitals NHS Foundation Trust, Preston
| | - L Capaldi
- Worcestershire Acute Hospitals NHS Trust, Worcester
| | - J Gale
- Portsmouth Oncology Centre, Queen Alexandra Hospital, Portsmouth
| | | | - A Lydon
- Torbay and South Devon NHS Foundation Trust, Torbay
| | | | - A Omlin
- Department of Oncology and Haematology, Kantonsspital, St Gallen, Switzerland
| | - J M O'Sullivan
- Centre for Cancer Research and Cell Biology, Queen's University Belfast, Belfast
| | - O Parikh
- East Lancashire Hospitals NHS Trust, Blackburn
| | - A Protheroe
- Oxford University Hospitals NHS Foundation Trust, Oxford
| | - S Rudman
- Guy's and Saint Thomas' NHS Foundation Trust, London
| | - N N Srihari
- Shrewsbury and Telford Hospital NHS Trust, Shrewsbury
| | - M Simms
- Hull and East Yorkshire Hospitals NHS Trust, Hull
| | | | - S Tolan
- The Clatterbridge Cancer Centre NHS Foundation Trust, Liverpool
| | - J Wagstaff
- Swansea University College of Medicine, Swansea
| | - J Wallace
- Beatson West of Scotland Cancer Centre, University of Glasgow, Glasgow
| | - J Wylie
- The Christie NHS Foundation Trust, Manchester
| | | | - M R Sydes
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, UCL, London
| | - M K B Parmar
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, UCL, London
| | - N D James
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham
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Reis Ferreira M, Andreyev HJN, Mohammed K, Truelove L, Gowan SM, Li J, Gulliford SL, Marchesi JR, Dearnaley DP. Microbiota- and Radiotherapy-Induced Gastrointestinal Side-Effects (MARS) Study: A Large Pilot Study of the Microbiome in Acute and Late-Radiation Enteropathy. Clin Cancer Res 2019; 25:6487-6500. [PMID: 31345839 DOI: 10.1158/1078-0432.ccr-19-0960] [Citation(s) in RCA: 105] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Revised: 06/18/2019] [Accepted: 07/22/2019] [Indexed: 11/16/2022]
Abstract
PURPOSE Radiotherapy is important in managing pelvic cancers. However, radiation enteropathy may occur and can be dose limiting. The gut microbiota may contribute to the pathogenesis of radiation enteropathy. We hypothesized that the microbiome differs between patients with and without radiation enteropathy.Experimental Design: Three cohorts of patients (n = 134) were recruited. The early cohort (n = 32) was followed sequentially up to 12 months post-radiotherapy to assess early radiation enteropathy. Linear mixed models were used to assess microbiota dynamics. The late cohort (n = 87) was assessed cross-sectionally to assess late radiation enteropathy. The colonoscopy cohort compared the intestinal mucosa microenvironment in patients with radiation enteropathy (cases, n = 9) with healthy controls (controls, n = 6). Fecal samples were obtained from all cohorts. In the colonoscopy cohort, intestinal mucosa samples were taken. Metataxonomics (16S rRNA gene) and imputed metataxonomics (Piphillin) were used to characterize the microbiome. Clinician- and patient-reported outcomes were used for clinical characterization. RESULTS In the acute cohort, we observed a trend for higher preradiotherapy diversity in patients with no self-reported symptoms (P = 0.09). Dynamically, diversity decreased less over time in patients with rising radiation enteropathy (P = 0.05). A consistent association between low bacterial diversity and late radiation enteropathy was also observed, albeit nonsignificantly. Higher counts of Clostridium IV, Roseburia, and Phascolarctobacterium significantly associated with radiation enteropathy. Homeostatic intestinal mucosa cytokines related to microbiota regulation and intestinal wall maintenance were significantly reduced in radiation enteropathy [IL7 (P = 0.05), IL12/IL23p40 (P = 0.03), IL15 (P = 0.05), and IL16 (P = 0.009)]. IL15 inversely correlated with counts of Roseburia and Propionibacterium. CONCLUSIONS The microbiota presents opportunities to predict, prevent, or treat radiation enteropathy. We report the largest clinical study to date into associations of the microbiota with acute and late radiation enteropathy. An altered microbiota associates with early and late radiation enteropathy, with clinical implications for risk assessment, prevention, and treatment of radiation-induced side-effects.See related commentary by Lam et al., p. 6280.
