Veronika Moravan

Predictive Factors for Acute and Late Urinary Toxicity After Permanent Prostate Brachytherapy: Long-Term Outcome in 712 Consecutive Patients

PURPOSE To describe the frequency of acute and late Radiation Therapy Oncology Group (RTOG) urinary toxicity, associated predictive factors, and resolution of International Prostate Symptom Score (IPSS) in 712 consecutive prostate brachytherapy patients. METHODS AND MATERIALS Patients underwent implantation between 1998 and 2003 (median follow-up, 57 months). The IPSS and RTOG toxicity data were prospectively collected. The patient, treatment, and implant factors were examined for an association with urinary toxicity. The time to IPSS resolution was examined using Kaplan-Meier curves, and multivariate modeling of IPSS resolution was done using Cox proportional hazards regression analysis. Logistic regression analysis was used to examine the factors associated with urinary toxicity. RESULTS The IPSS returned to baseline at a median of 12.6 months. On multivariate analysis, patients with a high baseline IPSS had a quicker resolution of their IPSS. Higher prostate D90 (dose covering 90% of the prostate), maximal postimplant IPSS, and urinary retention slowed the IPSS resolution time. The rate of the actuarial 5-year late urinary (>12 months) RTOG Grade 0, 1, 2, 3, and 4 was 32%, 36%, 24%, 6.2%, and 0.1%, respectively. At 7 years, the prevalence of RTOG Grade 0-1 was 92.5%. Patients with a larger prostate volume, greater number of needles, greater baseline IPSS, and use of hormonal therapy had more acute toxicity. On multivariate analysis, the significant predictors for late greater than or equal to RTOG toxicity 2 were a greater baseline IPSS, maximal postimplant IPSS, presence of acute toxicity, and higher prostate V150 (volume of the prostate covered by 150% of the dose). More recently implanted patients had less acute urinary toxicity and patients given hormonal therapy had less late urinary toxicity (all p < 0.02). CONCLUSION Most urinary symptoms resolved within 12 months after prostate brachytherapy, and significant long-term urinary toxicity was very low. Refined patient selection and greater technical experience in prostate brachytherapy were associated with less urinary toxicity.

PREDICTIVE FACTORS OF URINARY RETENTION FOLLOWING PROSTATE BRACHYTHERAPY

PURPOSE To evaluate the incidence and duration of urinary retention requiring catheterization and the factors predictive for these end points. METHODS AND MATERIALS Two hundred eighty-two patients treated with prostate brachytherapy alone were evaluated. Clinical and treatment-related factors examined included: age, baseline International Prostate Symptom Score (IPSS), presence of comorbidity, planning ultrasound target volume (PUTV), postimplant prostate CT scan volume, the CT:PUTV ratio, number of seeds inserted, number of needles used, use of neoadjuvant hormones, procedural physician, clinical stage, Gleason score, and pretreatment PSA. Dosimetric quality indicators were also examined. RESULTS Urinary obstruction after prostate brachytherapy developed in 43 (15%) patients. The median duration of catheter insertion was 21 days (mean 49, range 1-365). Univariate analysis demonstrated that presence of diabetes, preimplant volume, postimplant volume, CT:PUTV ratio, number of needles, and dosimetric parameters were predictive for catheterization. However, in multivariate analysis, only the baseline IPSS, CT:PUTV ratio, and presence of diabetes were significant independent predictive factors for catheterization. CONCLUSION Baseline IPSS was the most important predictive factor for postimplantation catheterization. The extent of postimplant edema, as reflected by the CT:PUTV ratio, predicted for need and duration of catheterization. The presence of diabetes was predictive for catheterization, but may relate to the absence of prophylactic steroids, and therefore requires further evaluation.

Rectal toxicity and rectal dosimetry in low-dose-rate 125I permanent prostate implants: A long-term study in 1006 patients

OBJECTIVE To describe the acute and late rectal toxicity in 1006 prostate brachytherapy patients implanted 1998-2003. To determine whether rectal dose-volume histogram as well as patient and treatment factors were associated with rectal toxicity. METHODS AND MATERIALS Median followup was 60.7 months. Rectal dosimetry was calculated as dose-volume histogram of the rectum using Day 28 CT-based dosimetry and expressed as volume of the rectum in cc receiving 50%, 100%, and 150% of the prescription dose (VR(50cc), VR(100cc), and VR(150cc), respectively). Univariate and multivariate analyses were performed to examine the influence of patient, implant, dosimetry, and learning curve factors on the development of acute and late toxicities using a modified Radiation Therapy Oncology Group (RTOG) scale. Acute toxicity was analyzed using logistic regression and late toxicity using Cox proportional hazards regression. Analysis of variance was used to examine the association between rectal toxicity and rectal dose. RESULTS Rectal dosimetry in 93.5% and rectal toxicity in 96.2% have been recorded. Median VR(100)=1.05cc. Late RTOG Grades 0, 1, 2, 3, and 4 were recorded in 68%, 23%, 7.3%, 0.9%, and 0.2% patients, respectively. On multivariate analysis, acute RTOG ≥2 rectal toxicity was associated with urinary retention (p=0.036) and learning curve (p=0.015); late RTOG ≥2 was associated with the presence of acute toxicity (p=0.0074), higher VR(100) (p=0.030) and learning curve (p=0.027). CONCLUSIONS Late rectal RTOG ≥2 rectal toxicity in this cohort was 8%. Increased VR(100), presence of acute rectal toxicity, and learning curve were associated with higher rate of late RTOG ≥2 toxicity. Severe late rectal toxicity after prostate brachytherapy was rare.

