Sbrt For Localized Prostate Cancer: Is It Ready For Take
- Ananya ChoudhuryAffiliations
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Pretreatment Assessment And Follow
The International Prostate Symptom Score and the Expanded Prostate Cancer Index Composite short form were used to evaluate urinary symptomatology prior to treatment and during subsequent follow-up visits . Initial assessments were performed on the day of initial consultation. Follow-up questionnaires were completed at start of treatment, 3-months post-treatment, every 3-months to 1-year post-treatment, and every 6 months thereafter. IPSS alternatively is scored between 0 and 35 with higher scores suggesting worse symptoms. The EPIC urinary domain is scored on a range from 0 to 100 with higher values representing more favorable urinary symptoms. Toxicities at each time point were scored using the CTCAE v4. The utilization of alpha1 antagonists was prospectively documented at each visit.
What Happens During Sbrt
Before treatment, your bowels must be emptied, yet your bladder should be full.
When you arrive for SBRT, youre positioned on a table, and the radiation therapist aligns you to small tattoos that are dotted on your skin. Next, a CT scanner built onto the radiation therapy machine takes a 3D image of your anatomy.
We usually implant markers into the prostate that can act like a GPS device, says Dr. Tendulkar.
Because of the high doses, a radiation oncologist, physicist and radiation therapist must all be present to verify that your position is perfect. If needed, they make millimeter adjustments to ensure the bladder and rectum are safely out of range.
Once the beam is turned on, treatment takes only three to four minutes, he says. If the markers show us that youre moving, well pause the treatment.
Our patients are typically in and out within half an hour.
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High Dose Stereotactic Body Radiotherapy
High dose stereotactic body radiotherapy treatment of men with newly diagnosed prostate cancer appears to result in shorter treatment times, less severe toxicity and excellent cancer control rates.1-6
Although prostate cancer generally responds well to radiation therapy, the possibility of radiation exposure to healthy tissue in the genitourinary and gastrointestinal systems can be of concern. SBRT is an advanced technique that precisely targets high doses of radiation to the cancer in a small number fractions, simultaneously avoiding surrounding tissue and reducing toxicity to non-cancerous cells.
Men with early stage prostate cancer can currently be treated with surgical prostatectomy, brachytherapy or external beam radiation therapy . SBRT, a form of EBRT condenses the radiation treatment for prostate cancer into as few as four to five sessions . The technique has become the standard of care for many non-surgical lung cancer patients, as it limits exposure to the heart and surrounding lungs. When treating tumors in the prostate, SBRT avoids the adjacent bladder, sex organs and rectum.
Possible Side Effects Of Radiation Treatment For Prostate Cancer
The radiation used to destroy cancer cells can also hurt normal cells in the nearby area. Side effects from radiation treatment are related to the area of the body being treated. Patients start to have side effects a few weeks into their treatment. While side effects may be unpleasant, there are treatments to help deal with them. Most side effects are temporary and slowly start to go away once treatment is done.
You will be seen by your radiation oncology providers often during treatment. These visits are a chance to ask questions and to talk about any side effects and how to best manage them. You can also call your providers to speak about any side effects.
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Stereotactic Body Radiation Therapy For Prostate Cancer In Men With A High Baseline International Prostate Symptom Score
- 1Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
- 2George Washington University, School of Medicine and Health Sciences, Washington, DC, United States
- 3University of Cincinnati College of Medicine, Cincinnati, OH, United States
- 4Arizona College of Osteopathic Medicine, Glendale, AZ, United States
- 5Julius L. Chambers Biomedical Biotechnology Research Institute, North Carolina Central University, Durham, NC, United States
- 6Department of Urology, Georgetown University Hospital, Washington, DC, United States
Background: Patients with a high pretreatment IPSS may have higher rates of late urinary morbidity after radiation therapy for prostate cancer . Stereotactic body radiation therapy delivers fewer high-dose fractions of radiation, which may be radiobiologically favorable to the conventional low-dose external beam fractions. The urinary toxicity associated with SBRT, however, remains unclear in patients with a high IPSS . We report our experience using SBRT for localized prostate cancer in patients with pretreatment IPSS 15.