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Affiliation(s)
- Miguel Reis Ferreira
- The Institute of Cancer Research, London, United Kingdom. .,The Royal Marsden NHS Foundation Trust, London, United Kingdom.,Guys and St Thomas NHS Foundation Trust, London, United Kingdom.,King's College London, London, United Kingdom
| | | | - Kabir Mohammed
- The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Lesley Truelove
- The Institute of Cancer Research, London, United Kingdom.,The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Sharon M Gowan
- The Institute of Cancer Research, London, United Kingdom
| | - Jia Li
- Imperial College, London, United Kingdom
| | - Sarah L Gulliford
- The Institute of Cancer Research, London, United Kingdom.,University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Julian R Marchesi
- Imperial College, London, United Kingdom. .,Cardiff University, Cardiff, United Kingdom
| | - David P Dearnaley
- The Institute of Cancer Research, London, United Kingdom.,The Royal Marsden NHS Foundation Trust, London, United Kingdom
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Murray J, Alexander E, Tree A, McNair H, Hansen V, Gao A, Thomas K, DeSouza NM, Dearnaley DP. Efficacy and toxicity from phase II study of dose escalation to intraprostatic tumor nodule in localized prostate cancer. J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.7_suppl.102] [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
102 Background: Intra-prostatic boost to dominant nodule is an attractive method for biological dose augmentation. Aim of study was to assess clinical feasibility of radiation boost to mp-MRI visible tumour using external beam radiotherapy. We report a planned analysis of toxicity and efficacy in the first two dose cohorts in this study. Methods: DELINEATE (ISRCTN04483921) was a single centre prospective phase 2 multi-cohort study including standard (Cohort A (A): 74Gy/37F) and moderately hypofractionated (Cohort B (B): 60Gy/20F) prostate image-guided IMRT regimens. Patients treated in A and B received integrated boost of 82Gy and 67Gy to mp-MRI-visible lesions. 55 patients were recruited to A and 158 patients recruited to B; the first 50 sequentially treated patients in B were included in analysis. Duration of androgen deprivation therapy was at clinician discretion. Primary endpoint was RTOG late toxicity at 1 year. Secondary endpoints included acute and late toxicity timepoints and biochemical relapse (BCR) free survival, using Phoenix definition. Treatment related toxicity was measured by RTOG, CTCAE v4 scales, IPSS and EPIC-26. Results: Between July 2011 and January 2015, 105 patients were treated within A&B. Median follow up for A was 74.5 months and 52 months for B. Median age was 71 years (range 57-80). In A and B, there were 27% and 40% of patients respectively classified with NCCN high risk disease. Cumulative RTOG toxicity in Table. 6 patients had BCR (5 patients: A and 1 patient: B). Within A, 1 patient had pelvic nodal progression and 1 local progression; patient in B had local progression. Conclusions: Delivery of intra-prostatic boost to dominant nodule is feasible with acceptable toxicity and good efficacy. Intra-prostatic boost is now part of the randomised phase 3 PIVOTALboost trial (ISRCTN80146950). Clinical trial information: 04483921. [Table: see text]
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Affiliation(s)
- Julia Murray
- The Royal Marsden NHS Foundation Trust and Institute of Cancer Research, London, United Kingdom
| | - Emma Alexander
- The Royal Marsden NHS Foundation Trust, Sutton, United Kingdom
| | - Alison Tree
- The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Helen McNair
- The Royal Marsden NHS Foundation Trust, Sutton, United Kingdom
| | - Vibeke Hansen
- The Royal Marsden NHS Foundation Trust, Sutton, United Kingdom
| | - Annie Gao
- The Institute of Cancer Research, London, United Kingdom
| | - Karen Thomas
- Royal Marsden Hospital NHS Foundation Trust, London, United Kingdom
| | - Nandita M DeSouza
