A Phase III Prospective Randomized Trial of Dose-Escalated Radiotherapy With or Without Short-Term Androgen Deprivation Therapy for Patients With Intermediate-Risk Prostate Cancer
Description
Detailed Description
OBJECTIVES:
Primary
- Demonstrate an overall survival (OS) advantage in patients with intermediate-risk
prostate cancer treated with dose-escalated radiotherapy (RT) with versus without
short-term androgen-deprivation therapy (ADT).
Secondary
- Determine whether the addition of ADT to dose-escalated RT versus RT alone improves
clinical failures, biochemical failure by the "nadir +2", freedom from failure, rate of
salvage ADT, and prostate cancer-specific mortality in these patients.
- Estimate the magnitude of benefit of ADT with respect to OS in patients treated with
different RT modalities (i.e., external-beam radiation therapy alone vs low-dose rate
brachytherapy boost vs high-dose rate brachytherapy boost).
- Compare acute and late treatment adverse events of these regimens and correlate these
events with the presence or absence of pre-existing comorbidity as documented by the
Adult Comorbidity Evaluation 27 assessment.
OUTLINE: This is a multicenter, dose-escalation study of radiotherapy. Patients are
stratified according to number of risk factors (1 vs 2-3), comorbidity (ACE-27 grade ≥ 2 vs
< 2), and radiotherapy (RT) modality (dose-escalated external-beam RT [EBRT] vs EBRT and
low-dose rate brachytherapy boost vs EBRT and high-dose rate brachytherapy boost). Patients
are randomized to 1 of 2 treatment arms.
- Arm I: Patients undergo EBRT* once daily on days 1-5 for about 9 weeks (44 treatments).
Some patients instead receive EBRT with high-dose rate or low-dose rate brachytherapy
implant on days 1-5 for about 5 weeks (25 treatments). NOTE: *Type of RT is at
discretion of treating physician and may include either 3D-conformal RT or
intensity-modulated RT.
- Arm II: Patients receive androgen-deprivation therapy comprising luteinizing-hormone
releasing-hormone (LHRH) agonist (leuprolide, goserelin, buserelin, or triptorelin)
subcutaneously or as an injection every 1 to 3 months AND an oral antiandrogen therapy
(flutamide 3 times daily or bicalutamide once daily) for 6 months. Beginning 8 weeks
after the first LHRH injection, patients undergo radiotherapy as in arm I.
After completion of study therapy, patients are followed up periodically.
Phase
N/AInclusion and Exclusion Criteria
- Histologically confirmed adenocarcinoma of the prostate diagnosed within the past 180 days and at intermediate-risk for recurrence by meeting ≥ 1 of the following criteria:
- Gleason score > 7
- Prostate Specific Antigen (PSA) > 10 and ≤ 20 ng/mL
- Baseline serum PSA value performed within 60 days with an FDA-approved assay (e.g., Abbott, Hybritech)
- Baseline PSA must not be obtained during any of the following time frames:10-day period after prostate biopsy, after initiation of androgen-deprivation therapy, or within the past 30 days after discontinuation of finasteride (90 days for dutasteride)
- Clinical stage T2b or T2c disease
- Patients previously diagnosed with low-risk (Gleason score < 6, clinical stage < T2a, and PSA < 10 ng/mL) prostate cancer undergoing active surveillance who are re-biopsied and found to have intermediate-risk disease according to the protocol criteria are eligible for enrollment within 6 months of the repeat biopsy procedure
- Patients with Gleason Score ≥ 8, PSA > 20 ng/mL, OR clinical stage ≥ T3 are ineligible for this trial
- If findings of extracapsular extension or seminal vesicle invasion are noted on prostate MRI, this study, if used, will not render patients ineligible for accrual to this protocol
- Primary tumor staging for eligibility purposes is to be based on palpable or core biopsy evidence only with respect to extracapsular extension or seminal vesicle involvement
- No patients with all 3 intermediate-risk factors who also have ≥ 50% of the number of their biopsy cores positive for cancer
- The percentage of biopsy cores involved will only be considered with respect to eligibility for those patients with all 3 of the above risk factors (i.e., patients with one or two of the above risk factors are eligible irrespective of the percentage of biopsy cores involved)
- Clinically negative lymph nodes as established by imaging (pelvic and/or abdominal CT scan or MRI), nodal sampling, or dissection within the past 60 days (required for patients with 2-3 risk factors)
- Abdominal imaging not required for a single intermediate-risk factor (these studies may be obtained at the discretion of the treating physician)
- Lymph nodes that are equivocal or questionable by imaging allowed without biopsy if nodes ≤ 1.5 cm
- Any node > 1.5 cm on imaging requires a negative biopsy
- No evidence of bone metastases on bone scan within the past 60 days
- Bone scan not required for patients with a single intermediate-risk factor (scan may be obtained at the discretion of the treating physician)
- Equivocal bone scan findings allowed if plain film x-rays negative for metastasis PATIENT CHARACTERISTICS:
- Zubrod performance status 0-1
- Absolute neutrophil count (ANC) ≥ 1,800/mm^3*
- Platelet count ≥ 100,000/mm^3*
- Hemoglobin ≥ 8.0 g/dL (transfusion or other intervention to achieve level allowed)*
- NOTE: *For patients undergoing brachytherapy only.
