Hypofractionated Radiation Therapy in Prostate Cancer

Study Description

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Brief Summary:

RATIONALE: It is not yet known whether extreme hypofractionation is equally safe and effective than standard radiation therapy in treating prostate cancer.

PURPOSE: This protocol presents a randomised phase II study aiming to investigate the tolerance and disease control of extreme hypofractionated Radiation Therapy for prostate cancer.

Condition or disease	Intervention/treatment	Phase
Malignant Neoplasm of Prostate; Local Disease	Radiation: Intensity modulated radiation therapy; Radiation: Volumetric modulated arc therapy; Radiation: Image guided radiation therapy	Not Applicable

Detailed Description:

This protocol presents a randomised phase II study aiming to investigate the tolerance and disease control of extreme hypofractionated RT for prostate cancer by delivering 5 x 7.25 Gy = 36.25 Gy over two alternative time schedules: either over 9 days (study A), or over 28 days once-a-week, the same week-day (study B).

The total dose and fractionation schedules have been chosen based on the assumption of their isoeffectivity regarding potential late rectal effects to be expected with a maximum equivalent dose of 74 Gy in 2 Gy fractions and assuming an alpha/beta = 3 Gy for the rectum.

In both arms, the prescribed dose per fraction to the urethra and the surrounding transitional zone will be dropped from 7.25 Gy to 6.5 Gy with a simultaneous integrated boost (SIB) technique. A dose of 5 x 6.5 Gy is equivalent to 31 x 2 Gy assuming an alpha/beta = 3 Gy for the urethra and equivalent to 37 x 2 Gy assuming an alpha/beta = 1.5 Gy for microscopic tumour foci in the transitional zone surrounding the urethra. The two treatment regimens chosen will each be the object of a separate phase I-II study covered by the same protocol and performed in parallel by the participating centres. Randomised assignment to either of the two studies will be introduced to avoid selection bias in treatment assignment within each centre.

OBJECTIVES:

Primary

• To determine the risk of urinary, rectal and sexual acute and late toxicities rates in patients receiving two different time schedules of extreme hypofractionated radiation therapy

  • Secondary

• To determine the Quality of life (EORTC QLQ-C30, Prostate cancer module EORTC QLQ-PR25) in patients receiving two different time schedules of extreme hypofractionated radiation therapy
• To determine the rate of local failure
• To determine in the two study arms the biochemical disease-free survival bDFS rate
• To determine in the two study arms the metastases-free survival rate
• To determine in the two study arms the disease-specific survival rate

OUTLINE:

This is a multicenter study.

Patients undergo extreme hypofractionated radiation therapy for prostate cancer by delivering 5 x 7.25 Gy = 36.25 Gy over two alternative time schedules:

Experimental Arm A: Over 9 days. Experimental Arm B: Over 28 days once-a-week, the same week-day. All patients will be followed up for at least 18 months to contribute to the analysis of the main endpoints of the study. With reference to the secondary endpoints, follow-up will be extended to 10 years.

Stopping rule: In order to avoid exposure of patients to a treatment that may be unsafe, acute GI and GU toxicity will be continuously monitored with the purpose of assisting in the decision of possibly interrupt recruitment in case of an alarming frequency.To this purpose, the procedure of Ivanova et al., 2005 will be applied.

Study Design

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Study Type :	Interventional (Clinical Trial)
Actual Enrollment :	170 participants
Allocation:	Randomized
Intervention Model:	Parallel Assignment
Intervention Model Description:	5 x 7.25 Gy delivery in 2 alternative time Schedule: over 9 days every other treatment or over 28 days once a week
Masking:	None (Open Label)
Primary Purpose:	Treatment
Official Title:	Stereotactic Body Radiation Therapy for cT1c - cT3a Prostate Cancer With a Low Risk of Nodal Metastases (≤ 20%, Roach Index): a Novalis Circle Phase II Prospective Randomized Trial
Study Start Date :	September 2012
Estimated Primary Completion Date :	June 2017
Estimated Study Completion Date :	September 2025

Arms and Interventions

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Arm	Intervention/treatment
Experimental: 9 days; Patients undergo extreme hypofractionated radiation therapy (Intensity modulated radiation therapy, Volumetric modulated arc therapy, Image guided radiation therapy) once a week over 28 days	Radiation: Intensity modulated radiation therapy; Minimize radiation doses to surrounding area Radiation: Volumetric modulated arc therapy; Highly conformational dose distribution Radiation: Image guided radiation therapy; Follow target by the use of fiducial markers and ERB
Experimental: 28 days; Patients undergo extreme hypofractionated radiation therapy (Intensity modulated radiation therapy, Volumetric modulated arc therapy, Image guided radiation therapy) other 9 days.	Radiation: Intensity modulated radiation therapy; Minimize radiation doses to surrounding area Radiation: Volumetric modulated arc therapy; Highly conformational dose distribution Radiation: Image guided radiation therapy; Follow target by the use of fiducial markers and ERB

Outcome Measures

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Primary Outcome Measures :

1. Tolerance to treatment [ Time Frame: up to 5 years ]
   Tolerance to treatment (urinary, rectal, sexual): Acute (up to 90 days) and late (up to 5 years) toxicity follow-up according to NCI CTCAE version 3.0

Secondary Outcome Measures :