- Royal Marsden NHS Foundation Trust and The Institute of Cancer Research, London, United Kingdom
| | - David P. Dearnaley
- Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, United Kingdom
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Wilkins AC, Gusterson B, Dearnaley DP, Hall E, Somaiah N. In Regard to Spratt. Int J Radiat Oncol Biol Phys 2018; 102:1596-1597. [PMID: 31014790 DOI: 10.1016/j.ijrobp.2018.08.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Revised: 07/17/2018] [Accepted: 08/01/2018] [Indexed: 11/28/2022]
Affiliation(s)
- Anna C Wilkins
- Institute of Cancer Research-Clinical Trials and Statistics Unit (ICR-CTSU), London, United Kingdom; Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, United Kingdom; The Royal Marsden, London, United Kingdom
| | - Barry Gusterson
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, United Kingdom
| | - David P Dearnaley
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, United Kingdom; The Royal Marsden, London, United Kingdom
| | - Emma Hall
- Institute of Cancer Research-Clinical Trials and Statistics Unit (ICR-CTSU), London, United Kingdom
| | - Navita Somaiah
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, United Kingdom; The Royal Marsden, London, United Kingdom
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Parker CC, James ND, Brawley CD, Clarke NW, Hoyle AP, Ali A, Ritchie AWS, Attard G, Chowdhury S, Cross W, Dearnaley DP, Gillessen S, Gilson C, Jones RJ, Langley RE, Malik ZI, Mason MD, Matheson D, Millman R, Russell JM, Thalmann GN, Amos CL, Alonzi R, Bahl A, Birtle A, Din O, Douis H, Eswar C, Gale J, Gannon MR, Jonnada S, Khaksar S, Lester JF, O'Sullivan JM, Parikh OA, Pedley ID, Pudney DM, Sheehan DJ, Srihari NN, Tran ATH, Parmar MKB, Sydes MR. Radiotherapy to the primary tumour for newly diagnosed, metastatic prostate cancer (STAMPEDE): a randomised controlled phase 3 trial. Lancet 2018; 392:2353-2366. [PMID: 30355464 PMCID: PMC6269599 DOI: 10.1016/s0140-6736(18)32486-3] [Citation(s) in RCA: 779] [Impact Index Per Article: 129.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Revised: 09/30/2018] [Accepted: 10/03/2018] [Indexed: 12/23/2022]
Abstract
BACKGROUND Based on previous findings, we hypothesised that radiotherapy to the prostate would improve overall survival in men with metastatic prostate cancer, and that the benefit would be greatest in patients with a low metastatic burden. We aimed to compare standard of care for metastatic prostate cancer, with and without radiotherapy. METHODS We did a randomised controlled phase 3 trial at 117 hospitals in Switzerland and the UK. Eligible patients had newly diagnosed metastatic prostate cancer. We randomly allocated patients open-label in a 1:1 ratio to standard of care (control group) or standard of care and radiotherapy (radiotherapy group). Randomisation was stratified by hospital, age at randomisation, nodal involvement, WHO performance status, planned androgen deprivation therapy, planned docetaxel use (from December, 2015), and regular aspirin or non-steroidal anti-inflammatory drug use. Standard of care was lifelong androgen deprivation therapy, with up-front docetaxel permitted from December, 2015. Men allocated radiotherapy received either a daily (55 Gy in 20 fractions over 4 weeks) or weekly (36 Gy in six fractions over 6 weeks) schedule that was nominated before randomisation. The primary outcome was overall survival, measured as the number of deaths; this analysis had 90% power with a one-sided α of 2·5% for a hazard ratio (HR) of 0·75. Secondary outcomes were failure-free survival, progression-free survival, metastatic progression-free survival, prostate cancer-specific survival, and symptomatic local event-free survival. Analyses used Cox proportional hazards and flexible parametric models, adjusted for stratification factors. The primary outcome analysis was by intention to treat. Two prespecified subgroup analyses tested the effects of prostate radiotherapy by baseline metastatic burden and radiotherapy schedule. This trial is registered with ClinicalTrials.gov, number NCT00268476. FINDINGS Between Jan 22, 2013, and Sept 2, 2016, 2061 men underwent randomisation, 1029 were allocated the control and 1032 radiotherapy. Allocated groups were balanced, with a median age of 68 years (IQR 63-73) and median amount of prostate-specific antigen of 97 ng/mL (33-315). 