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Thread: (H) Radiation Treatment

  1. #11
    Too Big to Fail? The Current Status of Proton Therapy in the USA
    [2018, Editorial]


    Radiation therapy is one of the cornerstones of contemporary cancer treatment and about 50% of patients will, at some point during their cancer history, require it. Since its first use in 1896 this therapy has evolved, following a rapid arrow of progress thanks to imaging, computing power and technical advances in delivery. Many feel that proton beam therapy, with its ability to target deep-seated tumours with less radiation exposure to the normal tissues, sits at the very tip of that arrow [1. There are now over two dozen active proton therapy centres in the USA and a comparable number elsewhere in the world, an expansion that seems to suggest that the radiation therapy community feels bullishly enthusiastic about this technology [2. Yet all is not well in the USA. Proton therapy is under attack from payers and policymakers, and other technologies have grown up to compete with it. Proton beam is at a ‘tipping point’ [3. It may prove a technology bubble that bursts, or it may yet become totally mainstream. It is worth reflecting on how this precarious situation arose.
    Last edited by DjinTonic; 04-14-2018 at 07:45 PM.

  2. #12
    Stereotactic radiotherapy for prostate cancer: A review and future directions
    [2017, Full Text]



    Prostate cancer affects over 200000 men annually in the United States alone. The role of conventionally fractionated external beam radiation therapy (RT) is well established as a treatment option for eligible prostate cancer patients; however, the use of stereotactic body radiotherapy (SBRT) in this setting is less well defined. Within the past decade, there have been a number of studies investigating the feasibility of SBRT as a potential treatment option for prostate cancer patients. SBRT has been well studied in other disease sites, and the shortened treatment course would allow for greater convenience for patients. There may also be implications for toxicity as well as disease control. In this review we present a number of prospective and retrospective trials of SBRT in the treatment of prostate cancer. We focus on factors such as biochemical progression-free survival, prostate specific antigen (PSA) response, and toxicity in order to compare SBRT to established treatment modalities. We also discuss future steps that the clinical community can take to further explore this new treatment approach. We conclude that initial studies examining the use of SBRT in the treatment of prostate cancer have demonstrated impressive rates of biochemical recurrence-free survival and PSA response, while maintaining a relatively favorable acute toxicity profile, though long-term follow-up is needed.

    Core tip: Initial studies examining the use of stereotactic body radiotherapy (SBRT) in the treatment of prostate cancer have demonstrated impressive rates of biochemical recurrence-free survival and prostate specific antigen response, while maintaining a relatively favorable acute toxicity profile. Here we review a number of recent prospective and retrospective studies to evaluate the efficacy and toxicity of SBRT in the treatment of low, intermediate, and high-grade prostate cancer.

    Stereotactic Body Radiotherapy for Low-Risk Prostate Cancer: A Ten-Year Analysis [2017, Full Text]



    This study represents the first 10 year analysis of the efficacy and toxicity of stereotactic body radiotherapy (SBRT) in the treatment of early low-risk prostate cancer.

    Materials and methods
    Two hundred and thirty males were treated with Cyberknife SBRT to a dose of 35 Gray (Gy) or 36.25 Gy in five consecutive days. All patients had a Gleason score of six and a PSA < 10ng/ml. Median follow-up is nine years. The median age was 69.5 years and median prostate specific antigen (PSA) was 5.6ng/ml. The treatment was delivered with homogeneous planning with a dose prescription of 82-87% of the maximum dose to cover the planning target volume (PTV).

    Ten-year biochemical disease free survival was 93% with either dose. Local control was 98.4%. Median prostate specific antigen (PSA) dropped to 0.1 by five years and has remained there. Toxicity was mild with 10% of patients having Grade two-three late urinary toxicity and 4% having the late grade two rectal toxicity. Mean Expanded Prostate Cancer Index Composite (EPIC) Quality of Life (QOL) scores declined initially for bowel and urinary domains, but recovered to baseline, where they remain. EPIC sexual scores have declined by 40%.

