Postprostatectomy adjuvant versus salvage radiotherapy: a complication-adjusted number-needed-to-treat analysis

BACKGROUND: Radiotherapy (RT) has been used with success after radical retropubic prostatectomy (RRP), both in the adjuvant and salvage settings. The purpose of the current investigation was to systematically compare adjuvant versus salvage RT in a manner that incorporates both treatment efficacy and complications. METHODS: A literature review was performed of reports of post-RRP salvage and adjuvant RT, and 12 trials comprising 1060 patients met the appropriate inclusion criteria. The biochemical failure-free survival in each study/arm was tabulated, and these values were entered into a model to compute an unadjusted number-needed-to treat (NNT). RT complications were then considered, accounting for differences in toxicity incidences in the salvage versus adjuvant setting, to compute complication-adjusted NNTs. In all the trials, the signs and magnitudes of the NNTs obtained were used to compare adjuvant with salvage RT. RESULTS: The absolute NNT analysis showed an advantage of adjuvant compared with salvage RT. After adjustment for RT complications, however, the advantage shifted to salvage RT. This transition point from superiority of adjuvant RT to superiority of salvage RT was sensitive to the estimated incidence and severity of RT side effects. CONCLUSIONS: Adjuvant post-RRP RT was advantageous in comparison to salvage RT if the side effects of RT were estimated to be negligible. However, with moderate incidence/severity of RT side effects, salvage RT was advantageous. The findings herein must be tested in a prospective study in which both health-related quality of life and cancer control are documented in patients receiving adjuvant versus salvage post-RRP RT. Further work is needed to better estimate parameters entered into the model to determine the precise transition point between adjuvant and salvage RT with modern RT techniques.     

Salvage therapy for locally recurrent prostate cancer after external beam radiotherapy

Opinion statement The greatest obstacle in the cure of patients with locally recurrent prostate cancer after radiation therapy is the lack of early detection markers. The majority of patients who are candidates for local salvage therapy have locally advanced disease, precluding successful salvage therapy. A low pretreatment prostate specific antigen (PSA) has shown to be a favorable prognostic variable for disease progression, regardless of the specific local salvage therapy used. Of all the local salvage treatment options for these patients, we believe that salvage radical prostatectomy (RP) offers patients the great-est likelihood of a cure. The salvage RP results approach those achieved with standard RP for patients of similar pathologic stage. When patients are treated early in the course of recurrent disease (preoperative PSA < 10 ng/mL), an estimated two-thirds of patients will be disease-free 5 years after salvage RP alone. With better patient selec-tion and continued technical modifications, the morbidity associated with salvage RP has substantially improved. Perioperative complications approach those observed with standard RP and approximately two-thirds of patients will recover urinary continence. Select patients may also recover functional erections when nerve-sparing techniques are used. Salvage cryotherapy and brachytherapy are minimally invasive alternatives to salvage RP. The cancer control results of these procedures appear to be inferior to results achieved with salvage RP. Each of these procedures is associated with signifi-cant morbidity and do not appear to provide a clear advantage over salvage RP in terms of posttreatment complications, urinary continence, and erectile function. A long-term cure is possible for patients with locally recurrent prostate cancer after radiation therapy. Local salvage therapy must be instituted early to be successful in the course of progressive disease.     

Erectile function following external beam radiotherapy for clinically organ-confined or locally advanced prostate cancer