367 (18%) patients received early docetaxel. 1082 (52%) participants nominated the daily radiotherapy schedule before randomisation and 979 (48%) the weekly schedule. 819 (40%) men had a low metastatic burden, 1120 (54%) had a high metastatic burden, and the metastatic burden was unknown for 122 (6%). Radiotherapy improved failure-free survival (HR 0·76, 95% CI 0·68-0·84; p<0·0001) but not overall survival (0·92, 0·80-1·06; p=0·266). Radiotherapy was well tolerated, with 48 (5%) adverse events (Radiation Therapy Oncology Group grade 3-4) reported during radiotherapy and 37 (4%) after radiotherapy. The proportion reporting at least one severe adverse event (Common Terminology Criteria for Adverse Events grade 3 or worse) was similar by treatment group in the safety population (398 [38%] with control and 380 [39%] with radiotherapy). INTERPRETATION Radiotherapy to the prostate did not improve overall survival for unselected patients with newly diagnosed metastatic prostate cancer. FUNDING Cancer Research UK, UK Medical Research Council, Swiss Group for Clinical Cancer Research, Astellas, Clovis Oncology, Janssen, Novartis, Pfizer, and Sanofi-Aventis.
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Affiliation(s)
- Christopher C Parker
- Academic Urology Unit, Royal Marsden Hospital, London, UK; Institute of Cancer Research, London, UK.
| | - Nicholas D James
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Christopher D Brawley
- Medical Research Council (MRC) Clinical Trials Unit at University College London (UCL), London, UK
| | - Noel W Clarke
- Genito-Urinary Cancer Research Group, Department of Surgery, The Christie Hospital, Manchester, UK; Department of Urology, Salford Royal Hospitals, Manchester, UK
| | - Alex P Hoyle
- Genito-Urinary Cancer Research Group, Department of Surgery, The Christie Hospital, Manchester, UK; Department of Urology, Salford Royal Hospitals, Manchester, UK
| | - Adnan Ali
- Genito-Urinary Cancer Research Group, Department of Surgery, The Christie Hospital, Manchester, UK; The FASTMAN/Genito-Urinary Cancer Research Groups, Division of Cancer Sciences, and Belfast-Manchester Movember Centre of Excellence, Manchester Cancer Research Centre, University of Manchester, Manchester, UK
| | - Alastair W S Ritchie
- Medical Research Council (MRC) Clinical Trials Unit at University College London (UCL), London, UK
| | | | - Simon Chowdhury
- Department of Medical Oncology, Guy's & St Thomas' NHS Foundation Trust, London, UK
| | - William Cross
- Department of Urology, St James University Hospital, Leeds, UK
| | - David P Dearnaley
- Academic Urology Unit, Royal Marsden Hospital, London, UK; Institute of Cancer Research, London, UK
| | - Silke Gillessen
- Division of Cancer Sciences, University of Manchester and the Christie, Manchester, UK; Division of Oncology and Haematology, Kantonsspital, St Gallen, Switzerland
| | - Clare Gilson
- Medical Research Council (MRC) Clinical Trials Unit at University College London (UCL), London, UK
| | - Robert J Jones
- Beatson West of Scotland Cancer Centre, University of Glasgow, Glasgow, UK
| | - Ruth E Langley
- Medical Research Council (MRC) Clinical Trials Unit at University College London (UCL), London, UK
| | - Zafar I Malik
- The Clatterbridge Cancer Centre NHS Foundation Trust, Liverpool, UK
| | - Malcolm D Mason
- Division of Cancer & Genetics, School of Medicine, Cardiff University, Cardiff, UK
| | - David Matheson
- Faculty of Education, Health and Wellbeing, University of Wolverhampton, Wolverhampton, UK
| | - Robin Millman
- Medical Research Council (MRC) Clinical Trials Unit at University College London (UCL), London, UK
| | - J Martin Russell
- Institute of Cancer Sciences, University of Glasgow, Glasgow, UK
| | - George N Thalmann
- Department of Urology, University Hospital, Inselspital, Bern, Switzerland