    Stereotactic body radiotherapy to a dose of 35 Gy-36.25 Gy is an effective treatment for early low-risk prostate cancer, with acceptably low toxicity. There appears to be no benefit to increasing the dose beyond 35 Gy. Ten-year biochemical disease free survival appears to be higher than with standard intensity modulated radiotherapy (IMRT).
    [Empasis mine]
    Last edited by DjinTonic; 04-16-2018 at 12:25 PM.

  3. #13
    Recently published articles from the journal Brachytherapy


    This appears to be a permanent (?) link to recent articles in the journal Brachytherapy.
    Last edited by DjinTonic; 04-14-2018 at 07:45 PM.

  4. #14
    Brachytherapy monotherapy may be sufficient for a subset of patients with unfavorable intermediate risk prostate cancer



    Brachytherapy (BT) monotherapy is a well-established treatment modality for favorable intermediate risk (FIR) prostate cancer. However, patients with unfavorable intermediate risk (UIR) disease are often recommended trimodality therapy involving BT, androgen deprivation therapy (ADT), and external beam radiation therapy (EBRT). We sought to investigate the relative benefit of supplemental therapies (ADT and/or EBRT) for FIR and UIR prostate cancer in a large dataset.

    We identified 3,723 patients with intermediate risk prostate cancer treated with BT between 1997 and 2013, including 1,989 and 1,734 patients with FIR and UIR disease, respectively. For the FIR cohort, Fine and Gray's competing risks regression model was used to evaluate whether there was a difference in prostate cancer specific mortality (PCSM) between BT vs. BT + supplemental therapy (ADT, EBRT, or both). For the UIR cohort, this regression model was used to evaluate whether supplemental ADT, EBRT, or both decreased PCSM beyond BT alone. Both regression models were adjusted for clinical and treatment-related factors.

    The median follow-up periods were 7.7 years (interquartile range: 5.4-10.5) for the FIR cohort and 7.8 years (interquartile range: 5.3-10.6) for the UIR cohort. For the FIR cohort, there was no difference in PCSM between BT monotherapy vs. BT + supplemental therapy (adjusted hazard ratio [AHR] = 1.70; 95% CI: 0.46-6.29; P = 0.43). For the UIR cohort, supplemental EBRT (AHR = 2.66; 95% CI: 1.12-6.34; P = 0.03), ADT (AHR = 0.96; 95% CI: 0.38-2.43; P = 0.93), or both (AHR = 1.46; 95% CI: 0.42-5.01; P = 0.55) were not associated with improved PCSM compared with BT alone.

    In our analysis, supplemental therapies did not offer an improvement in PCSM compared with BT alone for FIR or UIR prostate cancers. Further prospective clinical trials are required to determine whether BT monotherapy may be sufficient for a subset of patients with UIR disease.
    First Forum post: https://www.cancerforums.net/threads/53610-Brachy-monotherapy-may-suffice-for-some-patients-with-unfavorable-intermediate-risk

  5. #15
    Two decades of high dose rate brachytherapy with external beam radiotherapy for prostate cancer



    High-dose-rate brachytherapy (HDR-BT) has optimal prerequisites in radiotherapy of prostate cancer (PC) with a conformal dose distribution and high doses per fraction giving a biological dose escalation. We report the outcome after HDR-BT and external beam radiotherapy (EBRT) after 20 years of experience.

    Material and methods
    The study includes 623 patients, median age of 66 years, treated from 1995 to 2008 and a median follow up of 11 years (range 2–266 months). Androgen deprivation therapy was given to 429 patients (69%). The HDR-BT was given with two 10 Gy fractions and the EBRT with 2 Gy fractions to 50 Gy.

