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Thread: (H) Radiation Treatment

  1. #91
    The Financial Impact of Hypofractionated Radiation for Localized Prostate Cancer in the United States
    [2019, Full Text]


    Background. Until recently, dose intensified radiotherapy was the standard radiation method for localized prostate cancer. Multiple studies have demonstrated similar efficacy and tolerability with moderate hypofractionation. In recent years there has been an increasing focus placed on understanding the cost and value of cancer care. In this study we aimed to assess the economic impact of moderate hypofractionation for payers in the United States. Methods. We performed a population-based analysis of the total cost of external beam radiotherapy (EBRT) for localized prostate cancer in the US annually. The national annual target population of patients treated with definitive EBRT was calculated using the Surveillance, Epidemiology, and End Results (SEER) database. Treatment costs for various fractionation schemes were based on billing codes and 2018 pricing by the Centers for Medicare and Medicaid Services (CMS). Results. We estimate that 27,146 patients with localized prostate cancer are treated with EBRT annually in the US. The cost of standard fractionation in 45 or 39 fractions is US 26,782 and 23,625 per patient, respectively. With moderate hypofractionation in 28 or 20 fractions, the cost is US 17,793 and 13,402 per patient, respectively. The use of moderate hypofractionation would lead to 25-50% annual savings US158,315,472-US363,213,480 in the US. Conclusions. Moderate hypofractionation may have the potential to save approximately US0.16-0.36 billion annually, likely without impacting survival or tolerability. This may lead to lower personal financial toxicity. It would be reasonable for public and private payers to consider which type of radiation is most suited to reimbursement.

  2. #92
    The role of radiotherapy in localised and locally advanced prostate cancer
    [2019, Review, Full Text]



    For a patient suffering from non-metastatic prostate cancer, the individualized recommendation of radiotherapy has to be the fruit of a multidisciplinary approach in the context of a Tumor Board, to be explained carefully to the patient to obtain his informed consent. External beam radiotherapy is now delivered by intensity modulated radiotherapy, considered as the gold standard. From a radiotherapy perspective, low-risk localized prostate cancer is treated by image guided intensity modulated radiotherapy, or brachytherapy if patients meet the required eligibility criteria. Intermediate-risk patients may benefit from intensity modulated radiotherapy combined with 4–6 months of androgen deprivation therapy; intensity modulated radiotherapy alone or combined with brachytherapy can be offered to patients unsuitable for androgen deprivation therapy due to co-morbidities or unwilling to accept it to preserve their sexual health. High-risk prostate cancer, i.e. high-risk localized and locally advanced prostate cancer, require intensity modulated radiotherapy with long-term (≥2 years) androgen deprivation therapy with luteinizing hormone releasing hormone agonists. Post-operative irradiation, either immediate or early deferred, is proposed to patients classified as pT3 pN0, based on surgical margins, prostate-specific antigen values and quality of life. Whatever the techniques and their degree of sophistication, quality assurance plays a major role in the management of radiotherapy, requiring the involvement of physicians, physicists, dosimetrists, radiation technologists and computer scientists. The patients must be informed about the potential morbidity of radiotherapy and androgen deprivation therapy and followed regularly during and after treatment for tertiary prevention and evaluation. A close cooperation is needed with general practitioners and specialists to prevent and mitigate side effects and maintain quality of life.
    Last edited by DjinTonic; 02-19-2019 at 02:00 PM.

  3. #93
    Are we ready to use hypofractionated instead of conventional radiotherapy for prostate cancer? Not yet
    [2019, Editorial]


    An Editorial with a 8 key questions discussing ASTRO, ASCO, and AUA guidelines

  4. #94
    Improved survival for patients with prostate cancer receiving high-dose-rate brachytherapy boost to EBRT compared with EBRT alone



    High-dose-rate (HDR) brachytherapy boost is a treatment of intermediate- to high-risk prostate cancer, but long-term clinical outcome data are sparse. We report long-term survival and toxicity data in a cohort of patients treated in a single institution.

