Outcomes following radical prostatectomy or external beam radiation for veterans with Gleason 9 and 10 prostate cancer

Background

The optimal upfront treatment modality for patients with nonmetastatic Gleason Score 9 and 10 prostate cancer (GS 9–10 PCa) is unknown.

Methods

We conducted a retrospective cohort study of patients in the Veterans Health Administration (VHA) with GS 9–10 PCa treated with radical prostatectomy (RP) or external beam radiation therapy with androgen deprivation therapy (EBRT+ADT) from 1/2000 to 12/2010. Outcomes included overall survival (OS), distant metastasis‐free survival (DMFS), and salvage/adjuvant therapy‐free survival (SAFS), as assessed by Kaplan–Meier analysis.

Results

We identified 1220 veterans with GS 9–10 PCa; 335 were treated with RP, and 885 were treated with EBRT+ADT. With a median follow‐up of 9.9 years, propensity score‐matched analyses demonstrated that RP had superior 10‐year OS (70.8% [RP] vs. 61.2% [EBRT+ADT], p < 0.001), 10‐year DMFS rates were similar between RP (76.7%) and EBRT+ADT (81.0%), and 10‐year SAFS rates were lower for RP vs EBRT + ADT (35.2% [RP] vs. 75.2% [EBRT+ADT], p < 0.001). The receipt of salvage ADT was higher with upfront RP (51.9% vs. 26.1%, p < 0.001), despite receipt of adjuvant/salvage EBRT in 41.8% of RP patients. Among patients treated with RP, there were no differences in outcomes by race. However, higher survival rates were noted among Black patients treated with EBRT+ADT compared with White patients.

Conclusions

This analysis demonstrated higher 10‐year OS rates among men treated with upfront RP versus EBRT+ADT, though missing confounders and similar DMFS rates suggest the long‐term cause‐specific OS rates may be similar. We also highlight real‐world outcomes of a diverse patient population in the VHA and improved outcomes for Black patients receiving EBRT+ADT.

Moderately Hypofractionated Intensity Modulated Radiation Therapy With Simultaneous Integrated Boost for Prostate Cancer: Five-Year Toxicity Results From a Prospective Phase I/II Trial

BACKGROUND

In this phase I/II trial, 5-year physician-assessed toxicity and patient reported quality of life data is reported for patients undergoing moderately hypofractionated intensity modulated radiation therapy (IMRT) for prostate cancer using a simultaneous integrated boost (SIB) and pelvic lymph node (LN) coverage.

MATERIALS AND METHODS

Patients with T1-T2 localized prostate cancer were prospectively enrolled, receiving risk group based coverage of prostate ± seminal vesicles (SVs) ± pelvic lymph nodes (LNs). Low risk (LR) received 69.6 Gy/29 fractions to the prostate, while intermediate risk (IR) and high risk (HR) patients received 72 Gy/30fx to the prostate and 54Gy/30fx to the SVs. If predicted risk of LN involvement >15%, 50.4 Gy/30fx was delivered to pelvic LNs. Androgen deprivation therapy was given to IR and HR patients.

RESULTS

There were 55 patients enrolled and 49 patients evaluable at a median follow up of 60 months. Included were 11 (20%) LR, 23 (41.8%) IR, and 21 (38.2%) HR patients. Pelvic LN treatment was given in 25 patients (51%). Prevalence rates of late grade 2 GI toxicity at 1, 3, and 5 years was 5.8, 3.9, and 5.8%, respectively, with no permanent grade 3 events. Prevalence rates of late grade 2 GU toxicity at 1, 3, and 5 years rates were 15.4, 7.7, and 13.5%, respectively, with three grade 3 events (5.8%). The biochemical relapse free survival at 5 years was 88.3%. There were no local, regional, or distant failures, with all patients still alive at last follow up.

CONCLUSION

Moderate hypofractionation of localized prostate cancer utilizing a SIB technique and LN coverage produces tolerable acute/late toxicity. Given equivalent efficacy between moderate hypofractionation schedules, the optimal regimen will be determined by long-term toxicity reported from both the physician and patient perspective.

CLINICAL TRIAL REGISTRATION

www.ClinicalTrials.gov, identifier NCT01117935, Date of Registration: 5/6/2010.

