radiation treatments for clinically localized prostate cancer€¦ · ldr brachytherapy;...
TRANSCRIPT
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Radiation Treatments for
Clinically Localized Prostate
Cancer
Tomas Dvorak, MD
Raveendhara R Bannuru, MD
Stanley Ip, MD
Tufts Medical Center, Boston
4-21-2010
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Tomas Dvorak, MD
Speaker Disclosure Summary
• I or a member of my immediate family have not received anything of value related to the technology or topic being presented.
• Please indicate the financially interested company for any “Yes” response:
• No Research or institutional support from: none
• No Fees, honoraria or in-kind compensation other than cash (whether for consulting, speaking, legal testimony or advisory board service) from: none
• No Equity interest, stock or stock options from: none
• No Patent or other intellectual property rights from: none
• No Salary or royalty income from: none
• No Travel expenses or other financial benefit from: none
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Comparative evaluation of radiation
treatments for clinically localized
prostate cancer: an update [draft]
S. Ip, T. Dvorak, W.W. Yu, K. Patel, N. Obadan, M. Chung, R. Bannuru, J. Lau
Tufts Medical Center Evidence-based Practice Center
Technology Assessment, 2010
Funded by the Technology Assessment Program at the
Agency for Healthcare Research and Quality
Potential conflict of interest: None
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Topics
• disease burden
• management options
• different radiation treatment modalities
• review of Minnesota report
• comparative studies update
• conclusions
• limitations
• future research
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Disease burden
Jemal 2009
14%
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Epidemiology
• median age at diagnosis = 68 years
• prevalence at autopsy
– 40 year old: ~30%
– 80 year old: 70-80%
• lifetime risk of carrying a diagnosis: 16%
• lifetime risk of prostate death: 3%
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Diagnosis
• clinical symptoms (rare)
– difficulty urinating, blood in urine
• routine digital-rectal examination
– nodule on prostate gland
• PSA screening (most common)
– estimated ~50% of men undergo screening
– guidelines in flux
– elevated PSA triggers biopsy
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Prostate gland anatomy
www.uptodate.com
GU Toxicity GI Toxicity
Sexual dysfunction
2nd Malignancy
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Gleason score = cancer grade
www.prostate-cancer.org
Gleason Score:
• Primary pattern (1-5)
• Secondary pattern (1-5)
• Sum = GS (2-10)
• 3+3 = 6
• 3+4 = 7
• 4+3 = 7
• 4+5 = 9
• etc
•“Low” grade: 2-6
• “Intermediate” grade: 7
• “High” grade: 8-10
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Prostate cancer staging
www.cancerhelp.org.uk
Tufts EPC TA Inclusion Criteria: Clinically localized prostate cancer (T1-T2)
• T1 - clinically inapparent tumor neither palpable nor visible by imaging
– T1a - incidental histologic finding in 5% or less of tissue resected
– T1b - incidental histologic finding in more than 5% of tissue resected
– T1c - identified by needle biopsy (eg, because of elevated PSA)
• T2 - confined within prostate
– T2a - involves one half of one lobe or less
– T2b - involves more than one half of one lobe but not both lobes
– T2c - involves both lobes 10
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PLCO screening trial
Clinical Stage Screening Control
I 0.5% 0.5%
II 95.5% 93.8%
III 1.4% 1.9%
IV 2.1% 2.7%
Unknown 0.4% 1.1%
Andriole, 2009
T1-T2
N = 76,693
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Prostate cancer natural history
PSA Diagnosis Clinical Diagnosis OS = 7% - 9%
(T1c) (T2-T4) CSS = 54% - 71%
11 years (estimate) 20 years (follow-up)
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Draisma, 2003; Johansson 2004; Albertsen 2005
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Variable prognosis
Albertsen 2005
Who needs
treatment?“Low”
“Intermediate”
“High”
Yes!
No?
Yes?
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Risk stratification
• T1-T2a
• GS 2-6
• PSA <10
• T2b-T2c or
• GS 7 or
• PSA 10-20
• T3a or
• GS 8-10 or
• PSA >20
•T1c
•GS ≤ 6
•PSA <10
• <3 biopsy cores (+),
≤50% cancer in each core
• PSA density <0.15Very low risk
Low risk
Intermediate risk
High risk
NCCN v1.2010
Risk Factors(T-stage, PSA, GS)
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Management of prostate cancer
Prostate Cancer
(T1-T2)
No Initial Treatment
Radiation Therapy
Radical Prostatectomy
• Active Surveillance
• Watchful Waiting
• Observation
• External beam
• Brachytherapy
• Combination
• Open
• Laparoscopic
• Robotic
KQ1 KQ2, KQ3
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Radiation therapy
• rays that kill cells by DNA damage
– photons (x-rays; electromagnetic radiation)
– proton (particle)
– other particles (electrons, alpha, etc)
• damage everything in their path
– tumor
– surrounding normal tissues
• different tumors and different normal tissues
tolerate (repair) radiation differently
– prostate tumor
– bladder/urethra
– rectal mucosa
– penile bulb
– blood vessels
– nerves
US NLM
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Radiation therapy modalities
Radiation
Therapy
Teletherapy
(from outside of
the patient)
Brachytherapy
(implanted into
the patient)
Stereotactic
Body RT
External Beam
RT
Low Dose-Rate
Brachytherapy
(permanent
implant)
High Dose-Rate
Brachytherapy
(temporary
implant)
• 2D RT
• 3D CRT
• IMRT
• Proton therapy
• “Linac” based
• CyberKnife®
• Proton therapy
• I-125
• Pd-103
• Cs-131
• Ir-192
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Prostate: Radiation view
Teletherapy BrachytherapyWhere? How? Dose?
