Cultural Adaptation and Validation of the Punjabi Version of EPIC.

BACKGROUND: With earlier prostate cancer (PCa) diagnosis and increased survivorship, post-treatment quality of life (QoL) has become increasingly important. The Expanded Prostate Cancer Index Composite (EPIC) is a widely adopted QoL instrument for PCa. We aimed to create a Punjabi version of EPIC to further research in the Punjabi-speaking population. METHODS: A prototype of the Punjabi version of EPIC was created by forward-backward translations and revision. After concluding the cultural adaptation phase by interviewing 15 participants, a pilot version was created. Validation of the pilot version was performed by having 72 participants complete the Punjabi EPIC and another commonly used QoL instrument, the EORTC QLQ-c30, twice within a 4-week period. Test retest reliability (Pearson's correlations and difference distribution) and internal consistency (Cronbach's alpha) were measured using SAS version 9.4. RESULTS: Modifications were needed for the prototype Punjabi version after forward-backward translations. Cultural adaptation has highlighted a few issues including syntax and terminology.  Test-retest reliability of the Urinary, Bowel, Sexual and Hormone domains were 0.88, 0.91, 0.91, and 0.95, respectively, and subscale correlations ranged from 0.75 to 0.93. Internal consistency for domains and subscales was good except for Sexual Domain. Performance of EPIC is comparable, and in some cases, slightly better than validated Punjabi version of EORTC QLQ-C30. CONCLUSIONS: The EPIC questionnaire was successfully translated into Punjabi and was culturally adapted.  The resultant Punjabi version has high reliability and validity and will be an important tool for QoL research in the Punjabi population. EPIC was successfully translated, culturally adapted, and validated with high reliability and validity into Punjabi. It will be a valuable QoL tool for physicians in clinical and research settings, and for patients in decision-making.

Late Toxicity of Prostate Ultrahypofractionated Radiation Therapy Compared With Moderate Hypofractionation in a Randomized Trial.

PURPOSE: We report late toxicity, quality of life (QOL), and urinary symptom score with prostate cancer radiation therapy in a randomized trial comparing moderate hypofractionation and ultrahypofrationation. METHODS AND MATERIALS: Patients with intermediate and high-risk prostate cancer were randomized to either Arm 1 (70 Gy/28 fractions) or Arm 2 (36.25 Gy/5 weekly fractions). Late toxicity was evaluated using the Common Terminology Criteria for Adverse Events and Radiation Therapy Oncology Group/Subjective, Objective, Management, Analytical scales. QOL was assessed with the Expanded Prostate Inventory Composite-26 Short Form and urinary function with the International Prostate Symptom Score. RESULTS: Eighty participants were randomized. Two from Arm 1 withdrew, leaving 36 patients in Arm 1 and 42 in Arm 2. There were no significant differences in baseline characteristics, except for worse International Prostate Symptom Score in Arm 2. No difference was observed in freedom from grade 3 or worse toxicity between treatments (P = .921), with only a single grade 3 event in each arm. There was no significant difference in freedom from grade 2 or worse toxicity (P = .280). No difference was observed in freedom from grade 2 or worse genitorurinary toxicity, with cumulative probabilities of 69.0% and 87.0% at 5 years for Arms 1 and 2, respectively (0.132). No difference was observed in freedom from grade 2 or worse gastrointestinal toxicity, with cumulative probabilities of 74.0% in Arm 1 and 80.0% in Arm 2 (P = .430). There were no significant differences in Expanded Prostate Inventory Composite-26 Short Form QOL between arms. CONCLUSIONS: Ultrahypofrationation, delivered weekly, is well tolerated with no significant differences in freedom from late toxicity compared with moderate hypofractionation.

Web-Based Peer Navigation for Men with Prostate Cancer and Their Family Caregivers: A Pilot Feasibility Study.