BACKGROUND: External beam radiotherapy (XRT) has been a standard treatment for clinically localized prostate cancer. However, preservation of erectile function following XRT is controversial. In this study, the influence of XRT on erectile function of patients with clinically organ-confined or locally advanced prostate cancer was retrospectively evaluated. METHODS: The study included 34 of 84 patients with organ-confined or locally advanced prostate cancer who underwent XRT between 1995 and 2002. Erectile function following radiotherapy was assessed by a simple mailed questionnaire that was constructed for the study. To determine the predictive factors for erectile dysfunction following radiotherapy, data were analyzed by multivariate analysis with the Cox proportional hazards model. RESULTS: The modality of XRT was the only factor to independently predict erectile dysfunction following XRT. The maintenance rates of erectile function were 47.6% at 1 year and 19% at 3 years in patients who received the 3-dimensional conformal radiotherapy, which were significantly higher than in those who received conventional radiotherapy (P = 0.026). CONCLUSIONS: XRT significantly reduced the maintenance rate of erectile function during the follow-up period, with the rate being 19% at 3 years in patients who received 3-dimensional conformal radiation. The XRT modality was involved in the reduction of erectile function. These results suggest that erectile dysfunction is a possible adverse event following XRT.     

Androgen deprivation therapy as adjuvant/neoadjuvant to radiotherapy for high-risk localised and locally advanced prostate cancer: recent developments

Androgen deprivation therapy (ADT) has traditionally formed the mainstay of treatment for advanced/metastatic prostate cancer (PCa); however, it is now also having an increasingly important role in earlier stages of disease. Indeed, in patients with locally advanced or high-risk localised disease, the addition of neoadjuvant and adjuvant hormone therapy is now considered the standard of care for those men treated with radical radiotherapy. Although luteinising hormone-releasing hormone (LHRH) agonists have been used for many years as ADT, they may be associated with clinical flare and testosterone breakthrough. Newer hormonal agents continue to be developed, such as gonadotropin-releasing hormone antagonists, which reduce testosterone and prostate-specific antigen levels more rapidly than LHRH agonists, without testosterone flare. This review examines ADT use in combination with radiotherapy to improve outcomes in localised or locally advanced disease, and examines some of the latest developments in hormonal therapy for PCa.     

Triple course external beam radiotherapy for carcinoma of the prostate

In 1976 we began using a triple-course technique of external beam irradiation for localized carcinoma of the prostate. The treatment consisted of 2 courses of 20 Gy in 2 weeks to the pelvis and a third course of 20-25 Gy in 2-2 1/2 weeks as a boost to the prostate. A 2 week rest followed the first and second courses. The results of this treatment technique are reported on the first 50 patients who had been followed for at least 3 years. Although 96% of these patients developed bladder and/or bowel reactions, the majority of the symptoms were in the very mild to mild category, with only 2% severe reactions referrable to each organ. The incidence of late complications in this series compared favorably to those reported by other authors. Clinical local control was 96% while post-treatment needle biopsy performed on 22/50 patients yielded a negative rate of 86%. Those with Stages A and B disease had a negative biopsy rate of 94%. Three-year uncorrected disease-free survival for the whole group was 54%. This study has shown that with triple course external beam irradiation, excellent control of localized carcinoma of the prostate can be achieved with minimal acute morbidity.     

High-dose-rate brachytherapy without external beam irradiation for locally advanced prostate cancer.

BACKGROUND AND PURPOSE: High-dose-rate brachytherapy (HDR-BT) had been used only in combination with external beam irradiation (EBI) until our previously reported first trial of HDR-BT alone without EBI. The purpose of the current report is to evaluate the feasibility, toxicity and efficacy of this regimen, with more patient accrual and longer follow-up. MATERIAL AND METHODS: From 1995 through 2004, 111 patients with localized prostate cancer were treated with HDR-BT without EBI. Fifteen patients were considered as low-risk, 28 as intermediate-risk, and 68 as high-risk. The prescribed dose was 48 Gy/8 fractions/5 days or 54 Gy/9 fractions/5 days. Median follow-up time was 27 months (range 5-119). RESULTS: All the patients completed the treatment regimen. The 3- and 5-year PSA failure-free rates were 83% and 70%, and the local control rates 100% and 97%. The maximum toxicities observed were Grade 3 by CTCAE v3.0 (6 acute, 1 chronic). CONCLUSIONS: HDR-BT without EBI was feasible and its toxicity acceptable. Short-term tumor control was promising, even for locally advanced cases. More patient accrual and longer follow-up are needed to confirm the efficacy of this novel approach.     

