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ProSpare, a Rectal Obturator and its Effect on Prostate and Seminal Vesicle Interfraction Motion
Abstracts / Clinical Oncology 28 (2016) e9ee16 to date. Could PNRT improve biochemical control rate, overall survival and avoid or delay the need for systemic treatments? We conducted a retrospective study to analyse overall and PSA progression free survival of patients treated with pelvic nodal and prostate radiotherapy. Methods: We identified patients from our database treated between January 2008 and December 2009 with pelvic nodal and prostate irradiation using Tomotherapy with daily on-line image guidance. The prostate gland and pelvic nodes were treated to 74 Gy and 60 Gy in 37 fractions, respectively. Presenting PSA, Gleason score, staging, duration of hormonal treatments, date of PSA progression and death were analysed. Results: 48 patients were identified and analysis was carried out with the available data. 83% of patients had high-risk prostate cancer with a median PSA of 46; 6.73% had combined clinical and radiological T3 disease and 1 patient was node positive. The median overall and PSA progression free survival were not reached. Four patients had documented PSA progression (2 patients while receiving and 2 patients after completing adjuvant hormone treatments) and 2 have died. An additional patient died of an unrelated cause. 56% of patients remained free of further hormonal treatments. Conclusion: Our retrospective study showed that PSA progression after PNRT in selected high-risk patients was low. Median overall and PSA progression free survival were not reached. Although the results of PNRT appear promising, a matched analysis of patients treated without nodal RT is being undertaken for comparison. The results of a phase II randomised trial (PIVOTAL), in which our centre participated, evaluating the efficacy and toxicities of the addition of PNRT are awaited.
Combined High Dose Rate (HDR) Brachytherapy with External Beam Radiotherapy (EBRT) Results in a High Rate of Biochemical Disease Free Survival (DFS) in Localised Intermediate and High Risk Prostate Cancer Patients N. Joseph, C. Taylor, A. Choudhury, T. Elliott, J. Logue, J. Wylie The Christie NHS Foundation Trust, Manchester, UK
Purpose: Dose escalation has been shown to improve biochemical outcome in localised prostate cancer. An HDR brachytherapy boost is an effective strategyfor dose escalation, as it also exploits the low a/b ratio in prostate cancer, allowing the delivery of a high biological dose to the tumour. We sought to evaluate the biochemical DFS in patients with intermediate and high risk localised prostate cancer treated with EBRT plus HDR brachytherapy as a boost in our institution. Methods: Biochemical outcome was collected prospectively in 95 patients treated from 2008 to 2010, with an HDR boost of 12.5 Gy followed by EBRT delivered as 37.5 Gy in 15 fractions over 3 weeks. The ASTRO definition of biochemical failure (2 mg/l above PSA nadir) was used as the outcome measure. 71/95 (75%) were classified as high risk (stage > T2b or PSA > 20 mg/l or Gleason score > 7), whereas 24/95 (25%) were intermediate risk. 92/95 (97%) patients received neoadjuvant androgen deprivation therapy. Adjuvant hormone therapy was at the discretion of the treating clinician (6e24 months). Results: The median follow-up for the cohort was 65 months (range 18e88) with a 5 year biochemical DFS of 80.5% [95% confidence interval (CI) 72.8e89.0]. The prognostic factors used in the analysis model were: clinical stage, presenting PSA, Gleason score, PSA nadir and time to PSA nadir. Presenting PSA (HR 1.03; CI 1.01e1.05, P ¼ 0.003), PSA nadir > 0.1 mg/l (HR 7.28; CI 3.2e16.5, P ¼ 0.000002) and a shortened time to PSA nadir (HR 0.962; CI 0.929e0.997, P ¼ 0.035) were prognostic for poorer biochemical DFS on multivariate analysis. Conclusion: These data confirm that EBRT plus a single-fraction HDR brachytherapy boost achieves good biochemical control in a cohort of predominantly high risk patients. We have now moved to a dose of 15 Gy HDR, which forms the basis of the current UK national protocol.