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Efficacy vs toxicity
Treat
the target
Avoid
surrounding
tissues
Teletherapy BrachytherapyWhere? How? Dose?
Major focus of radiation oncology research efforts 19
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2D RT
Teletherapy BrachytherapyWhere? How? Dose?
Hanks, 1989
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Prostate: Planning CT scan
Teletherapy BrachytherapyWhere? How? Dose?
For Illustration Only
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3D Conformal RT
Teletherapy BrachytherapyWhere? How? Dose?
For Illustration Only
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Prostate motion
Moseley, 2007; Langen, 2008
Inter-fraction Intra-fraction
Teletherapy BrachytherapyWhere? How? Dose?
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Motion management
Daily
pre-treatment
imaging
Inter-fraction
Motion
• ultrasound
• X-ray with implanted fiducial markers
• CT scan (CBCT)
“Real-time”
imaging
Intra-fraction
Motion
• electromagnetic: continuous (Calypso®)
• X-ray: every few seconds (CyberKnife®)
Teletherapy BrachytherapyWhere? How? Dose?
Stereotactic
Immobilization
• body immobilization
• rectal balloon
• bladder volume control
Brachytherapy
• implant directly into the prostate
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Clinical impact of motion
de Crevoisier, 2005
Teletherapy BrachytherapyWhere? How? Dose?
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Intensity modulation (IMRT)
Fontenot 2009
Teletherapy BrachytherapyWhere? How? Dose?
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CyberKnife®
radpro.org.uk
Teletherapy BrachytherapyWhere? How? Dose?
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Proton therapy
www.procure.com; Fontenot 2009
Teletherapy BrachytherapyWhere? How? Dose?
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Radiation dose
• conventional dose = 1.8 – 2 Gy per day
• max tolerated 2D dose = 70 Gy
– unacceptable GI toxicity
• max tolerated 3D CRT dose = 79.2 Gy?
• max tolerated IMRT dose = 86.4 Gy?
• proton therapy dose = similar to IMRT?
• What dose is necessary for prostate cancer?
Teletherapy BrachytherapyWhere? How? Dose?
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Dose per fraction
• 80 Gy ≠ 80 Gy– 2 Gy x 40 fraction
– 10 Gy x 8 fractions
• Biologic Effective Dose (BED)– Total Dose * “conversion factor”
– Depends on radiobiology of irradiated tissue
– Tumor (eg, α/β 15)
– Acute toxicity (eg, α/β 10)
– Late toxicity (eg, α/β 2)
• BED (prostate cancer α/β 2?)– 80Gy: 2 Gy x 40 == 133 Gy
– 80Gy: 10 Gy x 8 == 347 Gy
Teletherapy BrachytherapyWhere? How? Dose?
Exponential damage
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Published dose comparisons
Dose/fxNo.
Fractions
Total
Dose
Tumor
BED*
Acute Rectal
BED$
Late Rectal
BED#
1.8 Gy/fx 44 79.2 Gy 150 Gy 93 Gy 108 Gy
2.0 Gy/fx 38 76 Gy 152 Gy 91 Gy 106 Gy
2.5 Gy/fx 28 70 Gy 158 Gy 88 Gy 105 Gy
3.0 Gy/fx 20 60 Gy 150 Gy 78 Gy 96 Gy
4.3 Gy/fx 12 51.6 Gy 163 Gy 74 Gy 96 Gy
7.25 Gy/fx 5 36.25 Gy 168 Gy 63 Gy 89 Gy
*Assumes α/β 2$Assumes α/β 10#Assume α/β 5
Teletherapy BrachytherapyWhere? How? Dose?
For Illustration Only
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Teletherapy/EBRT summary
CT PlanningIntensity
Modulation
Daily
Imaging
Stereotactic
Immobilization
1-5 “Large”
Fractions
2D RT
3D CRT X
IMRT X X
SBRT X X X X X
Protons X +/- X X +/-
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Modern SBRT
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LDR Brachytherapy
Teletherapy BrachytherapyWhere? How? Dose?
Img.medscape.com
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LDRBT Technique
• Which radionuclide?
