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PSA Bounces After Neoadjuvant Androgen Deprivation and External Beam Radiation: Impact on Definitions of Failure
PROSTATE CANCER
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PSA Bounces After Neoadjuvant Androgen Deprivation and External Beam Radiation: Impact on Definitions of Failure A. L. Zietman, J. P. Christodouleas and W. U. Shipley, Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts Int J Radiat Oncol Biol Phys, 62: 714 –718, 2005 Purpose: To determine the characteristics of prostate specific antigen (PSA) bounces after external beam radiation therapy (EBRT) with neoadjuvant androgen deprivation and their impact on definitions of biochemical failure. Methods and Materials: Characteristics of bounce were calculated for all patients treated by EBRT with neoadjuvant androgen deprivation at our institution between 1992 and 1998 (preexclusion analysis). Calculations were repeated for the subgroup that satisfied additional inclusion/ exclusion criteria (postexclusion analysis). The percentage of bounces scoring as false positives according to the ASTRO definition of biochemical failure was compared with those for three alternative definitions (Vancouver, Nadir-plus-two, and Nadir-plus-three) using McNemar’s tests. Results: Thirty-nine percent (preexclusion cohort) and 56% (postexclusion cohort) of patients demonstrated a PSA bounce. Twenty percent (preexclusion analysis) and 25% (postexclusion analysis) of these bounces scored as biochemical failure according to the ASTRO definition. The Nadir-plus-three definition scored the smallest percentage of bounces as failure, but the difference between this definition and the ASTRO definition reached statistical significance in neither preexclusion nor postexclusion analyses (P ⱖ 0.070). Conclusions: A substantial proportion of patients treated by EBRT with neoadjuvant deprivation experienced a PSA bounce. A large percentage of these bounces scored as biochemical failure according to the ASTRO definition. The Nadirplus-three definition is less vulnerable to this bias. Editorial Comment: Apparently, almost half of men who undergo radiation therapy receive androgen deprivation. This article points out that when the androgen deprivation is withdrawn many patients have a bounce in their PSA that can adversely affect the definition of cancer control. Patrick C. Walsh, M.D.
Erectile Function After Prostate Brachytherapy G. S. Merrick, W. M. Butler, K. E. Wallner, R. W. Galbreath, R. L. Anderson, B. S. Kurko, J. H. Lief and Z. A. Allen, Schiffler Cancer Center and Wheeling Jesuit University, Wheeling, West Virginia, Puget Sound Healthcare Corporation, Group Health Cooperative and University of Washington, Seattle, Washington, and Ohio University Eastern, St. Clairsville, Ohio Int J Radiat Oncol Biol Phys, 62: 437– 447, 2005 Purpose: To evaluate erectile function after permanent prostate brachytherapy using a validated patient administered questionnaire and to determine the effect of multiple clinical, treatment, and dosimetric parameters on penile erectile function. Methods and Materials: A total of 226 patients with preimplant erectile function determined by the International Index of Erectile Function (LIFE) questionnaire underwent permanent prostate brachytherapy in two prospective randomized trails between February 2001 and January 2003 for clinical Stage T1c-T2c (2002 American Joint Committee on Cancer) prostate cancer. Of the 226 patients, 132 were potent before treatment and, of those, 128 (97%) completed and returned the LIFE questionnaire after brachytherapy. The median follow-up was 29.1 months. Potency was defined as an IIEF score of ⱖ13. The clinical, treatment, and dosimetric parameters evaluated included patient age; preimplant IIEF score; clinical T stage; pretreatment prostate-specific antigen level; Gleason score; elapsed time after implantation; preimplant nocturnal erections; body mass index; presence of hypertension or diabetes mellitus; tobacco consumption; the volume of the prostate gland receiving 100%, 150%, and 200% of the p rescribed dose (V100/150/200); the dose delivered to 90% of the prostate gland (D90); androgen deprivation therapy; supplemental external beam radiotherapy (EBRT); isotope, prostate volume; planning volume; and radiation dose to the proximal penis. Results: The 3-year actuarial rate of potency preservation was 50.5%. For patients who maintained adequate posttreatment erectile function, the preimplant IIEF score was 29, and in patients with brachytherapy related ED, the preimplant IIEF score was 25. The median time to the onset of ED was 5.4 months. After brachytherapy, the median IIEF score was 20 in potent patients and 3 in impotent patients. On univariate analysis, the preimplant IIEF score, patient age, presence of nocturnal erections, and dose to the proximal penis predicted for postimplant erectile function. However, in multivariate analysis, only the preimplant IIEF score and the D50 to the proximal crura were statistically significant predictors of brachytherapy related erectile function. Conclusions: Using a patient-administered validated quality-of-life instrument, brachytherapy-induced ED occured in 50% of patients at 3 years. On multivariate analysis, preimplante erectile function and the D50 to the proximal crura were the best predictors of brachytherapy-related erectile function. Because the proximal penis is the most significant