SBRT for clinically localized prostate cancer was well-tolerated in men with baseline IPSS 15 . Grade 3 toxicities occurred but resolved with time. Our data suggest that poor baseline urinary function does not worsen following SBRT and may even improve. High baseline IPSS score should not be considered a contraindication to SBRT.
How Is Sbrt Different From Conventional Radiation Therapy For Prostate Cancer
Conventional radiotherapy can take up to 9 weeks. With this approach, you receive low doses of radiation on a daily basis. These low doses are necessary to avoid affecting your bladder or rectum.
Healthcare professionals can complete SBRT more quickly than conventional therapy because the intense, focused beams of radiation only target the prostate, not the areas around it. Thus, the bladder and rectum arent exposed to it.
SBRT involves a shorter treatment period than conventional radiotherapy. This may be more convenient if you keep a busy schedule or find it hard to come into the hospital regularly.
SBRT is a great option, but it is important that patients understand that there are other options based on the type of prostate cancer they have and that SBRT may not be the best approach for them, says Dr. Louis Potters, chair of radiation medicine and deputy physician-in-chief of Northwell Health Cancer Institute, one of the largest cancer programs in the New York metropolitan area.
This is a key factor, so that patients do not get their expectations set for a particular treatment but rather what is the best treatment for them.
Northwell Health offers a comprehensive approach to prostate cancer, with treatments including SBRT.
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What Is Stereotactic Body Radiotherapy
Traditionally, prostate cancer radiotherapy has been delivered over the course of multiple treatment sessions with a low dose per treatment session. In order to deliver the total dose needed to eradicate prostate cancer, up to 45 treatments were needed, which translates to nine weeks of daily treatments . It has since become appreciated that prostate cancer appears to be uniquely sensitive to a higher dose per treatment session, such that prostate cancer could be eradicated in a much shorter amount of time with significantly fewer treatments. Various ways of doing this have been explored. Among them, stereotactic body radiotherapy , also known as stereotactic ablative radiotherapy, is a radiation therapy technique that allows the prostate radiotherapy course to be condensed to just five treatment sessions. With SBRT, advanced treatment delivery technologies and radiation planning parameters are used to deliver higher doses per day in a safe and effective manner.
SBRT is now supported by high level evidence as a safe and effective treatment for low and intermediate risk prostate cancer. The UCLA SBRT Prostate Cancer program is led by Dr. Amar Kishan and Dr. Michael Steinberg.
How Does Sbrt Compare With Longer Courses Of Radiation
The first patient to be treated with modern prostate SBRT was treated in December 2000. Since then, a large amount of data and evidence have amassed demonstrating the safety and efficacy of SBRT. UCLA investigators have played a leading role in accumulating and publishing these data. To date, the best data available to support SBRT for prostate cancer are:
A study led by Dr. Amar Kishan that compiled the outcomes of 2142 men treated with SBRT between 2000-2012, showing low rates of toxicity and high efficacy with a median follow-up of nearly 7 years. The article can be found here:
The HYPO-RT-PC randomized trial, which directly compared conventional radiation against a high-dose-per-day treatment across seven sessions in 1200 Swedish men. Importantly, this trial used older radiation planning techniques and did not deliver modern SBRT. Regardless, the efficacy and long-term side effects were equivalent in both arms of the trial. The article can be found here:
The PACE-B randomized trial, which directly compared modern, longer course radiation against modern SBRT in 874 men in the United Kingdom. No differences in short term side effects were found. The article can be found here:
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About The Southwest Prostate Cancer Symposium
The Southwest Prostate Cancer Symposium is a multi-day conference that seeks to educate urologists, radiation oncologists, medical oncologists, and other healthcare professionals involved in the treatment of prostate cancer. The topics focus on current technical aspects of diagnosis and treatment of localized and advanced disease, particularly regarding imaging, technology, and training in the related devices. Dr. Zelefsky presented this lecture during the 24th SPCS in 2019. In 2020, the 25th SPCS will also offer training sessions involving imaging, scanning, and prostate cancer treatment-related devices on site. Please visit this page in order to register for future SPCS meetings.