– different energy: how far penetrate
– different half-life: how quickly deposit dose (BED implication)
• Available
– Iodine (I-125)
– Palladium (Pd-103)
– Cesium (Cs-131)
• What cumulative dose?
Teletherapy BrachytherapyWhere? How? Dose?
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HDR Brachytherapy
Teletherapy BrachytherapyWhere? How? Dose?
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HDRBT Technique
• One radionuclide
– Iridium (Ir-192)
• What dose schedule?
– Implant may require hospitalization
– Typically only one or two implants performed
due to patient comfort
– Fractions typically twice a day
– Dose schedule not well established (SBRT?)
Teletherapy BrachytherapyWhere? How? Dose?
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Treatment efficacy
0
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PSA• clinical outcomes
– overall survival
– disease-specific survival
– clinical progression
• biochemical outcomes
– PSA
– failure: nadir + 2 ng/ml
• toxicity/quality of life
– gastrointestinal (GI)
– genitourinary (GU)
– sexual dysfunction
– second malignancy
For Illustration Only
2 ng/ml
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Treatment toxicity
www.rtog.org
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Comparative effectiveness of therapies
for clinically localized prostate cancer(Minnesota EPC; AHRQ CER No. 13, Wilt et al., 2/2008;
available at effectivehealthcare.gov/reports/final.cfm)
• radical prostatectomy (RP), radiation therapy (EBRT), androgen deprivation (ADT), watchful waiting (WW)
• search date: through 9/2007
• 18 RCTs and 473 observational studies
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Findings from Minnesota report (I)
• no one therapy can be considered the
preferred treatment (limitations in the body
of evidence and tradeoffs between
effectiveness and adverse effects)
• all treatment options result in adverse
effects (urinary, bowel, and sexual)
• no trial enrolled pts with PSA-detected
disease
• no RCTs compared EBRT with WW41
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Findings from Minnesota report (II)
• no EBRT regimen (conventional, high-dose CRT, standard or hypofractionation) was superior in reducing mortality
• no RCTs on BT, cryotherapy, robotic assisted RP, primary ADT, proton beam, or IMRT
• 1 trial (N=106); ▼disease recurrence in RP vs EBRT (14% vs 39%, P = 0.04)
• ▼ disease-specific mortality in RP vs WW (5% vs 10%; P = 0.01) in 1 trial; not sig in an older trial
42
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43
Stanley Ip, MD
Speaker Disclosure Summary
• I or a member of my immediate family have not received anything of value related to the technology or topic being presented.
• Please indicate the financially interested company for any “Yes” response:
• No Research or institutional support from: none
• No Fees, honoraria or in-kind compensation other than cash (whether for consulting, speaking, legal testimony or advisory board service) from: none
• No Equity interest, stock or stock options from: none
• No Patent or other intellectual property rights from: none
• No Salary or royalty income from: none
• No Travel expenses or other financial benefit from: none
43
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44
Key questions in Tufts report
1. What are the benefits and harms of radiation therapy for clinically localized prostate cancer compared to no treatment or no initial treatment in terms of clinical outcomes?
2. What are the benefits and harms of different forms of radiation therapy for clinically localized prostate cancer in terms of clinical outcomes?
3. How do specific patient characteristics (eg, age, race/ethnicity, presence or absence of comorbidities) affect the outcomes of these different forms of radiation therapy?
44
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45
Population
• men with clinically localized prostate
cancer (T1-T2, N0-X, M0-X)
• regardless of age, histologic grade, or
PSA concentration
45
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46
Interventions and comparators of
interest
• primary radiation treatment– EBRT (CRT, IMRT, proton)
– SBRT (including CyberKnife®)
– LDRBT (permanent implant)
– HDRBT (temporary implant)
– combinations of above
• no treatment or no initial treatment (watchful waiting, active surveillance, or observation)
• excluded studies specifically evaluating androgen deprivation therapy (ADT) + RT
46
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47
Outcomes of interest
• overall and disease-specific survival
• clinical and/or biochemical progression
free survival
• quality of life including bowel, bladder, and
sexual dysfunction
• other adverse events (eg, second primary
cancer)
47
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48
Study design
• comparative studies
– RCTs
– non-randomized comparative studies
• excluded before-after single cohort studies
48
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49
Study selection in radiation treatments of localized
prostate cancerCitations identified in MEDLINE and
Cochrane Central database search for
primary studies, published between
January 2007 and December 2009
(n=1,283)
Primary study articles retrieved for full-
text review (n=165)
Abstracts failed to
meet criteria
(n=1,118)
Primary study articles reviewed (n=62)
Articles failed to
meet criteria (n=112)
RCTs relevant to
radiation treatments
identified in the
Minnesota report
(n=9)
49
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50
Rating the quality of the individual
studies
• AHRQ CER Methods Guide 1.0 (effectivehealthcare.ahrq.gov/repFiles/2007_10DraftMet
hodsGuide.pdf)
• 3 grades
– A (low risk of bias)
– B
– C (high risk of bias)
50
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51
Rating the strength of evidence for
each key question
• number and quality of primary studies; study design; duration of follow-up; consistency of results across studies
• rating
– HIGH confidence that the evidence reflects the true effect
– MODERATE confidence that the evidence reflects the true effect
– INSUFFICIENT – evidence is unavailable, limited, inconsistent, “C” quality, or does not permit an estimation of the true effect
51
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Number of studies in RT for localized
prostate cancer
RCT
Pros cohort
Retrocohort
RCT
Pros cohort
Retrocohort
RCT
Pros cohort
Retrocohort
RCT
Pros cohort
Retrocohort
RCT
Pros cohort
Retrocohort
RCT
Pros cohort
Retrocohort
RCT
Pros cohort
Retrocohort
KQ1
LDRBT
EBRT
HDRBT
LDRBT
Combo.therapies
IntraSBRT
IntraEBRT
IntraLDRBT
vs.
