Mark Sidhom

Post-prostatectomy radiation therapy: Consensus guidelines of the Australian and New Zealand Radiation Oncology Genito-Urinary Group

BACKGROUND AND PURPOSE Three randomised trials have demonstrated the benefit of adjuvant post-prostatectomy radiotherapy (PPRT) for high risk patients. Data also documents the effectiveness of salvage radiotherapy following a biochemical relapse post-prostatectomy. The Radiation Oncology Genito-Urinary Group recognised the need to develop consensus guidelines on to whom, when and how to deliver PPRT. MATERIALS AND METHODS Draft guidelines were developed and refined at a consensus conference in June 2006 attended by 63 delegates where urological, radiotherapy and diagnostic imaging experts spoke on aspects of PPRT. Unresolved issues were further developed by working parties and redistributed until consensus was reached. RESULTS Central to the recommendations is that patients with positive surgical margins, seminal vesicle invasion and/or extracapsular extension have a high risk of residual local disease and should be informed of the options of either immediate adjuvant radiotherapy or active surveillance with early salvage in the event of biochemical recurrence. Salvage radiotherapy should be instituted at the earliest confirmation of biochemical recurrence. Detailed contouring guidelines have been developed, defining the regions at risk of residual microscopic disease which should be included in the clinical target volume. The recommended doses are 60-64Gy for adjuvant, and 60-66Gy for salvage radiotherapy. The role of hormone therapy in conjunction with PPRT is yet to be defined. CONCLUSIONS These consensus guidelines have been developed to give clinical and technical guidance to radiation oncologists and urologists in the management of high risk post-prostatectomy patients.

A Phase III trial to investigate the timing of radiotherapy for prostate cancer with high-risk features: background and rationale of the Radiotherapy – Adjuvant Versus Early Salvage (RAVES) trial

To test the hypothesis that observation with early salvage radiotherapy (SRT) is not inferior to ‘standard’ treatment with adjuvant RT (ART) with respect to biochemical failure in patients with pT3 disease and/or positive surgical margins (SMs) after radical prostatectomy (RP).

Multidisciplinary care in oncology: medicolegal implications of group decisions

Consensus is growing that multidisciplinary meetings (MDMs) provide the best means of formulating comprehensive treatment plans for patients with cancer. Although many doctors attend MDMs and contribute to the decision-making process, only a few will become involved in a patients care after the team meeting. Despite this, if a patient was grieved by a decision made in a MDM and wished to recover damages, all doctors present at the meeting would be personally accountable for decisions related to their area of expertise. Doctors should be made aware of the legal implications of their participation in such meetings. A greater awareness of these responsibilities and improved team dynamics should optimise outcomes for patients while limiting exposure of the participants to legal liability. Special attention should be given to providing patients with adequate information in this combined speciality setting.

Why Do Some Lung Cancer Patients Receive No Anticancer Treatment

Introduction: A significant proportion of lung cancer patients receive no anticancer treatment. This varies from 19% in USA, 33% in Australia, 37% in Scotland, and 50% in Ireland. The aim of this study was to identify the reasons behind this. Methods: The Lung Cancer Multidisciplinary Meeting (MDM) in South-West Sydney prospectively collects data on all patients presented. All new lung cancer patients presented between December 1, 2005, and December 31, 2007, were reviewed. Patients were assigned optimal treatment based on evidence-based guidelines. Those patients in whom guidelines recommended no treatment (GNT) were compared with those whom the MDM recommended no treatment (MNT) and with those who actually received no treatment (ANT). Results: There were 335 patients with a median age of 69 years. A total of 82% had non-small cell lung cancer, 14% had small cell lung cancer, and 4% had no pathologic diagnosis. Eighty-five percent had locally advanced or metastatic disease. GNT was recommended in 4% (n = 13), MNT in 10% (n = 32) but ANT comprised 20% (n = 66). The differences between GNT and MNT were mainly due to patient comorbidities and clinician decision, but the differences between MNT and ANT were due to patient preference and declining performance status. In multivariate analysis, older age, poorer Eastern Cooperative Oncology Group status, non-small cell lung cancer, and non-English language predicted for ANT. Conclusions: The proportion of patients with lung cancer receiving no treatment is greater than that predicted by guidelines or recommended by the MDM but lower than that described in population-based studies suggesting that MDMs can improve treatment utilization in lung cancer.