Quality of Life Related Outcomes Following LDR Prostate Brachytherapy: a Single Centre Experience S. Lightowlers, H. Buckley, A. Styling, S. Kastner, S. Russell Addenbrooke’s Hospital, Cambridge, UK
Purpose: Following low dose rate (LDR) prostate brachytherapy, many patients experience lower urinary tract symptoms (LUTS) and a decline in
e13
potency [1]. At our centre, about 100 patients undergo brachytherapy annually; we aimed to prospectively assess toxicity experienced. Methods: The cohort of 115 patients underwent ultrasound-guided dynamic LDR prostate brachytherapy between June 2013 and December 2014. The prescription dose to the 100% isodose was 145 Gy. Data regarding symptoms were collected prospectively using International Prostate Symptom Score (IPSS), International Index of Erectile Function (IEFF)-5 and bowel toxicity score prior to, and at 6 weeks and 6 months after brachytherapy. Results: Questionnaires were returned at 6 weeks by 39 patients and at 6 months by 21 patients. The mean change in IPSS score at 6 weeks was a 9.5 point increase. The percentage of patients with mild, moderate and severe symptoms was 60%, 40% and 0%, respectively, at baseline compared with 5.4%, 61.2% and 32.4% at 6 weeks. At 6 months, the mean IPSS change was a 6.7 point increase. The percentage of patients with a ‘moderate’ score had increased from 33.3% to 80%, with only 5% having ‘severe’ symptoms. 33.3% had had resolution of IPSS score (defined as score within one point of antecedent IPSS) by 6 months. At 6 weeks, 38.5% had lower erectile function scores (suggesting more severe symptoms). The mean change in IEFF score was a 9 point decrease. At 6 months, only 5 patients completed the IEFF. Bowel toxicity scores were higher (suggesting more severe symptoms) than baseline for 56.4% at 6 weeks and 28.6% at 6 months. Conclusion: Toxicity profiles of available management options for early prostate cancer are important in patient decision making; however, there is significant variation in outcomes between published series [1]. Our centre’s reported toxicity data will facilitate this decision making process in patients referred to our service. Reference [1] Khaksar SJ, Laing RW, Henderson A, et al. Biochemical (prostate-specific antigen) relapse-free survival and toxicity after I-125 low-dose-rate prostate brachytherapy. BJU Int 2006;98(6):1210e1215.
ProSpare, a Rectal Obturator and its Effect on Prostate and Seminal Vesicle Interfraction Motion J. Murray *, H. McNair y, E. Alexander y, K. Thomas y, D. Dearnaley * * The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, Sutton, UK y The Royal Marsden NHS Foundation Trust, Sutton, UK
Purpose: ProSpare is a single-use, self-insertable endorectal device designed as a daily image-guidance tool for prostate cancer radiotherapy. In intermediate- to high-risk patients, seminal vesicles (SV) form part of the target volume. Prostate fiducial marker registration does not account for SV deformation or motion relative to the prostate gland. We investigated the effect of ProSpare on interfraction prostate and SV motion. Methods: 19 patients with localised prostate cancer were randomised to receive prostate radiotherapy with ProSpare either in the first or second half of their treatment. In all patients, 3 markers were implanted into the prostate and they received online image-guided radiotherapy using cone-beam-CT (CBCT-XVI system, Elekta). The first 5 assessable pre-treatment CBCTs with and without ProSpare were evaluated in all patients for prostate and SV interfraction motion. 190 CBCTs were analysed and online set-up corrections for prostate and SV using bony anatomy (BA) were determined. Systematic and random errors with and without ProSpare were calculated and CTVePTV margins for both the prostate and SV were generated using the Van Herk formula [1]. Results: The average age at treatment was 74 years, with median PSA and Gleason scores of 10.8 ng/ml and 7, respectively. The mean SV volume was 8.81 cm3 and 9.30 cm3 with and without ProSpare and the average contour length of SV in the cranio-caudal direction was 15 mm. Calculated CTVePTV margins (mm) with daily online matching to BA in the RL, SI and AP planes respectively were: Prostate With ProSpare: 1.2, 5.3, 5.2 Without ProSpare: 1.7, 7.1, 6.8 SV With ProSpare: 3.7, 5.9, 7.5 Without ProSpare: 3.0, 7.1, 12.1 Conclusion: ProSpare reduces prostate and SV interfraction motion. The SV calculated PTV margins were greater than for prostate, with ProSpare
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.
Combined High Dose Rate (HDR) Brachytherapy with External Beam Radiotherapy (EBRT) Results in a High Rate of Biochemical Disease Free Survival (DFS) in Localised Intermediate and High Risk Prostate Cancer Patients N. Joseph, C. Taylor, A. Choudhury, T. Elliott, J. Logue, J. Wylie The Christie NHS Foundation Trust, Manchester, UK
Purpose: Dose escalation has been shown to improve biochemical outcome in localised prostate cancer. An HDR brachytherapy boost is an effective strategyfor dose escalation, as it also exploits the low a/b ratio in prostate cancer, allowing the delivery of a high biological dose to the tumour. We sought to evaluate the biochemical DFS in patients with intermediate and high risk localised prostate cancer treated with EBRT plus HDR brachytherapy as a boost in our institution. Methods: Biochemical outcome was collected prospectively in 95 patients treated from 2008 to 2010, with an HDR boost of 12.5 Gy followed by EBRT delivered as 37.5 Gy in 15 fractions over 3 weeks. The ASTRO definition of biochemical failure (2 mg/l above PSA nadir) was used as the outcome measure. 71/95 (75%) were classified as high risk (stage > T2b or PSA > 20 mg/l or Gleason score > 7), whereas 24/95 (25%) were intermediate risk. 92/95 (97%) patients received neoadjuvant androgen deprivation therapy. Adjuvant hormone therapy was at the discretion of the treating clinician (6e24 months). Results: The median follow-up for the cohort was 65 months (range 18e88) with a 5 year biochemical DFS of 80.5% [95% confidence interval (CI) 72.8e89.0]. The prognostic factors used in the analysis model were: clinical stage, presenting PSA, Gleason score, PSA nadir and time to PSA nadir. Presenting PSA (HR 1.03; CI 1.01e1.05, P ¼ 0.003), PSA nadir > 0.1 mg/l (HR 7.28; CI 3.2e16.5, P ¼ 0.000002) and a shortened time to PSA nadir (HR 0.962; CI 0.929e0.997, P ¼ 0.035) were prognostic for poorer biochemical DFS on multivariate analysis. Conclusion: These data confirm that EBRT plus a single-fraction HDR brachytherapy boost achieves good biochemical control in a cohort of predominantly high risk patients. We have now moved to a dose of 15 Gy HDR, which forms the basis of the current UK national protocol.