    Between 1998 and 2004, 654 patients with localized prostate cancer received either 3-dimensional conformal radiotherapy (median 46 Gy) with an HDR (median 18 Gy in three fractions) boost ("3-D conformal radiotherapy [3DCRT] + HDR"; 215 patients) or 3DCRT alone ("3DCRT"; median 70 Gy; 439 patients) with curative intent. Men with National Comprehensive Cancer Network intermediate risk were offered neoadjuvant androgen deprivation and with high risk were also offered adjuvant androgen deprivation. Data collection included patient-reported outcome measures.

    The 3DCRT + HDR group was older (72.3 vs. 68.9 yrs), had higher presenting PSAs (iPSA) (15.66 and 12.57 ng/mL, respectively), higher proportion of Gleason scores >7 (15.3% vs. 12.4%), and higher proportions of extracapsular disease (29.3% vs. 25.5%). 3DCRT + HDR men had lower proportions of low-risk patients (3.3% vs. 19.4%) and higher proportions of high-risk patients (50.7% vs. 37.4%) than the 3DCRT group. The 5-, 10-, and 15-year overall survival was superior at 92%, 81%, and 67%, respectively, for the 3DCRT + HDR group, compared with 88%, 71%, and 53%, respectively, in the 3DCRT group (p < 0.001). The 5-, 10-, and 15-year cause specific survival also favored the HDR boost group with survival of 96%, 93%, and 87% (3DCRT + HDR) and 95% 88% and 79% (3DCRT), respectively (p < 0.037).

    HDR brachytherapy boost in conjunction with 3DCRT offered superior overall survival and cause-specific survival in our patient population.
    [Emphasis mine]

  5. #95
    Effect of Chemotherapy With Docetaxel With Androgen Suppression and Radiotherapy for Localized High-Risk Prostate Cancer: The Randomized Phase III NRG Oncology RTOG 0521 Trial
    [2019, Full Text]



    Radiotherapy (RT) plus long-term androgen suppression (AS) are a standard treatment option for patients with high-risk localized prostate cancer. We hypothesized that docetaxel chemotherapy (CT) could improve overall survival (OS) and clinical outcomes among patients with high-risk prostate cancer.

    The multicenter randomized NRG Oncology RTOG 0521 study enrolled patients with high-risk nonmetastatic disease between 2005 and 2009. Patients were randomly assigned to receive standard long-term AS plus RT with or without adjuvant CT.

    A total of 612 patients were enrolled; 563 were evaluable. Median prostate-specific antigen was 15.1 ng/mL; 53% had a Gleason score 9 to 10 cancer; 27% had cT3 to cT4 disease. Median follow-up was 5.7 years. Treatment was well tolerated in both arms. Four-year OS rate was 89% (95% CI, 84% to 92%) for AS + RT and 93% (95% CI, 90% to 96%) for AS + RT + CT (hazard ratio [HR], 0.69; 90% CI, 0.49 to 0.97; one-sided P = .034). There were 59 deaths in the AS + RT arm and 43 in the AS + RT + CT arm, with fewer deaths resulting from prostate cancer in the AS + RT + CT arm versus AS + RT (23 v 16 deaths, respectively). Six-year rate of distant metastasis was 14% for AS + RT and 9.1% for AS + RT + CT, (HR, 0.60; 95% CI, 0.37 to 0.99; two-sided P = .044). Six-year disease-free survival rate was 55% for AS + RT and 65% for AS + RT + CT (HR, 0.76; 95% CI, 0.58 to 0.99; two-sided P = .043).

    For patients with high-risk nonmetastatic prostate cancer, CT with docetaxel improved OS from 89% to 93% at 4 years, with improved disease-free survival and reduction in the rate of distant metastasis. The trial suggests that docetaxel CT may be an option to be discussed with selected men with high-risk prostate cancer.

  6. #96
    Comparison of the morbidity in men with intermediate and high-risk prostate cancer treated with either I-125 or Pd-103 brachytherapy combined with external beam irradiation


