Comparative Study

. 2020 Jan;77(1):3-10.

doi: 10.1016/j.eururo.2019.03.022. Epub 2019 Apr 13.

Prostate-only Versus Whole-pelvis Radiation with or Without a Brachytherapy Boost for Gleason Grade Group 5 Prostate Cancer: A Retrospective Analysis

Kiri A Sandler¹, Ryan R Cook², Jay P Ciezki³, Ashley E Ross⁴, Mark M Pomerantz⁵, Paul L Nguyen⁶, Talha Shaikh⁷, Phuoc T Tran⁸, Richard G Stock⁹, Gregory S Merrick¹⁰, David Jeffrey Demanes¹, Daniel E Spratt¹¹, Eyad I Abu-Isa¹¹, Trude B Wedde¹², Wolfgang Lilleby¹², Daniel J Krauss¹³, Grace K Shaw⁵, Ridwan Alam⁴, Chandana A Reddy⁴, Daniel Y Song⁸, Eric A Klein³, Andrew J Stephenson³, Jeffrey J Tosoian⁴, John V Hegde¹, Sun Mi Yoo¹, Ryan Fiano¹⁰, Anthony V D'Amico⁵, Nicholas G Nickols¹⁴, William J Aronson¹⁵, Ahmad Sadeghi¹⁶, Stephen C Greco⁸, Curtiland Deville Jr⁸, Todd McNutt⁸, Theodore L DeWeese⁸, Robert E Reiter¹⁷, Jonathan W Said¹⁸, Michael L Steinberg¹, Eric M Horwitz⁷, Patrick A Kupelian¹, Christopher R King¹, Amar U Kishan¹⁹

Affiliations

¹ Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA, USA.
² Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles, Los Angeles, CA, USA.
³ Department of Radiation Oncology, Cleveland Clinic, Cleveland, OH, USA.
⁴ Department of Urology, The James Buchanan Brady Urological Institute, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.
⁵ Lank Center for Genitourinary Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA.
⁶ Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA.
⁷ Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA.
⁸ Department of Radiation Oncology and Molecular Radiation Sciences, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.
⁹ Department of Radiation Oncology, The Icahn School of Medicine at Mount Sinai, New York City, NY, USA.
¹⁰ Schiffler Cancer Center, Wheeling Hospital, Wheeling Jesuit University, Wheeling, WV, USA.
¹¹ Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, USA.
¹² Department of Oncology, Oslo University Hospital, The Norwegian Radium Hospital, Oslo, Norway.
¹³ Oakland University William Beaumont School of Medicine, Royal Oak, MI, USA.
¹⁴ Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA, USA; Department of Radiation Oncology, Veteran Affairs Greater Los Angeles Healthcare System, Los Angeles, CA, USA.
¹⁵ Department of Radiation Oncology, Veteran Affairs Greater Los Angeles Healthcare System, Los Angeles, CA, USA; Department of Urology, University of California, Los Angeles, Los Angeles, CA, USA.
¹⁶ Department of Radiation Oncology, Veteran Affairs Greater Los Angeles Healthcare System, Los Angeles, CA, USA.
¹⁷ Department of Urology, University of California, Los Angeles, Los Angeles, CA, USA.
¹⁸ Department of Pathology, University of California, Los Angeles, Los Angeles, CA, USA.
¹⁹ Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA, USA. Electronic address: aukishan@mednet.ucla.edu.

PMID: 30992160
PMCID: PMC7521828
DOI: 10.1016/j.eururo.2019.03.022

Comparative Study

Prostate-only Versus Whole-pelvis Radiation with or Without a Brachytherapy Boost for Gleason Grade Group 5 Prostate Cancer: A Retrospective Analysis

Kiri A Sandler et al. Eur Urol. 2020 Jan.

. 2020 Jan;77(1):3-10.

doi: 10.1016/j.eururo.2019.03.022. Epub 2019 Apr 13.

Authors

Affiliations

¹ Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA, USA.
² Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles, Los Angeles, CA, USA.
³ Department of Radiation Oncology, Cleveland Clinic, Cleveland, OH, USA.
⁴ Department of Urology, The James Buchanan Brady Urological Institute, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.
⁵ Lank Center for Genitourinary Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA.
⁶ Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA.
⁷ Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA.
⁸ Department of Radiation Oncology and Molecular Radiation Sciences, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.
⁹ Department of Radiation Oncology, The Icahn School of Medicine at Mount Sinai, New York City, NY, USA.
¹⁰ Schiffler Cancer Center, Wheeling Hospital, Wheeling Jesuit University, Wheeling, WV, USA.
¹¹ Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, USA.
¹² Department of Oncology, Oslo University Hospital, The Norwegian Radium Hospital, Oslo, Norway.
¹³ Oakland University William Beaumont School of Medicine, Royal Oak, MI, USA.
¹⁴ Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA, USA; Department of Radiation Oncology, Veteran Affairs Greater Los Angeles Healthcare System, Los Angeles, CA, USA.
¹⁵ Department of Radiation Oncology, Veteran Affairs Greater Los Angeles Healthcare System, Los Angeles, CA, USA; Department of Urology, University of California, Los Angeles, Los Angeles, CA, USA.
¹⁶ Department of Radiation Oncology, Veteran Affairs Greater Los Angeles Healthcare System, Los Angeles, CA, USA.
¹⁷ Department of Urology, University of California, Los Angeles, Los Angeles, CA, USA.
¹⁸ Department of Pathology, University of California, Los Angeles, Los Angeles, CA, USA.
¹⁹ Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA, USA. Electronic address: aukishan@mednet.ucla.edu.