This study assessed the feasibility, acceptability and potential effects of True North Peer Navigation (PN)­a web-based peer navigation program for men with prostate cancer (PC) and their family caregivers. A one-arm, pre-post pilot feasibility study was conducted at two cancer centres in Canada. Participants were matched through a web-app with a specially trained peer navigator who assessed needs and barriers to care, provided support and encouraged a proactive approach to health for 3 months. Descriptive statistics were calculated, along with paired t-tests. True North PN was feasible, with 57.9% (84/145) recruitment, 84.5% (71/84) pre-questionnaire, 77.5% (55/71) app registration, 92.7% (51/55) match and 66.7% (34/51) post-questionnaire completion rates. Mean satisfaction with Peer Navigators was 8.4/10 (SD 2.15), mean program satisfaction was 6.8/10 (SD 2.9) and mean app usability was 60/100 (SD 14.8). At 3 months, mean ± SE patient/caregiver activation had improved by 11.5 ± 3.4 points (p = 0.002), patient quality of life by 1.1 ± 0.2 points (p < 0.0001), informational support by 0.4 ± 0.17 points (p = 0.03), practical support by 0.5 ± 0.25 points (p = 0.04) and less need for support related to fear of recurrence among patients by 0.4 ± 19 points (p = 0.03). The True North web-based peer navigation program is highly feasible and acceptable among PC patients and caregivers, and the associated improvements in patient and caregiver activation are promising. A randomized controlled trial is warranted to determine effectiveness.

Acute Toxicity of Ultrahypofractionation Compared With Moderate Hypofractionation in Prostate Cancer Treatment: A Randomized Trial.

PURPOSE: We report on the early toxic effects and quality of life of localized prostate cancer radiation therapy in a randomized trial comparing moderate hypofractionation (MHF) with ultrahypofractionation (UHF). METHODS AND MATERIALS: We randomized patients with intermediate- to high-risk localized prostate cancer to radiation therapy with MHF (70 Gy in 28 daily fractions) or UHF (36.25 Gy in 5 weekly fractions). We analyzed early toxic effects (using Common Terminology Criteria for Adverse Events and Radiation Therapy Oncology Group/Subjective, Objective, Management, Analytic scales) and patient-reported quality of life (using the Expanded Prostate Inventory Composite questionnaire) when all patients had at least 6 months of follow-up. RESULTS: We randomized 80 participants. Two patients withdrew from radiation therapy. We ran analysis on results for 78 patients. The 2 arms were balanced in key patient and disease characteristics, except for a statistically worse baseline urinary function in the UHF arm (International Prostate Symptom Score >7: 68% vs 36%, P = .004). There were no statistically significant differences between the 2 arms in grade 3 or grade 2 toxic effects: grade ≥3 MHF 8%, UHF 2% (P = .235); grade ≥2 MHF 36%, UHF 24% (P = .235). There were also no significant differences in percentages of patients with a "minimal important change" of quality of life in the Incontinence (MHF 36%, UHF 33%; P = .746), Irritative/Obstructive (MHF 56%, UHF 74%; P = .074), or Bowel domains (MHF 58%, UHF 52%; P = .508) on the Expanded Prostate Inventory Composite questionnaire. CONCLUSIONS: UHF radiation therapy for prostate cancer is well tolerated, and there were no significant differences in toxic effects and quality of life changes between UHF and MHF up to 6 months after treatment in the current trial.

Cultural adaptation and validation of the Chinese version of the expanded prostate cancer index composite.

AIM: The expanded prostate cancer index composite (EPIC) is a widely adopted instrument for the quality of life of patients with prostate cancer. We aimed to create a Chinese version of EPIC to further research in the Chinese-speaking population. METHODS: A prototype was created by forward-backward translations and revisions. During cultural adaptation, 15 participants were interviewed after they had completed the prototype. A few issues highlighted included confusion related to the question format, subject non-familiarity with the Chinese term for "hot flashes," and the use of the Chinese term for "breast" as a strictly female body part. A pilot version was created based on the cultural adaptation findings. Validation of the pilot version was performed by having 50 participants complete the Chinese EPIC and EORTC QLQ-c30 twice within a 4-week period. Test-retest reliability (Pearson's correlations and difference distribution) and internal consistency (Cronbach's α) were measured using SAS version 9.4. RESULTS: Test-retest reliability values for the urinary, bowel, sexual and hormone domains were 0.71, 0.51, 0.51 and 0.66, respectively; subscale test-retest reliability ranged between 0.29 and 0.82. Internal consistency for domains was good with Cronbach's α ranging from 0.76 to 0.78 for the initial test and 0.67 to 0.85 for the retest. The performance of this version of EPIC was comparable to the validated EORTC QLQ-C30. CONCLUSION: The EPIC questionnaire was successfully translated into Chinese and was culturally adapted. The resultant Chinese version has high reliability and validity and will be an important tool for research on quality of life in the Chinese population.