    The 10-year PC-specific survival was 100%, 92%, 91%, and 75% for low-, intermediate-, high- and very high-risk patients respectively, and the 10-year probability of PSA relapse was 0%, 21%, 33%, and 65% respectively. The 10-year actuarial prevalence for ≥grade 2 GU- and GI-toxicities were 28% and 12% respectively and for ≥grade 3, 4% and 1% respectively. Urethral stricture was the most frequent GU complication with a 10-year actuarial incidence of 10%. Treatment without dose constraints for the urethra conferred a higher incidence 18%, compared to 5% after 2003 (p < 0.001). Sixteen patients experienced grade 4 GU toxicity, of which 13 were treated before 2003. No grade 4 rectal toxicity was seen.

    The combination of EBRT and HDR-BT with adequate dose constraints to risk organs provides satisfactory long-term tumour control even in high-risk patients. GI toxicity stabilised but GU toxicity progressed during the 10-year follow up.

  6. #16
    Regular User
    Join Date
    Feb 2017
    This is the one that seems a little confusing. Perhaps just another senior blond moment.

  7. #17
    Jim, Thanks for the PMs. So you are asking about the meaning of "lower rates of salvage therapy" this study:

    [#2] Effect of Standard vs Dose-Escalated Radiation Therapy for Patients With Intermediate-Risk Prostate Cancer: The NRG Oncology RTOG 0126 Randomized Clinical Trial [2018]

    which concludes
    Despite improvements in biochemical failure and distant metastases, dose escalation did not improve OS. High doses caused more late toxic effects but lower rates of salvage therapy.
    So the higher-dose group had less biochemical failure (the return or persistence of higher PSA) and a lower incidence of distant mets and therefore less need for some kind of salvage therapy to treat this return of disease. However, overall survival was not better in this group and there were also more late toxic effects from the higher dosage. (Salvage therapy is treatment done when the initial treatment (with definitive intent) fails and disease either persists or returns.)
    Last edited by DjinTonic; 04-16-2018 at 07:02 PM.

  8. #18
    Towards a Clinical Decision Support System for External Beam Radiation Oncology Prostate Cancer Patients: Proton vs. Photon Radiotherapy? A Radiobiological Study of Robustness and Stability
    [2018, Full Text]



    We present a methodology which can be utilized to select proton or photon radiotherapy in prostate cancer patients. Four state-of-the-art competing treatment modalities were compared (by way of an in silico trial) for a cohort of 25 prostate cancer patients, with and without correction strategies for prostate displacements. Metrics measured from clinical image guidance systems were used. Three correction strategies were investigated; no-correction, extended-no-action-limit, and online-correction. Clinical efficacy was estimated via radiobiological models incorporating robustness (how probable a given treatment plan was delivered) and stability (the consistency between the probable best and worst delivered treatments at the 95% confidence limit). The results obtained at the cohort level enabled the determination of a threshold for likely clinical benefit at the individual level. Depending on the imaging system and correction strategy; 24%, 32% and 44% of patients were identified as suitable candidates for proton therapy. For the constraints of this study: Intensity-modulated proton therapy with online-correction was on average the most effective modality. Irrespective of the imaging system, each treatment modality is similar in terms of robustness, with and without the correction strategies. Conversely, there is substantial variation in stability between the treatment modalities, which is greatly reduced by correction strategies. This study provides a ‘proof-of-concept’ methodology to enable the prospective identification of individual patients that will most likely (above a certain threshold) benefit from proton therapy.
    [Emphasis mine; in silico = conducted via computer

  9. #19
    Factors associated with the omission of androgen deprivation therapy in radiation-managed high-risk prostate cancer
    [2016, Full Text]


    Flagged by Forum Brother garyi


    Androgen deprivation therapy (ADT) has been shown to improve survival for men with unfavorable-risk prostate cancer (PCa). We investigated the utilization and factors associated with the omission of ADT in radiation-managed high-risk PCa.

