Refers to article:
Dose Escalation for Prostate Cancer Radiotherapy: Predictors of Long-Term Biochemical Tumor Control and Distant Metastases–Free Survival Outcomes
Accepted 11 August 2011
December 2011 (Vol. 60, Issue 6, pages 1133 - 1139)
Zelefsky et al  report a retrospective analysis of 2251 patients with T1–3 N0–X M0 prostate cancer (PCa) divided into groups of 571 low-risk (22.4%), 1074 intermediate-risk (42.1%), and 906 high-risk (35.5%) patients, according to the National Comprehensive Cancer Network classification. Patients were scanned in the treatment position and anatomic data were transferred to the 3D treatment planning system, where prostate and seminal vesicles were delineated and then surrounded by a security margin. They were treated with three-dimensional (3D) conformal radiotherapy (CRT) or intensity-modulated radiotherapy (IMRT), performed on prostate and seminal vesicles only.
During irradiation, a multileaf collimator adapts automatically and continually to the contours of the target volume seen by each beam. IMRT requires specific software because movement of the leaves during irradiation allows for adaptation of the dose to be delivered and provides concave isodose curves, particularly at the anterior part of the rectum. In the study by Zelefsky et al , the prostate dose ranged from 64.8 to 86.4
End points were 10-yr biochemical disease-free survival (BDFS) and distant metastases–free survival (DMFS). With an 8-yr median follow-up, the 10-yr BDFS of each risk group was significantly influenced by dose escalation: 84% (>75.6
Despite 20% of patients being lost to follow-up , these results were in keeping with those in the literature . In daily practice, IMRT is a gold standard, provided that quality assurance criteria are implemented, and as stated by the authors, dose escalation >86
For intermediate-risk PCa, no data promote definitive RT. A retrospective analysis of 1044 patients with intermediate-risk patients (n
The major data come from two phase 3 trials. The Boston trial with 204 T1b–2b intermediate- or high-risk patients who received 3D-CRT (70
For high-risk PCa, the results reported by Zelefsky et al  show that IMRT combined with short-term ADT improves BDFS and DMFS but does not influence PCa mortality or OS. Individualization of high-risk localized PCa (T1–2 N0–X M0 with poor prognostic factors, Gleason score >7 and/or baseline prostate-specific antigen >20
For locally advanced PCa, pelvic lymph node irradiation is recommended with a dose of around 50
The 10-yr results of EORTC 22863 showed a striking gain in OS of 58.1% with 3-yr ADT versus 39.8% with conventional RT alone (p
Beyond techniques and figures, the time and the regular practice of a multidisciplinary approach for urologists and radiation oncologists, based on shared levels of evidence, will help tailor the personalized treatment plan of every patient.
Conflicts of interest
The author has received honoraria from Janssen for attending advisory board meetings and from Astellas for conference participation.
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Clinique Universitaire de Cancérologie-Radiothérapie, Centre Hospitalier Universitaire de Grenoble, Grenoble, France
© 2011 European Association of Urology, Published by Elsevier B.V.