Prospective surveillance and targeted physiotherapy for arm morbidity after breast cancer surgery: a pilot randomized controlled trial.

OBJECTIVE: To evaluate prospective surveillance and targeted physiotherapy (PSTP) compared to education (EDU) on the prevalence of arm morbidity and describe the associated program cost. DESIGN: Pilot randomized single-blinded controlled trial. SETTING: Urban with assessments and treatment delivered in hospitals. PARTICIPANTS: Women scheduled for breast cancer surgery. INTERVENTIONS: Participants were randomly assigned (1:1) to PSTP ( n = 21) or EDU ( n = 20) and assessed presurgery and 12 months postsurgery. All participants received usual care, namely, preoperative education and provision of an education booklet with postsurgical exercises. The PSTP group was monitored for arm morbidity every three months and referred for physiotherapy if arm morbidity was identified. The EDU group received three education sessions on nutrition, stress and fatigue management. MAIN OUTCOME MEASURES: Arm morbidity was based on changes in the surgical arm(s) from presurgery in four domains: (1) shoulder range of motion, (2) strength, (3) volume, and (4) upper body function. Complex arm morbidity indicated ≥2 domains impaired. Second, the cost of the PSTP program was described. RESULTS: At 12 months, 18 (49%) participants (10 PSTP and 8 EDU) had arm morbidity, with EDU participants presenting more complex arm morbidity compared to PSTP participants. PSTP participants attended 4.4 of 5 assessments with 90% retention. The PSTP program cost was $150 covered by the Health Care Provider and the Patient Out-of-Pocket Travel cost was CAN$40. CONCLUSION: Our results suggest that PSTP is feasible among women with breast cancer for early identification of arm morbidity. A larger study is needed to determine the cost and effectiveness benefits.

Hypofractionated Nodal Radiation Therapy for Breast Cancer Was Not Associated With Increased Patient-Reported Arm or Brachial Plexopathy Symptoms.

PURPOSE: To determine whether nodal radiation therapy (RT) for breast cancer using modest hypofractionation (HF) with 2.25 to 2.5 Gy per fraction (fx) was associated with increased patient-reported arm symptoms, compared with conventional fractionation (CF) ≤2 Gy/fx. METHODS AND MATERIALS: Two cancer registries were used to identify subjects who received computed tomography-planned nodal RT for pT1-3, pN0-2, M0 breast cancer, from 2007 to 2010 at 2 cancer institutions. After ethics approval, patients were mailed an explanatory letter and the Self-reported Arm Symptom Scale, a validated instrument with 8 questions about arm symptoms and 5 related to activities of daily living. Clinicopathologic characteristics and Self-reported Arm Symptom Scale scores were compared between HF/CF cohorts using nonparametric analysis, χ2 analysis, and multivariate ordinal regression. RESULTS: Of 1759 patients, 800 (45.5%) returned a completed survey. A total of 708 eligible cases formed the study cohort. Of these, 406 (57%) received HFRT (40 Gy/16 fx, 45 Gy/20 fx), and 302 (43%) received CFRT (45-50 Gy/25 fx, 50.4 Gy/28 fx). Median time interval after RT was 5.7 years. Forty-three percent and 75% of patients received breast-conserving surgery and chemotherapy, respectively. Twenty-two percent received breast boost RT, independent of fractionation. Median age at diagnosis was 59 years (HF) and 53 years (CF) (P<.001). The mean numbers of excised (n=12) and involved (n=3) nodes were similar between fractionation cohorts (P=.44), as were the mean sums of responses in arm symptoms (P=.17) and activities of daily living (P=.85). Patients receiving HF reported lower rates of shoulder stiffness (P=.04), trouble moving the arm (P=.02), and difficulty reaching overhead (P<.01) compared with the CF cohort. There was no difference in self-reported arm swelling or symptoms related to brachial plexopathy. CONCLUSIONS: Nodal RT with hypofractionation was not associated with increased patient-reported arm symptoms or functional deficits compared with CF. Subjects treated with CF reported more disability in certain aspects of arm/shoulder function. These data support shorter fractionation utilization when regional nodes are within the therapeutic target.