    Methods and Materials
    We used the National Cancer Database to identify men with National Comprehensive Cancer Network high-risk PCa treated with external beam radiation therapy (EBRT) with or without brachytherapy boost from 2004 to 2012. Multivariable logistic regression adjusting for clinical and sociodemographic factors was used to identify independent predictors for ADT use.

    A total of 57,968 radiation-treated high-risk PCa men were included in our analysis. There were 49,363 patients (85.2%) treated with EBRT alone and 8605 patients (14.8%) treated with EBRT plus brachytherapy boost. Overall, 77% of men received ADT. In multivariable regression analysis, the use of brachytherapy boost was associated with a significantly lower utilization of ADT (70% vs. 78%; adjusted odds ratio [AOR]: 0.65; 95% CI: 0.62–0.69; p-Value <0.0001), as was treatment at an academic vs. nonacademic center (AOR: 0.90; 95% CI: 0.86–0.95; p-Value <0.0001) and treatment in 2010–2012 compared to 2004–2006 (AOR: 0.85; 95% CI: 0.81–0.90; p-Value <0.0001). Conversely, greater ADT use was seen with higher Gleason scores, PSA, and T-category (all p-Values <0.001).

    Approximately one in four men with radiation-managed high-risk PCa do not receive ADT, which may reflect concerns about its toxicity profile despite known improvements in overall survival. Practice patterns suggest that some providers believe dose escalation through brachytherapy boost may obviate the need for ADT in some high-risk patients, but this hypothesis requires further testing.
    [Emphasis mine]

  10. #20
    [2018, Full Text]

    http://www.jurology.com/article/S0022-5347(18 )40025-0/fulltext
    Emoticon interference: remove the space after the 8

    The National Comprehensive Cancer Network (NCCN) recommends pelvic lymph node irradiation as an option for men with prostate cancer and high risk features. However, it is unknown how frequently lymph nodes are treated with external beam radiotherapy (EBRT). We surveyed a national cohort of men with prostate cancer to determine the frequency of lymph node irradiation and factors associated with use of nodal irradiation.

    We queried the National Cancer Data Base (2005-2015) for men diagnosed with localized (cN0/cM0) prostate cancer treated primarily with EBRT directed at the prostate with or without brachytherapy or androgen deprivation (n= 197,378 ). Logistic regression analyses were used to assess temporal trends and factors associated with pelvic lymph node irradiation at the time of EBRT. All analyses were stratified by NCCN risk groups.

    In total, 37% of men receiving primary EBRT also underwent nodal irradiation. On multivariable analysis, use of nodal irradiation did not change over time from 2005 to 2015 overall (36.9% to 41.1%, p=0.4), for low risk patients (27.3% to 25.6%, p=0.5), or for intermediate risk patients (34.7% to 35.3%, p=0.8 ). It did increase over time for all men with high risk disease (46.5% to 53.3%; OR 1.18, 95% CI 1.01-1.38, p=0.044) and for men with very high risk disease (46.7% to 59.6%; OR 1.34, 95% CI 1.06-1.69, p=0.014). Factors associated with increased odds of nodal irradiation included increasing Gleason score, PSA and clinical T stage. Patients treated at an academic hospital were less likely to undergo nodal irradiation compared to men treated at a community hospital (34.8% vs 44.5%; OR 0.75, 95% CI 0.57-0.98, p=0.006). Patients who traveled >120 miles to their treatment facility were also less likely to received nodal irradiation compared to men who traveled <60 miles (25.2% vs 37.0%; OR 0.57, 95% CI 0.39-0.85, p=0.006).

    For men with localized prostate cancer receiving EBRT as primary treatment, pelvic nodes were irradiated in about one-third of patients and nodal irradiation increased recently for men with high risk disease. About half of men with high risk disease received nodal irradiation overall. Higher risk disease, treatment at community hospitals, and shorter travel distance for patients were associated with greater odds of receiving nodal irradiation.
    (See graph also.)


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