- Email: [email protected]
Audit of Offline Imaging in Men with Prostate Cancer and Implanted Fiducial Markers
e14
Abstracts / Clinical Oncology 28 (2016) e9ee16
enabling a reduction in these margins when using online BA. ProSpare will now be assessed in post-prostatectomy radiotherapy within a randomised controlled trial, POPS. Reference [1] van Herk M, Remeijer P, Rasch C, et al. The probability of correct target dosage: dose-population histograms for deriving treatment margins in radiotherapy. Int J Radiat Oncol Biol Phys 2000;47(4):1121e1135.
The Sequencing Conundrum in Metastatic Castrate-resistant Prostate Cancer (mCRPC): the Rosemere Cancer Centre Experience to Unlocking the Optimal Sequence S. Pan, V. Kumar, N. Charnley, O. Parikh, A. Birtle Royal Preston Hospital, Rosemere Cancer Centre, Preston, UK
Purpose: New life-prolonging treatments including docetaxel, cabazitaxel, abiraterone and enzalutamide have been a turning point in the management and outcomes of patients with mCRPC. The question remains of the optimal sequence and, often, this decision is physician-dependent, made based on non-randomised comparisons. This study aimed to evaluate the sequencing data, particularly in patients receiving cabazitaxel. Methods: A retrospective study of 33 mCRPC patients treated with cabazitaxel after progression during or following docetaxel treatment at the Rosemere Cancer Centre. Data relating to patient’s characteristics, treatments and clinical outcomes were collected from medical records and anonymised for analysis. Results: 33 patients were analysed, they had a median (interquartile range, IQR) age of 71.1 (67.4e75.1) years and a median (range) of 3 (2e4) different life-prolonging therapies. In 72% (24/33) of patients, cabazitaxel was secondline therapy after docetaxel and the median (IQR) time from mCRPC diagnosis to the start of cabazitaxel was 1.5 (1.0e2.0) years. Analysing the sequencing data based on the number of therapies (docetaxel e D; abiraterone e A; cabazitaxel e C; enzalutamide e E) received, 7 patients received 2 therapies (DC); 22 patients received 3 therapies (DAC: n ¼ 7; DCA: n ¼ 15); 4 patients received 4 therapies (DCAE: n ¼ 1; DACE: n ¼ 1; DCEA: n ¼ 1; DAEC: n ¼ 1). The median overall survival from diagnosis of mCRPC was 26.2 months for DAC and 40 months for DCA. An additional 14 months of survival was gained when cabazitaxel was used as second-line after docetaxel. Conclusion: This real life sequencing data from our centre shows promising results for median overall survival benefit when cabazitaxel is optimally prescribed as second-line therapy after docetaxel in a sequencing schedule. To further validate the data, the multicentre ECLIPSE study is ongoing.
Accumulated Dose to the Rectum, Calculated from Auto-contoured Image Guidance CT Scans, is Lower than Planned Dose in the Majority of Patients Treated with Radiotherapy for Prostate Cancer J. Scaife, S. Thomas, K. Harrison, A. Bates, J. Forman, M. Sutcliffe, M. Romanchikova, M. Parker, N. Burnet University of Cambridge, Cambridge, UK
Purpose: The radiotherapy (RT) dose plan considers a single point in time and cannot allow for variation in target or organ position during a course of treatment. In prostate RT, the ability to calculate the accumulated dose (DA) actually delivered to the rectum, which is dose limiting, has the potential to reduce toxicity or permit dose escalation. Methods: We devised an automated method for contouring the rectum on daily mega-voltage (MV) image guidance CT scans, with median conformity index 0.64 (IQR 0.53e0.71) compared with expert manual contours. We also devised a method to recalculate and summate dose on the daily CTs. The system was automated using expertise developed at CERN. Data for 109 prostate cancer patients (4033 scans) were processed. The volume of rectum that received 20, 30, 40, 50, 60, 65, 70 and 75 Gy, and the accumulated generalised equivalent uniform dose (gEUD), were compared with the treatment plan. Results: Using our system, results for the 109 patients were generated in less than 4 days. In 33/109 cases (30%), we found accumulated volume was planned volume, for all of the dose levels assessed. In 106/109 cases (97%), accumulated volume was planned volume for at least one dose level.