External beam radiotherapy and hyperthermia in the treatment of patients with locally advanced prostate carcinoma

BACKGROUND: The current study was conducted to evaluate the combination of external beam radiation therapy and hyperthermia in the treatment of patients with locally advanced prostate carcinoma. METHODS: Twenty-six patients were treated on a Phase I/II protocol between June 1990 and April 1993. The median age of the patients was 69 years. Nine patients had well differentiated adenocarcinoma, ten patients had moderately differentiated adenocarcinoma, and six patients had poorly differentiated adenocarcinoma. All patients had American Urologic Society Stage C2-D1 adenocarcinoma. The median pretreatment prostate specific antigen (PSA) level was 29 ng/mL (range, 6-104 ng/mL). All patients received external beam radiation therapy using a four-field technique. The median radiation dose was 6,800 centigrays (cGy) given in 200-cGy fractions. Hyperthermia was administered concurrently with radiation therapy to temperatures of 42.5 degrees C for 30 minutes using a transrectal ultrasound applicator with 3 thermometry probes, given as either a single treatment (9 patients) or as two treatments (17 patients). Overall survival (OS) and biochemical no evidence of disease (bNED) status were calculated using Kaplan-Meier analysis. A consensus conference definition of PSA failure was used. The Cox proportional hazards model was used for multivariate analysis. The median follow-up for all patients was 71 months. RESULTS: The median time to PSA nadir was 15 months with a median PSA nadir value of 1.0 ng/mL. The median and 5-year OS was 88 months and 73%, respectively, and the median and 5-year bNED survival was 36 months and 35%, respectively. Multivariate analysis revealed only the pretreatment PSA level (P = 0.03) and the PSA nadir reached (P < 0.01) to be significant predictors of bNED survival. The duration of hyperthermia therapy showed a trend toward significance for OS (P = 0.06). CONCLUSIONS: The current Phase I/II protocol evaluating the combination of prostate hyperthermia and external beam radiation therapy for the treatment of patients with locally advanced prostate carcinoma suggests prostate hyperthermia to be feasible with no apparent significant increased toxicity, although there was no significant improvement in treatment outcome when compared with other studies reported in the literature evaluating external beam radiation therapy with or without androgen suppression. However, further investigation into the duration as well as the temperature of the hyperthermia with a greater number of patients is warranted.     

192Ir low dose rate brachytherapy for boosting locally advanced prostate cancers after external beam radiotherapy: a phase II trial.

BACKGROUND AND PURPOSE: To evaluate on 201 locally advanced prostatic cancers prospectively treated in a phase II trial, the efficacy of a combination of external beam radiotherapy (39.6 Gy) and (192)Ir low dose rate brachytherapy (Bt) (40-45 Gy). PATIENTS AND METHODS: Sixty-four patients were included in the intermediate prognosis group with only one of the following adverse factors (PSA > 10 ng/ml, Gleason score > or = 7 or clinical stage > or =T2b) and 137 in the unfavourable group when at least two of these factors were present. RESULTS: The actuarial 4 years biochemical no evidence of disease is 82.8% for the entire population. It is, respectively, 97 and 76% in the intermediate and unfavourable prognosis groups (P < 0.0001). Grade > or =3 late urinary complications occurred in 13 patients (6.5%). Eight patients (4%) presented late grade 2 rectal complications but no grades 3-5 was observed. CONCLUSIONS: Even if an alpha/beta of 1.5-3 Gy theoretically favours the use of a high dose rate mode of irradiation, the early results presented here are as good as those reported for similar groups of patients with high dose rate treatments. Late toxicity is identical but our urinary toxicity is within the less favourable and rectal toxicity within the most favourable results. We can postulate that while inducing very high hyperdosage regions (V150) mainly focused on the peripheral zone, most of the Bt techniques consist of a more ablative treatment. Many of the radiobiological studies on Bt did not in fact take into account the heterogeneity of irradiation inside the CTV. This study highlights the need to explore pulsed dose rate therapies, permanent implant and new available radioisotopes such as (169)Ytterbium that will offer the safety of low and lower dose rates. The actual late toxicity of the different Bt techniques is not yet inexistent indeed.     

