Radiation Therapy for Prostate Cancer

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Presentation transcript:

Radiation Therapy for Prostate Cancer Ronald Chen, MD MPH Associate Professor, Radiation Oncology University of North Carolina – Chapel Hill Associate Director, UNC Lineberger Comprehensive Cancer Center NASPCC 10-13-18

Disclosures Accuray Inc: consulting and research funding Bayer: consulting

Outline 1) Shortening radiation treatment for prostate cancer 2) “Oligometastatic” prostate cancer

Reducing radiation treatment time

Definitions Daily Dose (Gy) Number of Treatments Total Dose (Gy) Duration (Weeks) Conventional 1.8-2 38-45 75-81 8-9 Moderate Hypofractionation 2.4-3.4 15-30 57-70 3-6 Extreme Hypofractionation 7-10 4-5 35-50 1-2

Concern – is this effective? Daily Dose (Gy) Number of Treatments Total Dose (Gy) Duration (Weeks) Conventional 1.8-2 38-45 75-81 8-9 Moderate Hypofractionation 2.4-3.4 15-30 57-70 3-6 Extreme Hypofractionation 7-10 4-5 35-50 1-2

Concern – is this safe? Daily Dose (Gy) Number of Treatments Total Dose (Gy) Duration (Weeks) Conventional 1.8-2 38-45 75-81 8-9 Moderate Hypofractionation 2.4-3.4 15-30 57-70 3-6 Extreme Hypofractionation 7-10 4-5 35-50 1-2

Moderate Hypofractionation Daily Dose # Doses Total Dose Italy 168 2 40 80 3.1 20 62 MDACC 204 1.8 42 75.6 2.4 30 72 Australia 217 32 64 2.75 55 Fox Chase 303 38 76 2.7 26 70.2 HYPRO 804 39 78 3.4 19 64.6 Lukka 936 33 66 2.62 52.5 RTOG 1092 41 73.8 2.5 24 60 PROFIT 1206 3 CHHiP 3216 37 74

Moderate Hypofractionation 9 clinical trials Low risk prostate cancer to high risk cancer Hypofractionation No increase in recurrence Similar side effects Benefits to patients: Patient convenience Equally effective and cheaper cost = more cost-effective

Extreme Hypofractionation Reducing radiation treatment to only 1-2 weeks “Cyberknife” is a branded machine that is often used

Extreme Hypofractionation Largest reported study to date: Pooled analysis of patients from 8 institutions (UCLA, Harvard/Beth-Israel, Italy, Georgetown, Swedish Medical Center/Seattle, etc) N=1100, enrolled 2003-2011 35-40 Gy/4-5 fractions King CR et al. Radiat Oncol 109:217-221, 2013.

Efficacy 5-year relapse free survival Low risk (N=641): 95% Intermediate (N=334): 84% High (N=125): 81%

Efficacy N=477, low or intermediate risk 7-7.25 Gy/fraction x 5 = 35-36.25 Gy total Katz AJ et al. Frontier Oncol 4:article 240, 2014.

Efficacy Median PSA at 7 years: 0.11

Quality of Life Prospectively collected using EPIC Urinary Bowel Sexual (14% ADT) Katz AJ et al. Frontier Oncol 4:article 301, 2014.

Randomized Trial Intermediate/high risk prostate cancer 2 Gy x 39 = 78 Gy 6.1Gy x 7 = 42.7 Gy N=1180 patients 5-year free from recurrence: 84% vs 84% No difference in toxicity No ADT Widmark A et al. ESTRO 2018.

Conclusions Daily Dose (Gy) Number of Treatments Total Dose (Gy) Duration (Weeks) Conventional 1.8-2 38-45 75-81 8-9 Moderate Hypofractionation 2.4-3.4 15-30 57-70 3-6 Extreme Hypofractionation 7-10 4-5 35-50 1-2

Treatment for oligometastatic prostate cancer

Oligometastatic Cancer Cancer that has metastasized to only a few places Currently, standard treatment is ADT Can aggressive treatment help some patients? Is this potentially curable?

STOMP Trial 62 patients with prostate cancer recurrence ≤ 3 metastases Randomize: Observation Surgery or stereotactic body RT to all metastases Ost P et al. JCO 36(5):446-53, 2018.

Results Time to starting ADT Obs: 13 months Treatment: 21 months

Conclusion Targeted (surgery or SBRT) to all metastases for patients with oligometastatic prostate cancer is Well tolerated Delays the need for ADT – which may be beneficial to patients

Other Ongoing Trials Patient with newly diagnosed metastatic prostate cancer Few areas of metastasis Treat all the areas of disease (prostate and metastases) – does that help improve patient outcomes?