Accumulated gEUD was < planned gEUD in 97/109 participants (89%); median difference in gEUD was e1.2 Gy (IQR e0.5 to e2.3 Gy). Conclusion: This automated system gives the ability to track dose volumes in real time during a course of prostate RT. DA to the rectum was found to be less than that planned in the majority of patients; this could offer the potential to escalate dose to the prostate on an individual adaptive basis. We have assessed toxicity at least 2 years (median 4 years) after RT in these patients; future work will correlate this with the dose data.
A Study into the Benefits of Medication Usage Reviews (MURs) in Patients being Treated for Prostate Cancer T. Smith *, S. Mehta y, P. Chambers * * University College London Hospital, London, UK y Kingston University, London, UK
Purpose: In the UK, more people are living into old age, where cancer is more common [1]. It is estimated that the average cancer patient over the age of 65 years suffers from at least one chronic condition [2]. This can lead to polypharmacy, increased adverse drug reactions, non-adherence and sub-optimal healthcare outcomes. Medicine reviews have been shown to have a positive impact in optimising patient medication [3]. This study therefore aimed to investigate the potential benefits of MURs in an older cancer patient population. Methods: The study included patients over the age of 65 years who were being treated for prostate cancer. Data were collected via a survey consisting of 26 questions, which was conducted over the telephone. The questionnaire included questions relating to general information, both cancer and noncancer treatment and finally about MURs. Results: 40 (response rate 80%) patients participated in this survey. 30% of patients (n ¼ 12/40) suffered from 1 comorbid condition, whereas 37.5% (n ¼ 15/40) suffered 2 and 15% (n ¼ 6/40) suffered from 3 comorbid conditions. When commencing cancer medication, 100% (n ¼ 40/40) of participants stated that they were counselled both on directions of use and any adverse effects they should expect. Adherence of anticancer medication was high (80%), yet 60% claimed to be non-adherent to their non-cancer medication with the primary reason being there was no perceived benefit. A medication reconciliation reviewed by both a pharmacist and doctor revealed that 1 in 5 patients would benefit from a review of non-cancer treatment. Conclusion: The work has revealed a need to help optimise treatment for elderly cancer patients by rationalising treatment based on an understanding of both cancer prognosis and the benefits of non-cancer medications. The work has led to the development of a pilot to optimise medication for cancer patients. References [1] Ahmad AS, Ormiston-Smith N, Sasieni PD. Trends in the lifetime risk of developing cancer in Great Britain: comparison of risk for those born in 1930 to 1960. Br J Cancer 2015;2014:606. [2] Ritchie CS, Kvale E, Fisch MJ. Multimorbidity: an issue of growing importance for oncologists. J Oncol Practice 2011;7(6):371e374. [3] Latif A, Pollock K, et al. The contribution of the Medicines Use Review (MUR) consultation to counselling practice in community pharmacies. Patient Educ Counsel 2011;83(3):336e344.
Audit of Offline Imaging in Men with Prostate Cancer and Implanted Fiducial Markers L. Sweeney, J. Staffurth Velindre Cancer Centre, Cardiff, UK
Purpose: Geometric accuracy in radiotherapy delivery remains paramount to outcome [1]. This is of increased importance in an era of improved conformality, increased hypofractionation and sub-volume boosts. Intraprostatic fiducial marker insertion can aid both offline and online evaluation and is preferred by clinicians for matching [2]. Methods: Men with prostate fiducial markers inserted over a 4 year period were identified. We included men having prostate alone or with pelvic nodes treated, both within and outside of clinical trials. Imaging was reviewed to quantify set-up variation and the impact of the current use of ‘No Action Level’ [3] (NAL) as an offline protocol.