Concurrent boost radiotherapy as preoperative treatment for locally advanced rectal carcinoma: a new beam arrangement

PURPOSE: To describe a new beam arrangement for preoperative concurrent boost radiotherapy in locally advanced rectal carcinoma. MATERIAL AND METHODS: Three different volumes, ie posterior pelvis, total mesorectal space, and gross tumor volume plus 2 cm, are selected to receive radiation doses of 47 Gy, 51 Gy, and 54 Gy, respectively, in 24 fractions. There are two prerequisites for the use of such a radiotherapy schedule: complete displacement of the small bowel outside the boost volume, and horizontal positioning of the rectal long axis. Both conditions can be attained by patient positioning on a new device, the "Up-Down Table" (UDT). The dose gradient between the three volumes is realized with two daily arc rotation fields with an isocenter that is different from the three additional multileaf collimator pelvic fields (postero-anterior + 2 laterolateral). RESULTS: The treatment data are reported according to the ICRU 62 criteria. A comparison was made between concurrent arc rotation and concomitant static boost techniques. CONCLUSION: The new beam arrangement, with the use of the UDT, allows to administer different radiation doses to three volumes with different tumor cell density in order to obtain the same probability of local response in all target volumes without increasing the toxicity.     

Moderate dose intraoperative and external beam radiotherapy for locally recurrent rectal carcinoma.

BACKGROUND AND PURPOSE: Late adverse effects (i.e. neuropathy, chronic bowel obstruction) limit the effective dose given in intraoperative radiotherapy (IORT) and external beam radiotherapy (EBRT). Initial results of a multi-modality treatment approach using moderate dose IORT and moderate dose EBRT are presented. PATIENTS AND METHODS: Thirty-one consecutive patients with recurrent rectal carcinomas had IORT and EBRT after complete (R0, n = 14) or incomplete resection (R1, n = 9; R2, n = 8). The mean [ORT dose was 13.7 Gy (range 12-20 Gy) supplemented with an EBRT dose of 41.4 Gy. Twenty-two patients had preoperative EBRT and 22 patients had concomitant chemotherapy (5-FU, Leucovorine). RESULTS: After a median follow-up of 28 months, 16 patients had re-recurrent disease and 11 patients had died. Nine patients failed locally (four in-field, four marginal and one anastomotic re-recurrence), three combined with distant metastasis, resulting in overall and IORT infield local control rates of 71% and 87%, respectively. Distant metastases alone were found in seven patients. The 4-year overall and relapse-free survival rates were 58% and 48%, respectively. After incomplete resection the local failure rate increased (R0 21%, R1/2 35%) and the 4-year relapse-free survival rate decreased significantly (29% versus 71%) due to a markedly increased distant metastasis rate (53% versus 7%). Acute and late toxicities were not increased. CONCLUSION: The combination of moderate dose IORT and EBRT is a safe and efficacious component in a multi-modality treatment approach.     