    Introduction & Objectives: Combination external beam irradiation therapy (EBRT) with brachytherapy boost (BT) may provide superior outcomes compared to radical prostatectomy in intermediate to high risk patients but also may be associated with considerable morbidity. I-125 has a higher energy and delivers a wider margin of radiation which may benefit extra-prostatic disease while Pd-103 has a shorter half-life which may provide a benefit in men with fast growing tumors. We compared morbidity for these 2 isotopes by determining proctitis, gross hematuria, incontinence, need for post-implant TURP and use of alpha blockers and anticholinergic medications.
    Materials & Methods: 990 men with intermediate and high-risk prostate cancer were treated with 45 Gy of EBRT and BT with either Pd-103 (n=714) or I-125 (n=276). Mean age and follow up time were 67.5 vs. 66.7 years (p=0.126) and 93.8 vs. 77.7 months (p<0.001, range 2-22 years). Radiation doses were converted to the biological equivalent does (BED) using an a/b of 2. The mean BEDs were 204.7 vs. 218.4 Gy (p<0.001), respectively. Morbidity was determined prospectively by a patient administered questionnaire and need for post-BT procedures. Associations were tested by ANOVA and chi-square analysis (Pearson).
    Results: Any occurrence of proctitis was reported in 240 (33.7%) men treated with Pd-103 vs. 18 (6.5%) for I-125 (p<0.001). At last follow-up, proctitis was grade 1 in 20 (2.8%) men vs. 1 (0.4%), grade 2 in 3 (0.4%) vs 0 and grade 3 in 1 (0.1%) vs 1 (0.4%, p=0.061). Gross hematuria occurred in 8 (1.1%) vs. 1 (0.4%, p=0.026). Urinary incontinence was reported as urge, stress or mixed and occurred in 28 (3.9%) vs. 1 (2.9%), 12 (1.7%) vs. 2 (1.4%) and 3 (0.4%) vs. 0 (p=0.009), respectively. Pad usage was required in 10 (1.4%) vs. 1 (0.4%, p=0.532). Slightly more post implant TURPs occurred following I-125 (2.5 vs. 1%, p=0.068 ). Alpha blocker and anticholinergic usage were greater for I-125 (27.1 vs. 8.1%, p<0.001) and 2.5% vs. 0.3% (p=0.001).
    Conclusions: Both I-125 and Pd-103 exhibit low morbidity when combined with EBRT. Early proctitis rates were higher with Pd-103, possibly secondary to the more rapid delivery of the radiation (less time for mucosal recovery) but long-term rates were similar for both isotopes. More men reported incontinence after Pd-103 but significant leakage, requiring urinary pads use was the same for both isotops. However, more men receiving I-125 required alpha blockers and anticholinergic use which may be a result of the higher radiation dose delivered to the prostate and urethra.

  7. #97
    Single-fraction brachytherapy as monotherapy for early-stage prostate cancer: The UCSF experience



    High-dose-rate (HDR) brachytherapy as monotherapy is an effective treatment option for localized prostate cancer, but experience with single-fraction brachytherapy is limited by studies with small sample size. We report a large single-institution experience with single-fraction HDR brachytherapy as monotherapy for early-stage prostate cancer.

    Retrospective chart review was performed for men treated with HDR brachytherapy as monotherapy for low- to intermediate-risk prostate cancer. Competing risk analyses were performed to estimate subdistribution hazard ratio and cumulative incidence of biochemical recurrence (BCR) and prostate cancer-specific mortality.

    We identified 124 men with a median followup of 2.2 years (interquartile range 25th to 75th percentile: 1.8-3). Overall, 21.0% of patients (n = 26) were low risk, 44.4% (n = 55) were favorable intermediate risk, and 34.7% (n = 43) were unfavorable intermediate risk. At 2 years, the cumulative incidence of BCR was 3.5%: 0% for low risk, 4.0% for favorable intermediate risk patients, and 4.5% for unfavorable intermediate risk patients. In total, 12 BCRs were observed (9.7%) and approximately half occurred after median followup of 2.2 years. Compared with low-risk and favorable intermediate-risk disease, unfavorable intermediate-risk disease was significantly associated with BCR (subdistribution hazard ratio: 3.6, 95% CI: 1.1 to 11.1, p = 0.03). Prostate cancer-specific mortality was 0%. No patient experienced Grade 3 or higher acute or late genitourinary toxicity.

    Single-fraction brachytherapy for early-stage prostate cancer was safe with promising short-term disease control rates, especially for low-risk patients. Longer term followup is needed as we observed an overall BCR rate of 9.7%.