PMID: 30992160
PMCID: PMC7521828
DOI: 10.1016/j.eururo.2019.03.022

Abstract

Background: The role of elective whole-pelvis radiotherapy (WPRT) remains controversial. Few studies have investigated it in Gleason grade group (GG) 5 prostate cancer (PCa), known to have a high risk of nodal metastases.

Objective: To assess the impact of WPRT on patients with GG 5 PCa treated with external-beam radiotherapy (EBRT) or EBRT with a brachytherapy boost (EBRT+BT).

Design, setting, and participants: We identified 1170 patients with biopsy-proven GG 5 PCa from 11 centers in the United States and one in Norway treated between 2000 and 2013 (734 with EBRT and 436 with EBRT+BT).

Outcome measurements and statistical analysis: Biochemical recurrence-free survival (bRFS), distant metastasis-free survival (DMFS), and prostate cancer-specific survival (PCSS) were compared using Cox proportional hazards models with propensity score adjustment.

Results and limitations: A total of 299 EBRT patients (41%) and 320 EBRT+BT patients (73%) received WPRT. The adjusted 5-yr bRFS rates with WPRT in the EBRT and EBRT+BT groups were 66% and 88%, respectively. Without WPRT, these rates for the EBRT and EBRT+BT groups were 58% and 78%, respectively. The median follow-up was 5.6yr. WPRT was associated with improved bRFS among patients treated with EBRT+BT (hazard ratio [HR] 0.5, 95% confidence interval [CI] 0.2-0.9, p=0.02), but no evidence for improvement was found in those treated with EBRT (HR 0.8, 95% CI 0.6-1.2, p=0.4). WPRT was not significantly associated with improved DMFS or PCSS in the EBRT group (HR 1.1, 95% CI 0.7-1.7, p=0.8 for DMFS and HR 0.7, 95% CI 0.4-1.1, p=0.1 for PCSS), or in the EBRT+BT group (HR 0.6, 95% CI 0.3-1.4, p=0.2 for DMFS and HR 0.5 95% CI 0.2-1.2, p=0.1 for PCSS).

Conclusions: WPRT was not associated with improved PCSS or DMFS in patients with GG 5 PCa who received either EBRT or EBRT+BT. However, WPRT was associated with a significant improvement in bRFS among patients receiving EBRT+BT. Strategies to optimize WPRT, potentially with the use of advanced imaging techniques to identify occult nodal disease, are warranted.

Patient summary: When men with a high Gleason grade prostate cancer receive radiation with external radiation and brachytherapy, the addition of radiation to the pelvis results in a longer duration of prostate-specific antigen control. However, we did not find a difference in their survival from prostate cancer or in their survival without metastatic disease. We also did not find a benefit for radiation to the pelvis in men who received radiation without brachytherapy.

Keywords: Brachytherapy; Gleason grade group 5; Prostate cancer; Radiation therapy; Whole-pelvis irradiation.

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Conflict of interest statement

Financial disclosures: Amar U. Kishan certifies that all conflicts of interest, including specific financial interests and relationships and affiliations relevant to the subject matter or materials discussed in the manuscript (eg, employment/affiliation, grants or funding, consultancies, honoraria, stock ownership or options, expert testimony, royalties, or patents filed, received, or pending), are the following: None.

Figures

**Fig. 1 –**
Adjusted Kaplan-Meier curve and number at risk for biochemical recurrence-free survival by treatment group. BT = brachytherapy; EBRT = external-beam radiation therapy; WPRT = whole-pelvis radiation therapy.

**Fig. 2 –**
Adjusted Kaplan-Meier curve and number at risk for distant metastasis-free survival by treatment group. BT = brachytherapy; EBRT = external-beam radiation therapy; WPRT = whole-pelvis radiation therapy.

**Fig. 3 –**
Adjusted Kaplan-Meier curve and number at risk for prostate cancer-specific survival by treatment group. BT = brachytherapy; EBRT = external-beam radiation therapy; WPRT = whole-pelvis radiation therapy.

See this image and copyright information in PMC

Comment in

Randomized Trials and the Goldilocks Problem.
Chen RC. Chen RC. Eur Urol. 2020 Jan;77(1):11-13. doi: 10.1016/j.eururo.2019.05.002. Epub 2019 May 16. Eur Urol. 2020. PMID: 31103392 No abstract available.
Is pelvic prophylactic radiotherapy in prostate cancer just right?
Taussky D, Delouya G. Taussky D, et al. Transl Androl Urol. 2020 Oct;9(5):2296-2298. doi: 10.21037/tau-20-881. Transl Androl Urol. 2020. PMID: 33209698 Free PMC article. No abstract available.

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Prostate-only Versus Whole-pelvis Radiation with or Without a Brachytherapy Boost for Gleason Grade Group 5 Prostate Cancer: A Retrospective Analysis

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Prostate-only Versus Whole-pelvis Radiation with or Without a Brachytherapy Boost for Gleason Grade Group 5 Prostate Cancer: A Retrospective Analysis

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