Abstracts / Clinical Oncology 28 (2016) e9ee16 Results: 43 men were identified. 41 patients were prescribed rectal enemas for the first 15 fractions of radiotherapy. 26 men had CBCT imaging, 17 patients had 2D imaging. 3/43 men were planned for daily online imaging and are not reported here. The variations in set-up from planning simulation were e1.5 cm to þ1.1 cm in both the x- and y-axes and e1.5 cm to þ1.5 cm in the zaxis. After application of the NAL, 81.8% of the x-axis, 80.4% of the y-axis and 76.6% of the z-axis images were within our 3 mm tolerance. The rate of gross errors (>5 mm) was reduced by w50% in each plane with the NAL. However, about 6% of images still displayed a gross error in at least one plane. In 14.3% of men, the NAL introduced more gross errors than if none had been applied. Conclusion: Based on this information, reducing PTV margins for patients imaged offline is not recommended. NAL is beneficial at reducing the frequency of gross error on imaging; however a significant number of images with gross errors still remain. Online imaging is urgently required to allow tighter margins and trials of extreme hypofractionation. References [1] Button MR, Staffurth JN. Clinical application of image-guided radiotherapy in bladder and prostate cancer. Clin Oncol 2010;22:698e706. [2] Barney BM, Lee RJ, Handrahan D, et al. Image-guided radiotherapy (IGRT) for prostate cancer comparing kV imaging of fiducial markers with cone beam computed tomography. Int J Radiat Oncol Biol Phys 2011;80:301e305. [3] de Boer HC, van Os MJ, Jansen PP, Heijmen BJ. Application of the No Action Level (NAL) protocol to correct for prostate motion based on electronic portal imaging of implanted markers. Int J Radiat Oncol Biol Phys 2005;61(4):969e983.
Radium-223 in Metastatic Castration Resistant Prostate Cancer (mCRPC): a Single Cancer Centre Experience N. Tsoukalas, M. Saigí Morguí, C. Mills, V. Lewington, S. Chowdhury, S. Rudman Guy’s and St Thomas’ NHS Foundation Trust, Cancer Centre, London, UK
Purpose: Radium-223 is an alpha emitter that selectively targets bone metastases. It has been approved for the treatment of mCRPC patients with bone metastases and without visceral involvement. We now present data for the first year of radium-223 administration at Guy’s Hospital. Methods: Patients with mCRPC with bone metastases received radium-223 from June 2014 to June 2015. 50 kBq/kg radium-223 was given intravenously every 28 days for 6 cycles. Results: Data from 31 male patients with median age 69 years (50e88) were collected. ECOG PS was 0e1 in 58% and 2 in 42%. 65% of patients had >6 bone metastases, whereas 32% had a superscan. 68% of patients had bone pain WHO score 2 or more and 42% patients were receiving concurrent bisphosphonates. The majority of patients (81%) had received more than 2 lines of prior treatments (71% had received docetaxel, 26% cabazitaxel, 87% abiraterone and 19% enzalutamide). 17 (55%) patients had finished treatment at the time of analysis, whereas the remaining 14 patients continue to receive radium-223. Of those patients who had completed treatment, 4 (23%) received 6 cycles of radium-223, 3 (18%) received 5 cycles, 1 (6%) received 4 cycles, 5 (29%) received 3 cycles, 1 (6%) received 2 cycles and 3 (18%) received 1 cycle. The causes of treatment interruption were disease progression (62%) or toxicity (38%). 56% of patients who received 3 cycles of treatment had PS 2. The main adverse events were asthenia 65%, anorexia 42%, anaemia 39% and nausea 23%, whereas some less common toxicities were thrombocytopenia, neutropenia and diarrhoea. Conclusion: Radium-223 treatment may be beneficial to patients outside of a clinical trial setting. However, in our series, patients of poorer PS were more likely not to complete treatment. We conclude that optimal patient selection remains crucial in order to ensure effective treatment delivery.