Five-year results from a phase I/II study of moderately hypofractionated intensity-modulated radiation therapy (IMRT) for localized prostate cancer including simultaneously integrated boost and pelvic lymph node (LN) coverage

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Background: This study reports the 5 year toxicity and efficacy data of a phase I/II trial of moderately hypofractionated intensity modulated radiation therapy (IMRT) for localized prostate cancer utilizing a simultaneous integrated boost and pelvic lymph node (LN) coverage. Methods: Men with localized prostate cancer were prospectively enrolled and received IMRT to the prostate +/- seminal vesicles (SVs) +/- LNs based on National Comprehensive Cancer Network (NCCN) guidelines. Low-risk (LR) patients received 69.6 Gy in 29 fractions to the prostate alone; intermediate-risk (IR) and high-risk (HR) patients received 72Gy to the prostate, 54Gy to the SVs, and 50.4Gy to LNs (if risk of LN involvement > 15% by the Roach formula) all in 30 fractions. IR and HR patients received androgen deprivation therapy. Results: Fifty-five patients were enrolled and 49 patients evaluable with a median follow up of 60 months. There were 11 (20%) LR, 23 (41.8%) IR, and 21 (38.2%) HR patients. Twenty-five patients (51%) received prostate and LN treatment. At 5 years, the cumulative incidence of late grade 2+ gastrointestinal (GI) and genitourinary (GU) toxicity was 22.6% and 38.2% respectively. Prevalence rates of late grade 2 GI toxicity at 1, 3, and 5 years was 5.8%, 3.9%, and 5.8% respectively. Late grade 2+ GI toxicities that did not resolve by 60 months included 3 out of 52 patients (5.8%). Prevalence rates of late grade 2 GU toxicity at 1, 3, and 5 years rates were 15.4%, 7.7%, and 13.5% respectively. There were 3 patients (5.8%) who experienced grade 3 GU toxicity and no grade 3 GI toxicities. The biochemical relapse free survival at 5 years for the cohort was 88.3%. There were no local, regional, or distant failures, with all patients still alive at last follow up. Conclusions: Moderate hypofractionation of localized prostate cancer utilizing a simultaneous integrated boost and LN coverage produces excellent biochemical control and acceptable acute/late toxicity. This phase I/II trial adds to maturing data with 5 year outcomes which justify its use for cost and patient convenience factors. Clinical trial information: NCT01117935.

Racial differences in the PSA bounce in predicting prostate cancer outcomes after brachytherapy: Evidence from the Department of Veterans Affairs

PURPOSE

African American men have historically had poorer prostate cancer biochemical and survival outcomes than Caucasians. However, emerging data suggest nononcologic factors drive much of this disparity. Prior evidence has suggested an association between a transient prostate specific antigen (PSA) bounce and improved biochemical control. However, racial differences in this relationship have remained relatively unexplored.

METHODS AND MATERIALS

We identified 4477 men treated for low- or intermediate-risk prostate cancer within the U.S. Department of Veterans Affairs (VA) from 2000 to 2010 with brachytherapy alone or in combination with external beam radiotherapy without androgen deprivation. Longitudinal PSA data were used to define to biochemical failure and PSA bounce. Cox proportional hazard models were used explore racial differences in the relationship between the PSA bounce and time to biochemical failure.

RESULTS

Thirty-one percent of our sample experienced a PSA bounce, with African Americans more likely to experience a bounce (42%) compared with Caucasians (29%); p < 0.001. Despite this, African Americans had a higher likelihood of biochemical failure (hazard ratio [HR] 1.4; p = 0.006). However, African American men experiencing a PSA bounce were less likely to experience a biochemical failure (HR = 0.64; p = 0.046), whereas this relationship was not statistically significant for Caucasians (HR = 0.78; p = 0.092). On multivariate analysis, African Americans receiving brachytherapy alone were most sensitive to the protective benefit of the PSA bounce (HR = 0.64).

CONCLUSIONS

A PSA bounce was associated with improved biochemical control among patients receiving brachytherapy as part of their treatment for low- or intermediate-risk prostate cancer at the VA. African American men treated with brachytherapy had a particularly pronounced biochemical control benefit of a PSA bounce.