vs.
Patient Survival Biochemical Failure GU or GI Toxicity
52
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53
Raveendhara R Bannuru, MD
Speaker Disclosure Summary
• I or a member of my immediate family have not received anything of value related to the technology or topic being presented.
• Please indicate the financially interested company for any “Yes” response:
• No Research or institutional support from: none
• No Fees, honoraria or in-kind compensation other than cash (whether for consulting, speaking, legal testimony or advisory board service) from: none
• No Equity interest, stock or stock options from: none
• No Patent or other intellectual property rights from: none
• No Salary or royalty income from: none
• No Travel expenses or other financial benefit from: none
53
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54
Key question 1
What are the benefits and harms of radiation therapy (RT) for clinically localized prostate cancer compared to no treatment or no initial treatment (NT) in terms of clinical outcomes?
54
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55
Q1. RT vs NT
patient survival
AdjHR (95%CI) Comparisons Quality
Studies 3 retro cohorts (n = 334 to 3094)
Strength of
evidence
insufficient (few studies)
(n=756)
(n=334)
(n=2311)
(n=2499)
55
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56
Q1. RT vs NT
genitourinary toxicity
Study 1 retro cohort (n = 2053)*
Findings BT vs NT
adjHR 1.68 (P = NS)
EBRT vs NT
adjHR 1.77 (P = NS)
BT+EBRT vs NT
adjHR 4.56 (P = 0.02)
Strength of
evidence
insufficient
56*Elliott et al. J Urology.178(2):529-534, 2007
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57
Q1. RT vs NT
second primary cancer (SPC)
Studies 1 retro cohort*
Findings BT vs NT (n = 50956)
overall: adjHR 0.96 (P = NS)
late (≥ 5 yr): adjHR 1.20 (P = NS)
EBRT vs NT (n = 89133)
overall: adjHR 1.14 (P < 0.0001)
late (≥ 5 yr): adjHR 1.26 (P < 0.0001)
Strength of
evidence
insufficient
57*Abdel-Wahab et al. Int J Radiation Oncology Biol Phy 72(1):58-68, 2008
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58
Key questions 2
What are the benefits and harms of different forms of radiation therapy for clinically localized prostate cancer in terms of clinical outcomes?
58
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59
Q2. Comparing different RTs
• SBRT vs other modalities
• LDRBT vs EBRT
• LDRBT vs HDRBT
• combination therapies
• intra-SBRT comparisons
• intra-EBRT comparisons
• intra-LDRBT comparisons
59
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60
Stereotactic Body Radiation Therapy
(including CyberKnife®) vs
other radiation modalities
Findings no studies
Strength of
evidence
insufficient
60
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61
LDRBT vs EBRT
Radiation
Therapy
Teletherapy
Brachytherapy
Stereotactic
Body RT
(SBRT)
External Beam
RT
(EBRT)
Low Dose-Rate
Brachytherapy
(LDRBT)
High Dose-Rate
Brachytherapy
(HDRBT)
Analysis
61
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LDRBT vs EBRT
freedom from biochemical failure
62
[1] no ADT
Eade (2008)
Pe (2009)
[2] with ADT
Wong (2009)
Pickles (2010)
Gondi (2007)
Jabbar (2010)
ID
Study
374
360
809
278
213
258
N
4
5
5
5
5
5
year
Followup
B
B
B
B
C
C
quality
374
360
809
278
213
258
N
4
5
5
5
5
5
year
Followup
Favors LDRBT Favors EBRT0-.3 -.2 -.1 -.05 0 .05 .1 .2
Outcome: freedom from biochemical failure
Risk Difference
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63
LDRBT vs EBRT
freedom from biochemical failure
Studies 6 retro cohorts (n = 278 to 853 )
Findings no diff (no ADT, 2 studies)
▲ freedom from biochemical failure with
LDRBT (ADT included)
Strength of
evidence
insufficient (only 2 “no ADT” studies)
63
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64
LDRBT vs EBRT
disease-specific mortality
Study 1 retro cohort (n = 1520)*
Findings 7 yr disease-specific mortality
adjRR 0.68 (95% CI 0.30,1.5)
Strength of
evidence
insufficient
64*Zhou et al. Int J Radiation Oncology Biol Phys 73 (1):15 -23, 2009
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65
LDRBT vs EBRT
genitourinary toxicity/QoL
Studies 4 pro cohorts (n = 168 to 598)
2 retro cohorts (n = 374 and 853)
65
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66
LDRBT vs EBRT
genitourinary toxicity (RTOG)
66
.