Quality of Life Related Outcomes Following LDR Prostate Brachytherapy: a Single Centre Experience S. Lightowlers, H. Buckley, A. Styling, S. Kastner, S. Russell Addenbrooke’s Hospital, Cambridge, UK
Purpose: Following low dose rate (LDR) prostate brachytherapy, many patients experience lower urinary tract symptoms (LUTS) and a decline in
e13
potency [1]. At our centre, about 100 patients undergo brachytherapy annually; we aimed to prospectively assess toxicity experienced. Methods: The cohort of 115 patients underwent ultrasound-guided dynamic LDR prostate brachytherapy between June 2013 and December 2014. The prescription dose to the 100% isodose was 145 Gy. Data regarding symptoms were collected prospectively using International Prostate Symptom Score (IPSS), International Index of Erectile Function (IEFF)-5 and bowel toxicity score prior to, and at 6 weeks and 6 months after brachytherapy. Results: Questionnaires were returned at 6 weeks by 39 patients and at 6 months by 21 patients. The mean change in IPSS score at 6 weeks was a 9.5 point increase. The percentage of patients with mild, moderate and severe symptoms was 60%, 40% and 0%, respectively, at baseline compared with 5.4%, 61.2% and 32.4% at 6 weeks. At 6 months, the mean IPSS change was a 6.7 point increase. The percentage of patients with a ‘moderate’ score had increased from 33.3% to 80%, with only 5% having ‘severe’ symptoms. 33.3% had had resolution of IPSS score (defined as score within one point of antecedent IPSS) by 6 months. At 6 weeks, 38.5% had lower erectile function scores (suggesting more severe symptoms). The mean change in IEFF score was a 9 point decrease. At 6 months, only 5 patients completed the IEFF. Bowel toxicity scores were higher (suggesting more severe symptoms) than baseline for 56.4% at 6 weeks and 28.6% at 6 months. Conclusion: Toxicity profiles of available management options for early prostate cancer are important in patient decision making; however, there is significant variation in outcomes between published series [1]. Our centre’s reported toxicity data will facilitate this decision making process in patients referred to our service. Reference [1] Khaksar SJ, Laing RW, Henderson A, et al. Biochemical (prostate-specific antigen) relapse-free survival and toxicity after I-125 low-dose-rate prostate brachytherapy. BJU Int 2006;98(6):1210e1215.
ProSpare, a Rectal Obturator and its Effect on Prostate and Seminal Vesicle Interfraction Motion J. Murray *, H. McNair y, E. Alexander y, K. Thomas y, D. Dearnaley * * The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, Sutton, UK y The Royal Marsden NHS Foundation Trust, Sutton, UK
Purpose: ProSpare is a single-use, self-insertable endorectal device designed as a daily image-guidance tool for prostate cancer radiotherapy. In intermediate- to high-risk patients, seminal vesicles (SV) form part of the target volume. Prostate fiducial marker registration does not account for SV deformation or motion relative to the prostate gland. We investigated the effect of ProSpare on interfraction prostate and SV motion. Methods: 19 patients with localised prostate cancer were randomised to receive prostate radiotherapy with ProSpare either in the first or second half of their treatment. In all patients, 3 markers were implanted into the prostate and they received online image-guided radiotherapy using cone-beam-CT (CBCT-XVI system, Elekta). The first 5 assessable pre-treatment CBCTs with and without ProSpare were evaluated in all patients for prostate and SV interfraction motion. 190 CBCTs were analysed and online set-up corrections for prostate and SV using bony anatomy (BA) were determined. Systematic and random errors with and without ProSpare were calculated and CTVePTV margins for both the prostate and SV were generated using the Van Herk formula [1]. Results: The average age at treatment was 74 years, with median PSA and Gleason scores of 10.8 ng/ml and 7, respectively. The mean SV volume was 8.81 cm3 and 9.30 cm3 with and without ProSpare and the average contour length of SV in the cranio-caudal direction was 15 mm. Calculated CTVePTV margins (mm) with daily online matching to BA in the RL, SI and AP planes respectively were: Prostate With ProSpare: 1.2, 5.3, 5.2 Without ProSpare: 1.7, 7.1, 6.8 SV With ProSpare: 3.7, 5.9, 7.5 Without ProSpare: 3.0, 7.1, 12.1 Conclusion: ProSpare reduces prostate and SV interfraction motion. The SV calculated PTV margins were greater than for prostate, with ProSpare
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.