Hypofractionated Radiation Therapy for Localized Prostate Cancer: An ASTRO, ASCO, and AUA Evidence-Based Guideline

Morgan, Scott C.; Hoffman, Karen E.; Loblaw, D.A.; Buyyounouski, Mark K.; Patton, Caroline; Barocas, Daniel A.; Bentzen, Søren M.; Chang, Michael; Efstathiou, Jason A.; Greany, Patrick; Halvorsen, Per H.; Koontz, Bridget F.; Lawton, Colleen A.; Leyrer, C.M.; Lin, Daniel W.; Ray, Michael E.; Sandler, Howard M.

doi:10.1200/jco.18.01097

Cited by 135 publications

(96 citation statements)

References 101 publications

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“…Recently published international, evidence-based guidelines recommend the routine use of H-RT with a moderately hypofractionated regimen for localised prostate cancer across all risk groups, independent of age, comorbidity, anatomy or baseline urinary function. 38 PROs are increasingly being utilised to provide the patient perspective on comparative functional and HRQoL outcomes for treatments with similar efficacy and toxicity profiles. 39,40 Our results demonstrating a lack of clinically relevant differences in PROs and HRQoL add to the growing evidence base for the use of H-RT in men with non-metastatic PCa.…”

Section: Discussionmentioning

confidence: 99%

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Patient-Reported Functional Outcomes After Hypofractionated or Conventionally Fractionated Radiation for Prostate Cancer: A National Cohort Study in England

Nossiter

Sujenthiran

Cowling

et al. 2020

JCO

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PURPOSE The aim of the current study was to determine patient-reported functional outcomes in men with prostate cancer (PCa) undergoing moderately hypofractionated (H-RT) or conventionally fractionated radiation therapy (C-RT) in a national cohort study. PATIENDS AND METHODS All men diagnosed with PCa between April 2014 and September 2016 in the English National Health Service undergoing C-RT or H-RT were identified in the National Prostate Cancer Audit and mailed a questionnaire at least 18 months after diagnosis. We estimated differences in patient-reported urinary, bowel, sexual, and hormonal function—Expanded Prostate Cancer Index Composite short-form 26 domain scores on a 0 to 100 scale—and health-related quality of life—EQ-5D-5L on a 0 to 1 scale—using linear regression with adjustment for patient, tumor, and treatment-related factors in addition to GI and genitourinary baseline function, with higher scores representing better outcomes. RESULTS Of the 17,058 men in the cohort, 77% responded: 8,432 men received C-RT (64.2%) and 4,699 H-RT (35.8%). Men in the H-RT group were older (age ≥ 70 years: 67.5% v 60.9%), fewer men had locally advanced disease (56.5% v 71.3%), were less likely to receive androgen-deprivation therapy (79.5% v 87.8%), and slightly more men had pretreatment genitourinary procedures (24.2% v 21.2%). H-RT was associated with small increases in adjusted mean Expanded Prostate Cancer Index Composite short-form 26 sexual (3.3 points; 95% CI, 2.1 to 4.5; P < .001) and hormonal function scores (3.2 points; 95% CI, 1.8 to 4.6; P < .001). These differences failed to meet established thresholds for a clinically meaningful change. There were no statistically significant differences in urinary or bowel function and quality of life. CONCLUSION This is the first national cohort study comparing functional outcomes after H-RT and C-RT reported by patients. These real-world results further support the use of H-RT as the standard for radiation therapy in men with nonmetastatic PCa.

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Section: Discussionmentioning

confidence: 99%

“…However, the results from the RCTs comparing C-RT versus H-RT do not demonstrate a consistent increase in late toxicity associated with hypofractionation. 38…”

Section: Methodsological Considerationsmentioning

confidence: 99%

Patient-Reported Functional Outcomes After Hypofractionated or Conventionally Fractionated Radiation for Prostate Cancer: A National Cohort Study in England

Nossiter

Sujenthiran

Cowling

et al. 2020

JCO

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“…Based on clinical stage, histological grade and serum levels of prostate-specific antigen (PSA), current treatment options for prostate cancer include surgery, radiotherapy and/or chemotherapy (6)(7)(8)(9). Such interventions are most effective in early disease, especially if it is still localised to the prostate.…”

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confidence: 99%

Chemoprevention of Prostate Cancer by Natural Agents: Evidence from Molecular and Epidemiological Studies