.
.
[1] Acute GU toxicity >=Grade 3
Wong (2009)
Eade (2008)
[2] Late GU toxicity >=Grade 3
Wong (2009)
Eade (2008)
[3] Urethral strictures
Eade (2008)
ID
Study
809
374
809
374
374
N
B
B
B
B
B
quality
809
374
809
374
374
N
B
B
B
B
B
quality
0-.1 -.05 -.02 0 .02 .05 .1 .15
Outcome: GU Toxicity
Risk Difference
Decrease risk LDRBT Decrease risk EBRT
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67
LDRBT vs EBRT
genitourinary outcomes
Studies 4 pro cohorts (n = 168 to 598)
2 retro cohorts (n = 374 and 853)
Findings GU: ▲ with LDRBT or no difference
Strength of
evidence
insufficient
(few high quality studies)
67
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68
LDRBT vs EBRT
bladder cancer incidence
Study 1 retro (n=115,948)*
Findings ▼ bladder cancer incidence 10 yrs
after Tx in LDRBT
RR 0.72 (95% CI 0.59, 0.87)
Strength of
evidence
insufficient
68*Nieder et al. J Urology 180 (5):2005-2009, 2008
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69
LDRBT vs EBRT
gastrointestinal toxicity/QoL
Studies 4 pro (n = 168 to 598 )
3 retro (n = 233 to 853)
69
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70
LDRBT vs EBRT
gastrointestinal toxicity (RTOG)
70
.
.
[4] Acute GI toxicity >=Grade 3
Wong (2009)
Lesperance (2008)
[5] Late GI toxicity >=Grade 3
Wong (2009)
Eade (2008)
Lesperance (2008)
ID
Study
809
233
809
374
229
N
B
C
B
B
C
quality
809
233
809
374
229
N
B
C
B
B
C
quality
0-.1 -.05 -.02 0 .02 .05 .1 .15
Outcome: GI Toxicity
Risk Difference
Decrease risk LDRBT Decrease risk EBRT
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71
LDRBT vs EBRT
gastrointestinal outcomes
Studies 4 pro (n = 168 to 598 )
3 retro (n = 233 to 853)
Findings GI: ▼ with LDRBT or no diff
Strength of
evidence
insufficient
(few high quality studies)
71
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72
LDRBT vs EBRT
rectal cancer incidence
Study 1 retro (n=115,948 )*
Findings ▼ rectal cancer incidence 10 yrs after
Tx in LDRBT
RR 0.64; 95% CI (0.45,0.91)
Strength of
evidence
insufficient
72*Nieder et al. J Urology 180 (5):2005-2009, 2008
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73
LDRBT vs EBRT
sexual dysfunction
73
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74
LDRBT vs EBRT
sexual dysfunction
Studies 4 pro cohorts (n = 168 to 598 )
Findings 1 less,1 more with LDRBT
Strength of
evidence
insufficient
(inconsistent results)
74
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75
HDRBT vs LDRBT
Radiation
Therapy
Teletherapy
Brachytherapy
Stereotactic
Body RT
(SBRT)
External Beam
RT
(EBRT)
Low Dose-Rate
Brachytherapy
(LDRBT)
High Dose-Rate
Brachytherapy
(HDRBT)
Analysis
75
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76
HDRBT vs LDRBT
biochemical control
Study 1 retro cohort, (n = 454)*
Ir-192 vs Pd-103
Findings 88% vs 89% (P = NS)
Strength of
evidence
insufficient
76*Martinez et al. Am J Clin Oncol. Nov 2009
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77
HDRBT vs LDRBT
genitourinary and gastrointestinal toxicity
Study 1 retro cohort, (n=454)*
Ir-192 vs Pd-103
Findings GU toxicity
acute: 4.5% vs 14.5% (P = NR)
late: 9% vs 8.5% (P = NR)
GI toxicity
acute: 0% vs 0.5% (P = NR)
late: 0.5% vs 2% (P = NR)
Strength of
evidence
insufficient
*Martinez et al. Am J Clin Oncol. Nov 2009
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78