Do multidisciplinary meetings follow guideline-based care?

PURPOSE Multidisciplinary meetings (MDMs) are increasingly being mandated as essential to oncology practice. However, there is a paucity of data on their effectiveness. The aim of this study was to assess whether MDM recommendations were concordant with guidelines in the treatment of lung cancer. PATIENTS AND METHODS The Lung Cancer Multidisciplinary Meeting in South West Sydney, Australia, prospectively collects data on all patients whose cases have been presented. New patients with lung cancer who presented between December 1, 2005, and December 31, 2007, were reviewed. Patients were assigned to treatment on the basis of evidence-based guidelines according to pathology, stage, and Eastern Cooperative Oncology Group (ECOG) performance status. MDM recommendations were compared with guideline treatment, and reasons for discrepancy were noted. RESULTS There were 335 patients with a median age of 69 years. Of these, 82% had non-small-cell lung cancer (NSCLC), 14% had small-cell lung cancer, and 4% had no pathologic diagnosis. Eighty-four percent had locally advanced or metastatic disease. Concordance of MDM recommendations with guideline treatment existed in 29 (58%) of 50 cases for surgery, 201 (88%) of 228 cases for radiotherapy, and 200 (77%) of 260 cases for chemotherapy. Overall concordance with guideline treatment was 71% (239 of 335 cases). On multivariate analysis, age greater than 70 years, ECOG performance status of 2 or higher, and stage III NSCLC were associated with the MDM not recommending guideline treatment. The primary reasons for this were physician decision (39%), comorbidity (25%), and technical factors (22%). CONCLUSION MDM recommendations were largely concordant with guidelines. Physician discretion in not recommending guideline treatment was most often exercised in older patients and those with borderline performance status. Individual factors that may preclude guideline treatment cannot be accounted for by guidelines.

Group decisions in oncology: Doctors’ perceptions of the legal responsibilities arising from multidisciplinary meetings

There is growing consensus that multidisciplinary meetings (MDMs) are the optimal means of arriving at a comprehensive treatment plan for cancer patients. However, if a patient was grieved by a decision made by an MDM and wished to recover damages, the courts would find all involved consultants responsible for decisions related to their area of expertise. The aim of this study was to assess (i) whether doctors participating in oncology MDMs are aware that they are individually accountable for the MDM decisions and (ii) whether MDMs are conducted in a way that reflects this individual responsibility. A 35‐question survey was developed and peer reviewed. Doctors attending MDMs in four Australian tertiary‐care hospitals were invited to respond. One hundred and thirty‐six responses (91% response rate) were received from 18 MDMs across 4 hospitals. Only 48% of doctors believe they are individually liable for decisions made by the MDM. This awareness was greater for an MDM where the patient attends, than in those that were ‘discussion only’ (58 vs 37%; P = 0.036). Seventy‐three per cent stated they would like further education about their legal responsibilities in MDMs. Thirty‐three per cent of doctors feel that the MDM discussion environment is suboptimal and radiation oncologists are significantly more likely to hold this view. Even though 85% of doctors have disagreed with the final MDM decision in an important way at some time, 71% did not formally dissent on those occasions. Doctors should be made aware of the legal implications of their participation in MDMs. A greater awareness of these responsibilities and improved team dynamics should optimize patient outcomes while limiting exposure of participants to legal liability.

Quantitative evaluation of diffusion-weighted imaging techniques for the purposes of radiotherapy planning in the prostate.