- Fertile patients must use effective contraception during and for the 3 months after cessation of protocol treatment
- No invasive malignancy or hematological malignancy (e.g., leukemia, lymphoma, myeloma) within the past 5 years except adequately treated non-melanomatous skin cancer
- Prior diagnoses of carcinoma in situ allowed
- No severe or active co-morbidity with any of the following:
- Unstable angina and/or congestive heart failure requiring hospitalization within the past 6 months
- Transmural myocardial infarction within the past 6 months
- Acute bacterial or fungal infection requiring intravenous antibiotics
- Chronic obstructive pulmonary disease exacerbation or other respiratory illness requiring hospitalization or precluding study therapy, within the past 30 days
- Hepatic insufficiency resulting in clinical jaundice and/or coagulation defects
- Laboratory tests for liver function and coagulation parameters not required for entry into this protocol
- AIDS based upon current Centers for Disease Control (CDC) definition
- HIV testing not required for entry into this protocol
- HIV-seropositive patients who do not meet criteria for diagnosis of AIDS allowed PRIOR CONCURRENT THERAPY:
- See Disease Characteristics
- No prior radical surgery (prostatectomy), high-intensity focused ultrasound, or cryosurgery for prostate cancer
- No prior hormonal therapy, such as LHRH agonists (e.g., goserelin, leuprolide), antiandrogens (e.g., flutamide, bicalutamide), estrogens (e.g., DES), or bilateral orchiectomy
- No finasteride within past 30 days (90 days for dutasteride)
- No prior or concurrent cytotoxic chemotherapy for prostate cancer
- Prior chemotherapy for a different cancer allowed
- No prior radiotherapy (RT), including brachytherapy, to the region of the study cancer that would result in overlap of RT fields
- Patients undergoing brachytherapy must have transrectal ultrasound confirmation of prostate volume < 60 cc, American Urological Association (AUA) score ≤ 15 within the past 60 days of registration, and no history of prior transurethral resection of the prostate (TURP)
- TURP allowed for patients who receive external-beam radiation therapy only
Sites
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California
- Los Angeles County-USC Medical Center, Los Angeles, California, 90033
- University of Southern California/Norris Cancer Center, Los Angeles, California, 90033
- 21st Century Oncology - El Segundo, El Segundo, California, 90245
- Veterans Administration Long Beach Medical Center, Long Beach, California, 90822
- University of California At San Diego, San Diego, California, 92103
- Stanford University Hospitals and Clinics, Stanford, California, 94305
- Kaiser Permanente, Hayward, Hayward, California, 94545
- Kaiser Permanente Cancer Treatment Center, South San Francisco, California, 94080
- Kaiser Permanente Oakland-Broadway, Oakland, California, 94611
- Alta Bates Summit Medical Center-Herrick Campus, Berkeley, California, 94704
- UCSF-Mount Zion, San Francisco, California, 94115
- California Pacific Medical Center, San Francisco, California, 94118
- South Sacramento Cancer Center, Sacramento, California, 95823
- Kaiser Permanente-Rancho Cordova Cancer Center, Rancho Cardova, California, 95670
- University of California at Davis Cancer Center, Sacramento, California, 95817