A longitudinal analysis of chronic arm morbidity following breast cancer surgery.

Arm morbidity (AM) arising from breast cancer (BC) treatment can detrimentally impact quality of life; often limiting a survivor's ability to participate in valued activities. The present study explored (a) the developmental time course of AM [restricted range of motion (ROM), pain, and arm volume changes], negative affect, and perceived disability in the immediate years post-surgery, and (b) the mediating role of perceived disability on the relationship between AM and negative affect over time. In this 5-year longitudinal study, BC survivors from four Canadian oncology clinics (n = 431) completed five annual clinical assessments, where differences in ROM (shoulder abduction, external rotation) and arm volume between the affected and non-affected arm were measured. The profile of mood states (POMS), disability of arm, shoulder, hand, and McGill Pain Questionnaire-Short form were completed. Results from general linear modeling showed that AM, negative affect, and perceived disability were greatest 1-year post-surgery, declined, and with the exception of arm volume changes, were significantly lower 5 years later. Negative affect was significantly associated with restrictions in shoulder abduction and external rotation (average r = -0.15; p < 0.05) and present arm pain (average r = 0.28, p < 0.01) at most assessments. The mediating role of perceived disability on the relationship between AM and negative affect was statistically significant in a majority of assessments. Perceived disability is the underlying factor driving the relationship between AM and mood disturbance over time. Rehabilitative therapy to improve survivors' functional well-being might mitigate the negative impacts of AM on emotional health.

Radiotherapy and Conservative Surgery in the Locoregional Management of Merkel Cell Carcinoma: The British Columbia Cancer Agency Experience.

BACKGROUND: Merkel cell carcinoma (MCC) is an uncommon aggressive skin malignancy. Published series mainly focus on wide excision, which can be difficult at some sites (e.g., face) and in patients with comorbidities. In British Columbia, an approach of conservative surgery followed by radiotherapy is common. MATERIALS AND METHODS: This is a retrospective review of 179 patients treated for MCC with curative intent in British Columbia. RESULTS: Totals of 68, 63, and 37 patients underwent narrow excision of primary, attempted wide excision, and biopsy only, respectively. Adjuvant radiotherapy reduced local recurrence after narrow excision (<10 mm margin) from 25 to 4.9 % (p = .03) and was effective in the presence of microscopic positive margins. Local recurrence rate was 7.1 % if the margin was >10 mm irrespective of radiation use. Local RFS was improved by adjuvant radiation therapy (RT) (p = 0.04), and there was a trend to reduced nodal relapse after elective nodal RT (p = .07). Irradiation of macroscopic tumor at 37 primary and 33 nodal sites provided 5-year local and nodal RFS of 90 and 75 %, respectively. The 5-year cancer specific survival was 77 % and was not improved by the use of adjuvant radiotherapy. CONCLUSIONS: Local excision plus adjuvant RT is an effective treatment for MCC. Adjuvant radiation should be considered when the excision margin is <1 cm.

Loss, adaptation and new directions: The impact of arm morbidity on leisure activities following breast cancer.

The impact of arm morbidity on leisure and quality of life is an understudied area in cancer survivorship. The purpose of this study was to qualitatively describe the impact of breast cancer-related arm morbidity on leisure participation in Canadian women. A grounded theory approach was used to generate thematic categories and a model. Drawing on participants from a larger cohort study (n = 740), 40 women with arm morbidity symptoms were purposively sampled and interviewed. Three themes emerged: a sense of loss, adapting participation, and new directions. Women with arm morbidity may experience an abrupt loss of previously enjoyed leisure activities and engage in a process of adapting to discover new meanings and directions. Comprehensive, person-centred cancer survivorship programs may assist with adaptation to arm morbidity.

Impact of Prostate Cancer Treatment on the Sexual Quality of Life for Men-Who-Have-Sex-with-Men.

