International Journal of Radiation Oncology*Biology*Physics
Clinical InvestigationThe Impact of Brachytherapy on Prostate Cancer–Specific Mortality for Definitive Radiation Therapy of High-Grade Prostate Cancer: A Population-Based Analysis
Introduction
In 2010, the American Cancer Society estimated that there were approximately 210,000 men diagnosed with prostate cancer (1). In the era of prostate-specific antigen (PSA) screening, approximately 15% of prostate cancer patients present with localized, high-risk prostate cancer (2). Although no absolute consensus exists for the definition of “high risk,” the commonly used D’Amico risk classification defines high-risk tumors as follows: Gleason score ≥8, stage ≥T2c, or PSA >20 ng/mL (3). Outcomes from randomized clinical trials have reported 10-year PCSM rates of 10.3%–16% 4, 5, 6, 7 in patients with high-risk prostate cancer. These results are suboptimal, and management strategies continue to be refined.
Local therapy options for the definitive treatment of prostate cancer include radical prostatectomy (RP), EBRT, and BT with or without supplemental EBRT. Although BT achieves tumor control rates equivalent to other options for low-risk and selected intermediate-risk prostate cancers, its use in high-risk prostate cancer is controversial (3). Early retrospective reports found that prostate seed implantation was associated with inferior biochemical control rates among patients with high-risk prostate cancer (3). However, subsequent single and multi-institution investigators have reported 10- to 15-year biochemical control rates of 68.6%–92.6% in patients treated with brachytherapy monotherapy or combination therapy 8, 9, 10, 11, 12. These results compare favorably with historical outcomes with EBRT and androgen deprivation therapy (ADT) for high-risk prostate cancer where biochemical failures occurred in up to 50% of patients at 10 years 4, 5, 6, 7.
We hypothesized that BT-containing treatment for patients with high-risk prostate cancer may achieve survival rates higher than EBRT alone when evaluated in a large observational cohort of U.S. males. To test this hypothesis, we undertook a population-based study using the SEER database to compare PCSM in patients with high-risk prostate cancer treated with BT, BT + EBRT, or EBRT alone.
Section snippets
Methods and Materials
Patient data were identified from the National Cancer Institute’s SEER database. We selected patients who were diagnosed January 1, 1988, through December 31, 2002, with T1–T3N0M0 prostate adenocarcinoma and who received nonsurgical treatment with radiation therapy: EBRT, BT, or combination (BT + EBRT). Data regarding ADT use are not available in the SEER database. We excluded patients who underwent any surgery other than biopsy. To define a high-risk population, we limited our search to
Patient demographics
We identified 12,745 patients who were diagnosed with localized, high-grade prostate adenocarcinoma from 1988 through 2002 and treated with radiation therapy. Of these, 9,369 (73.5%) were treated with EBRT alone, 910 (7.1%) with prostate BT alone, and 2,466 (19.4%) with combination BT + EBRT. Patients treated with BT and BT + EBRT were younger (p < 0.01) and lived in census tracts with higher median household income (p = 0.01). The EBRT alone group included fewer T1 and more T3 tumors than the
Discussion
The use of BT for localized, high-grade prostate adenocarcinomas increased in the study population from 1988 to 2002, and a wide geographic variation in BT utilization was observed. Predictors of the use of BT, with or without EBRT, included later year of diagnosis, younger age, urban residence, non-Hispanic ethnicity, and lower T-stage. Our results suggest that geographic disparities exist in the use of BT in the treatment of high-risk, localized prostate cancer. We found an association
Conclusion
In conclusion, we report that in a large population-based study of men with high-risk prostate cancer treated during 1988–2002, the utilization of BT as a component of treatment increased during the study period and was associated with a reduced rate of PCSM. These data could be considered hypothesis-generating regarding the role of BT in the multimodality management of high-risk prostate cancer. Future clinical trials should be conducted to evaluate prospectively the influence of BT on
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Cited by (32)
Benefits and Risks of Primary Treatments for High-risk Localized and Locally Advanced Prostate Cancer: An International Multidisciplinary Systematic Review[Formula presented]
2020, European UrologyCitation Excerpt :The categories were EBRT versus EBRT + BT, EBRT/BT dose/fractionation/field size comparisons, and the addition of chemotherapy to RT as multimodality therapy. There were 17 studies comparing EBRT with BT (monotherapy or as boost to EBRT; ±ADT) [20–22,70–72,74,76,77,82–87,92,100]. Of these, there was one RCT [20–22], two prospective comparative studies [70,84], and 14 NRSs.
ASCENDE-RT: An Analysis of Health-Related Quality of Life for a Randomized Trial Comparing Low-Dose-Rate Brachytherapy Boost With Dose-Escalated External Beam Boost for High- and Intermediate-Risk Prostate Cancer
2017, International Journal of Radiation Oncology Biology PhysicsCitation Excerpt :Focusing on radiation therapy, randomized trials have shown that dose-escalated, external beam radiation therapy (EBRT) improves biochemical-progression-free survival (b-PFS), although adverse effects are usually more common in the dose-escalated arms (1-8). Because only a small (if any) overall survival advantage is likely with dose escalation (9, 10), it is crucial to develop a deeper understanding of the impact of dose escalation on HR-QoL to assist physicians and patients in making informed decisions with respect to treatment options. The present study is a multicenter, randomized, controlled trail comparing b-PFS using the American Society for Radiation Oncology consensus definition, as well as other survival endpoints, treatment-related morbidity, and HR-QoL outcomes, between dose escalation with an EBRT boost (DE-EBRT) versus dose escalation using a low-dose-rate prostate brachytherapy (LDR-PB) boost.
American Brachytherapy Society Task Group Report: Use of androgen deprivation therapy with prostate brachytherapy—A systematic literature review
2017, BrachytherapyCitation Excerpt :Recent publications using large national databases indicate an increase in CSS (35) and OS (36) in PCa patients treated with any form of brachytherapy. Brachytherapy results in superior disease outcomes, particularly bPFS (22–24, 35, 36), higher complete prostate metabolic atrophy, and lower nadir PSA (21). For these reasons, addition of ADT to either brachytherapy monotherapy or a boost may have less impact on outcomes than when ADT is combined with EBRT.
Survival outcomes of dose-escalated external beam radiotherapy versus combined brachytherapy for intermediate and high risk prostate cancer using the national cancer data base
2016, Journal of UrologyCitation Excerpt :Of the patients 82% did not receive ADT. A population based analysis using the SEER (Surveillance, Epidemiology and End Results) database reviewed patients with prostate cancer at high risk and found that adding brachytherapy decreased prostate cancer specific mortality.16 However this study was limited as it could not account for the EBRT dose received or for receipt of ADT.
Prostate cancer
2016, Medicina Clinica
This research was supported in part by National Cancer Institute Cancer Center Support (Grant No. P30 CA56036).
Conflict of interest: none.