Hypofractionated Adaptive Image-Guided Radiation Therapy for Localized Adenocarcinoma of the Prostate

This study is currently recruiting participants. (see Contacts and Locations)
Verified July 2013 by Sidney Kimmel Comprehensive Cancer Center
Sponsor:
Information provided by (Responsible Party):
Sidney Kimmel Comprehensive Cancer Center
ClinicalTrials.gov Identifier:
NCT00809991
First received: December 16, 2008
Last updated: July 24, 2013
Last verified: July 2013
  Purpose

This will be a Phase II study evaluating the effectiveness and toxicity of a specific radiation therapy regimen. This choice of daily dose is based on the prior published experience showing safety and efficacy of hypofractionated regimens. The total dose is calculated to be effective for late effects which has been shown to be effective and safe in a large prospective Phase II study. If the hypothesis for the prostate is is true, then this regimen should be at least as effective or more effective for tumor control than the current conventional therapy.


Condition Intervention Phase
Prostate Cancer
Radiation: hypofractionation
Phase 2

Study Type: Interventional
Study Design: Allocation: Non-Randomized
Endpoint Classification: Safety/Efficacy Study
Intervention Model: Single Group Assignment
Masking: Open Label
Primary Purpose: Treatment
Official Title: Hypofractionated Adaptive Image-Guided Radiation Therapy for Localized Adenocarcinoma of the Prostate

Resource links provided by NLM:


Further study details as provided by Sidney Kimmel Comprehensive Cancer Center:

Primary Outcome Measures:
  • Assess the incidence of grade 2 or greater GU and GI toxicity and self-reported quality of life data with image-guided radiation therapy in doses of 3.6 Gy per day to a total dose of 57.6Gy (16 fractions). [ Time Frame: 7 years ] [ Designated as safety issue: Yes ]

Secondary Outcome Measures:
  • Assess biochemical and clinical control rates associated with the hypofractionated dose regimen for both low-risk and intermediate-risk groups. Assessment will be performed at median 4 years and again at median 7 years' follow-up. [ Time Frame: 7 years ] [ Designated as safety issue: Yes ]

Estimated Enrollment: 188
Study Start Date: November 2008
Estimated Study Completion Date: November 2015
Estimated Primary Completion Date: November 2015 (Final data collection date for primary outcome measure)
Arms Assigned Interventions
Experimental: Arm 1
This will be a Phase II study evaluating the effectiveness and toxicity of a regimen of 3.6 Gy per day to a total dose of 57.6 Gy (16 fractions). This choice of daily dose is based on the prior published experience showing safety and efficacy of hypofractionated regimens of 2.5 Gy, 2.7 Gy, and 3.0 Gy daily fractions. The total dose is calculated to be iso-effective for late effects to a conventionally fractionated total dose of 81 Gy, which has been shown to be effective and safe in a large prospective Phase II study. If the alpha/beta ratio for prostate is between 1.5-3.0, then this regimen should be at least as effective or more effective for tumor control than 81 Gy given in conventional fractions.
Radiation: hypofractionation
This will be a Phase II study evaluating the effectiveness and toxicity of a regimen of 3.6 Gy per day to a total dose of 57.6 Gy (16 fractions). This choice of daily dose is based on the prior published experience showing safety and efficacy of hypofractionated regimens of 2.5 Gy, 2.7 Gy, and 3.0 Gy daily fractions. The total dose is calculated to be iso-effective for late effects to a conventionally fractionated total dose of 81 Gy, which has been shown to be effective and safe in a large prospective Phase II study. If the alpha/beta ratio for prostate is between 1.5-3.0, then this regimen should be at least as effective or more effective for tumor control than 81 Gy given in conventional fractions.

Detailed Description:

Radiation therapy is an effective and frequently utilized modality for the treatment of clinically localized prostate cancer. Traditionally, external beam radiation has been delivered in a fractionated manner using daily doses of 1.8-2.0 Gy. This daily dose was derived from early animal experiments and clinical experience, supported by mathematical models of normal tissue and tumor response to fraction size. The most widely used of these models is the linear-quadratic formula, which predicts responses to different fraction sizes based on the alpha/beta ratio of any given tissue.

One of the main motivations for delivering a treatment at low dose rate or with many fractions is that late-responding normal tissue are generally more sensitive than early-responding tissues (i.e. tumor) to increases in fraction size. So increasing the number of fractions generally spares late-responding tissues more than the tumor. This can be quantified in terms of the alpha/beta ratio:

  • Small alpha/beta ratio (2-4 Gy), typical of late sequelae, means high sensitivity to fractionation changes.
  • Large alpha/beta ratio (>8 Gy), typical of tumor control, means low sensitivity to fractionation changes.