INTRODUCTION: With earlier prostate cancer (PCa) diagnosis and an increased focus on survivorship, post-treatment sexual quality of life (QoL) has become increasingly important. Research and validated instruments for sexual QoL assessment based on heterosexual samples have limited applicability for men-who-have-sex-with-men (MSM). AIM: We aimed to create a validated instrument for assessing sexual needs and concerns of MSM post-PCa treatment. Here we explore post-PCa treatment sexual concerns for a sample of MSM, as the first part of this multi-phase project. METHODS: Individual semi-structured interviews were conducted with 16 MSM face-to-face or via Internet-based video conferencing. Participants were asked open-ended questions about their experiences of sexual QoL following PCa. Interviews were recorded, transcribed verbatim, uploaded to NVivo 8(TM) , and analyzed using qualitative methodology. MAIN OUTCOME MEASURE: We have conducted semi-structure qualitative interviews on 16 MSM who were treated for PCa. Focus was on post-treatment sexual concerns. RESULTS: The following themes were inductively derived: (i) erectile, urinary, ejaculation, and orgasmic dysfunctions; (ii) challenges to intimate relationships; and (iii) lack of MSM-specific oncological and psychosocial support for PCa survivorship. Sexual practices pre-treatment ranked in order of frequency were masturbation, oral sex, and anal sex, an ordering that prevailed post-treatment. Sexual QoL decreased with erectile, urinary, and ejaculation dysfunctions. Post-treatment orgasms were compromised. Some single men and men in non-monogamous relationships reported a loss of confidence or difficulty meeting other men post-treatment. Limited access to targeted oncological and psychosocial supports posed difficulties in coping with PCa for MSM. CONCLUSIONS: The negative impact on sexual QoL can be severe for MSM and requires targeted attention. Penile-vaginal intercourse and erectile function have been the primary focus of sexual research and rehabilitation for men with PCa, and do not adequately reflect the sexual practices of MSM. Our findings suggest that future research dedicated to MSM with PCa is needed to incorporate their sexual practices and preferences specifically into treatment decisions, and that targeted oncological and psychosocial support services are also warranted.

Template-based Intensity-Modulated Radiation Therapy: A Cost-effective Intensity-Modulated Radiation Therapy Planning Procedure for Prostate Cancer.

INTRODUCTION: Intensity-modulated radiation therapy (IMRT) has been widely accepted for the treatment of prostate cancer. In comparison with traditional three-dimensional conformal radiation therapy (3D-CRT), it improves local control while minimizing side effects. However, IMRT comes at a significantly higher cost. In this report, we describe the development of template-based IMRT (TB-IMRT) planning for prostate cancer that does not require additional resources above 3D-CRT. METHODS: Twenty patients previously treated using 3D-CRT were retrospectively planned using the TB-IMRT planning technique. Planning target volume coverage, dose to organs at risk, and resource usage were compared between 3D-CRT and TB-IMRT techniques. RESULTS: All 3D-CRT and TB-IMRT plans met the planning guidelines. TB-IMRT compared better than 3D-CRT in terms of the homogeneity index (0.039 ± 0.007 vs. 0.052 ± 0.008) and conformity index (0.866 ± 0.024 vs. 0.752 ± 0.054). TB-IMRT also provided better sparing of organs at risk. Planning times were significantly less for TB-IMRT (average 13.43 ± 2.18 minutes) compared with conventional plans (45.4 ± 17.0 minutes). Times required for patient-specific quality assurance were similar between TB-IMRT and 3D-CRT. CONCLUSIONS: The TB-IMRT technique for prostate allows for all the potential benefits of IMRT without any additional resources above conventional 3D-CRT.

Late urinary side effects 10 years after low-dose-rate prostate brachytherapy: population-based results from a multiphysician practice treating with a standardized protocol and uniform dosimetric goals.