| | - Claire L Amos
- Medical Research Council (MRC) Clinical Trials Unit at University College London (UCL), London, UK
| | | | - Amit Bahl
- Bristol Haematology and Oncology Centre, Bristol, UK
| | - Alison Birtle
- Rosemere Cancer Centre, Lancashire Teaching Hospitals, Preston, UK; School of Cancer Sciences, University of Manchester, Manchester, UK
| | - Omar Din
- Department of Clinical Oncology, Weston Park Cancer Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Hassan Douis
- Department of Radiology, University Hospital Birmingham NHS Foundation Trust, Birmingham, UK
| | - Chinnamani Eswar
- The Clatterbridge Cancer Centre NHS Foundation Trust, Liverpool, UK
| | - Joanna Gale
- Portsmouth Oncology Centre, Queen Alexandra Hospital, Portsmouth, UK
| | - Melissa R Gannon
- Department of Health Services Research, London School of Hygiene & Tropical Medicine, London, UK
| | - Sai Jonnada
- Department of Oncology, Gloucestershire Hospitals NHS Foundation Trust, Gloucester, UK
| | - Sara Khaksar
- St Luke's Cancer Centre, Royal Surrey County Hospital, Guildford, UK
| | | | - Joe M O'Sullivan
- Centre for Cancer Research and Cell Biology, Queen's University Belfast, Belfast, UK
| | - Omi A Parikh
- Department of Clinical Oncology, East Lancashire Hospitals NHS Trust, Blackburn, UK
| | - Ian D Pedley
- Northern Centre for Cancer Care, Freeman Hospital, Newcastle upon Tyne, UK
| | | | - Denise J Sheehan
- Exeter Oncology Centre, Royal Devon & Exeter Hospital, Exeter, UK
| | | | - Anna T H Tran
- Department of Clinical Oncology, The Christie NHS Foundation Trust, Manchester, UK
| | - Mahesh K B Parmar
- Medical Research Council (MRC) Clinical Trials Unit at University College London (UCL), London, UK
| | - Matthew R Sydes
- Medical Research Council (MRC) Clinical Trials Unit at University College London (UCL), London, UK.
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Woods BS, Sideris E, Sydes MR, Gannon MR, Parmar MKB, Alzouebi M, Attard G, Birtle AJ, Brock S, Cathomas R, Chakraborti PR, Cook A, Cross WR, Dearnaley DP, Gale J, Gibbs S, Graham JD, Hughes R, Jones RJ, Laing R, Mason MD, Matheson D, McLaren DB, Millman R, O'Sullivan JM, Parikh O, Parker CC, Peedell C, Protheroe A, Ritchie AWS, Robinson A, Russell JM, Simms MS, Srihari NN, Srinivasan R, Staffurth JN, Sundar S, Thalmann GN, Tolan S, Tran ATH, Tsang D, Wagstaff J, James ND, Sculpher MJ. Addition of Docetaxel to First-line Long-term Hormone Therapy in Prostate Cancer (STAMPEDE): Modelling to Estimate Long-term Survival, Quality-adjusted Survival, and Cost-effectiveness. Eur Urol Oncol 2018; 1:449-458. [PMID: 31158087 PMCID: PMC6692495 DOI: 10.1016/j.euo.2018.06.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Revised: 05/23/2018] [Accepted: 06/12/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND Results from large randomised controlled trials have shown that adding docetaxel to the standard of care (SOC) for men initiating hormone therapy for prostate cancer (PC) prolongs survival for those with metastatic disease and prolongs failure-free survival for those without. To date there has been no formal assessment of whether funding docetaxel in this setting represents an appropriate use of UK National Health Service (NHS) resources. OBJECTIVE To assess whether administering docetaxel to men with PC starting long-term hormone therapy is cost-effective in a UK setting. DESIGN, SETTING, AND PARTICIPANTS We modelled health outcomes and costs in the UK NHS using data collected within the STAMPEDE trial, which enrolled men with high-risk, locally advanced metastatic or recurrent PC starting first-line hormone therapy. INTERVENTION SOC was hormone therapy for ≥2 yr and radiotherapy in some patients. Docetaxel (75mg/m2) was administered alongside SOC for six three-weekly cycles. