Clinical Trial Comparing 3-D RT vs. IMRT in Post- Prostatectomy Prostate Cancer Patients

Phase II Randomized Clinical Trial Comparing 3-D Conformal Radiation Therapy (RT) vs. Intensity Modulated Radiation Therapy in Post- Prostatectomy Prostate Cancer Patients

Compare the incidence of acute rectal, bladder and other acute toxicities between 3-D Conformal Radiation Therapy (RT/CRT) and Intensity Modulated Radiation Therapy (IMRT) in Post-Prostatectomy Prostate Cancer Patients treated with post-operative radiation therapy

In 2015, the American Cancer Society estimates that almost 220,800 men are expected to be diagnosed with prostate cancer, and about 27,540 men are expected to die of this disease. Curative treatment of prostate cancer consists of either surgery (i.e., radical prostatectomy) or radiation therapy (RT). Approximately one-third of men who undergo a prostatectomy will require post-operative adjuvant or salvage RT.

During the last 2 decades, the techniques used to deliver RT have evolved from 2-D RT in the 1980's and early 1990's, to 3-D conformal RT (3-D CRT) in the late 1990's, to intensity modulated radiation therapy (IMRT) within the last decade.

To date, no randomized prospective head to head comparison between 3-D CRT and IMRT to assess toxicity differences has ever been conducted in the treatment of post-prostatectomy prostate cancer patients. Retrospective evidence suggests comparable acute and late genitourinary (GU) and gastrointestinal (GI) toxicity. In addition, no postoperative randomized trials investigating hormonal therapy (HT) and RT have been published, but three prior phase III studies of men treated definitively for prostate cancer, one by the Radiation Therapy Oncology Group (RTOG) (86-10), one by investigators at Harvard, and one by the Trans-Tasman Radiation Oncology Group, concluded that neoadjuvant and concurrent short-term hormonal therapy (i.e., 4-6 months) RT reduces cause-specific mortality compared with RT alone.

The purpose of this study is to estimate, correlate, and compare the incidence of acute rectal, bladder and other acute toxicities between 3-D CRT and IMRT in prostate cancer patients treated with post-operative radiation therapy, to quantify, compare, and correlate the dose volume histogram (DVH) doses (e.g., Vmean, Vmedian, V25, V50, V75) to the surrounding critical organs (i.e., rectum and bladder) between 3-D CRT and IMRT, and to measure, compare, and correlate the quality of life scores of participants using the EORTC Quality of Live Questionnaires (QLQ), called "QLQ-C30" and "EPIC-26". These survey instruments will measure quality of life differences during the study; the comparison will be done between 3-D CRT and IMRT treatment arms.

Hormonal therapy will also be required for patients with high risk disease (both the adjuvant and salvage groups) and as per standard of care for patients with low risk disease, but is not explored in this study.

There are 2 arms (groups) in this study:

Arm 1: 3-D Conformal Radiation Therapy (plus hormonal therapy)

Arm 2: Intensity Modulated Radiation Therapy (plus hormonal therapy)

INCLUSION Criteria:

Subjects must meet all of the inclusion criteria to participate in this study.

• Histologically documented adenocarcinoma of the prostate.

• Status post radical prostatectomy with sampling of the pelvic lymph nodes with histologically confirmed adenocarcinoma of the prostate, with the patients falling into either the "adjuvant low or high risk groups" or the "salvage low or high risk groups" as indicated below. In those cases where patients undergo a prostatectomy without any sampling of the pelvic lymph nodes, patients will be also considered eligible if they are found to have a negative pelvic CT or MRI scan which shows no evidence of lymphatic nodal metastases after the prostatectomy.

  • "Adjuvant High Risk Group" are those patients with an undetectable or persistent/decreasing PSA levels (before starting therapy) who MUST be able to start radiation therapy treatments within 6 months of radical prostatectomy with at least ONE of the 3 disease features:

    • Pathologic T2N0 (with no clinical evidence of metastases) and Gleason Score ≥ 8
    • Pathologic T3aN0 (with no clinical evidence of metastases) with Extra-Capsular Extension and Gleason Score ≥ 8
    • Pathologic T3bN0 (with no clinical evidence of metastases) with any Gleason Score

  • "Salvage High Risk Group" are those patients who experience a PSA failure (defined as at least 1 detectable PSA level > 0.2 ng/ml or at least 2 consecutive increases in PSA levels over baseline which are at least 1 month apart after radical prostatectomy) with at least ONE of the 4 following features:

    • Pathologic T3bN0 disease (with no clinical evidence of metastases),
    • Pathologic T2-3aN0 disease (with no clinical evidence of metastases) with Gleason Score ≥ 8,
    • Pathologic T2-3aN0 disease (with no clinical evidence of metastases) with PSA Doubling Time ≤ 10 months,
    • Pathologic T2-3aN0disease (with no clinical evidence of metastases) with Pre-RT PSA level ≥ 1.0 ng/ml

  • "Adjuvant Low Risk Group" are those patients with an undetectable or persistent/decreasing PSA levels (before starting therapy) who MUST be able to start radiation therapy treatments within 6 months of radical prostatectomy with at least ONE of the 2 disease features:

    • Pathologic T2N0 (with no clinical evidence of metastases), Gleason Score ≤ 7, with positive margins
    • Pathologic T3aN0 (with no clinical evidence of metastases) with Extra-Capsular Extension, Gleason Score ≤ 7, with or without positive margins

  • "Salvage Low Risk Group" are those patients who experience a PSA failure (defined as at least 1 detectable PSA level > 0.2 ng/ml or at least 2 consecutive increases in PSA levels over baseline which are at least 1 month apart after radical prostatectomy) with the following feature: - Pathologic T2-3aN0 disease (with no clinical evidence of metastases) with Gleason Score ≤7, with or without positive margins

• Neoadjuvant hormonal therapy prior to radical prostatectomy is allowed, and post-prostatectomy hormonal therapy prior to any protocol therapy is also allowed.

• Prior chemotherapy, and/or radiation therapy is allowed if it has been at least 3 years or longer since those therapies were given from the time of registration, with the exception of previous pelvic radiation which is NOT allowed under any circumstances.

• Karnofsky Performance Status ≥ 70. (Appendix A)

• Hematologic parameters must be within the following limits:

  • WBC ≥ 3,000/uL
  • Platelet Count ≥ 100,000/uL
  • Hemoglobin level ≥ 10.0 g/dl

• Patients with a history of an invasive malignancy within the last 3 years are not eligible for the protocol; patients who are NED from a prior invasive malignancy for at least 3 years or longer are eligible for the trial. Patients with history of benign tumors such as a pituitary macroadenomas, meningiomas, or craniopharyngiomas are eligible as long as the benign tumor is under local control regardless of the time frame. Patients with concurrent adequately treated basal cell or squamous cell carcinoma of the skin are also eligible for the protocol.

• Patients must sign an Informed Consent Form.

• Must not have concomitant medical, psychological or social circumstances which would interfere with compliance with the protocol treatment and follow-up.

• Age ≥ 18 years.

• Men of childbearing potential must be willing to consent to using effective contraception while on treatment and for a reasonable period thereafter, which should be for at least 6 months after the completion of protocol therapy.

EXCLUSION CRITERIA

Subjects meeting any of the exclusion criteria at baseline will be excluded from study participation.

• Patients who have received prior pelvic irradiation are not eligible.
• Any coexisting medical condition precluding full compliance with the study.
• Patients with active infections or known infection with HIV. Testing for HIV status will not be required.
• Psychological, familiar, sociological or geographical conditions which would not permit compliance with the study protocol.