2019

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Background/Aim: Prostate cancer is one of the most common cancers in men which remains a global public health issue. Treatment of prostate cancer is becoming increasingly intensive and aggressive, with a corresponding increase in resistance, toxicity and side effects. This has revived an interest in nontoxic and cost-effective preventive strategies including dietary compounds due to the multiple effects they have been shown to have in various oncogenic signalling pathways, with relatively few significant adverse effects. Materials and Methods: To identify such dietary components and micronutrients and define their prostate cancer-specific actions, we systematically reviewed the current literature for the pertinent mechanisms of action and effects on the modulation of prostate carcinogenesis, along with relevant updates from epidemiological and clinical studies. Results: Evidence from various recent experimental, clinical and epidemiological studies indicates that select dietary micronutrients (i.e., lycopene, epigallocatechin gallate, sulforaphane, indole-3-carbinol, resveratrol, quercetin, curcumin & piperine) and zinc play a key role in prostate cancer prevention and progression and therefore hold great promise for the future overall management of prostate cancer. Conclusion: A formulation that comprises these micronutrients using the optimal, safest form and dosing should be investigated in future prostate cancer chemoprevention studies and as part of standard prostate cancer therapy.

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“…Patients treated with either modality received conventionally fractionated RT (maximum dose, 70.2 Gy [RBE]); however, these dosimetric associations may carry greater importance in the context of growing interest in hypofractionation based on data extrapolated from the intact setting. [21][22][23][24][25] Although official recommendations regarding postoperative hypofractionation are pending, small retrospective studies have reported low rates of acute and late GU and GI toxicities with early follow-up. [26][27][28][29] In the largest of these studies (n = 1176), Cozzarini et al reported a significantly higher 5-year risk of late grade ≥3 GU toxicity with postoperative hypofractionation (18.1% vs 6.9%) after a median follow-up of 98 months.…”

Section: Discussionmentioning

confidence: 99%

Comparative toxicity outcomes of proton‐beam therapy versus intensity‐modulated radiotherapy for prostate cancer in the postoperative setting

Santos

Barsky

Hwang

et al. 2019

Cancer

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Background Despite increasing utilization of proton‐beam therapy (PBT) in the postprostatectomy setting, no data exist regarding toxicity outcomes relative to intensity‐modulated radiotherapy (IMRT). The authors compared acute and late genitourinary (GU) and gastrointestinal (GI) toxicity outcomes in patients with prostate cancer (PC) who received treatment with postprostatectomy IMRT versus PBT. Methods With institutional review board approval, patients with PC who received adjuvant or salvage IMRT or PBT (70.2 gray with an endorectal balloon) after prostatectomy from 2009 through 2017 were reviewed. Factors including combined IMRT and PBT and/or concurrent malignancies prompted exclusion. A case‐matched cohort analysis was performed using nearest‐neighbor 3‐to‐1 matching by age and GU/GI disorder history. Logistic and Cox regressions were used to identify univariate and multivariate associations between toxicities and cohort/dosimetric characteristics. Toxicity‐free survival (TFS) was assessed using the Kaplan‐Meier method. Results Three hundred seven men (mean ± SD age, 59.7 ± 6.3 years; IMRT, n = 237; PBT, n = 70) were identified, generating 70 matched pairs. The median follow‐up was 48.6 and 46.1 months for the IMRT and PBT groups, respectively. Although PBT was superior at reducing low‐range (volumes receiving 10% to 40% of the dose, respectively) bladder and rectal doses (all P ≤ .01), treatment modality was not associated with differences in clinician‐reported acute or late GU/GI toxicities (all P ≥ .05). Five‐year grade ≥2 GU and grade ≥1 GI TFS was 61.1% and 73.7% for IMRT, respectively, and 70.7% and 75.3% for PBT, respectively; and 5‐year grade ≥3 GU and GI TFS was >95% for both groups (all P ≥ .05). Conclusions Postprostatectomy PBT minimized low‐range bladder and rectal doses relative to IMRT; however, treatment modality was not associated with clinician‐reported GU/GI toxicities. Future prospective investigation and ongoing follow‐up will determine whether dosimetric differences between IMRT and PBT confer clinically meaningful differences in long‐term outcomes.

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Hypofractionated Radiation Therapy for Localized Prostate Cancer: An ASTRO, ASCO, and AUA Evidence-Based Guideline

Cited by 135 publications

References 101 publications

Patient-Reported Functional Outcomes After Hypofractionated or Conventionally Fractionated Radiation for Prostate Cancer: A National Cohort Study in England

Patient-Reported Functional Outcomes After Hypofractionated or Conventionally Fractionated Radiation for Prostate Cancer: A National Cohort Study in England

Chemoprevention of Prostate Cancer by Natural Agents: Evidence from Molecular and Epidemiological Studies

Comparative toxicity outcomes of proton‐beam therapy versus intensity‐modulated radiotherapy for prostate cancer in the postoperative setting

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