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS The model generated lifetime predictions of costs, changes in survival duration, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratios (ICERs). RESULTS AND LIMITATIONS The model predicted that docetaxel would extend survival (discounted quality-adjusted survival) by 0.89 yr (0.51) for metastatic PC and 0.78 yr (0.39) for nonmetastatic PC, and would be cost-effective in metastatic PC (ICER £5514/QALY vs SOC) and nonmetastatic PC (higher QALYs, lower costs vs SOC). Docetaxel remained cost-effective in nonmetastatic PC when the assumption of no survival advantage was modelled. CONCLUSIONS Docetaxel is cost-effective among patients with nonmetastatic and metastatic PC in a UK setting. Clinicians should consider whether the evidence is now sufficiently compelling to support docetaxel use in patients with nonmetastatic PC, as the opportunity to offer docetaxel at hormone therapy initiation will be missed for some patients by the time more mature survival data are available. PATIENT SUMMARY Starting docetaxel chemotherapy alongside hormone therapy represents a good use of UK National Health Service resources for patients with prostate cancer that is high risk or has spread to other parts of the body.
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Affiliation(s)
- Beth S Woods
- Centre for Health Economics, University of York, York, UK.
| | | | - Matthew R Sydes
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, University College London, London, UK
| | - Melissa R Gannon
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, University College London, London, UK
| | - Mahesh K B Parmar
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, University College London, London, UK
| | | | - Gerhardt Attard
- The Institute of Cancer Research, London, UK; The Royal Marsden NHS Foundation Trust, London, UK
| | | | - Susannah Brock
- Dorset Cancer Centre, Poole Hospital NHS Foundation Trust, Poole, UK
| | - Richard Cathomas
- Swiss Group for Clinical Cancer Research (SAKK), Bern, Switzerland; Kantonsspital Graubünden, Chur, Switzerland
| | | | - Audrey Cook
- Gloucestershire Oncology Centre, Cheltenham, UK
| | - William R Cross
- Department of Urology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - David P Dearnaley
- The Institute of Cancer Research, London, UK; The Royal Marsden NHS Foundation Trust, London, UK
| | - Joanna Gale
- Portsmouth Oncology Centre, Queen Alexandra Hospital, Portsmouth, UK
| | - Stephanie Gibbs
- Barking, Havering and Redbridge University Hospitals NHS Trust, Romford, UK
| | | | - Robert Hughes
- Mount Vernon Group, Mount Vernon Hospital, Northwood, UK
| | | | - Robert Laing
- St Luke's Cancer Centre, Royal Surrey NHS Trust, Guildford, UK
| | | | | | | | - Robin Millman
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, University College London, London, UK
| | - Joe M O'Sullivan
- Centre for Cancer Research and Cell Biology, Queen's University, Belfast, UK
| | - Omi Parikh
- Department of Oncology, East Lancashire Hospitals NHS Trust, Burnley, UK
| | | | | | | | | | - Angus Robinson
- Sussex Cancer Centre, Royal Sussex County Hospital, Brighton, UK
| | - J Martin Russell
- Institute of Cancer Sciences, University of Glasgow, Glasgow, UK; Forth Valley Royal Hospital, Larbert, UK
| | | | | | | | - John N Staffurth
- Velindre Cancer Centre, Cardiff and School of Medicine, Cardiff University, Cardiff, UK
| | | | | | | | | | - David Tsang
- Southend and Basildon Hospitals, Southend, UK
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Lemanska A, Byford RC, Cruickshank C, Dearnaley DP, Ferreira F, Griffin C, Hall E, Hinton W, De Lusignan S, Sherlock J, Tomkinson K, Van Vlymen J, Faithfull S. Extracting primary care records for prostate cancer patients in the CHHiP multicentre randomised control trial: A healthcare data linkage study. Int J Popul Data Sci 2018. [DOI: 10.23889/ijpds.v3i4.741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Abstract
IntroductionThe aim is to investigate the effect of cardiovascular and diabetes comorbidities on radiotherapy-related side-effects in prostate cancer. Previous research suggests that comorbidities increase the risk of side-effects, but some cardiovascular medications may reduce symptoms by protecting against radiation damage. The evidence is inconclusive and mechanisms are not fully understood.