Outcomes with Bladder-sparing Strategies in the South East Wales Cancer Network S. Cox, J. Tanguay Velindre Cancer Centre, Cardiff, UK
Purpose: Radical RT with a radiosensitiser is an alternative to surgery for muscle-invasive bladder cancer (MIBC) [1], with neoadjuvant chemotherapy
e15
(NAC) offering a survival benefit [2]. Outcomes with bladder-sparing strategies in our centre are presented. Methods: Retrospective study of patients with MIBC (or poor prognostic pT1 disease) treated with radical RT between 2007 and 2014. NAC was a gemcitabine/platinum-based doublet. Concurrent weekly cisplatin (40 mg/m2) was replaced by mitomycin C (12 mg/m2 day 1)/capecitabine (825 mg/m2 bd on days of RT) in 2011. 176 (95.1%) patients completed the prescribed RT course (median 55 Gy in 20 fractions). Results: 185 patients, median age 75 years, were treated: RT alone 97 patients (52%) (group 1); RT þ radiosensitiser 16 patients (9%) (group 2); NAC and RT alone 37 patients (20%) (group 3); NAC and RT þ radiosensitiser 35 patients (19%) (group 4). 18 (10%) patients were node-positive. OS at 5 years was 37% (group 1 31%, group 2 70%, group 3 43%, group 4 40%). RFS at 2 years was 42% (group 1 42%, group 2 72%, group 3 45%, group 4 25%). Median survival for group 3 is yet to be met. 5 year OS for node-negative patients was 39% and 22% if node-positive. Grade 3 haematological toxicity and venous thromboembolism on NAC was 14% and 8%, respectively. 14% did not complete 3 cycles due to NAC toxicity, and proceeded to RT alone. Grade 3e4 radiation cystitis occurred in 2%, grade 3e4 colitis in 5%. 8 patients (4%) died on/within 30 days of treatment; 50% in group 1 (predominantly due to disease) and 25% in groups 3 and 4 each (colitis and sepsis). 13 patients (7%) had salvage cystectomy for disease, 1 (0.5%) for irritative symptoms. Conclusion: Our outcomes are consistent with the literature, demonstrating a survival benefit for NAC and radiosensitisers. However, in an older population with locally advanced disease, they can cause added toxicity. Careful patient selection is vital to ensure patients are treated maximally. References [1] National Institute for Health and Care Excellence. Bladder cancer: diagnosis and management. NICE guideline (NG2), 2015. [2] Advanced Bladder Cancer Meta-analysis Collaboration. Neoadjuvant chemotherapy in invasive bladder cancer: a systemic review and metaanalysis. Lancet 2015;361:1927e1934.
Comparison of Axitinib and Everolimus in the Second Line Treatment of Metastatic Renal Cell Carcinoma Following Previous Treatment with a Tyrosine Kinase Inhibitor: a Multicentre Retrospective Analysis S. Iqbal *, W. Badreldin y, S. Sundar z, N. Thompson z, J. Tanguay * * Velindre Cancer Centre, Cardiff, UK y Queen Mary University of London, London, UK z Nottingham University Hospital, Nottingham, UK
Purpose: Axitinib and everolimus both have phase II randomised controlled trial evidence (AXIS and RECORD 1) showing efficacy in the second and subsequent line treatment of metastatic renal cell carcinoma (mRCC). Both treatments are licensed for use in this setting. No randomised head to head comparison has been published thus far. Methods: We compared the effectiveness of axitinib and everolimus in patients with mRCC previously treated with at least 1 tyrosine kinase inhibitor (TKI) in usual clinical practice. A retrospective review was performed across 3 UK centres (Velindre Cancer Centre Cardiff, Barts Cancer Institute London and University Hospital of Leicester) comprising 76 patients with histologically confirmed RCC who received axitinib or everolimus following progression of disease after prior treatment with at least 1 TKI. Patients were identified using institutional databases. Progression free survival (PFS) and overall survival (OS) were calculated using the Kaplan-Maier method from the time of initiation of axitinib or everolimus. Results: Mean age of patients was 59.1 years. 45 patients received axitinib and 31 received everolimus. Both groups were comparable in basic demographics, such as age, MSKCC prognostic group, prior nephrectomy and previous systemic therapy. Response rate was 13.3% with axitinib and 6.5% with everolimus. Median PFS was 9 months (95% CI 5.2; 12.8) with axitinib and 4 months (95% CI 2.4; 5.6) with everolimus. Median OS was 13 months with axitinib and 10 months with everolimus. Both treatments were generally well tolerated. Grade 3 or above toxicity in the axitinib group were hypertension (16%) and gastrointestinal (11%) with 2 bowel perforations. In the everolimus group, common mild toxicities were skin rash, mucositis and peripheral oedema. 13% patients in the everolimus group had pneumonitis. Conclusion: Patients treated with axitinib had a tendency towards improved PFS and OS compared with patients treated with everolimus in second line
Abstracts / Clinical Oncology 28 (2016) e9ee16
enabling a reduction in these margins when using online BA. ProSpare will now be assessed in post-prostatectomy radiotherapy within a randomised controlled trial, POPS. Reference [1] van Herk M, Remeijer P, Rasch C, et al. The probability of correct target dosage: dose-population histograms for deriving treatment margins in radiotherapy. Int J Radiat Oncol Biol Phys 2000;47(4):1121e1135.