PURPOSE: To determine late urinary toxicity (>12 months) in a large cohort of uniformly treated low-dose-rate prostate brachytherapy patients. METHODS AND MATERIALS: From 1998 to 2009, 2709 patients with National Comprehensive Cancer Network-defined low-risk and low-tier intermediate-risk prostate cancer were treated with Iodine 125 ((125)I) low-dose-rate prostate brachytherapy; 2011 patients with a minimum of 25 months of follow-up were included in the study. Baseline patients, treatment, implant factors, and late urinary toxicity (Radiation Therapy Oncology Group [RTOG] grading system and International Prostate Symptom Score [IPSS]) were recorded prospectively. Time to IPSS resolution, late RTOG genitourinary toxicity was examined with Kaplan-Meier and log-rank tests. Cox proportional hazards regression was done for individual covariates and multivariable models. RESULTS: Median follow-up was 54.5 months (range, 2-13 years). Actuarial toxicity rates reached 27% and 10% (RTOG ≥2 and ≥3, respectively) at 9-13 years. Symptoms resolved quickly in the majority of patients (88% in 6-12 months). The prevalence of RTOG 0, 1, 2, 3, and 4 toxicity with a minimum of 7 years' follow-up was 70%, 21%, 6.4%, 2.3%, and 0.08%, respectively. Patients with a larger prostate volume, higher baseline IPSS, higher D90, acute toxicity, and age >70 years had more late RTOG ≥2 toxicity (all P≤.02). The IPSS resolved slower in patients with lower baseline IPSS and larger ultrasound prostate volume, those not receiving androgen deprivation therapy, and those with higher D90. The crude rate of RTOG 3 toxicity was 6%. Overall the rate of transurethral resection of the prostate was 1.9%; strictures, 2%; incontinence, 1.3%; severe symptoms, 1.8%; late catheterization, 1.3%; and hematuria, 0.8%. The majority (80%) resolved their symptoms in 6-12 months. CONCLUSION: Long-term urinary toxicity after brachytherapy is low. Although actuarial rates increase with longer follow-up (27% RTOG 2 and 10% RTOG 3 at 13 years), symptoms resolve relatively quickly; between 5 and 13 years' follow-up, >90% of patients have minimal urinary toxicity. Refining patient selection criteria, planning, and treatment delivery may further reduce toxicity.

Outcomes of Merkel cell carcinoma treated with radiotherapy without radical surgical excision.

BACKGROUND: Achieving clear surgical margins in Merkel cell carcinoma (MCC) can be difficult due to tumor location or patient comorbidity. Clinical impression suggests that radiation treatment achieves good control of macroscopic disease. METHODS: A retrospective chart review was undertaken of all patients with pathological evidence of MCC and treated with curative intent at the BC Cancer Agency between 1979 and 2007. This is a report on the outcomes of those with gross disease treated with radiotherapy, without radical surgery. RESULTS: Fifty-seven patients received definitive radiotherapy to the primary and/or nodal disease. Median age was 75 years and median follow-up was 34 months (84.5 months for those alive at last follow-up). American Joint Committee on Cancer (AJCC) stage distribution was 23, 19, and 58 % for stages I, II, and III, respectively. Tumor control at sites treated for macroscopic disease was 88 % at 12 months and 82 % at 2 years, and 5-year local relapse-free survival (RFS) was 90 %. Five-year RFS, cancer-specific survival (CSS), and overall survival were 57, 68, and 39 %, respectively. On univariate and multivariate analyses, only male sex was associated with a worse RFS, and a radiotherapy dose >50 Gy was associated with a better CSS. LIMITATIONS: The retrospective nature of the study and small sample size limit the strength of the conclusions. CONCLUSIONS: Radical radiotherapy is effective in the curative treatment of MCC, especially in patients who would tolerate wide surgical excision poorly, or where it would cause significant cosmetic or functional deficits.

Population-based validation of a policy change to use long-term androgen deprivation therapy for cT3-4 prostate cancer: impact of the EORTC22863 and RTOG 85-31 and 92-02 trials.