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PSA Bounces After Neoadjuvant Androgen Deprivation and External Beam Radiation: Impact on Definitions of Failure A. L. Zietman, J. P. Christodouleas and W. U. Shipley, Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts Int J Radiat Oncol Biol Phys, 62: 714 –718, 2005 Purpose: To determine the characteristics of prostate specific antigen (PSA) bounces after external beam radiation therapy (EBRT) with neoadjuvant androgen deprivation and their impact on definitions of biochemical failure. Methods and Materials: Characteristics of bounce were calculated for all patients treated by EBRT with neoadjuvant androgen deprivation at our institution between 1992 and 1998 (preexclusion analysis). Calculations were repeated for the subgroup that satisfied additional inclusion/ exclusion criteria (postexclusion analysis). The percentage of bounces scoring as false positives according to the ASTRO definition of biochemical failure was compared with those for three alternative definitions (Vancouver, Nadir-plus-two, and Nadir-plus-three) using McNemar’s tests. Results: Thirty-nine percent (preexclusion cohort) and 56% (postexclusion cohort) of patients demonstrated a PSA bounce. Twenty percent (preexclusion analysis) and 25% (postexclusion analysis) of these bounces scored as biochemical failure according to the ASTRO definition. The Nadir-plus-three definition scored the smallest percentage of bounces as failure, but the difference between this definition and the ASTRO definition reached statistical significance in neither preexclusion nor postexclusion analyses (P ⱖ 0.070). Conclusions: A substantial proportion of patients treated by EBRT with neoadjuvant deprivation experienced a PSA bounce. A large percentage of these bounces scored as biochemical failure according to the ASTRO definition. The Nadirplus-three definition is less vulnerable to this bias. Editorial Comment: Apparently, almost half of men who undergo radiation therapy receive androgen deprivation. This article points out that when the androgen deprivation is withdrawn many patients have a bounce in their PSA that can adversely affect the definition of cancer control. Patrick C. Walsh, M.D.
Erectile Function After Prostate Brachytherapy G. S. Merrick, W. M. Butler, K. E. Wallner, R. W. Galbreath, R. L. Anderson, B. S. Kurko, J. H. Lief and Z. A. Allen, Schiffler Cancer Center and Wheeling Jesuit University, Wheeling, West Virginia, Puget Sound Healthcare Corporation, Group Health Cooperative and University of Washington, Seattle, Washington, and Ohio University Eastern, St. Clairsville, Ohio Int J Radiat Oncol Biol Phys, 62: 437– 447, 2005 Purpose: To evaluate erectile function after permanent prostate brachytherapy using a validated patient administered questionnaire and to determine the effect of multiple clinical, treatment, and dosimetric parameters on penile erectile function. Methods and Materials: A total of 226 patients with preimplant erectile function determined by the International Index of Erectile Function (LIFE) questionnaire underwent permanent prostate brachytherapy in two prospective randomized trails between February 2001 and January 2003 for clinical Stage T1c-T2c (2002 American Joint Committee on Cancer) prostate cancer. Of the 226 patients, 132 were potent before treatment and, of those, 128 (97%) completed and returned the LIFE questionnaire after brachytherapy. The median follow-up was 29.1 months. Potency was defined as an IIEF score of ⱖ13. The clinical, treatment, and dosimetric parameters evaluated included patient age; preimplant IIEF score; clinical T stage; pretreatment prostate-specific antigen level; Gleason score; elapsed time after implantation; preimplant nocturnal erections; body mass index; presence of hypertension or diabetes mellitus; tobacco consumption; the volume of the prostate gland receiving 100%, 150%, and 200% of the p rescribed dose (V100/150/200); the dose delivered to 90% of the prostate gland (D90); androgen deprivation therapy; supplemental external beam radiotherapy (EBRT); isotope, prostate volume; planning volume; and radiation dose to the proximal penis. Results: The 3-year actuarial rate of potency preservation was 50.5%. For patients who maintained adequate posttreatment erectile function, the preimplant IIEF score was 29, and in patients with brachytherapy related ED, the preimplant IIEF score was 25. The median time to the onset of ED was 5.4 months. After brachytherapy, the median IIEF score was 20 in potent patients and 3 in impotent patients. On univariate analysis, the preimplant IIEF score, patient age, presence of nocturnal erections, and dose to the proximal penis predicted for postimplant erectile function. However, in multivariate analysis, only the preimplant IIEF score and the D50 to the proximal crura were statistically significant predictors of brachytherapy related erectile function. Conclusions: Using a patient-administered validated quality-of-life instrument, brachytherapy-induced ED occured in 50% of patients at 3 years. On multivariate analysis, preimplante erectile function and the D50 to the proximal crura were the best predictors of brachytherapy-related erectile function. Because the proximal penis is the most significant