A Systems Engineering and Decision-Support Tool to Enhance Care of Veterans Diagnosed With Prostate Cancer

A prostate-specific antigen tracking system identifies patients who require intervention before they present with clinical problems, ensuring that testing occurs at appropriate intervals.

Comparative study of late rectal toxicity in veterans undergoing low-dose rate prostate brachytherapy treated with or without supplemental external beam radiotherapy

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Background: Supplemental external beam radiation therapy (sEBRT) is often prescribed in men undergoing low dose rate (LDR) brachytherapy for prostate cancer. A population of patients was analyzed to assess the effect of sEBRT on late rectal toxicity. It was hypothesized that sEBRT+LDR would be associated with a higher risk of late rectal toxicity, compared to LDR brachytherapy alone. Methods: This retrospective cohort study examined LDR brachytherapy patients, treated with or without sEBRT, with a minimum of 5 years follow-up. All were treated at a credentialed Veterans Affairs medical center that enrolled many of these patients on RTOG 0234. Longitudinal assessments were evaluated using the Computerized Patient Record System, and toxicities were coded using the CTCAE v4.0. The Kaplan-Meier method was used for analysis. Results: Median follow-up was 7.5 years for 245 consecutive patients from 2004 and 2007. sEBRT was administered to 33.5%. Follow-up beyond 5 years was available for 89%. Overall rates of grade ≥ 2 and ≥ 3 rectal toxicities were 6.9% and 2.9%, respectively. The risk of grade ≥ 2 rectal toxicity was 2.8-fold higher for patients receiving sEBRT (1.1 - 7.2, 95% CI, p = 0.02). The risk of grade ≥ 3 rectal toxicity was 11.9-fold higher for patients who received sEBRT (1.5 - 97.4, 95% CI, p = 0.003). Six out of 7 patients with a grade ≥ 3 rectal toxicity received sEBRT, including one who required an abdominoperineal resection due to radiation proctopathy. The median post-LDR D90, V150, V200, and R100 values were 103.3%, 59.4%, 30.1%, and 0.5 cc. The minimum R100 associated with a grade ≥ 2 toxicity was 0.2 cc, and the minimum R100 for a grade ≥ 3 toxicity was 0.4 cc. Grade ≥ 2 rectal toxicity was seen in 3% vs 13% of patients who had post-implant dosimetry of R100 < 1 cc vs R100≥ 1 cc, respectively. Conclusions: In a cohort of LDR brachytherapy patients with high rates of follow-up, sEBRT+LDR was associated with significantly higher risk of grade ≥ 2 and ≥ 3 late rectal toxicity. This analysis supports previous findings and maintains concern about the supplemental use of EBRT with LDR brachytherapy while its benefit for tumor control has yet to be prospectively validated.

Phase I/II study of hypofractionated intensity modulated radiotherapy (IMRT) for prostate cancer including simultaneously integrated boost (SIB)

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Background: The purpose of this study is to evaluate the toxicity of hypofractionationed H- IMRT treatment including SIB IMRT when pelvic nodes were covered. Additionally, we assessed early treatment efficacy through PSA control (biochemical failure defined as PSA more than nadir + 2 ng/mL). Methods: Men with localized prostate cancer were enrolled in a phase I/II trial to receive H-IMRT to the prostate, seminal vesicles)(SV) and pelvic lymph nodes (LN) using simultaneous integrated boost (SIB) method. Low risk (LR) patients received 69.4 Gy to the prostate only in 29 fractions. The intermediate (IR) and high risk (HR) patients received 72 Gy to the prostate, 54 Gy to the proximal 1 cm SV, and 50.4 Gy to the pelvic LN when risk of LN involvement >15% by Roach formula. Treatment was given in 30 fractions using intraprostatic fiducials and daily image guidance. PTV expansion for prostate and SV was 0.3 mm posteriorly and 0.7 cm in all other directions. The IR and HR patients received androgen deprivation therapy (3 years for HR patients, and 6 months for IR patients). Acute and late genitourinary (GU) and gastrointestinal (GI) toxicity were prospectively evaluated according to CTCAE v3.0. Results: 55 men (29 African American and 26 white) were enrolled on trial with 20% LR, 41% IR and 39% HR disease (NCCN criteria). The median age was 55 with median follow-up time of 37.9 months. 26 patients received pelvic nodal SIB-IMRT. Toxicity is reported in the table. The biochemical control rate for the cohort was 91% at 3 years. Patients with pelvic LN IMRT experienced grade 2+ acute GI toxicity 38% vs 21% in the non-nodal IMRT group. (p= 0.25 by chi-square test). Conclusions: Hypofractionated SIB-IMRT can be delivered safely. Late grade III GI and GU toxicity for our cohort were 0% and 3.6% respectively. Our prospective trial shows acceptable toxicity with moderate hypofractionation in treating prostate cancer while maintaining good PSA control. Clinical trial information: NCT01117935. [Table: see text]