1. 1. Quality of life [ Time Frame: 9 days (Treatment arm A) or 28 days (Treatment arm B), 12 weeks, 6, 12, 18 months and yearly thereafter, up to 5 years ]
   Quality of life (EORTC QLQ-C30, Prostate cancer module EORTC QLQ-PR25)
2. 2. Local failure [ Time Frame: 9 days (Treatment arm A) or 28 days (Treatment arm B), 12 weeks, 6, 12, 18 months and yearly thereafter, up to 5 years ]
   Assessed by digital rectal examination (DRE). MRI or PET-CT with choline or acetate may be a confirmatory option. Biopsy confirmation is required for those patients with exclusive local failures and candidates for local salvage.
3. 3. Biochemical disease-free survival bDFS [ Time Frame: 9 days (Treatment arm A) or 28 days (Treatment arm B), 12 weeks, 6, 12, 18 months and yearly thereafter, up to 5 years ]
   Phoenix definition (PSA nadir + 2 ng/ml)
4. 4. Metastases-free survival [ Time Frame: 9 days (Treatment arm A) or 28 days (Treatment arm B), 12 weeks, 6, 12, 18 months and yearly thereafter, up to 5 years ]
   Outcomes 3 or 4 - investigations PET-CT choline
5. 5. Disease-specific survival [ Time Frame: 9 days (Treatment arm A) or 28 days (Treatment arm B), 12 weeks, 6, 12, 18 months and yearly thereafter, up to 5 years ]
   Alive/dead status, date and cause of death and prostate cancer disease status (outcomes 3/4 and 5).

Eligibility Criteria

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Ages Eligible for Study:	18 Years to 85 Years (Adult, Senior)
Sexes Eligible for Study:	Male
Accepts Healthy Volunteers:	No

Criteria

Inclusion Criteria:

• Age: >18
• WHO performance status ≤ 2
• Any patient where prophylactic lymph node irradiation is not required, i.e. risk of nodal microscopic involvement ≤ 20% (according to Roach et al (25):

"N+ (in %) = (Gleason score - 6) x 10 + 2/3 PSA at diagnosis)"

• T-stage: cT1-cT3a.
• Previous TURP is allowed provided there is at least 8 weeks interval with radiotherapy.

• Combined hormonal treatment (Neoadjuvant-concomitant androgen deprivation, AD, for 6 months) is mandatory if two or more of the following tumour characteristics are present: ≥cT2c, Gleason 4+3, PSA >10 ng/ml, perineural invasion, and/or >1/3 of positive biopsies. RT shall be delivered between 2 and 3 months (+/- 1 week) after starting AD and according to the following chronologic sequence:

  1. Neoadjuvant AD for 2 months (30 days of bicalutamide 50mg qd, and a 3-month slow-releasing LH-RH analog to be started 15 days after initiating bicalutamide).
  2. Randomization at the end of the neoadjuvant AD period (2 months after starting AD).
  3. Planning RT (to be started within 1 month after randomization (i.e., between the 2nd and 3th month after initiating AD)
• Concomitant and adjuvant HT for 4 more months (a second 3-month slow-releasing LH-RH analog injection).

Exclusion Criteria:

• Inability to obtain a written informed consent
• Patient preference to be treated with one rather than the other treatment arm.
• WHO performance status > 2
• cT3b,cT4
• Gleason score ≥8
• Clinical N+ on metastases work-up or N+ risk >20% (Roach algorithm)
• Severe urinary obstructive symptoms (IPSS symptom index >19)
• Previous TURP less than 8 weeks before radiotherapy
• Previous prostate surgery other than TURP

Contacts and Locations

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Locations

Belgium
Onze Lieve Vrouwziekenhuis
Aalst, Belgium, 9300
Finland
University Hospital
Turku, Finland
Israel
Sheba Medical Center
Ramat Gan, Israel
Netherlands
VU University Medical Center
Amsterdam, Netherlands
Portugal
Portuguese Institut of Oncology
Porto, Portugal
Spain
Teknon Oncologic Institute
Barcelona, Spain
Hospital Universitario Sanchinarro
Madrid, Spain
Switzerland
University Hospital
Geneva, Switzerland, 1211
Turkey
Neolife Medical Center
Istanbul, Turkey

Sponsors and Collaborators

Raymond Miralbell

Investigators

Principal Investigator:	Raymond Miralbell, Pr.	University Hospital, Geneva

More Information

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Study Description Study Design Arms and Interventions Outcome Measures Eligibility Criteria Contacts and Locations More Information

Responsible Party:	Raymond Miralbell, Pr., University Hospital, Geneva
ClinicalTrials.gov Identifier:	NCT01764646 History of Changes
Other Study ID Numbers:	11-196
First Posted:	January 9, 2013
Last Update Posted:	May 15, 2017
Last Verified:	May 2017
Individual Participant Data (IPD) Sharing Statement:
Plan to Share IPD:	Undecided
Plan Description:	No plan to share participant data for now

Keywords provided by Raymond Miralbell, University Hospital, Geneva:

Prostate cancer; Radiation therapy

Additional relevant MeSH terms:

Prostatic Neoplasms; Neoplasms; Genital Neoplasms, Male; Urogenital Neoplasms	Neoplasms by Site; Genital Diseases, Male; Prostatic Diseases