ObjectiveTo explore whether routine primary care data can supplement clinical trial data in evaluating the impact of comorbidities and prescription medications on patient outcomes.
ApproachThe CHHiP radiotherapy trial (CRUK/06/16) recruited 3,216 prostate cancer patients from 71 centres in UK, Ireland, Switzerland, and New Zealand between 2002 and 2011. Baseline comorbidity and radiotherapy-related side-effects over time were recorded. This was linked to computerised medical records (CMRs) from the Royal College of General Practitioners (RCGP) Research and Surveillance Centre (RSC) database. RCGP RSC is a network of 192 English general practices with over 2 million patients (2.8% of the population).
ResultsThe English population of CHHiP patients (N=2811) was used. 120 CMRs were linked, which exceeded the estimation of 79 linked records. However, six CMRs showed no evidence of regular GP care and a further eight patients were not recruited into the CHHiP trial until after they had de-registered from an RCGP RSC practice.
Information on cardiovascular and diabetes comorbidities was extracted for 106 patients. The mean age was 69±7 years, representative of the CHHiP population. From the CMRs, 23 (22%) patients had diabetes and 47 (44%) had hypertension including 37 (35%) who took angiotensin converting enzyme (ACE) inhibitors (medications lowering blood pressure). In addition, 44 (41%) patients took aspirin, 65 (61%) statins (lowering blood lipids) and 14 (13%) took metformin (lowering blood sugar levels).
Conclusion/ImplicationsThe small sample limits statistical analysis. However, a clinical trial was successfully linked to GP data to determine comorbidities and medications of patients. This will serve as a pilot for further research. The advantage of data linkage is that it may provide a mechanism for long-term follow-up of radiotherapy-related side-effects.
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Lemanska A, Dearnaley DP, Jena R, Sydes MR, Faithfull S. Older Age, Early Symptoms and Physical Function are Associated with the Severity of Late Symptom Clusters for Men Undergoing Radiotherapy for Prostate Cancer. Clin Oncol (R Coll Radiol) 2018; 30:334-345. [PMID: 29459102 PMCID: PMC5952898 DOI: 10.1016/j.clon.2018.01.016] [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] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Revised: 12/15/2017] [Accepted: 12/22/2017] [Indexed: 12/21/2022]
Abstract
AIMS To identify symptom clusters and predisposing factors associated with long-term symptoms and health-related quality of life after radiotherapy in men with prostate cancer. MATERIALS AND METHODS Patient-reported outcomes (PROs) data from the Medical Research Council RT01 radiotherapy with neoadjuvant androgen deprivation therapy trial of 843 patients were used. PROs were collected over 5 years with the University of California, Los Angeles Prostate Cancer Index (UCLA-PCI) and the 36 item Short-Form Health Survey (SF-36). Symptom clusters were explored using hierarchical cluster analysis. The association of treatment dose, baseline patient characteristics and early symptom clusters with the change in severity of PROs over 3 years was investigated with multivariate linear mixed effects models. RESULTS Seven symptom clusters of three or more symptoms were identified. The clusters were stable over time. The longitudinal profiles of symptom clusters showed the onset of acute symptoms during treatment for all symptom clusters and significant recovery by 6 months. Some clusters, such as physical health and sexual function, were adversely affected more than others by androgen deprivation therapy, and were less likely to return to pretreatment levels over time. Older age was significantly associated with decreased long-term physical function, physical health and sexual function (P < 0.001). Both baseline and acute symptom clusters were significant antecedents for impaired function and health-related quality of life at 3 years. CONCLUSIONS Men with poorer physical function and health before or during treatment were more likely to report poorer PROs at year 3. Early assessment using PROs and lifestyle interventions should be used to identify those with higher needs and provide targeted rehabilitation and symptom management.
