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Association of Brachytherapy Boost with Overall Survival for Gleason 9-10 Prostate Cancer: The Impact of Primary versus Secondary Pattern 5

Published:January 10, 2023DOI:https://doi.org/10.1016/j.brachy.2022.12.004

      ABSTRACT

      PURPOSE

      The addition of a brachytherapy (BT) boost to external beam radiotherapy (EBRT) reduces recurrence risk in men with high-risk prostate cancer (PCa) and may reduce PCa-mortality for Gleason grade group 5 (GG5). Whether the extent of pattern five, a risk factor for distant metastases, impacts the benefit of a BT boost is unclear.

      METHODS

      Men with localized GG5 PCa treated with (

      National Comprehensive Cancer Network. NCCN Guidelines: prostate cancer. Updated March 2022. Access March 29, 2022.

      ) EBRT or (
      • Mohler JL
      • Antonarakis ES
      • Armstrong AJ
      • et al.
      Prostate Cancer, version 2.2019, NCCN clinical practice guidelines in oncology.
      ) EBRT+BT between 2010 and 2016 were identified in the National Cancer Database. EBRT monotherapy group received conventionally fractionated (1.8−2.0 Gy per fraction) ≥74 Gy or moderately hypofractionated (2.5−3.0 Gy per fraction) ≥60 Gy. EBRT + BT group received conventionally fractionated ≥45 Gy or moderately hypofractionated ≥37.5 Gy, and either LDR or HDR BT. All patients received concomitant ADT; none received chemotherapy, immunotherapy, or surgery. OS was compared using Kaplan-Meier, log-rank test, and multivariable Cox proportional hazards in the overall cohort, followed by subgroups based on primary versus secondary pattern 5. Propensity score- and exact-matching was used to corroborate results.

      RESULTS

      A total of 8260 men were eligible: EBRT alone (89%) versus EBRT + BT (11%). 5-year OS for EBRT versus EBRT + BT was 76.3% and 85.0%, respectively (p = 0.002; multivariable adjusted HR 0.84, 95% CI 0.65−0.98; p = 0.04). These results remained consistent after propensity score and exact matching. The OS advantage of a BT boost was more prominent in men with Gleason 4 + 5 PCa (p = 0.001) and not observed in men with Gleason 5 + 5 or 5 + 4 PCa.

      CONCLUSIONS

      Extent of pattern five may be useful in appropriately selecting men for EBRT+BT and should be considered as a pre-randomization stratification variable for future clinical trial design.

      Keywords

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      References

      1. National Comprehensive Cancer Network. NCCN Guidelines: prostate cancer. Updated March 2022. Access March 29, 2022.

        • Mohler JL
        • Antonarakis ES
        • Armstrong AJ
        • et al.
        Prostate Cancer, version 2.2019, NCCN clinical practice guidelines in oncology.
        J Natl Compr Canc Netw. 2019; 17: 479-505
        • Morris WJ
        • Tyldesley S
        • Rodda S
        • et al.
        Androgen Suppression Combined with Elective Nodal and Dose Escalated Radiation Therapy (the ASCENDE-RT Trial): an analysis of survival endpoints for a randomized trial comparing a low-dose-rate brachytherapy boost to a dose-escalated external beam boost for high- and intermediate-risk prostate cancer.
        Int J Radiat Oncol Biol Phys. 2017; 98: 275-285
        • Rodda S
        • Tyldesley S
        • Morris WJ
        • et al.
        ASCENDE-RT: an analysis of treatment-related morbidity for a randomized trial comparing a low-dose-rate brachytherapy boost with a dose-escalated external beam boost for high- and intermediate-risk prostate cancer.
        Int J Radiat Oncol Biol Phys. 2017; 98: 286-295
        • Kishan AU
        • Cook RR
        • Ciezki JP
        • et al.
        Radical prostatectomy, external beam radiotherapy, or external beam radiotherapy with brachytherapy boost and disease progression and mortality in patients with Gleason score 9-10 prostate cancer.
        JAMA. 2018; 319: 896-905
        • Epstein JI
        • Zelefsky MJ
        • Sjoberg DD
        • et al.
        A contemporary prostate cancer grading system: A validated alternative to the gleason score.
        Eur Urol. 2016; 69: 428-435
        • Hamstra DA
        • Pugh SL
        • Lepor H
        • et al.
        Gleason pattern 5 is associated with an increased risk for metastasis following androgen deprivation therapy and radiation: An analysis of RTOG 9202 and 9902.
        Radiother Oncol. 2019; 141: 137-143
        • Winchester DP
        • Stewart AK
        • Phillips JL
        • Ward EE.
        The national cancer data base: past, present, and future.
        Ann Surg Oncol. 2010; 17: 4-7
        • Lerro CC
        • Robbins AS
        • Phillips JL
        • Stewart AK.
        Comparison of cases captured in the national cancer data base with those in population-based central cancer registries.
        Ann Surg Oncol. 2013; 20: 1759-1765
        • Sabolch A
        • Feng FY
        • Daignault-Newton S
        • et al.
        Gleason pattern 5 is the greatest risk factor for clinical failure and death from prostate cancer after dose-escalated radiation therapy and hormonal ablation.
        Int J Radiat Oncol Biol Phys. 2011; 81: e351-e360
        • Mahal BA
        • Muralidhar V
        • Chen YW
        • et al.
        Gleason score 5 + 3 = 8 prostate cancer: much more like Gleason score 9?.
        BJU Int. 2016; 118: 95-101
        • Michalski JM
        • Moughan J
        • Purdy J
        • et al.
        Effect of standard vs dose-escalated radiation therapy for patients with intermediate-risk prostate cancer: the NRG oncology RTOG 0126 randomized clinical trial.
        JAMA Oncol. 2018; 4e180039
        • Kuban DA
        • Tucker SL
        • Dong L
        • et al.
        Long-term results of the M. D. Anderson randomized dose-escalation trial for prostate cancer.
        Int J Radiat Oncol Biol Phys. 2008; 70: 67-74