What Is The Success Rate Of Sbrt For Prostate Cancer
In some cases, SBRT can be a more effective form of treatment for prostate cancer than conventional radiation or surgery.
A 5-year study found that those who received SBRT for prostate cancer had a 94 percent survival rate at 3 years and 89.7 percent survival rate at 5 years. No deaths appeared to be related to prostate cancer.
That said, whether SBRT will be an effective treatment for you depends on your particular circumstances.
In one small observational study , people received SBRT to treat a reoccurrence of prostate cancer. At a follow-up period of 11.2 months after the SBRT, participants did not show any signs of prostate tumors.
These people had received conventional radiation therapy, not SBRT, as their first treatment before the prostate cancer came back.
There are several reasons you may not be a good candidate for SBRT, including the following:
- Your prostate cancer is still very mild, and your healthcare team opts to monitor it without treatment.
- Your doctor recommends a different treatment method based on the severity of your prostate cancer as well as other existing health conditions.
- You have high-risk prostate cancer that needs a different type of treatment.
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Androgen Deprivation Therapy With Prostate Sbrt
The addition of ADT to EBRT has been shown to improve overall survival for patients with intermediate- and high-risk prostate cancer, though these studies were conducted before the era of dose-escalated EBRT . In a modern trial by Bolla et al. demonstrating the superiority of ADT with EBRT compared to patients treated with EBRT alone, only 197/819 patients received dose-escalated EBRT, and though the study did demonstrate improved clinical outcomes for these patients, the study was not powered to show improvements for the patients receiving dose-escalation . Whether or not ADT has a role in the era of dose-escalated EBRT for patients with intermediate risk prostate cancer is currently an active research question, and is being investigated by RTOG 0815. The indications of ADT for patients undergoing prostate SBRT are similarly unclear. In a multi-institutional pooled data set of patients undergoing SBRT for prostate cancer, 147 patients underwent ADT in conjunction with SBRT . There was no difference in 5-year FFBF between patients receiving ADT and those not receiving ADT, though there was no uniform criteria for ADT use. The relatively poor results with SBRT alone for patients with high-risk prostate cancer suggest that some additional form of systemic therapy may prove beneficial. However, there are at this time no clear indications for the use of ADT with SBRT for patients with prostate cancer.
Clinical Outcomes For Prostate Sbrt
Table 1Full table
A randomized trial has demonstrated that a low-dose-rate brachytherapy boost added to whole pelvis EBRT to 46 Gy in 23 fractions provides superior FFBF when compared to dose-escalated EBRT for intermediate and high risk prostate cancer . Following a similar treatment paradigm, some investigators have suggested that SBRT can be used as a minimally-invasive alternative to brachytherapy as a method of delivering conformal radiation therapy and have demonstrated the efficacy of using a SBRT boost along with CF- EBRT for intermediate- and high-risk prostate cancer. The largest of these reports comes from Georgetown University, where 108 patients with prostate cancer were treated with SBRT to 19.5 Gy in 3 fractions followed by EBRT to the prostate, proximal seminal vesicles, and areas of extracapsular extension to 4550.4 Gy in 2528 fractions . The 3-year actuarial FFBF was 100% for intermediate- and 89.8% for high-risk patients. For a complete list of studies describing the outcomes of SBRT boost given in conjunction with EBRT, please see Table 2.
