Gary S. Gustafson

Brachytherapy provides comparable outcomes and improved cost-effectiveness in the treatment of low/intermediate prostate cancer

PURPOSEnTo evaluate the cost-effectiveness and outcomes of low-dose-rate (LDR) and high-dose-rate (HDR) brachytherapy compared with intensity-modulated radiation therapy (IMRT) in patients with low/intermediate risk of prostate cancer.nnnMETHODS AND MATERIALSnOne thousand three hundred twenty-eight patients with low or intermediate risk of prostate cancer were treated with LDR (n=207), HDR with four fractions (n=252), or IMRT (n=869) between January 1992 and December 2008. LDR patients were treated with palladium seeds to a median dose of 120 Gy, whereas HDR patients were treated to a median dose 38.0 Gy (four fractions). IMRT patients received 42-44 fractions with a median dose of 75.6 Gy. Clinical outcomes were compared, including biochemical failure, cause-specific survival, and overall survival.nnnRESULTSnOverall, no differences in 5-year biochemical control (BC) or cause-specific survival were noted among treatment modalities. The calculated reimbursement for LDR brachytherapy, HDR brachytherapy with four fractions, and IMRT was

Outcomes Associated With 3 Treatment Schedules of High-Dose-Rate Brachytherapy Monotherapy for Favorable-Risk Prostate Cancer

9,938;

Prognostic Significance of Neuroendocrine Differentiation in Patients With Gleason Score 8–10 Prostate Cancer Treated With Primary Radiotherapy

17,514; and

Favorable Preliminary Outcomes for Men With Low- and Intermediate-risk Prostate Cancer Treated With 19-Gy Single-fraction High-dose-rate Brachytherapy

29,356, respectively. HDR and LDR brachytherapy were statistically less costly to Medicare and the institution than IMRT (p<0.001), and LDR brachytherapy was less costly than HDR brachytherapy (p=0.01 and p<0.001). Incremental cost-effectiveness ratios for cost to Medicare for BC with IMRT were

Results of Image-Guided, Dose-Escalated Radiation Therapy for Localized Prostate Cancer: 10-Year Results Using an Off-Line, Adaptive Technique

4045 and

Low and Intermediate Risk Prostate Cancer Treated with Single Fraction 19 Gy High Dose Rate Brachytherapy as Monotherapy: Outcomes Comparison to Multi-Fraction Regimens

2754 per percent of BC for LDR and HDR brachytherapy, respectively. Incremental cost-effectiveness ratio using institutional cost comparing IMRT with LDR and HDR brachytherapy was

Comparison of Toxicity Profiles Associated With 3 High-Dose-Rate Brachytherapy Treatment Schedules for Favorable-Risk Prostate Cancer

4962 and

Favorable Toxicity Profiles for Low- and Intermediate-Risk Prostate Cancer Patients Treated With Single-Fraction High-Dose-Rate Brachytherapy

4824 per 1% improvement in BC.nnnCONCLUSIONSnIn this study of patients with low and intermediate risk of prostate cancer, comparable outcomes at 5 years were noted between modalities with increased costs associated with IMRT.

Long-Term Clinical Outcomes for Patients Treated With Adjuvant Versus Early Versus Delayed Salvage Radiation Therapy in the Postprostatectomy Setting