局部晚期鼻咽癌放疗与化疗综合治疗的生存分析

目的探讨局部晚期鼻咽癌放化综合治疗疗效和毒副反应。方法回顾性分析77例经病理证实鼻咽癌患者。年龄17～74岁,男:女=3.8:1。1992年福州分期T1、12、T3、T4期分别为11、33、22、11例,N0、N1、N2、N3期分别为7、15、44、11例。临床分期Ⅲ期56例,ⅣA期21例。所有患者放疗前接受诱导化疗1～3个疗程:顺铂20 mg/m~2,氟尿嘧啶500 mg/m~2,其中62例应用甲酰四氢叶酸钙100 mg/m~2,均为第1～3天,2周后重复。化疗结束后2周内放疗:鼻咽原发病灶均采用~(60)Co照射1.8～2.0 Gy/次,总剂量64～78 Gy;57例采用面颈联合野 耳前野 鼻前野治疗,20例采用耳前野 鼻前野照射,9例采用耳后野加量6～8 Gy分3～4次,13例给予颅底小野补量4～8 Gy分2～4次;颈部放射源用~(60)Co、180 kV X线和9 MeV电子束,N0期患者仅照射上颈部,有颈部转移者照射全颈,预防剂量50～55 Gy,根治剂量60～68 Gy;1例外照射结束后因鼻咽腔内肿瘤残留,给予后装治疗2次,间隔1周,10 Gy/次)。放疗结束后3周给予辅助化疗:顺铂20 mg/m~2,氟尿嘧啶500 mg/m~2,甲酰四氢叶酸钙100 mg/m~2,均为第1～3天,3周后重复,共2～4疗程。结果中位随访60个月,5年总生存率、无瘤生存率、无复发生存率、无远处转移生存率分别为68%、58%、81、75%。≥4个化疗周期与≤3个化疗周期生存曲线比较差异无统计学意义(X~2=0.05,P=0.831)。主要急性反应有血液学毒性:1级11例,2级7例,3级2例;黏膜炎:2级33例,3级20例,4级1例;消化道反应:1级21例,2级11例,3级1例;皮肤反应:2级30例,3级4例。晚期损伤:1例发生放射性脑损伤,无其他颅神经损伤发生;张口困难轻度4例,中度1例;听力减退轻度31例,中度7例,严重1例。化疗周期≥4个与≤3个的听力损伤差异有统计学意义(z=2.06,P=0.039)。绝大多数放疗结束后都有程度不等的口干,随访中都明显好转,至末次随访时轻度口干13例,中度3例。结论以顺铂和氟尿嘧啶为基础的诱导化疗 放疗 辅助化疗局部晚期鼻咽癌的疗效较单纯放疗无明显提高,但可能加重患者听力的晚期损伤。     

192Ir or 125I prostate brachytherapy as a boost to external beam radiotherapy in locally advanced prostatic cancer: a dosimetric point of view.

PURPOSE: This work aims at comparing the dosimetric possibilities of 125I or 192Ir prostate brachytherapy (Bt) as a boost to external beam radiotherapy in the treatment of locally advanced adenocarcinoma. METHODS AND MATERIALS: From 1/1997 to 12/2002, 260 patients were treated. Until 12/2001 a low dose rate (LDR) treatment with 192Ir wires was used, later replaced by a high dose rate (HDR) delivered with an 192Ir stepping source technology. For the present work, we selected 40 patients including the last 20 treated, respectively, by LDR and HDR. The planning CT Scans of all these 40 patients were transferred into the 3D Prowess system for 125I permanent implants design according to the Seattle method. The reference data for dosimetric comparisons were the V100 and the prescribed dose for 192Ir as well as the dose delivered with 125I techniques to the 192Ir V100. We compared V100-150 data as well as doses to the organs at risks (OR) and cold spots (CS). RESULTS: The V100 is 85.3+/-8% for 192Ir LDR and 96+/-2% for HDR techniques (P < 0.0001). In comparison with 125I, the 192Ir LDR mode induces higher hyperdosage volumes inside the CTV but also more CS, while maximal doses to urethra and rectum are, respectively, 17 and 39% less with 125I (P < 0.0001). In comparison with the 192Ir HDR mode, 125I Bt induces higher hyperdosage volumes and slightly more CS deliberately planned around the bladder neck. If delivered doses to urethra are identical, those to the 20% anterior part of the rectum are 33% less with 125I (P < 0,0001). The 125I Bt technique was only possible in 24 out of the 40 patients studied due to pelvic bone arch interference. CONCLUSIONS: At the present time, there is no evident dosimetric superiority of one Bt method when all the criteria are taken into account. However, improving Bt techniques to implant any prostatic size could found the superiority of the 125I or permanent implants. 125I indeed allows large hyperdosage volumes inside the CTV in comparison with 192Ir HDR techniques while lowering doses to OR and minimizing CS.     