  8. #98
    Safety of SBRT in post TURP prostate cancer patients: A propensity score matched pair analysis



    To determine the genitourinary (GU) toxicity outcomes in prostate cancer patients treated with stereotactic body radiotherapy (SBRT) who have undergone a prior transurethral resection of prostate (TURP) and compare it to a similar nonTURP cohort.

    Materials and Methods
    Fifty prostate cancer patients who had undergone a single TURP, had a good baseline urinary function and were subsequently treated with SBRT were chosen from a prospectively maintained database. These were propensity score matched to a similar non-TURP cohort treated during the same time period. Matching was done for diabetes mellitus and volume of radiotherapy. Acute GU and late GU toxicity were scored using the Radiation Therapy Oncology Group (RTOG) criteria. Stricture and incontinence were scored using common terminology for common adverse events (CTCAE) version 4.0.

    Median follow up for the entire cohort was 26 months (non-TURP vs TURP, 30 months vs 22 months, p = 0.34). The median duration between TURP and start of SBRT was 10 months. There was no significant difference between non-TURP vs TURP cohort in terms of RTOG acute GU toxicities ≥ grade 2 (8% vs 6%, p = 0.45), RTOG late GU toxicities ≥ grade 2 (8% vs 12%, p=0.10), stricture rates (4% vs 6%, p = 0.64) and incontinence rates (0% vs 4%, p = 0.15). The median duration of time to late toxicity was 16 months vs 10 months (p=0.12) in non-TURP and TURP cohort respectively.

    Although modestly increased as compared to non-TURP patients, GU toxicities remains low with SBRT in post TURP patients. SBRT can be safely performed in carefully selected post TURP prostate cancer patients.

  9. #99
    Prostate-only Versus Whole-pelvis Radiation with or Without a Brachytherapy Boost for Gleason Grade Group 5 Prostate Cancer: A Retrospective Analysis



    The role of elective whole-pelvis radiotherapy (WPRT) remains controversial. Few studies have investigated it in Gleason grade group (GG) 5 prostate cancer (PCa), known to have a high risk of nodal metastases.

    To assess the impact of WPRT on patients with GG 5 PCa treated with external-beam radiotherapy (EBRT) or EBRT with a brachytherapy boost (EBRT+BT).

    We identified 1170 patients with biopsy-proven GG 5 PCa from 11 centers in the United States and one in Norway treated between 2000 and 2013 (734 with EBRT and 436 with EBRT+BT).

    Biochemical recurrence-free survival (bRFS), distant metastasis-free survival (DMFS), and prostate cancer-specific survival (PCSS) were compared using Cox proportional hazards models with propensity score adjustment.

    A total of 299 EBRT patients (41%) and 320 EBRT+BT patients (73%) received WPRT. The adjusted 5-yr bRFS rates with WPRT in the EBRT and EBRT+BT groups were 66% and 88%, respectively. Without WPRT, these rates for the EBRT and EBRT+BT groups were 58% and 78%, respectively. The median follow-up was 5.6yr. WPRT was associated with improved bRFS among patients treated with EBRT+BT (hazard ratio [HR] 0.5, 95% confidence interval [CI] 0.2-0.9, p=0.02), but no evidence for improvement was found in those treated with EBRT (HR 0.8, 95% CI 0.6-1.2, p=0.4). WPRT was not significantly associated with improved DMFS or PCSS in the EBRT group (HR 1.1, 95% CI 0.7-1.7, p=0.8 for DMFS and HR 0.7, 95% CI 0.4-1.1, p=0.1 for PCSS), or in the EBRT+BT group (HR 0.6, 95% CI 0.3-1.4, p=0.2 for DMFS and HR 0.5 95% CI 0.2-1.2, p=0.1 for PCSS).

    WPRT was not associated with improved PCSS or DMFS in patients with GG 5 PCa who received either EBRT or EBRT+BT. However, WPRT was associated with a significant improvement in bRFS among patients receiving EBRT+BT. Strategies to optimize WPRT, potentially with the use of advanced imaging techniques to identify occult nodal disease, are warranted.

    When men with a high Gleason grade prostate cancer receive radiation with external radiation and brachytherapy, the addition of radiation to the pelvis results in a longer duration of prostate-specific antigen control. However, we did not find a difference in their survival from prostate cancer or in their survival without metastatic disease. We also did not find a benefit for radiation to the pelvis in men who received radiation without brachytherapy.


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