The Sequencing Conundrum in Metastatic Castrate-resistant Prostate Cancer (mCRPC): the Rosemere Cancer Centre Experience to Unlocking the Optimal Sequence S. Pan, V. Kumar, N. Charnley, O. Parikh, A. Birtle Royal Preston Hospital, Rosemere Cancer Centre, Preston, UK
Purpose: New life-prolonging treatments including docetaxel, cabazitaxel, abiraterone and enzalutamide have been a turning point in the management and outcomes of patients with mCRPC. The question remains of the optimal sequence and, often, this decision is physician-dependent, made based on non-randomised comparisons. This study aimed to evaluate the sequencing data, particularly in patients receiving cabazitaxel. Methods: A retrospective study of 33 mCRPC patients treated with cabazitaxel after progression during or following docetaxel treatment at the Rosemere Cancer Centre. Data relating to patient’s characteristics, treatments and clinical outcomes were collected from medical records and anonymised for analysis. Results: 33 patients were analysed, they had a median (interquartile range, IQR) age of 71.1 (67.4e75.1) years and a median (range) of 3 (2e4) different life-prolonging therapies. In 72% (24/33) of patients, cabazitaxel was secondline therapy after docetaxel and the median (IQR) time from mCRPC diagnosis to the start of cabazitaxel was 1.5 (1.0e2.0) years. Analysing the sequencing data based on the number of therapies (docetaxel e D; abiraterone e A; cabazitaxel e C; enzalutamide e E) received, 7 patients received 2 therapies (DC); 22 patients received 3 therapies (DAC: n ¼ 7; DCA: n ¼ 15); 4 patients received 4 therapies (DCAE: n ¼ 1; DACE: n ¼ 1; DCEA: n ¼ 1; DAEC: n ¼ 1). The median overall survival from diagnosis of mCRPC was 26.2 months for DAC and 40 months for DCA. An additional 14 months of survival was gained when cabazitaxel was used as second-line after docetaxel. Conclusion: This real life sequencing data from our centre shows promising results for median overall survival benefit when cabazitaxel is optimally prescribed as second-line therapy after docetaxel in a sequencing schedule. To further validate the data, the multicentre ECLIPSE study is ongoing.
Accumulated Dose to the Rectum, Calculated from Auto-contoured Image Guidance CT Scans, is Lower than Planned Dose in the Majority of Patients Treated with Radiotherapy for Prostate Cancer J. Scaife, S. Thomas, K. Harrison, A. Bates, J. Forman, M. Sutcliffe, M. Romanchikova, M. Parker, N. Burnet University of Cambridge, Cambridge, UK
Purpose: The radiotherapy (RT) dose plan considers a single point in time and cannot allow for variation in target or organ position during a course of treatment. In prostate RT, the ability to calculate the accumulated dose (DA) actually delivered to the rectum, which is dose limiting, has the potential to reduce toxicity or permit dose escalation. Methods: We devised an automated method for contouring the rectum on daily mega-voltage (MV) image guidance CT scans, with median conformity index 0.64 (IQR 0.53e0.71) compared with expert manual contours. We also devised a method to recalculate and summate dose on the daily CTs. The system was automated using expertise developed at CERN. Data for 109 prostate cancer patients (4033 scans) were processed. The volume of rectum that received 20, 30, 40, 50, 60, 65, 70 and 75 Gy, and the accumulated generalised equivalent uniform dose (gEUD), were compared with the treatment plan. Results: Using our system, results for the 109 patients were generated in less than 4 days. In 33/109 cases (30%), we found accumulated volume was planned volume, for all of the dose levels assessed. In 106/109 cases (97%), accumulated volume was planned volume for at least one dose level.