HDRBT vs LDRBT
sexual dysfunction
Study 1 retro cohort, (n = 454)*
Ir-192 vs Pd-103
Findings 20% vs 30% (P = NS)
Strength of
evidence
insufficient
78*Martinez et al. Am J Clin Oncol. Nov 2009
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79
Combination therapies
• LDRBT plus different EBRT doses
• EBRT vs (EBRT + bHDRBT)
• (EBRT + LDRBT) vs (EBRT + HDRBT)
• LDRBT vs (LDRBT + EBRT)
• EBRT vs BT vs (EBRT + BT)
• EBRT vs LDRBT vs (EBRT + LDRBT)
79
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80
BT + EBRT vs EBRT
genitourinary outcomes
Studies 2 retro cohorts (n = 358; 876)
Findings LDRBT + EBRT vs EBRT*
GU toxicity: 18% vs 5% (P = 0.009)
BT + EBRT vs EBRT**
urethral strictures: 5.2% vs 1.7%
(P = 0.013)
Strength of
evidence
insufficient (few studies)
80
*Wong et al. Cancer 115 (23):5596 -606, 2009; **Elliot et al. J Urology 178 (2):529 -34, 2007
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81
BT + EBRT vs EBRT
second primary cancer
Studies 1 retro cohort (n = 57,496)*
Findings ▲ second primary cancers in combo
10.3% vs 5.7% (P < 0.0001)
▲ late (≥ 5 yrs) second primary
cancers in combo
4.2% vs 1.4% (P < 0.0001)
Strength of
evidence
insufficient
81*Abdel-Wahab et al. Int J Radiation Oncology Biol Phy 72(1):58-68, 2008
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82
Intra-SBRT
Radiation
Therapy
Teletherapy
Brachytherapy
Stereotactic
Body Radiation
Therapy
(SBRT)
External Beam
RT
(EBRT)
Low Dose-Rate
Brachytherapy
(LDRBT)
High Dose-Rate
Brachytherapy
(HDRBT) 82
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83
Study 1 retro cohort (n = 304)*
Findings 35 Gy vs 36.25 Gy in 5 fractions
Late GU: 0% vs 0.5% (P = NS)
Late GI: 0% vs 0%
Strength of
evidence
insufficient
83*Katz et al. BMC Urol. 1;10(1):1, 2010
Intra-SBRT
genitourinary and gastrointestinal toxicity
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84
Intra-EBRT
Radiation
Therapy
Teletherapy
Brachytherapy
Stereotactic
Body Radiation
Therapy
(SBRT)
External Beam
RT
(EBRT)
Low Dose-Rate
Brachytherapy
(LDRBT)
High Dose-Rate
Brachytherapy
(HDRBT) 84
• Dose
• Fraction size
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85
EBRT dose comparisons
freedom from biochemical failure
Studies 3 RCTs (n= 301 to 664)
5 retro cohorts (n=398 to 2047)
Findings increased dose
▲ freedom from biochemical failure at
5 to 10 years
Strength of
evidence
moderate
(consistent results)
85
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86
.
.
[1] no ADT
Kuban (2008)
Zietman (2010)
Eade (2007)
Kupelian (2008)
[2] with ADT
Zelefsky (2008)
ID
Study
301
391
410
704
835
N
70 vs. 78
70 vs. 79
70 vs. >=80
<72 vs. >=82
70 vs 86
(Gy)
comparison
10
10
8
7
7
followup
Year of
RCT
RCT
retro
retro
retro
design
B
B
B
B
B
quality
301
391
410
704
835
N
70 vs. 78
70 vs. 79
70 vs. >=80
<72 vs. >=82
70 vs 86
(Gy)
comparison
Favors EBRT higher dose Favors EBRT lower dose
0-.5 -.3 -.1 0 .1 .3
Outcome: Freedom from biochemical failure (>5 years of followup)
Risk Difference
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87
EBRT dose comparisons
toxicity
Studies 1 RCT (n=392)
2 pro cohorts (n=402, 956)
6 retro cohorts (n=80 to 1571)
Findings no diff in acute and late GU or GI
toxicities
Strength of
evidence
moderate
(consistent results)
87
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88
.
.
.
.