Development of a PSA tracking system for patients wtih prostate cancer following definitive radiotherapy to enhance rural health

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Background: Patients with prostate cancer (PC) may benefit from early intervention when they experience relapse/recur. About 50% of our PC patients are rural and experience barriers to care due to distance, cost, and convenience. We sought to create a PSA tracking system with the Veterans Administration’s (VA) Electronic Medical Record (EMR) that would provide a remote way to monitor disease progression after definitive radiotherapy (XRT) by annual PSA testing alone. Methods: Using VA’s EMR, we developed a query tool to identify all patients ever treated at our center with XRT for prostate cancer who were alive, had not been seen in our clinic in more than a year, did not have metastatic disease, and had a rising PSA of at least 0.5 ng/ml above nadir, or who had no PSA drawn within 15 months. Results: Among roughly 50,000 unique patients in the McGuire VAMC EMR, we found 1,858 patients treated with XRT for PC more than 5 years ago between 1997 and 2015. Of these 1,190 were still alive and 455 had not been seen by our clinic in 400 days or more. Of these 455 patients, 159 patients had not had a PSA drawn within 15 months and/or their most recent PSA was more than 0.5 ng/ml above nadir, triggering a chart review followed by either a phone call, repeat testing, in person follow up visit, or removal from follow up monitoring if clinically indicated. 296 patients were receiving appropriate care outside of our clinic and had no sign of significant rise in PSA. An analysis by the VA showed annual savings of $60,360 per year in fuel costs by avoiding unnecessary visits. Conclusions: The VA’s robust EMR and a new query tool can identify patients with prostate cancer who are lost to follow up or who needed intervention from among thousands of patients in the EMR, improving quality while reducing cost and unnecessary time and travel for rural and all patients. More importantly, our tool could be modified to improve survival for all VA patients with prostate cancer by creating a VA-wide PSA failure detection system. The system would alert providers to any patient who may benefit from early salvage radiotherapy or hormonal therapy before their disease progresses beyond the therapeutic window of benefit.

Phase II study of lovastatin to prevent rectal injury from radiation therapy for prostate cancer

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Background: Late radiation induced rectal injury remains an issue. Large population based studies indicate an incidence of at least 15%. Statins have been shown to reduce the risk of late radiation injury in animal models. The purpose of this study was to prospectively test lovastatin as a potential protector against radiation induced rectal injury, particularly bleeding. Methods: Eligible patients included men with adenocarcinoma of the prostate who were to be treated with radiation therapy with curative intent. Patients receiving primary radiation therapy (external beam alone, brachytherapy alone, or a combination of both) or post-prostatectomy radiation were eligible, as long as the minimum dose to the rectum was 60 Gy. Patients began lovastatin 20-80 mg/d on day 1 of radiation. Lovastatin was continued for 1 year and patients were followed for an additional year. Patients were seen at 1, 2, 4, 6, 9, 12, 18, 21 and 24 months after treatment. At each follow-up, they were assessed for GI, GU and erectile complications using both patient reported (IIEF, EPIC) and physician reported (CTCAE v3) instruments. The primary endpoint of the study was the incidence of rectal bleeding at 24 months (Grade 2 or higher). Results: From April 2007 through May 2013, 73 patients were enrolled. 21 patients either withdrew or were removed from the study due to noncompliance with the lovastatin regimen or toxicity from the drug. Patients who withdrew or were removed were replaced, in order to achieve the target number of 53 evaluable patients with complete 2-year follow-up. A total of 50 patients are evaluable. All but 2/50 evaluable patients achieved the 24-month follow-up goal. At 24 months, there were a total of 4 patients with rectal bleeding attributable to radiation; 3 were grade 2 and 1 was grade 3 (4/48=8%). Conclusions: The incidence of rectal bleeding at 2 years in this population of patients receiving lovastatin during and after radiation therapy for prostate cancer was less than expected based on historical controls. These data suggest that statins may be useful to protect patients from radiation induced rectal injury. Clinical trial information: NCT00580970.