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Affiliation(s)
- A Lemanska
- School of Health Sciences, Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK.
| | - D P Dearnaley
- Institute of Cancer Research and Royal Marsden NHS Trust, London, UK
| | - R Jena
- Cambridge University Hospitals, Addenbrookes Hospital, Cambridge, UK
| | - M R Sydes
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, London, UK
| | - S Faithfull
- School of Health Sciences, Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK
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Wilkins AC, Gusterson B, Szijgyarto Z, Haviland J, Griffin C, Stuttle C, Daley F, Corbishley CM, Dearnaley DP, Hall E, Somaiah N. Ki67 Is an Independent Predictor of Recurrence in the Largest Randomized Trial of 3 Radiation Fractionation Schedules in Localized Prostate Cancer. Int J Radiat Oncol Biol Phys 2018; 101:309-315. [PMID: 29559283 PMCID: PMC5947826 DOI: 10.1016/j.ijrobp.2018.01.072] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Revised: 12/27/2017] [Accepted: 01/22/2018] [Indexed: 12/30/2022]
Abstract
PURPOSE To assess whether the cellular proliferation marker Ki67 provides prognostic information and predicts response to radiation therapy fractionation in patients with localized prostate tumors participating in a randomized trial of 3 radiation therapy fractionation schedules (74 Gy/37 fractions vs 60 Gy/20 fractions vs 57 Gy/19 fractions). METHODS AND MATERIALS A matched case-control study design was used; patients with biochemical/clinical failure >2 years after radiation therapy (BCR) were matched 1:1 to patients without recurrence using established prognostic factors (Gleason score, prostate-specific antigen, tumor stage) and fractionation schedule. Immunohistochemistry was used to stain diagnostic biopsy specimens for Ki67, which were scored using the unweighted global method. Conditional logistic regression models estimated the prognostic value of mean and maximum Ki67 scores on BCR risk. Biomarker-fractionation interaction terms determined whether Ki67 was predictive of BCR by fractionation. RESULTS Using 173 matched pairs, the median for mean and maximum Ki67 scores were 6.6% (interquartile range, 3.9%-9.8%) and 11.0% (interquartile range, 7.0%-15.0%) respectively. Both scores were significant predictors of BCR in models adjusted for established prognostic factors. Conditioning on matching variables and age, the odds of BCR were estimated to increase by 9% per 1% increase in mean Ki67 score (odds ratio 1.09; 95% confidence interval 1.04-1.15, P = .001). Interaction terms between Ki67 and fractionation schedules were not statistically significant. CONCLUSIONS Diagnostic Ki67 did not predict BCR according to fractionation schedule in CHHiP; however, it was a strong independent prognostic factor for BCR.
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Affiliation(s)
- Anna C Wilkins
- Institute of Cancer Research-Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, United Kingdom; Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, United Kingdom; The Royal Marsden, Sutton, London, United Kingdom
| | - Barry Gusterson
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, United Kingdom
| | - Zsolt Szijgyarto
- Institute of Cancer Research-Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, United Kingdom
| | - Joanne Haviland
- Institute of Cancer Research-Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, United Kingdom
| | - Clare Griffin
- Institute of Cancer Research-Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, United Kingdom
| | - Christine Stuttle
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, United Kingdom
| | - Frances Daley
- Division of Breast Cancer Research, The Institute of Cancer Research, London, United Kingdom
| | - Catherine M Corbishley
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, United Kingdom
| | - David P Dearnaley
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, United Kingdom; The Royal Marsden, Sutton, London, United Kingdom
| | - Emma Hall
- Institute of Cancer Research-Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, United Kingdom
| | - Navita Somaiah
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, United Kingdom; The Royal Marsden, Sutton, London, United Kingdom.
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