Table 2
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Stereotactic Body Radiation Therapy For Prostate Cancer
| The safety and scientific validity of this study is the responsibility of the study sponsor and investigators. Listing a study does not mean it has been evaluated by the U.S. Federal Government. Read our disclaimer for details. |
| Recruitment Status : Active, not recruitingFirst Posted : March 26, 2019Last Update Posted : August 25, 2021 |
- Study Details
The purpose of this study is to learn the long term efficacy and side effects associated with utilizing Stereotactic Body Radiation Therapy radiation for prostate cancer utilizing the Elekta Versa or Agility System. SBRT uses advanced imaging techniques to deliver targeted radiation to a tumor. The Elekta Versa and Agility Systems are approved by the Food and Drug Association for SBRT treatment of cancer.
Traditional External beam radiation therapy for prostate carcinoma is typically done over the course of approximately 42-45 daily treatments SBRT is a way to condense this treatment into a course of 5 treatments, delivering more dose per day.
| Phase | ||
|---|---|---|
| Prostate Cancer | Radiation: Stereotactic Body Radiation Therapy radiation for prostate cancer utilizing the Elekta Versa or Agility System. | Not Applicable |
Very promising early results utilizing SBRT for prostate cancer treatment have been described in the literature, and multiple ongoing phase 3 trials are underway.
Possible Side Effects Of Ebrt
Some of the side effects from EBRT are the same as those from surgery, while others are different.
Bowel problems: Radiation can irritate the rectum and cause a condition called radiation proctitis. This can lead to diarrhea, sometimes with blood in the stool, and rectal leakage. Most of these problems go away over time, but in rare cases normal bowel function does not return. To help lessen bowel problems, you may be told to follow a special diet during radiation therapy to help limit bowel movement during treatment. Sometimes a balloon-like device or gel is put between the rectum and the prostate before treatment to act like a spacer to lessen the amount of radiation that reaches the rectum.
Urinary problems: Radiation can irritate the bladder and lead to a condition called radiation cystitis. You might need to urinate more often, have a burning sensation while you urinate, and/or find blood in your urine. Urinary problems usually improve over time, but in some men they never go away.
Some men develop urinary incontinence after treatment, which means they cant control their urine or have leakage or dribbling. As described in the surgery section, there are different levels and types of incontinence. Overall, this side effect occurs less often with radiation therapy than after surgery. The risk is low at first, but it goes up each year for several years after treatment.
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Side Effects Of Radiation Therapy
Compared to earlier radiation methods, these modern techniques reduce the chance of urinary and bowel problems.
With several treatment options available, your doctor will work with you to develop and oversee a treatment plan that precisely addresses your prostate cancer while minimizing the risk to surrounding tissues.
This is why it is important to choose an experienced radiation oncologist who specializes in the management of prostate cancer. High volume centers where practitioners have significant experience and treat large numbers of patients with prostate cancer may be associated with good outcomes and fewer lasting problems related to treatment. The majority of patients who undergo radiation do not have permanent effects on bowel or urinary function, and patients who develop erectile difficulty after these therapies can often be treated successfully with medications such as sildenafil or tadalafil.
Radical Prostatectomy vs. Radiation: How to Compare the Results
Making a decision about prostate cancer treatment is not easy. When considering radiation therapy or radical prostatectomy, one of your top concerns is seeking reassurance that your cancer will be cured following treatment.
Intensity Modulated Radiation Therapy
IMRT, an advanced form of 3D-CRT therapy, is the most common type of external beam radiation therapy for prostate cancer. It uses a computer-driven machine that moves around the patient as it delivers radiation. Along with shaping the beams and aiming them at the prostate from several angles, the intensity of the beams can be adjusted to limit the doses of radiation reaching nearby normal tissues. This lets doctors deliver an even higher radiation dose to the cancer.
Some newer radiation machines have imaging scanners built into them. This advance, known as image guided radiation therapy , lets the doctor take pictures of the prostate just before giving the radiation to make minor adjustments in aiming. This appears to help deliver the radiation even more precisely and results in fewer side effects.
A variation of IMRT is called volumetric modulated arc therapy . It uses a machine that delivers radiation quickly as it rotates once around the body. This allows each treatment to be given over just a few minutes. Although this can be more convenient for the patient, it hasnt yet been shown to be more effective than regular IMRT.
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