PURPOSEnWe report the outcomes associated with 3 high-dose-rate (HDR) brachytherapy regimens used as monotherapy for favorable-risk prostate cancer.nnnMETHODS AND MATERIALSnFour hundred ninety-four patients with stagexa0≤T2b prostate cancer, Gleason score ≤7, and prostate-specific antigen levels ≤15xa0ng/mL underwent HDR brachytherapy as monotherapy. Of those, 319 received 38xa0Gy in 4 fractions, 79 received 24xa0Gy in 2 fractions, and 96 received 27xa0Gy in 2 fractions. Acute and chronic genitourinary (GU) and gastrointestinal (GI) toxicities were defined as side effects occurring ≤6 andxa0>6xa0months, respectively, after radiation therapy (RT) and were graded according to the Common Terminology Criteria for Adverse Events version 3.0. The time to toxicity was calculated from the date of RT completion. Variables were analyzed with χ(2) test. P values <.05 were considered significant.nnnRESULTSnThe median overall follow-up time was 4xa0years (range, 5.5, 3.5, and 2.5xa0years for 38xa0Gy, 24xa0Gy, and 27xa0Gy, respectively, P<.001). Acute and chronic grade ≥2 GU and GI toxicity profiles were similar among groups. Acceptable rates of grade 2 GU toxicities were seen with overall acute/chronic frequency/urgency, dysuria, retention, incontinence, and hematuria rates of 14%/20%, 6%/7%, 7%/4%, 1.5%/2%, and 1.5%/7%, respectively. Minimal grade 3 and no grade 4 or 5 toxicities were seen. Grade 1, 2, and 3 chronic urethral stricture rates were 0.3%, 2%, and 1%, respectively. All GI toxicities were similar between groups, with overall rates of acute/chronic grade 2 diarrhea, rectal pain/tenesmus, rectal bleeding, and proctitis of 1%/1%, <1%/0.5%, 0%/2%, and <1%/1%, respectively. No grade 3, 4, or 5 toxicities were seen. All comparisons were similar for hormone-naïve patients. The median time to maximal GU/GI toxicity was similar between groups, ranging from 1 to 1.6 to 0.9 to 1.2xa0years, respectively. There were no differences in clinical outcomes between the 3 groups at 5xa0years.nnnCONCLUSIONSnThe acute and chronic toxicity profiles associated with these 3 HDR brachytherapy schedules were similar and were well tolerated. Acceptable grade 2, minimal grade 3, and no grade 4 or 5 toxicities were seen. This, combined with the fact that the clinical outcomes were similar, leads to the conclusion that all 3 regimens may be acceptable options for the management of low-risk to intermediate-risk prostate cancer.

Boost Versus Monotherapy: A Propensity-Score Matched-Pair Analysis of High-Dose-Rate Brachytherapy with or without External Beam Radiotherapy for Low- and Intermediate-Risk Prostate Cancer

PURPOSEnTo determine the prognostic significance of neuroendocrine differentiation (NED) in Gleason score 8-10 prostate cancer treated with primary radiotherapy (RT).nnnMETHODS AND MATERIALSnChromogranin A (CgA) staining was performed and overseen by a single pathologist on core biopsies from 176 patients from the William Beaumont prostate cancer database. A total of 143 had evaluable biopsy material. Staining was quantified as 0%, <1%, 1-10%, or >10% of tumor cells. Patients received external beam RT alone or together with high-dose-rate brachytherapy. Cox regression and Kaplan-Meier estimates determined if the presence/frequency of neuroendocrine cells correlated with clinical endpoints.nnnRESULTSnMedian follow-up was 5.5 years. Forty patients (28%) had at least focal positive CgA staining (<1% n = 21, 1-10% n = 11, >10% n = 8). No significant differences existed between patients with or without staining in terms of age, pretreatment prostate-specific antigen, tumor stage, hormone therapy administration, % biopsy core involvement, mean Gleason score, or RT dose/modality. CgA staining concentration independently predicted for biochemical and clinical failure, distant metastases (DM), and cause-specific survival (CSS). For patients with <1% vs. >1% staining, 10-year DM rates were 13.4% vs. 55.3%, respectively (p = 0.001), and CSS was 91.7% vs. 58.9% (p < 0.001). As a continuous variable, increasing CgA staining concentration predicted for inferior rates of DM, CSS, biochemical control, and any clinical failure. No differences in outcomes were appreciated for patients with 0% vs. <1% NED.nnnCONCLUSIONSnFor Gleason score 8-10 prostate cancer, >1% NED is associated with inferior clinical outcomes for patients treated with radiotherapy. This relates most directly to an increase in distant disease failure.