Prostate only vs. whole pelvis radiotherapy for locally advanced and aggressive disease


If a patient is diagnosed with either high-risk prostate cancer that appears to be confined to the prostate or potentially locally advanced disease that may have progressed into nearby pelvic tissues, the question arises whether it is better to simply radiate the prostate alone with curative intent or to radiate both the prostate and the nearby tissues, which is inevitably going to increase the risk for adverse events.

Aizer et al. have attempted to determine whether whole pelvis radiotherapy (WPRT) or prostate-only radiotherapy (PORT) yields improved biochemical disease-free survival (BDFS) in patients with advanced or aggressive prostate adenocarcinoma by analyzing data from a sample of 277 consecutive patients, treated between 2000 and 2007 at two teaching institutions, who had prostate adenocarcinoma and at least a 15 percent likelihood of lymph node involvement.

Biochemical progression was defined according to the Phoenix criteria, in which a patient is said to have progressive disease if their PSA increases to 2 ng/ml above the nadir PSA level achieved after initial radiotherapy.

The data reported from this study are as follows:

  • 68/277 patients received WPRT, and these patients had more advanced and aggressive disease at baseline.
  • 209/277 patients received PORT
  • The median radiation dose in both arms was 75.6 Gy.
  • The median follow-up was 30 months.
  • The 4-year BDFS rate was 69.4 percent in the PORT cohort and 86.3 percent in the WPRT cohort (p = .02).
  • The pretreatment PSA level, Gleason score, use of hormonal therapy, and use of WPRT (vs. PORT) were all predictive for a higher likelihood of BDFS.
  • Patients undergoing WPRT had increased acute gastrointestinal toxicity, but no significant difference in acute genitourinary toxicity wasnoted.
  • There wer no apparent differences in late toxicity.

The authors conclude that WPRT may yield improved BDFS compared to PORT in patients with advanced or aggressive prostate adenocarcinoma, but the use of WPRT results in a greater incidence of acute toxicity.

While the results of this study are hardly surprising, it is useful to have a quantified understanding of the risks associated with these two types of therapy in patients with a significant risk of node-positive prostate cancer.

It should be pointed out that current clinical radiotherapy strategies in patients of this type seek to maximize the curative dose of radiation delivered to the prostate, while providing a lower but sufficient therapeutic dose of radiation to the surrounding tissues so as to minimize adverse events while maximizing the possibility of curative outcome.

One Response

  1. This study further supports the adjuvant prostate bed (PBRT) vs. whole pelvis (WPRT), with ADT, post-RP study from Stanford University. WPRT was my direction based on that study.

    Tony

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