OBJECTIVE Diffusion-weighted imaging (DWI) is an important technique for the localization of prostate cancer, and its response assessment during treatment with radiotherapy (RT). However, it has known limitations in terms of distortions and artefacts using standard acquisition techniques. This study evaluates two alternative methods that offer the promise of improved image quality and the potential for more reliable and consistent diffusion data. METHODS Three DWI techniques were investigated; single-shot echoplanar imaging (EPI), EPI combined with reduced volume excitation (ZOOMit; Siemens Healthcare, Erlangen, Germany) and read-out segmentation with navigator-echo correction (RESOLVE; Siemens Healthcare). Daily measurements of apparent diffusion coefficient (ADC) value were made in a quality assurance phantom to assess the repeatability of each sequence. In order to evaluate the geometric integrity of these sequences, ten normal volunteers were scanned, and the prostate was contoured to compare its similarity with T2 weighted images. RESULTS Phantom ADC values were significantly higher using the standard EPI sequence than those of the other two sequences. Differences were also observed between sequences in terms of repeatability, with RESOLVE and EPI performing better than ZOOMit. Overall, the RESOLVE sequence provided the best agreement for the in vivo data with smaller differences in volume and higher contour similarity than T2 weighted imaging. CONCLUSION Important differences have been observed between each of the three techniques investigated with RESOLVE performing the best overall. We have adopted this sequence for routine RT simulation of prostate patients at Liverpool Cancer Therapy Centre. ADVANCES IN KNOWLEDGE This work will be of interest to the increasing number of centres wanting to incorporate quantitative DWI in a clinical setting.

A decision model to estimate the cost-effectiveness of intensity modulated radiation therapy (IMRT) compared to three dimensional conformal radiation therapy (3DCRT) in patients receiving radiotherapy to the prostate bed

BACKGROUND Intensity modulated radiation therapy (IMRT) is a radiation therapy technology that facilitates the delivery of an improved dose distribution with less dose to surrounding critical structures. This study estimates the longer term effectiveness and cost-effectiveness of IMRT in patients post radical prostatectomy. METHODS A Markov decision model was developed to calculate the incremental quality adjusted life years (QALYs) and costs of IMRT compared with three dimensional conformal radiation therapy (3DCRT). Costs were estimated from the perspective of the Australian health care system. RESULTS IMRT was both more effective and less costly than 3DCRT over 20 years, with an additional 20 QALYs gained and over

Endorectal balloons in the post prostatectomy setting: Do gains in stability lead to more predictable dosimetry?

1.1 million saved per 1000 patients treated. This result was robust to plausible levels of uncertainty. CONCLUSIONS IMRT was estimated to have a modest long term advantage over 3DCRT in terms of both improved effectiveness and reduced cost. This result was reliant on clinical judgement and interpretation of the existing literature, but provides quantitative guidance on the cost effectiveness of IMRT whilst long term trial evidence is awaited.

FROGG high-risk prostate cancer workshop: patterns of practice and literature review: part I: intact prostate

PURPOSE To perform a comparative study assessing potential benefits of endorectal-balloons (ERB) in post-prostatectomy patients. METHOD AND MATERIALS Ten retrospective post-prostatectomy patients treated without ERB and ten prospective patients treated with the ERB in situ were recruited. All patients received IMRT and IGRT using kilovoltage cone-beam computed tomography (kVCBCT). kVCBCT datasets were registered to the planning dataset, recontoured and the original plan recalculated on the kVCBCTs to recreate anatomical conditions during treatment. The imaging, structure and dose data were imported into in-house software for the assessment of geometric variation and cumulative equivalent uniform dose (EUD) in the two groups. RESULTS The difference in location (ΔCOV) for the bladder between planning and each CBCT was similar for each group. The range of mean ΔCOV for the rectum was 0.15-0.58 cm and 0.15-0.59 cm for the non-ERB and ERB groups. For superior-CTV and inferior-CTV the difference between planned and delivered D95% (mean ± SD) for the non-ERB group was 2.1 ± 6.0 Gy and -0.04 ± 0.20 Gy. While for the ERB group the difference in D95% was 8.7 ± 12.6 Gy and 0.003 ± 0.104 Gy. CONCLUSIONS The use of ERBs in the post-prostatectomy setting did improve geometric reproducibility of the target and surrounding normal tissues, however no improvement in dosimetric stability was observed for the margins employed.