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. 2021 May 31;13(11):2732.
doi: 10.3390/cancers13112732.

Optimizing External Beam Radiotherapy as per the Risk Group of Localized Prostate Cancer: A Nationwide Multi-Institutional Study (KROG 18-15)

Seo Hee Choi  1   2 , Young Seok Kim  3 , Jesang Yu  3 , Taek-Keun Nam  4 , Jae-Sung Kim  5 , Bum-Sup Jang  5 , Jin Ho Kim  6 , Youngkyong Kim  7 , Bae Kwon Jung  8 , Ah Ram Chang  9 , Young-Hee Park  9 , Sung Uk Lee  10 , Kwan Ho Cho  10 , Jin Hee Kim  11 , Hunjung Kim  12 , Youngmin Choi  13 , Yeon Joo Kim  3   14 , Dong Soo Lee  15 , Young Ju Shin  16 , Su Jung Shim  17 , Won Park  18 , Jaeho Cho  2
Affiliations

Optimizing External Beam Radiotherapy as per the Risk Group of Localized Prostate Cancer: A Nationwide Multi-Institutional Study (KROG 18-15)

Seo Hee Choi et al. Cancers (Basel). .

Abstract

Purpose: This nationwide multi-institutional study analyzed the patterns of care and outcomes of external beam radiotherapy (EBRT) in localized prostate cancer patients. We compared various risk classification tools and assessed the need for refinements in current radiotherapy (RT) schemes.

Methods and materials: We included non-metastatic prostate cancer patients treated with primary EBRT from 2001 to 2015 in this study. Data of 1573 patients from 17 institutions were analyzed and re-grouped using a risk stratification tool with the highest predictive power for biochemical failure-free survival (BCFFS). We evaluated BCFFS, overall survival (OS), and toxicity rates.

Results: With a median follow-up of 75 months, 5- and 10-year BCFFS rates were 82% and 60%, and 5- and 10-year OS rates were 95% and 83%, respectively. NCCN risk classification revealed the highest predictive power (AUC = 0.556, 95% CI 0.524-0.588; p < 0.001). Gleason score, iPSA < 12 ng/mL, intensity-modulated RT (IMRT), and ≥179 Gy1.5 (EQD2, 77 Gy) were independently significant for BCFFS (all p < 0.05). IMRT and ≥179 Gy1.5 were significant factors in the high-risk group, whereas ≥170 Gy1.5 (EQD2, 72 Gy) was significant in the intermediate-risk group and no significant impact of dose was observed in the low-risk group. Both BCFFS and OS improved significantly when ≥179 Gy1.5 was delivered using IMRT and hypofractionation in the high-risk group without increasing toxicities.

Conclusions: With NCCN risk classification, dose escalation with modern high-precision techniques might increase survivals in the high-risk group, but not in the low-risk group, although mature results of prospective studies are awaited.

Keywords: NCCN; dose-escalation; hypofractionation; prostate cancer; radiotherapy; risk assessment.

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Conflict of interest statement

The authors have disclosed that they have not received any financial consideration from any person or organization to support the preparation, analysis, results, or discussion of this article.

Figures

Figure 1
Figure 1
Kaplan–Meier survival curves of biochemical failure (BCF)-free survival, overall survival (OS), and cause-specific survival rates in all patients.
Figure 2
Figure 2
(a) Receiver operating characteristic curves for each risk-stratification tool as a predictor of biochemical failure (BCF)-free survival, and (b) BCF-free survival and (c) cause-specific survival rates according to risk groups stratified using four different classification tools (NCCN, D’Amico, AUA, and CPG guidelines). AUA, American Urological Association; CPG, Cambridge Prognostic Groups; NCCN, National Comprehensive Cancer Network. * denotes statistically significant p value.
Figure 2
Figure 2
(a) Receiver operating characteristic curves for each risk-stratification tool as a predictor of biochemical failure (BCF)-free survival, and (b) BCF-free survival and (c) cause-specific survival rates according to risk groups stratified using four different classification tools (NCCN, D’Amico, AUA, and CPG guidelines). AUA, American Urological Association; CPG, Cambridge Prognostic Groups; NCCN, National Comprehensive Cancer Network. * denotes statistically significant p value.
Figure 3
Figure 3
Kaplan–Meier survival curves of patients treated with radiotherapy using intensity-modulated radiotherapy (IMRT), hypofractionation (HF), and higher dose (≥179 Gy1.5). (a) Biochemical failure (BCF)-free survival (BCFFS), overall survival (OS), and cause-specific survival rates in all patients (829 patients with all three factors vs. the rest). BCFFS and OS rates were significantly improved with this combination, but no significant differences were observed in cause-specific survival rates. (b) BCFFS rates in each NCCN risk group. BCFFS rates were significantly improved with this combination in intermediate- and high-risk groups. (c) OS rates in each NCCN risk group. OS rate was significantly improved with this combination only in the high-risk group. NCCN, National Comprehensive Cancer Network. * denotes statistically significant p value.
Figure 3
Figure 3
Kaplan–Meier survival curves of patients treated with radiotherapy using intensity-modulated radiotherapy (IMRT), hypofractionation (HF), and higher dose (≥179 Gy1.5). (a) Biochemical failure (BCF)-free survival (BCFFS), overall survival (OS), and cause-specific survival rates in all patients (829 patients with all three factors vs. the rest). BCFFS and OS rates were significantly improved with this combination, but no significant differences were observed in cause-specific survival rates. (b) BCFFS rates in each NCCN risk group. BCFFS rates were significantly improved with this combination in intermediate- and high-risk groups. (c) OS rates in each NCCN risk group. OS rate was significantly improved with this combination only in the high-risk group. NCCN, National Comprehensive Cancer Network. * denotes statistically significant p value.
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