Heather Jones, MD
University of Pennsylvania Cancer Center
Last Modified: November 6, 2001
Presenter: M. Roach III
Presenter's Affiliation: Radiation Oncology, UCSF, San Francisco, CA
Type of Session: Plenary
Many unanswered questions await definitive resolution in the treatment of prostate cancer. There has been significant controversy in the field of radiation oncology regarding the optimal field size and ideal integration of hormonal therapies. This particular trial tests the hypothesis that: 1.TAS and WP radiotherapy (RT) followed by a prostate boost improves the progression-free survival (PFS) by at least 10% compared to TAS and PO RT. 2. This trial also test the hypothesis that neoadjuvant (NHT) followed by concurrent TAS and RT improves the PFS compared to RT followed by adjuvant TAS (AHT) by at least 10%. Secondary objectives included comparing treatments with regard to local control, time to distant failure and overall survival (OS). This trial is an initial report of RTOG 9413.
This preliminary analysis demonstrates that Whole Pelvis RT is associated with an improvement in PFS compared to Prostate Only RT in patients with a risk of lymph node involvement >15%. The failure to see an early advantage in PFS with NHT compared to AHT may result from the fact that the time from the date of randomization to discontinuation of TAS is two months later on the AHT arms. Further analysis suggests that WP RT+NHT may be best in terms of PFS (p=0.011) and OS (p=0.12). Longer follow-up is required to confirm the trends seen in this preliminary report since the median survival is not likely to be reached for several years.
This study attempts to tackle two issues in the treatment of prostate cancer 1. the treatment volume and 2. the use of hormones neoadjuvantly versus adjuvantly. Early results would seem to indicate that neoadjuvant HT and whole pelvis irradiation as an advantage over adjuvant HT and prostate alone RT. However, the followup in this study is too short to make sweeping recommendations. When the data does mature, we can hope to gain some insight into the whole pelvis vs prostate only volume issue. A major question remains: Is it treatment of the lymph nodes that improves the outcome or just the treatment of the periprostatic tissues with the larger pelvic fields. Also, the definition of PSA failure used in this study is not the currently endorsed recommendation and may influence the reported PSA failure rate in this study. In RTOG 9413, we have yet another study that demonstrates that the addition of neoadjuvant androgen ablation to definitive radiation therapy is associated with a highly significant improvement in local control and freedom from disease progression; its impact on survival remains an open question.
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