SEGMENTAL URETHRAL DOSIMETRY AND URINARY TOXICITY IN PATIENTS WITH NO URINARY SYMPTOMS BEFORE PERMANENT PROSTATE BRACHYTHERAPY

PURPOSE To determine whether segmental urethral dosimetry is predictive for the degree of urinary morbidity after prostate brachytherapy in patients with no urinary symptoms before prostate brachytherapy. METHODS AND MATERIALS Between May 2000 and November 2005, 1,107 patients underwent iodine-125 monotherapy with urethral sparing techniques. A total of 166 patients fulfilled the selection criteria: baseline (International Prostate Symptom Score) IPSS < or =5, no androgen deprivation therapy, and prostate ultrasound planning volumes (PUTV) <45 mL. The median follow-up was 44 months. Urinary morbidity was defined by maximum increase in IPSS, time to IPSS resolution, maximum Radiation Therapy Oncology Group (RTOG) score, time to RTOG resolution, and urinary retention. Surrogate deviated urethra was contoured and doses calculated at the base, mid-prostate, apex, and urogenital diaphragm. Univariate and multivariate analysis was used to evaluate urethral and prostate dosimetry, age, PUTV, and number of needles for their association with urinary morbidity. RESULTS Urethral dose was fairly constant in all urethra segments except prostate base, where the variation in does was large. On multivariate analysis, higher urethral base D50, V100, and larger PUTV were predictive for higher maximum increase in IPSS. Higher urethral base V100 and larger PUTV predicted for prolonged IPSS resolution. Higher urethral base D50 and larger needle number predicted for longer RTOG resolution. Higher urethral base V100 predicted for RTOG > or =2 toxicity. CONCLUSIONS Radiation dose to the urethral base, larger PUTV, and needle number, predicted for increased urinary toxicity after prostate brachytherapy. Correlation between urinary morbidity and urethral base dosimetry may reflect a large variation in urethral dose observed at the prostate base.

Preliminary reliability and validity testing of a new Skin Toxicity Assessment Tool (STAT) in breast cancer patients undergoing radiotherapy.

Clear consensus on the clinical evaluation of acute skin toxicity among cancer patients undergoing radical radiotherapy (RT) is currently lacking. This study investigates the reliability and validity of a new Skin Toxicity Assessment Tool (STAT) to evaluate the objective and subjective manifestations of RT-induced acute skin effects. The STAT was designed by a multidisciplinary team involved in the management of radiation skin reactions. The tool has 3 components: patient and treatment parameters, observer scoring, and patient-reported symptoms, and was piloted in a cohort of 27 breast cancer patients by pairs of independent blinded observers. Each patient was assessed weekly during RT and 2 weeks after therapy completion. Validity and reliability testing of the STAT was performed. Information on the tools ease of use was obtained by recording the time necessary to complete the assessment at each visit and by a survey among the tools users. All subjects developed some degree of skin reaction during breast RT. The level of agreement between observers in eliciting subjective complaints ranged from 72% to 92% (95% CI = 63–96%; &kgr; = 0.33–0.68). The interobserver agreement in scoring skin reactions ranged from 65.0 to 97.5% (&kgr; = 0.46–0.81). Objective and subjective toxicity scores were significantly correlated (P < 0.05). The STAT was easy to use and required on average a few minutes to complete at each visit. The STAT is an easy-to-use, standardized instrument to evaluate acute skin reaction and may be applied to clinical care and research in patients undergoing radiotherapy.

Twelve Committed Men: the feasibility of a community-based participatory HIV-prevention intervention within a Canadian men’s correctional facility

Objectives: The intervention objectives were to evaluate and describe the feasibility of using a community-based research (CBR) approach to adapt and implement HIV-prevention materials and tools with incarcerated men. We found no prior published reports about CBR HIV-prevention education in Canadian correctional facilities. Methods: Twelve members of the correctional Peer Education Committee (PEC) and Aboriginal PEC, whom a correctional nurse identified as being interested in preventive health, were purposively invited to participate. Eight participants were serving life sentences, three were Aboriginal and their education levels ranged from below grade 8 to 11 years of post-secondary education. The setting was a medium-security federal correctional facility, housing 324 men. The intervention was guided by CBR and ‘greater involvement of people with AIDS’ principles. Participants were invited to attend four workshops, over seven days in May 2014, and to provide their insights regarding future scaled-up CBR HIV prevention. Each workshop included an HIV-prevention presentation and a focus group discussion, two of which were audio-recorded. Findings: All participants attended all sessions. Synthesis of mixed-method findings, with quantitative and qualitative data triangulation, demonstrated two major outcomes: ‘new knowledge was generated’ regarding feasibility of CBR HIV prevention in a men’s correction facility; and ‘capacity building occurred’ with increased participants’ social capital. Thirty incarcerated men requested HIV testing following the intervention, because participants spread their knowledge about HIV prevention to others. Participants asked to become ‘health ambassadors’ – champion advisors for future scaled-up CBR HIV-prevention intervention for the entire correctional facility. Conclusion: CBR HIV prevention is feasible within a Canadian men’s correctional facility.

Familial support impacts incarcerated women's housing stability

Purpose – This participatory health research project of researchers and women prisoners examined housing and homelessness as perceived by incarcerated women to understand this public health concern and help guide policy. The paper aims to discuss these issues. Design/methodology/approach – A participatory research team designed and conducted a survey of 83 incarcerated women in BC, Canada. Using descriptive statistics, the authors examined socio-demographic factors related to social support networks and family housing and women’s housing preference upon release. Findings – In total, 44 percent of participants reported no family home upon release while 31 percent reported lost family ties due to their incarceration. Most vulnerable subpopulations were women aged 25-34, aboriginal women and those with multiple incarcerations. Housing preferences differed between participants suggesting needs for varied options. Further implementation, evaluation and appraisal of social programs are required. Research limita...