- Sutter Solano Medical Center, Vallejo, California, 94589
- Marin General Hospital, Greenbrae, California, 94904
- Radiological Associates of Sacramento, Sacramento, California, 95815
- The Permanente Medical Group-Roseville Radiation Oncology, Roseville, California, 95678
- Rohnert Park Cancer Center, Rohnert Park, California, 94928
-
Arizona
- Arizona Center for Cancer Care-Peoria, Peoria, Arizona, 85381
- 21st Century Oncology-Scottsdale, Scottsdale, Arizona, 85251
- Mayo Clinic in Arizona, Scottsdale, Arizona, 85259
-
Utah
- Huntsman Cancer Institute/University of Utah, Salt Lake City, Utah, 84112
-
Oregon
- Rogue Valley Medical Center, Medford, Oregon, 97504
- Providence Medford Medical Center, Medford, Oregon, 97504
- Three Rivers Community Hospital, Grants Pass, Oregon, 97527
- Providence Milwaukie Hospital, Milwaukie, Oregon, 97222
- Legacy Mount Hood Medical Center, Gresham, Oregon, 97030
- Legacy Good Samaritan Hospital and Medical Center, Portland, Oregon, 97210
-
Colorado
- Saint Mary's Hospital and Regional Medical Center, Grand Junction, Colorado, 81502
- The Shaw Regional Cancer Center, Edwards, Colorado, 81632
- The Urology Center of Colorado, Denver, Colorado, 80211
- Rocky Mountain Cancer Centers-Aurora, Aurora, Colorado, 80012
- Poudre Valley Radiation Oncology, Fort Collins, Colorado, 80528
-
New Mexico
- Lovelace Medical Center-Downtown, Albuquerque, New Mexico, 87102
- University of New Mexico Cancer Center, Albuquerque, New Mexico, 87106
- Radiation Oncology Associates, Albuquerque, New Mexico, 87109
- Memorial Medical Center - Las Cruces, Las Cruces, New Mexico, 88011
-
Idaho
- Idaho Urologic Institute PA, Meridian, Idaho, 83642
-
Washington
- Compass Oncology Vancouver, Vancouver, Washington, 98684
- Legacy Salmon Creek Hospital, Vancouver, Washington, 98686
- Saint Joseph Medical Center, Tacoma, Washington, 98405
-
Montana
- Bozeman Deaconess Cancer Center, Bozeman, Montana, 59715
-
Kansas
- Cancer Center of Kansas - Dodge City, Dodge City, Kansas, 67801
- Cancer Center of Kansas - Wellington, Wellington, Kansas, 67152
- Wesley Medical Center, Wichita, Kansas, 67214
- Wichita CCOP, Wichita, Kansas, 67214
- Cancer Center of Kansas - Main Office, Wichita, Kansas, 67214
- Cancer Center of Kansas-Wichita Medical Arts Tower, Wichita, Kansas, 67208
- Associates In Womens Health, Wichita, Kansas, 67208
- Cancer Center of Kansas - Winfield, Winfield, Kansas, 67156
- Cancer Center of Kansas - El Dorado, El Dorado, Kansas, 67042
- Lawrence Memorial Hospital, Lawrence, Kansas, 66044
- University of Kansas Medical Center, Kansas City, Kansas, 66160
-
Texas
- Texas Oncology-Wichita Falls Texoma Cancer Center, Wichita Falls, Texas, 76310
- Brooke Army Medical Center, Fort Sam Houston, Texas, 78234
- University of Texas Southwestern Medical Center, Dallas, Texas, 75390
- M D Anderson Cancer Center, Houston, Texas, 77030
-
Nebraska
- Missouri Valley Cancer Consortium CCOP, Omaha, Nebraska, 68106
-
Missouri
- Mercy Hospital-Joplin, Joplin, Missouri, 64804
- Ozark Health Ventures LLC dba Cancer Research for The Ozarks Springfield, Springfield, Missouri, 65802
- CoxHealth South Hospital, Springfield, Missouri, 65807
- Mercy Hospital Springfield, Springfield, Missouri, 65804
- Siteman Cancer Center - Saint Peters, Saint Peters, Missouri, 63376
- Barnes-Jewish West County Hospital, Saint Louis, Missouri, 63141
