Intensity-Modulated Radiotherapy Causes Fewer Side Effects than Three-Dimensional Conformal Radiotherapy When Used in Combination With Brachytherapy for the Treatment of Prostate Cancer
ABSTRACT To measure the benefits of intensity-modulated radiotherapy (IMRT) compared with three-dimensional conformal radiotherapy (3D-CRT) when used in combination with brachytherapy for the treatment of prostate cancer.
We conducted a retrospective review of all patients with localized prostate cancer who received external-beam radiotherapy (EBRT) in combination with brachytherapy with at least 1 year follow-up (n = 812). Combination therapy consisted of (103)Pd or (125)I implant, followed by a course of EBRT. From 1993 to March 2003 521 patients were treated with 3D-CRT, and from April 2003 to March 2009 291 patients were treated with IMRT. Urinary symptoms were prospectively measured with the International Prostate Symptom Score questionnaire with a single quality of life (QOL) question; rectal bleeding was assessed per the Radiation Therapy Oncology Group/European Organization for Research and Treatment of Cancer Late Radiation Morbidity Scoring Schema. The Pearson χ(2) test was used to compare toxicities experienced by patients who were treated with either IMRT or 3D-CRT. Logistic regression analyses were also performed to rule out possible confounding factors.
Within the first 3 months after treatment, patients treated with 3D-CRT scored their urinary symptoms as follows: 19% mild, 44% moderate, and 37% severe; patients treated with IMRT scored their urinary symptoms as follows: 36% mild, 47% moderate, and 17% severe (p < 0.001). The 3D-CRT patients rated their QOL as follows: 35% positive, 20% neutral, and 45% negative; IMRT patients rated their QOL as follows: 51% positive, 18% neutral, and 31% negative (p < 0.001). After 1 year of follow-up there was no longer any difference in urinary morbidity between the two groups. Logistic regression confirmed the differences in International Prostate Symptom Score and QOL in the acute setting (p < 0.001 for both). Grade ≥ 2 rectal bleeding was reported by 11% of 3D-CRT patients and 7% of IMRT patients (p = 0.046); logistic regression analysis also confirmed this observation (p = 0.040).
When used in combination with brachytherapy, IMRT offers less Grade ≥ 2 rectal bleeding, less acute urinary toxicities, and is associated with a higher QOL compared with 3D-CRT.
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ABSTRACT: Die Häufigkeit, ein fortgeschrittenes Prostatakarzinom zu diagnostizieren, ist seit Einführung der PSA-Diagnostik drastisch gesunken. Die Therapie dieser Patientengruppe ist jedoch aufgrund der schlechten Prognose eine Herausforderung, welche seit Jahren kontrovers diskutiert wird. Neben der Frage der Radiatio der Lymphabflusswege wird die aktuelle Datenlage zur kombinierten Strahlentherapie mit hormonablativer Therapie dargestellt. Das Risiko von PSA-Rezidiven nimmt zu, seit radikale Prostatektomien von Patienten mit hohen Risikofaktoren oder fortgeschrittenen Tumoren häufiger durchgeführt werden. Hier hat entweder die adjuvante oder die Salvage-Radiatio einen festen Platz im Therapiealgorithmus des Prostatakarzinoms. Die LDR- und die HDR-Brachytherapie sind primäre Therapieoptionen bei Patienten mit niedrigen bzw. hohen Risikofaktoren und lokalisierter Erkrankung. Ein gutes Nebenwirkungsmanagement ist notwendig, um auftretende therapieassoziierte Symptome anhaltend zu lindern. Dieser Artikel vermittelt die möglichen Nebenwirkungen einer Strahlentherapie und die Behandlungskonzepte. Radiogene Zweittumoren stellen eine schwerwiegende Folge nach Strahlentherapie dar; auch hierzu wird eine Einschätzung der vorhandenen Daten dargelegt.Der Urologe 12/2012; 51(12). DOI:10.1007/s00120-012-3030-3 · 0.44 Impact Factor
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ABSTRACT: What's known on the subject? and What does the study add? While the frequencies and severity of late toxicities following prostate brachytherapy are well known, less has been published with regard to time to first onset. Several series with limited median follow-up have published time to onset. An extensive analysis of timing to late toxicity following brachytherapy for cervical cancer has also been published. This study is the largest of its kind with the longest median follow-up to capture very late events. It can provide a basis for physician and patient education about when late toxicities can reasonably be expected to occur. The study also shows that a significant amount of erectile dysfunction might be more age related than radiation induced. OBJECTIVES: • To assess the timing of first onset of late rectal bleeding, late haematuria and erectile dysfunction (ED) following brachytherapy with or without external beam radiation therapy (EBRT) for prostate adenocarcinoma. • To identify treatment factors and patient characteristics that affect the time to first onset. PATIENTS AND METHODS: • In all, 2046 patients were definitively treated for prostate adenocarcinoma with a full (125) I or (103) Pd implant or a partial (103) Pd implant followed by EBRT with 6 years median follow-up (range 2-17 years). • Patients were selected for an event of Radiation Therapy Oncology Group (RTOG) grade 2 or greater rectal bleeding, ≥RTOG grade 2 haematuria, or a drop in the Mount Sinai Erectile Dysfunction Score from potent to impotent (excluding patients who received androgen deprivation therapy). • Life tables were generated to calculate actuarial incidence rates of toxicity. • Wilcoxon rank sum and Cox regression were utilized to identify treatment factors affecting time to onset. RESULTS: • The incidence rate per 1000 patients for 0-2 years, 2-5 years and 5-10 years following radiation for rectal bleeding is 14.3, 15.9 and 6.5, respectively; for haematuria, 14.0, 8.2 and 1.3, respectively; and for ED, 82.4, 48.2 and 42.2, respectively. • Just 5% of rectal bleeding occurs after 5 years from radiation vs 18% of haematuria cases and 22% of ED. • On multivariate analysis, time to first onset of rectal bleeding was affected by the addition of EBRT only whereas the time to onset of haematuria was affected by the biological effective dose of the radiation and the addition of EBRT. • The only factor on multivariate analysis to affect time to onset of ED was the age of the patient at treatment, independent of radiation dose or technique. CONCLUSIONS: • Unique temporality to first onset of selected toxicities was observed in patients after radioactive implant for prostate adenocarcinoma with or without EBRT. • Clinicians and patients should be counselled when to expect late toxicities. • The only factor to affect time to onset of ED is the age of the patient, suggesting possible over-reporting of radiation-induced ED in the light of normal age-related events.BJU International 10/2012; DOI:10.1111/j.1464-410X.2012.11436.x · 3.13 Impact Factor
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ABSTRACT: The incidence of advanced prostate cancer has decreased since the introduction of prostate-specific antigen (PSA) measurements. The treatment of these patients remains a challenge due to the bad prognosis and continues to be controversially discussed. The article discusses the questions concerning radiotherapy including pelvic lymph nodes as well as an additional androgen deprivation therapy. The risk of recurrent cancer has increased since the introduction of radical prostatectomy for patients with high risk factors or locally advanced tumors. In these cases adjuvant and salvage radiotherapy represent a mainstay of therapy. Low-dose rate (LDR) and high-dose rate (HDR) brachytherapy are primary treatment options for patients with low and high risk factors and localized disease. An elaborate management of treatment-related toxicities is mandatory and may provide persistent symptom relief. A comprehensive assessment of radiation side effects and treatment concepts is provided. The development of secondary cancers after radiotherapy represents a most severe side effect for which an assessment of available data is presented.Der Urologe 11/2012; · 0.44 Impact Factor