A randomized trial comparing radical prostatectomy plus endocrine therapy versus external beam radiotherapy plus endocrine therapy for locally advanced prostate cancer: results at median follow-up of 102 months

BACKGROUND: To investigate the optimal treatment of locally advanced prostate cancer, a prospective randomized trial was conducted to compare radical prostatectomy plus endocrine therapy versus external beam radiotherapy plus endocrine therapy. METHODS: One hundred patients with T2b-3N0M0 prostate cancer were enrolled and 95 were evaluated. Of 95 cases, 46 underwent radical prostatectomy with pelvic lymph node dissection and 49 were treated with external beam radiation by linear accelerator with 40-50 Gy to the whole pelvis and 20-Gy boost to the prostatic area. For all patients, endocrine therapy was initiated 8 weeks before surgery or radiotherapy and continued thereafter. The long-term outcome and morbidity were examined. RESULTS: Median follow-up period was 102 months. At 10 years overall survival rates in the surgery group were better than the radiation group (76.2% versus 71.1% for biochemical progression-free rates; P=0.25, 83.5% versus 66.1% for clinical progression-free rates; P=0.14, 85.7% versus 77.1% for cause-specific survival rates; P=0.06, and 67.9% versus 60.9% for overall survival rates; P=0.30), although none of them reached statistical significance. Erectile dysfunction was recognized in almost all patients as a result of continuous endocrine therapy. Incontinence requiring more than one pad per day was observed more frequently in the surgery group than the radiation group (P<0.01). CONCLUSIONS: For the treatment of patients with locally advanced prostate cancer, when combined with endocrine therapy, either radical prostatectomy or external beam radiotherapy demonstrated favorable long-term outcomes. The radiation dose of 60-70 Gy might not be enough for the local treatment of locally advanced prostate cancer.     

前列腺癌的外照射放疗进展

外照射放疗作为前列腺癌的主要治疗手段之一,随着放疗技术的进步、靶区认识的统一,已进入精确放疗时代.高剂量放疗的准确实施,使前列腺癌的疗效显著提高.而影像引导的放射治疗、质子放疗和低分割放疗则是疗效进一步提高的研究方向.     

Class solutions for conformal external beam prostate radiotherapy

PURPOSE: To determine a class solution coplanar plan from comparisons of three-field (3F), four-field (4F), and six-field (6F) plans in conformal non-intensity-modulated prostate radiotherapy. METHODS AND MATERIALS: Doses to two clinical target volumes, prostate only (PO) and prostate plus seminal vesicles (PSV) were evaluated in each of 10 patients using a variety of 3F, 4F, and 6F plans with a planning target volume margin of 10 mm. All plans were prescribed to 64 and 74 Gy. The class solution plan for each of 3F, 4F, and 6F was chosen from a variety of symmetrical and asymmetrical field arrangements that had been previously assessed. The class solution plans, 3F (0, 90, 270 degrees ), 4F (35, 90, 270, 325 degrees ), and 6F (50/lat/25) were compared with reference plans: 3F (0, 120, 240 degrees ), 4F (0, 90, 180, 270 degrees ), and 6F (55, 90, 125, 235, 270, 305 degrees ). Rectal volumes irradiated to greater than 50% (V(50)), 80% (V(80)), and 90% (V(90)) of the prescribed dose, normal tissue complication probabilities (NTCP) for rectum, bladder, and femoral heads (FH), and tumor control probabilities (TCP) were assessed. FH tolerance was set at 52 Gy to 10% volume. RESULTS: The field arrangement that gave the lowest irradiated rectal volume with acceptable bladder and FH doses was a 3F (0, 90, 270 degrees ) class solution plan. This plan gave a reduction in rectal V(80) of 1.2-12.4% for the PO group and 2.3-23.8% for the PSV group compared with the other plans. The reduction in rectal V(90) was 0.2-11.9% for the PO group and 1.5-23.3% for the PSV group using the 3F (0, 90, 270 degrees ) plan. This plan provided one of the lowest rectal NTCPs, but the difference was not significant when compared with the 4F class solution plan. When target volumes with 10-mm margins remain unchanged to 74 Gy, the irradiated rectal volumes for all plans were higher and rectal NTCPs can be trebled. CONCLUSION: The use of appropriate beam arrangements can provide a class solution plan using only 3 fields compared with 4 or 6 fields for the parameters considered. Both 3F (0, 90, 270 degrees ) and 4F (35, 90, 270, 325 degrees ) plans can be used as a class solution plan. Other practical issues that may influence the choice of class solution include delivery time with smaller number of fields, ease of verification, the use of 10-mm multileaf collimation vs. conformal blocks, and field shape fitting limitations when using dynamic wedges.     