- Siteman Cancer Center-South County, Saint Louis, Missouri, 63129
- Washington University School of Medicine, Saint Louis, Missouri, 63110
-
North Dakota
- Sanford Clinic North-Fargo, Fargo, North Dakota, 58122
-
Minnesota
- Mayo Clinic Health Systems-Mankato, Mankato, Minnesota, 56001
- Mayo Clinic Health System in Albert Lea, Albert Lea, Minnesota, 56007
- Fairview-Southdale Hospital, Edina, Minnesota, 55435
- Mayo Clinic, Rochester, Minnesota, 55905
-
Wisconsin
- Mayo Clinic Health System-Franciscan Healthcare, La Crosse, Wisconsin, 54601
- Agnesian Cancer Center, Fond Du Lac, Wisconsin, 54935
- Community Memorial Hospital, Menomonee Falls, Wisconsin, 53051
- Froedtert and the Medical College of Wisconsin, Milwaukee, Wisconsin, 53226
- Appleton Medical Center, Appleton, Wisconsin, 54911
- Columbia Saint Mary's Hospital - Ozaukee, Mequon, Wisconsin, 53097
- Wheaton Franciscan Cancer Care - All Saints, Racine, Wisconsin, 53405
- Columbia Saint Mary's Water Tower Medical Commons, Milwaukee, Wisconsin, 53211
- Bellin Memorial Hospital, Green Bay, Wisconsin, 54301
-
Illinois
- Memorial and Saint Elizabeth's Health Care Services LLP, Swansea, Illinois, 62226
- Loyola University Medical Center, Maywood, Illinois, 60153
- Hines Veterans Administration Hospital, Hines, Illinois, 60141
- Advocate Illinois Masonic Medical Center, Chicago, Illinois, 60657
- University of Chicago, Chicago, Illinois, 60637
-
Iowa
- Finley Hospital, Dubuque, Iowa, 52001
-
Kentucky
- Owensboro Health Mitchell Memorial Cancer Center, Owensboro, Kentucky, 42303
- The James Graham Brown Cancer Center at University of Louisville, Louisville, Kentucky, 40202
- Baptist Health Lexington, Lexington, Kentucky, 40503
- University of Kentucky, Lexington, Kentucky, 40536
-
Indiana
- Indiana University Health Bloomington, Bloomington, Indiana, 47403
- Richard L. Roudebush Veterans Affairs Medical Center, Indianapolis, Indiana, 46202
- Indiana University Medical Center, Indianapolis, Indiana, 46202
- IU Health Methodist Hospital, Indianapolis, Indiana, 46202
- Saint Francis Hospital and Health Centers, Beech Grove, Indiana, 46107
- IU Health Central Indiana Cancer Centers-Indianapolis, Indianapolis, Indiana, 46219
- IU Health Goshen Center for Cancer Care, Goshen, Indiana, 46526
- Saint Vincent Anderson Regional Hospital/Cancer Center, Anderson, Indiana, 46016
- Reid Hospital and Health Care Services, Richmond, Indiana, 47374
-
Alabama
- University of Alabama at Birmingham, Birmingham, Alabama, 35294
-
Michigan
- McLaren-Central Michigan, Mount Pleasant, Michigan, 48858
- Sparrow Hospital, Lansing, Michigan, 48912
- McLaren Cancer Institute-Owosso, Owosso, Michigan, 48867
-
Ohio
- Samaritan North Health Center, Dayton, Ohio, 45415
- Good Samaritan Hospital - Dayton, Dayton, Ohio, 45406
- Grandview Hospital, Dayton, Ohio, 45405
- Upper Valley Medical Center, Troy, Ohio, 45373
- Miami Valley Hospital, Dayton, Ohio, 45409
- Kettering Medical Center, Kettering, Ohio, 45429
-
Georgia
- John B Amos Cancer Center, Columbus, Georgia, 31904
- Piedmont Fayette Hospital, Fayetteville, Georgia, 30214
- Piedmont Hospital, Atlanta, Georgia, 30309
- Grady Health System, Atlanta, Georgia, 30303
- Emory University/Winship Cancer Institute, Atlanta, Georgia, 30322
- Atlanta VA Medical Center, Decatur, Georgia, 30033
-
Florida
- Bay Medical Center, Panama City, Florida, 32401