Accumulated gEUD was < planned gEUD in 97/109 participants (89%); median difference in gEUD was e1.2 Gy (IQR e0.5 to e2.3 Gy). Conclusion: This automated system gives the ability to track dose volumes in real time during a course of prostate RT. DA to the rectum was found to be less than that planned in the majority of patients; this could offer the potential to escalate dose to the prostate on an individual adaptive basis. We have assessed toxicity at least 2 years (median 4 years) after RT in these patients; future work will correlate this with the dose data.
A Study into the Benefits of Medication Usage Reviews (MURs) in Patients being Treated for Prostate Cancer T. Smith *, S. Mehta y, P. Chambers * * University College London Hospital, London, UK y Kingston University, London, UK
Purpose: In the UK, more people are living into old age, where cancer is more common [1]. It is estimated that the average cancer patient over the age of 65 years suffers from at least one chronic condition [2]. This can lead to polypharmacy, increased adverse drug reactions, non-adherence and sub-optimal healthcare outcomes. Medicine reviews have been shown to have a positive impact in optimising patient medication [3]. This study therefore aimed to investigate the potential benefits of MURs in an older cancer patient population. Methods: The study included patients over the age of 65 years who were being treated for prostate cancer. Data were collected via a survey consisting of 26 questions, which was conducted over the telephone. The questionnaire included questions relating to general information, both cancer and noncancer treatment and finally about MURs. Results: 40 (response rate 80%) patients participated in this survey. 30% of patients (n ¼ 12/40) suffered from 1 comorbid condition, whereas 37.5% (n ¼ 15/40) suffered 2 and 15% (n ¼ 6/40) suffered from 3 comorbid conditions. When commencing cancer medication, 100% (n ¼ 40/40) of participants stated that they were counselled both on directions of use and any adverse effects they should expect. Adherence of anticancer medication was high (80%), yet 60% claimed to be non-adherent to their non-cancer medication with the primary reason being there was no perceived benefit. A medication reconciliation reviewed by both a pharmacist and doctor revealed that 1 in 5 patients would benefit from a review of non-cancer treatment. Conclusion: The work has revealed a need to help optimise treatment for elderly cancer patients by rationalising treatment based on an understanding of both cancer prognosis and the benefits of non-cancer medications. The work has led to the development of a pilot to optimise medication for cancer patients. References [1] Ahmad AS, Ormiston-Smith N, Sasieni PD. Trends in the lifetime risk of developing cancer in Great Britain: comparison of risk for those born in 1930 to 1960. Br J Cancer 2015;2014:606. [2] Ritchie CS, Kvale E, Fisch MJ. Multimorbidity: an issue of growing importance for oncologists. J Oncol Practice 2011;7(6):371e374. [3] Latif A, Pollock K, et al. The contribution of the Medicines Use Review (MUR) consultation to counselling practice in community pharmacies. Patient Educ Counsel 2011;83(3):336e344.
Audit of Offline Imaging in Men with Prostate Cancer and Implanted Fiducial Markers L. Sweeney, J. Staffurth Velindre Cancer Centre, Cardiff, UK
Purpose: Geometric accuracy in radiotherapy delivery remains paramount to outcome [1]. This is of increased importance in an era of improved conformality, increased hypofractionation and sub-volume boosts. Intraprostatic fiducial marker insertion can aid both offline and online evaluation and is preferred by clinicians for matching [2]. Methods: Men with prostate fiducial markers inserted over a 4 year period were identified. We included men having prostate alone or with pelvic nodes treated, both within and outside of clinical trials. Imaging was reviewed to quantify set-up variation and the impact of the current use of ‘No Action Level’ [3] (NAL) as an offline protocol.