PURPOSE: After publication of EORTC-22863 trial, prolonged androgen deprivation therapy (ADT) combined with radiation therapy (RT) became standard policy for high-risk prostate cancer patients in British Columbia (BC) in 1997. We evaluated whether population-based survival improved after this policy change. PATIENTS AND METHODS: Two cohorts comprising all patients with T3-T4 prostate cancer treated with curative-intent RT in BC were reviewed. The Early cohort (n=730) was all patients treated between 1993 and 1995, and the Late cohort (n=584) was all patients treated between 1999 and 2001. The BC Cancer Registry, which collects data on survival, was linked to RT and pharmacy databases. Duration of ADT, age, stage, grade, presenting PSA, and Charlson comorbidity index (CCI; none=0, minor=1, major=2+), were abstracted from charts. RESULTS: Usage of ≥6 months and ≥18 months of neoadjuvant and adjuvant ADT increased from 14% and 1% to 97% and 59% (p<0.0001). Baseline characteristics were similar, except for lower Gleason score (G2-6: 45% vs. 20%, G7: 35% vs. 48%, G8-10: 19% vs. 32%; p<0.0001), higher T-stage (T4: 9% vs. 5%, p=0.004) and higher comorbidity (CCI 0: 62% vs. 71%, CCI 1: 26% vs. 20%, CCI 2+: 11% vs. 9%, p=0.002) in the Early cohort. Disease-specific survival adjusted for competing risks from other causes mortality was improved (90% vs. 86%, p=0.042). On multivariate analysis, the Late cohort was independently associated with improved 8-year overall survival (76% vs. 64%, p=0.0002). CONCLUSIONS: This population-based study demonstrated improved overall survival following a policy change to use of prolonged ADT with curative RT for patients with T3-T4 prostate cancer.

Template-based breast IMRT planning for increased workload efficiency.

BACKGROUND: To be less resource intensive, we developed a template-based breast IMRT technique (TB-IMRT). This study aims to compare resources and dose distribution between TB-IMRT and conventional breast radiation (CBR). METHODS: Twenty patients with early stage breast cancer were planned using CBR and TB-IMRT. Time to plan, coverage of volumes, dose to critical structures and treatment times were evaluated for CBR and TB-IMRT. Two sided-paired t tests were used. RESULTS: TB-IMRT planning time was less than CBR (14.0 vs 39.0 min, p < 0.001). Fifteen patients with CBR needed 18 MV, and 11 of these were planned successfully with TB-IMRT using 6 MV. TB-IMRT provided better homogeneity index (0.096 vs 0.124, p < 0.001) and conformity index (0.68 vs 0.59, p = 0.003). Dose to critical structures were comparable between TB-IMRT and CBR, and treatment times were also similar (6.0 vs 7.8 min, p = 0.13). CONCLUSIONS: TB- IMRT provides reduction of planning time and minimizes the use of high energy beams, while providing similar treatment times and equal plans compared to CBR. This technique permits efficient use of resources with a low learning curve, and can be done with existing equipment and personnel.

Population-based 10-year oncologic outcomes after low-dose-rate brachytherapy for low-risk and intermediate-risk prostate cancer.

BACKGROUND: The objective of this study was to report the rates of disease-free survival (DFS), cause-specific survival (CSS), and overall survival after low-dose-rate (LDR) prostate brachytherapy (PB). METHODS: Data from 1006 consecutive patients with prostate cancer who received LDR-PB and underwent implantation on or before October 23, 2003 were extracted from a prospective database on November 11, 2011. The selected patients had low-risk (58%) or intermediate-risk (42%) disease according to National Comprehensive Cancer Network criteria. The Phoenix threshold was used to define biochemical relapse. Sixty-five percent of patients received 3 months of neoadjuvant androgen-deprivation therapy (ADT) and 3 months of concomitant ADT. Univariate and multivariate analyses are reported in relation to patient, tumor, and treatment variables. RESULTS: The median follow-up was 7.5 years. By using Fine and Gray competing risks analysis, the 5-year and 10-year actuarial DFS rates were 96.7% (95% confidence interval, 95.2%-97.7%) and 94.1% (95% confidence interval, 92%-95.6%), respectively. When applied to the whole cohort, none of the usual prognostic variables, including dose metrics, were correlated with DFS. However, in both univariate and multivariate models, increasing dose was the only covariate that correlated with improved DFS for the subset of men (N = 348) who did not receive ADT (P = .043). The actuarial 10-year CSS rate was 99.1% (95% confidence interval, 97.3%-99.7%). The overall survival rate was 93.8% at 5 years (95% confidence interval, 92%-95.1%) and 83.5% at 10 years (95% confidence interval, 79.8%-86.6%). Only age at implantation (P = .0001) was correlated with overall survival in multivariate analysis. CONCLUSIONS: In a consecutive cohort of 1006 men with National Comprehensive Cancer Network low-risk and intermediate-risk prostate cancer, the actuarial rate of recurrent disease after LDR-PB was approximately 3% at 5 years and 6% at 10 years.