External-beam radiotherapy for localized or locally advanced prostate cancer in Japan: a multi-institutional outcome analysis

BACKGROUND: The outcomes of patients with localized or locally advanced prostate cancer treated with external-beam radiotherapy are not well known in Japan. METHODS: Thirty-four institutions combined data on 679 patients with localized or locally advanced prostate cancer treated with a total dose >/=60 Gy between 1995 and 2002. RESULTS: With a median follow-up of 46 months, the 5-year overall, clinical progression-free, and biochemical relapse-free survival rate were 93.0, 95.3 and 71.9% for all patients, respectively. The 5-year progression-free, and biochemical relapse-free survival rates according to the risk group were 100%, 90.8% in the low-risk group, 98.3%, 75.7% in the intermediate-risk group and 93.6%, 67.6% in the high-risk group, respectively. The multivariate analysis for biochemical relapse-free survival revealed that prostate-specific antigen (relative risk, 1.002; 95% CI, 1.001-1.003; P = 0.0041), Gleason score (relative risk, 1.166; 95% CI, 1.046-1.302; P = 0.0055), T classification (relative risk, 2.897; 95% CI, 1.999-4.230; P = 0.0000), pelvic irradiation (relative risk, 2.042; 95% CI, 1.328-3.273; P = 0.0008), and androgen abletion (relative risk, 0.321; 95% CI, 0.240-0.427; P = 0.0000) were significant prognostic factors. Only 1.1% of patients experienced late morbidity of Grade 3. CONCLUSION: Radiotherapy for prostate cancer seemed to be effective, with little risk of normal tissue complications.     

Hormonal therapy for locally advanced prostate cancer

A patient with locally advanced prostate cancer (stages C and D1) has a poor prognosis with a high risk of developing and dying of distant metastases. Hormonal therapy is the major form of systemic therapy for metastatic (stage D2) prostate cancer. The most commonly used forms of hormonal therapy are orchiectomy, diethylstilbestrol, and luteinizing hormone releasing hormone, agonists that prevent the stimulation of tumor cells by testosterone. They produce a 60%-80% symptomatic or objective response rate, but their ability to prolong overall survival remains uncertain. Surgical adrenalectomy, hypophysectomy, and pharmacologic adrenal suppression prevent the clinically less significant adrenal androgen stimulation of tumor cells. Antiandrogens competitively inhibit the interaction between androgens and cytosolic androgen receptors. Complete androgen blockade (luteinizing hormone releasing hormone agonist and antiandrogen) was initially espoused to be superior to single-agent hormonal therapy, but preliminary results from a multigroup randomized trial suggest that it has only a minimal advantage. The benefit of hormonal therapy in stages C and D1 prostate cancer at the time of diagnosis has not been clearly established. Available studies are few, and most often they are uncontrolled or include only small numbers of patients. However, they suggest that the early use of hormonal therapy prolongs disease-free survival but does not prevent ultimate disease progression or prolong overall survival. Hormone receptor assays may be helpful in the selection of patients who would benefit from early hormonal therapy.