Abstracts / Clinical Oncology 28 (2016) e9ee16 Results: 43 men were identified. 41 patients were prescribed rectal enemas for the first 15 fractions of radiotherapy. 26 men had CBCT imaging, 17 patients had 2D imaging. 3/43 men were planned for daily online imaging and are not reported here. The variations in set-up from planning simulation were e1.5 cm to þ1.1 cm in both the x- and y-axes and e1.5 cm to þ1.5 cm in the zaxis. After application of the NAL, 81.8% of the x-axis, 80.4% of the y-axis and 76.6% of the z-axis images were within our 3 mm tolerance. The rate of gross errors (>5 mm) was reduced by w50% in each plane with the NAL. However, about 6% of images still displayed a gross error in at least one plane. In 14.3% of men, the NAL introduced more gross errors than if none had been applied. Conclusion: Based on this information, reducing PTV margins for patients imaged offline is not recommended. NAL is beneficial at reducing the frequency of gross error on imaging; however a significant number of images with gross errors still remain. Online imaging is urgently required to allow tighter margins and trials of extreme hypofractionation. References [1] Button MR, Staffurth JN. Clinical application of image-guided radiotherapy in bladder and prostate cancer. Clin Oncol 2010;22:698e706. [2] Barney BM, Lee RJ, Handrahan D, et al. Image-guided radiotherapy (IGRT) for prostate cancer comparing kV imaging of fiducial markers with cone beam computed tomography. Int J Radiat Oncol Biol Phys 2011;80:301e305. [3] de Boer HC, van Os MJ, Jansen PP, Heijmen BJ. Application of the No Action Level (NAL) protocol to correct for prostate motion based on electronic portal imaging of implanted markers. Int J Radiat Oncol Biol Phys 2005;61(4):969e983.
Radium-223 in Metastatic Castration Resistant Prostate Cancer (mCRPC): a Single Cancer Centre Experience N. Tsoukalas, M. Saigí Morguí, C. Mills, V. Lewington, S. Chowdhury, S. Rudman Guy’s and St Thomas’ NHS Foundation Trust, Cancer Centre, London, UK
Purpose: Radium-223 is an alpha emitter that selectively targets bone metastases. It has been approved for the treatment of mCRPC patients with bone metastases and without visceral involvement. We now present data for the first year of radium-223 administration at Guy’s Hospital. Methods: Patients with mCRPC with bone metastases received radium-223 from June 2014 to June 2015. 50 kBq/kg radium-223 was given intravenously every 28 days for 6 cycles. Results: Data from 31 male patients with median age 69 years (50e88) were collected. ECOG PS was 0e1 in 58% and 2 in 42%. 65% of patients had >6 bone metastases, whereas 32% had a superscan. 68% of patients had bone pain WHO score 2 or more and 42% patients were receiving concurrent bisphosphonates. The majority of patients (81%) had received more than 2 lines of prior treatments (71% had received docetaxel, 26% cabazitaxel, 87% abiraterone and 19% enzalutamide). 17 (55%) patients had finished treatment at the time of analysis, whereas the remaining 14 patients continue to receive radium-223. Of those patients who had completed treatment, 4 (23%) received 6 cycles of radium-223, 3 (18%) received 5 cycles, 1 (6%) received 4 cycles, 5 (29%) received 3 cycles, 1 (6%) received 2 cycles and 3 (18%) received 1 cycle. The causes of treatment interruption were disease progression (62%) or toxicity (38%). 56% of patients who received 3 cycles of treatment had PS 2. The main adverse events were asthenia 65%, anorexia 42%, anaemia 39% and nausea 23%, whereas some less common toxicities were thrombocytopenia, neutropenia and diarrhoea. Conclusion: Radium-223 treatment may be beneficial to patients outside of a clinical trial setting. However, in our series, patients of poorer PS were more likely not to complete treatment. We conclude that optimal patient selection remains crucial in order to ensure effective treatment delivery.