Evaluation of dosimetric consequences of seroma contour variability in accelerated partial breast irradiation using a constructed representative seroma contour.

PURPOSE: Contouring variability of the seroma can have important implications in the planning and delivery of accelerated partial breast irradiation (APBI). This study aimed to quantify the dosimetric impact of these interobserver and intraobserver contouring variations by construction of a representative seroma contour (RSC). METHODS AND MATERIALS: Twenty-one patients with a seroma suitable for APBI underwent four computed tomography (CT) scans: one planning CT and three additional CTs on the first, third, and fifth days of treatment. Three radiation oncologists contoured the seroma on each CT scan. For 3 patients, oncologists repeated contouring twice to assess intraobserver variations. Seroma contour variability was quantified by construction of an RSC. In addition, the percent volume overlap (PVO) was calculated. Root-mean-square (RMS) differences in seroma volume, size, and center of mass position compared to those of the RSC were calculated. Treatment fields from the original plan were applied to the repeated CTs by using the same isocenter shifts as the original plan. The dosimetric impact of the contour variations was assessed using V(95) (volume receiving at least 95% of the prescribed dose) and equivalent uniform dose (EUD). RESULTS: Interobserver RMS volume differences were, on average, 5.6 times larger than intraobserver differences. The median interobserver RMS seroma volume difference was 1.48 cm(3). The median PVO was 51.6%. V(95) and EUD of the seroma contours were similar for all patients. The median RMS differences of the seroma V(95) and EUD were 0.01% (range, 0%-3.99%) and 0.05 Gy (range, 0-0.98 Gy). CONCLUSIONS: Construction of the RSC showed that interobserver variations were most responsible for contour variations of the seroma. Current planning margins provided adequate dose coverage of the seroma despite these contour variations.

Rectal toxicity and rectal dosimetry in low-dose-rate (125)I 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.

Biochemical control with radiotherapy improves overall survival in intermediate and high-risk prostate cancer patients who have an estimated 10-year overall survival of >90%.

PURPOSE: To identify subgroups of patients with carcinoma of the prostate treated with radical radiotherapy that have improved overall survival when disease is biochemically controlled. METHODS AND MATERIALS: A cohort of 1,060 prostate cancer patients treated with radical radiotherapy was divided into nine subgroups based on National Comprehensive Cancer Network risk category and estimated 10-year overall survival (eOS 10y) derived from the age adjusted Charlson Comorbidity Index. Patients with and without biochemical control were compared with respect to overall survival. Actuarial estimates of overall survival were calculated using the Kaplan-Meier method. Univariate and multivariate Cox proportional hazards models were used for analysis of overall survival. RESULTS: Median follow-up was 125 months (range, 51-176 months). Only the subgroups with high or intermediate risk disease and an eOS 10y of >90% had a statistically significantly improved overall survival when prostate cancer was biochemically controlled. In all other groups, biochemical control made no significant difference to overall survival. In the subgroup with high-risk disease and eOS 10y >90%, actuarial overall survival was 86.3% (95% confidence interval [CI] 78.5%-94.1%) and 62.1% (95% CI 52.9%-71.3%) for patients with biochemical control and biochemical relapse respectively (p = 0.002). In the intermediate risk group with eOS >90%, actuarial overall survival was 95.3% (95% CI 89.0%-100%) and 79.8% (95% CI 68.0%-91.6%) for biochemically controlled and biochemically relapsed patients (p = 0.033). On multivariate analysis, National Comprehensive Cancer Network risk group (p = 0.005), biochemical control (p = 0.033) and eOS 10y (p < 0.001) were statistically significant. CONCLUSION: Biochemical control translates into improved overall survival in patients with high or intermediate risk disease and an estimated 10-year overall survival of >90%.