A Phase 2 Study of Concurrent Radiation Therapy, Temozolomide, and the Histone Deacetylase Inhibitor Valproic Acid for Patients With Glioblastoma

PURPOSE

Valproic acid (VPA) is an antiepileptic agent with histone deacetylase inhibitor (HDACi) activity shown to sensitize glioblastoma (GBM) cells to radiation in preclinical models. We evaluated the addition of VPA to standard radiation therapy (RT) plus temozolomide (TMZ) in patients with newly diagnosed GBM.

METHODS AND MATERIALS

Thirty-seven patients with newly diagnosed GBM were enrolled between July 2006 and April 2013. Patients received VPA, 25 mg/kg orally, divided into 2 daily doses concurrent with RT and TMZ. The first dose of VPA was given 1 week before the first day of RT at 10 to 15 mg/kg/day and subsequently increased up to 25 mg/kg/day over the week prior to radiation. VPA- and TMZ-related acute toxicities were evaluated using Common Toxicity Criteria version 3.0 (National Cancer Institute Cancer Therapy Evaluation Program) and Cancer Radiation Morbidity Scoring Scheme for toxicity and adverse event reporting (Radiation Therapy Oncology Group/European Organization for Research and Treatment).

RESULTS

A total of 81% of patients took VPA according to protocol. Median overall survival (OS) was 29.6 months (range: 21-63.8 months), and median progression-free survival (PFS) was 10.5 months (range: 6.8-51.2 months). OS at 6, 12, and 24 months was 97%, 86%, and 56%, respectively. PFS at 6, 12, and 24 months was 70%, 43%, and 38% respectively. The most common grade 3/4 toxicities of VPA in conjunction with RT/TMZ therapy were blood and bone marrow toxicity (32%), neurological toxicity (11%), and metabolic and laboratory toxicity (8%). Younger age and class V recursive partitioning analysis (RPA) results were significant for both OS and PFS. VPA levels were not correlated with grade 3 or 4 toxicity levels.

CONCLUSIONS

Addition of VPA to concurrent RT/TMZ in patients with newly diagnosed GBM was well tolerated. Additionally, VPA may result in improved outcomes compared to historical data and merits further study.

Stereotactic Body Radiation Therapy of Lung Tumors: Preliminary Experience Using Normal Tissue Complication Probability-Based Dose Limits

OBJECTIVES

To assess the feasibility and toxicity of stereotactic body radiotherapy (SBRT) for patients with locally advanced or metastatic tumors in lung.

METHODS

Twenty-five tumors in 17 patients were treated. All treatments were delivered in 3 daily fractions of 9 to 15 Gy per fraction. Normal tissue complication probability (NTCP) calculations (using the Lyman model) were performed to facilitate dose prescription, and doses were prescribed with a maximum allowable NTCP risk of pneumonitis of up to 20%, not to exceed 15 Gy per fraction. Planning target volumes were designed to allow for respiratory variation in tumor location.

RESULTS

The median dose prescribed was 35 Gy (range, 24 to 45 Gy). Twenty-three of 25 tumors remained controlled at median follow-up of 14 months. Four patients experienced grade 1-2 acute toxicity. Late toxicity developed in 2 patients who received treatment to peri-hilar tumors, including one patient in whom bronchial stenosis developed with complete occlusion and lobar atelectasis 6 months after treatment. No patient had grade 3 or 4 radiation pneumonitis.

CONCLUSIONS

SBRT prescribed within the confines of NTCP-restricted dosing on this protocol resulted in no radiation pneumonitis. Tissues other than lung parenchyma which are unaccounted for by NTCP may be dose-limiting when performing hypofractionated SBRT in the lung.

Design of decision support systems

This paper focuses on design difficulties encountered in the implementation of effective DSS. The key point is that the standard MIS development life-cycle approach is dysfunctional in a DSS design setting. Four major ideas are introduced: system/problem migration, subset evolution, soft/hard capabilities, and weak/strong design process.