Outcomes with Bladder-sparing Strategies in the South East Wales Cancer Network S. Cox, J. Tanguay Velindre Cancer Centre, Cardiff, UK
Purpose: Radical RT with a radiosensitiser is an alternative to surgery for muscle-invasive bladder cancer (MIBC) [1], with neoadjuvant chemotherapy
e15
(NAC) offering a survival benefit [2]. Outcomes with bladder-sparing strategies in our centre are presented. Methods: Retrospective study of patients with MIBC (or poor prognostic pT1 disease) treated with radical RT between 2007 and 2014. NAC was a gemcitabine/platinum-based doublet. Concurrent weekly cisplatin (40 mg/m2) was replaced by mitomycin C (12 mg/m2 day 1)/capecitabine (825 mg/m2 bd on days of RT) in 2011. 176 (95.1%) patients completed the prescribed RT course (median 55 Gy in 20 fractions). Results: 185 patients, median age 75 years, were treated: RT alone 97 patients (52%) (group 1); RT þ radiosensitiser 16 patients (9%) (group 2); NAC and RT alone 37 patients (20%) (group 3); NAC and RT þ radiosensitiser 35 patients (19%) (group 4). 18 (10%) patients were node-positive. OS at 5 years was 37% (group 1 31%, group 2 70%, group 3 43%, group 4 40%). RFS at 2 years was 42% (group 1 42%, group 2 72%, group 3 45%, group 4 25%). Median survival for group 3 is yet to be met. 5 year OS for node-negative patients was 39% and 22% if node-positive. Grade 3 haematological toxicity and venous thromboembolism on NAC was 14% and 8%, respectively. 14% did not complete 3 cycles due to NAC toxicity, and proceeded to RT alone. Grade 3e4 radiation cystitis occurred in 2%, grade 3e4 colitis in 5%. 8 patients (4%) died on/within 30 days of treatment; 50% in group 1 (predominantly due to disease) and 25% in groups 3 and 4 each (colitis and sepsis). 13 patients (7%) had salvage cystectomy for disease, 1 (0.5%) for irritative symptoms. Conclusion: Our outcomes are consistent with the literature, demonstrating a survival benefit for NAC and radiosensitisers. However, in an older population with locally advanced disease, they can cause added toxicity. Careful patient selection is vital to ensure patients are treated maximally. References [1] National Institute for Health and Care Excellence. Bladder cancer: diagnosis and management. NICE guideline (NG2), 2015. [2] Advanced Bladder Cancer Meta-analysis Collaboration. Neoadjuvant chemotherapy in invasive bladder cancer: a systemic review and metaanalysis. Lancet 2015;361:1927e1934.
Comparison of Axitinib and Everolimus in the Second Line Treatment of Metastatic Renal Cell Carcinoma Following Previous Treatment with a Tyrosine Kinase Inhibitor: a Multicentre Retrospective Analysis S. Iqbal *, W. Badreldin y, S. Sundar z, N. Thompson z, J. Tanguay * * Velindre Cancer Centre, Cardiff, UK y Queen Mary University of London, London, UK z Nottingham University Hospital, Nottingham, UK
Purpose: Axitinib and everolimus both have phase II randomised controlled trial evidence (AXIS and RECORD 1) showing efficacy in the second and subsequent line treatment of metastatic renal cell carcinoma (mRCC). Both treatments are licensed for use in this setting. No randomised head to head comparison has been published thus far. Methods: We compared the effectiveness of axitinib and everolimus in patients with mRCC previously treated with at least 1 tyrosine kinase inhibitor (TKI) in usual clinical practice. A retrospective review was performed across 3 UK centres (Velindre Cancer Centre Cardiff, Barts Cancer Institute London and University Hospital of Leicester) comprising 76 patients with histologically confirmed RCC who received axitinib or everolimus following progression of disease after prior treatment with at least 1 TKI. Patients were identified using institutional databases. Progression free survival (PFS) and overall survival (OS) were calculated using the Kaplan-Maier method from the time of initiation of axitinib or everolimus. Results: Mean age of patients was 59.1 years. 45 patients received axitinib and 31 received everolimus. Both groups were comparable in basic demographics, such as age, MSKCC prognostic group, prior nephrectomy and previous systemic therapy. Response rate was 13.3% with axitinib and 6.5% with everolimus. Median PFS was 9 months (95% CI 5.2; 12.8) with axitinib and 4 months (95% CI 2.4; 5.6) with everolimus. Median OS was 13 months with axitinib and 10 months with everolimus. Both treatments were generally well tolerated. Grade 3 or above toxicity in the axitinib group were hypertension (16%) and gastrointestinal (11%) with 2 bowel perforations. In the everolimus group, common mild toxicities were skin rash, mucositis and peripheral oedema. 13% patients in the everolimus group had pneumonitis. Conclusion: Patients treated with axitinib had a tendency towards improved PFS and OS compared with patients treated with everolimus in second line