[1] Acu te GU toxicity >=Grade 3
Zietman (2005)
Wong (2009)
Jani (2007)
[2] Late GU toxici ty >=Grade 3
Zietman (2005)
Michalski (disease grp 1) (2010)
Michalski (disease grp 2) (2010)
Lin* (2007)
Goldner (2009)
Wong (2009)
Hanssen (2008)
Jani (2007)
[3] Acu te GI toxici ty >=Grade 3
Zietman (2005)
Wong (2009)
Jani (2007)
[4] Late GI toxici ty >=Grade 3
Zietman (2005)
Michalski (disease grp 1) (2010)
Michalski (disease grp 2) (2010)
Lin* (2007)
Goldner (2009)
Wong (2009)
Hanssen (2008)
Jani (2007)
ID
Study
391
584
481
391
194
134
401
233
584
80
461
391
584
481
391
194
134
402
233
584
80
461
N
79 vs. 70 Gy
76 vs. 68 Gy
76 vs. 70 Gy
79 vs. 70 Gy
78 vs. 68 Gy
78 vs. 68 Gy
74 vs. 70 Gy
78 vs. 68 Gy
76 vs. 68 Gy
76 vs. 70 Gy
76 vs. 70 Gy
79 vs. 70 Gy
76 vs. 68 Gy
76 vs. 70 Gy
79 vs. 70 Gy
78 vs. 68 Gy
78 vs. 68 Gy
74 vs. 70 Gy
78 vs. 68 Gy
76 vs. 68 Gy
76 vs. 70 Gy
76 vs. 70 Gy
comparison
RCT
retro
retro
RCT
pros
pros
pros
retro
retro
retro
retro
RCT
retro
retro
RCT
pros
pros
pros
retro
retro
retro
retro
design
B
B
C
B
B
B
C
B
B
C
C
B
B
C
B
B
B
C
B
B
C
C
quality
391
584
481
391
194
134
401
233
584
80
461
391
584
481
391
194
134
402
233
584
80
461
N
79 vs. 70 Gy
76 vs. 68 Gy
76 vs. 70 Gy
79 vs. 70 Gy
78 vs. 68 Gy
78 vs. 68 Gy
74 vs. 70 Gy
78 vs. 68 Gy
76 vs. 68 Gy
76 vs. 70 Gy
76 vs. 70 Gy
79 vs. 70 Gy
76 vs. 68 Gy
76 vs. 70 Gy
79 vs. 70 Gy
78 vs. 68 Gy
78 vs. 68 Gy
74 vs. 70 Gy
78 vs. 68 Gy
76 vs. 68 Gy
76 vs. 70 Gy
76 vs. 70 Gy
comparison
0-.15 -.1 -.05 0 .05 .1 .15
Outcome: Toxicity or Adverse Outcomes
Risk Difference
Decrease risk EBRT higher dose Decrease risk EBRT lower dose
88
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89
EBRT fraction size comparisons
freedom from biochemical failure
Studies 3 RCTs (n = 89 to 936)
Findings no diff between standard and
hypofractionation
Strength of
evidence
moderate
(consistent results)
89
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9090
.
[1] no ADT
Lukka (2005)
Yeoh (2006)
Norkus (2009)
ID
Study
936
217
89
N
6
6
1
year
Followup
RCT
RCT
RCT
design
B
B
C
quality
936
217
89
N
6
6
1
year
Followup
Favors EBRT hypofraction Favors EBRT std fraction
0-.5 -.3 -.1 0 .1 .3
Outcome: Freedom from biochemical failure
Risk Difference
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91
EBRT fraction size comparisons
genitourinary and gastrointestinal toxicity
Studies 2 RCTs (n =100, 936)
2 retro cohorts (n =130, 219)
Findings little or no diff in acute and late GU or
GI toxicities
Strength of
evidence
moderate
(consistent results)
91
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92
.
.
.
.
[1] Acute GU toxicity >=Grade 3
Lukka (2005)
Pollack (2006)
Leborgne (2008)
[2] Late GU toxicity >=Grade 3
Lukka (2005)
Leborgne (2009)
[3] Acute GI toxicity >=Grade 3
Lukka (2005)
Pollack (2006)
Leborgne (2008)
[4] Late GI toxicity >=Grade 3
Lukka (2005)
Leborgne (2009)
ID
Study
936
100
108
936
219
936
100
108
936
219
N
hypofraction vs. std
hypofraction vs. std
hypofraction vs. std
hypofraction vs. std
hypofraction vs. std
hypofraction vs. std
hypofraction vs. std
hypofraction vs. std
hypofraction vs. std
hypofraction vs. std
comparison
RCT
RCT
retro
RCT
retro
RCT
RCT
retro
RCT
retro
design
B
B
C
B
B
B
B
C
B
B
quality
936
100
108
936
219
936
100
108
936
219
N
hypofraction vs. std
hypofraction vs. std
hypofraction vs. std
hypofraction vs. std
hypofraction vs. std
hypofraction vs. std
hypofraction vs. std
hypofraction vs. std
hypofraction vs. std
hypofraction vs. std
comparison
EBRT hypofraction
0-.1 -.05 0 .05 .1
Outcome: Toxicity or Adverse Outcomes
Risk Difference
Decrease risk Decrease risk EBRT standard
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93
Intra-LDRBT
Radiation
Therapy
Teletherapy
Brachytherapy
Stereotactic
Body Radiation
Therapy
(SBRT)
External Beam
RT
(EBRT)
Low Dose-Rate
Brachytherapy
(LDRBT)
High Dose-Rate
Brachytherapy
(HDRBT) 93
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94
Intra-LDRBT comparisons
overall survival
Study 1 retro cohort (n = 3928)*
Findings (BED < 200 Gy, 200-220 Gy, > 220
Gy): ▲ survival with ▲ dose
87% vs 89% vs 95% (P = 0.048)
Strength of
evidence
insufficient
94*Stone et al. Int J Radiation Oncology Biol Phys 73(2):341-346, 2009
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95
Intra-LDRBT
freedom from biochemical failure
Studies 1 RCT (n=314), 1 retro cohort (n=3928)
Findings RCT (I-125 vs Pd-103)*
97% vs 99% (P = NS)
retro cohort**
(BED <140 Gy, 140-200 Gy, >200 Gy)
▲ freedom from failure with ▲ dose
41% vs 78% vs 83% (P <0.0001)
Strength of
evidence
insufficient (few studies)
95
*Wallner et al. Int J Radiation Oncology Biol Phys 57(5):1297-1303, 2003; Merrick et
al. Am J Clin Oncology 30(3):228-233,2007; **Stone et al. Int J Radiation Oncology
Biol Phys 69(5):1472-1477, 2007
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96
Intra-LDRBT comparisons
genitourinary & gastrointestinal toxicity
Studies 2 RCT (n = 314; n = 69)
Findings RCT (I-125 vs Pd-103)*
GU toxicity: no diff (AUA score)
GI toxicity: no diff (rectal bleed)
RCT (LDRBT ± hyaluronic acid)**
▼ GI toxicity with hyaluronic acid
12% vs 0% (P = 0.047)
Strength of
evidence
insufficient
96
*Herstein et al. Cancer J 11(5):385-389, 2005; **Prada et al. Brachytherapy 8(2):210-217, 2009
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97
Key question 3
How do specific patient characteristics (eg, age, race/ethnicity, presence or absence of comorbidities) affect the outcomes of these different forms of radiation therapy?
97
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98
Baseline risk as outcome modifiersLow Intermediate High
EBRT vs Obs survival
EBRT
survival EBRT survival EBRT
Intra-EBRT
(78 vs 70 Gy)
▲ bFFF
▲ dose
no diff ▲ bFFF
▲ dose
Intra-LDRBT
(140, 140-200, >200
Gy)
▲ bFFF
▲ dose
▲ bFFF
▲ dose
▲ bFFF
▲ dose
EBRT or BT or
EBRT + BT
no diff bFFF: 3D<BT<hi-IMRT<
EBRT+BT
no diff
Intra-EBRT
(70.2, 75.6, 81, 86.4)
no diff ▲ bFFF
▲ dose
▲ bFFF
▲ dose
Strength of
evidence
insufficient (only 1 study per comparison)98
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99
Baseline PSA as outcome modifiers
Study 1 RCT, 78 Gy vs 70 Gy (n = 301)*
Findings PSA ≤10 ng/ml:
no diff
PSA >10 ng/ml:
▲ bFFF with ▲ EBRT dose
(P <0.001)
Strength of
evidence
insufficient
99*Kuban et al. Int J Radiation.Oncology, Biol Phys 70(1):67-74,2008
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100
Baseline Gleason score as outcome
modifiers
Study 1 retro cohort (n = 3928)*
Findings Score 7:
no diff in bFFF with ▲ BT dose
Score 8-10:
▲ bFFF with ▲ BT dose (P <0.001)
Strength of
evidence
insufficient
100*Stone et al. Int J Radiation Oncology Biol Phys 69(5):1472-1477, 2007
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101
Strength of evidence for RT for
clinically localized prostate cancerComparisons Disease specific
survival
Freedom from
biochemical
failure
GU/GI toxicity
RT vs NT insuff insuff insuff
SBRT vs EBRT insuff insuff insuff
SBRT vs HDRBT insuff insuff insuff
SBRT vs LDRBT insuff insuff insuff
EBRT vs HDRBT insuff insuff insuff
EBRT vs LDRBT insuff insuff insuff
HDRBT vs LDRBT insuff insuff insuff
Combined mod. insuff insuff insuff
Intra SBRT insuff insuff insuff
Intra EBRT insuff moderate moderate
Intra LDRBT insuff insuff insuff
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102
Conclusions
• insufficient data to determine if RT is superior to no Tx or no initial Tx
• could not determine if one form of RT is superior to another form in terms of overall or disease-specific survival
• ▲ EBRT dose is associated with long-term biochemical control
• BT is associated with ▲ GU and ▼ GI toxicity compared with EBRT
102
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Limitations
• paucity of high quality adequately powered RCTs
• variability in outcome measures (eg, definitions of biochemical failure)
• differences in baseline disease risk between comparison groups
103
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104
Future research
• standardize outcome measures
• RCT
– RT vs NT (2 ongoing – UK; Canada)
– extreme hypofractionation (1-5) vs standard
fractionation
– BT vs EBRT
– proton vs others
• safety data related to RT delivery
104
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105
Acknowledgement
Mei Chung, MPH
Joseph Lau, MD
Ndidiamaka Obadan, MD, MSc
Kamal Patel, MPH, MBA
Winifred W. Yu, MS, RD
105