It is generally assumed that the mechanistic basis for the different fractionation response of tumors and late-responding normal tissues relates to the larger proportion of cycling cells in tumors. But prostate tumors contain unusually small fractions of cycling cells. Brenner and Hall as well as Duchesne and Peters have reasoned that prostate tumors might not respond to changes in fractionation in the same way as other cancers; both papers hypothesize that prostate tumors might respond to changes in fractionation or dose rate more like a late-responding normal tissue. , In mathematical terms, the suggestion is that the alpha/beta ratio for prostate cancer might be low, comparable to that for late-responding tissues or even lower. Previous estimates of alpha/beta ratios of normal tissue and tumor tissue have generally been 3 and 10, respectively. Recent evidence has estimated the alpha/beta ratio of prostate cancer to be as low as 1.5. If these hypotheses are true, then the optimal therapeutic ratio for prostate cancer would be achieved using daily doses higher than 2 Gy.

Several preliminary clinical reports have found reasonable PSA control rates and no increase in late toxicity using doses of 2.5 to 3 Gy. Kupelian from the Mayo Clinic found PSA-free survival rates of 97%, 88%, and 70% in low-, intermediate-, and high-risk patients, respectively. The dose regimen used was 70 Gy in 2.5 Gy daily fractions. Both acute and late toxicity were not higher than seen with typical dose regimens. A group from Christie Hospital reported 82%, 56%, and 39% 5-year biochemical disease free survival rates (low, intermediate, and high risk, respectively) in patients treated with 50 Gy in 16 fractions (3.125 Gy per fraction), with acceptable bowel and bladder toxicity.

These results, although promising, require further validation. If the hypothesis that prostate cancer alpha/beta ratio is lower than normal tissue is correct, then the optimal fractional dose is likely to be even higher than the doses tested thus far, but if incorrect, the result may be increased normal tissue toxicity.

  Eligibility

Ages Eligible for Study:   18 Years and older
Genders Eligible for Study:   Male
Accepts Healthy Volunteers:   No
Criteria

Inclusion Criteria:

  • Histologically confirmed, locally confined adenocarcinoma of the prostate
  • Clinical stages T1a to T2b PSA of less than 10 ng per ml
  • Gleason score of less than 3+4=7
  • The patient has decided to undergo external beam radiation as treatment choice for his prostate cancer
  • Signed study-specific consent form prior to registration

Exclusion Criteria:

  • Stage T3 to 4 disease
  • Gleason 4+3=7 or higher score
  • PSA greater than 10 ng per ml
  • Clinical or Pathological Lymph node involvement N1
  • Evidence of distant metastases M1
  • Radical surgery for carcinoma of the prostate
  • Previous Chemotherapy or pelvic radiation therapy
  • Previous or concurrent cancers other than basal or squamous cell skin cancers or superficial bladder cancer unless disease free for at least 5 years
  • History of inflammatory bowel disease
  • Major medical or psychiatric illness which, in the investigator's opinion, would prevent completion of treatment and would interfere with follow up
  Contacts and Locations
Choosing to participate in a study is an important personal decision. Talk with your doctor and family members or friends about deciding to join a study. To learn more about this study, you or your doctor may contact the study research staff using the Contacts provided below. For general information, see Learn About Clinical Studies.

Please refer to this study by its ClinicalTrials.gov identifier: NCT00809991

Contacts
Contact: Shirl DiPasquale, RN 410-614-1598 sdipasq1@jhmi.edu
Contact: Danny Song, MD 410-502-5875

Locations
United States, Maryland
The Johns Hopkins University School of Medicne Recruiting
Baltimore, Maryland, United States, 21231
Contact: Shirl DiPasquale, RN    410-614-3158    sdipasq1@jhmi.edu   
Contact: Beth Griffith, RN    410-502-9243    bgriffit@jhmi.edu   
Sub-Investigator: Theodore DeWeese, MD         
Sponsors and Collaborators
Sidney Kimmel Comprehensive Cancer Center
Investigators
Principal Investigator: Danny Song, MD The Johns Hopkins University School of Medcine
  More Information

No publications provided

Responsible Party: Sidney Kimmel Comprehensive Cancer Center
ClinicalTrials.gov Identifier: NCT00809991     History of Changes
Other Study ID Numbers: J-0859, NA_00019393
Study First Received: December 16, 2008
Last Updated: July 24, 2013
Health Authority: United States: Institutional Review Board

Keywords provided by Sidney Kimmel Comprehensive Cancer Center:
Prostate Cancer

Additional relevant MeSH terms:
Adenocarcinoma
Prostatic Neoplasms
Carcinoma
Neoplasms, Glandular and Epithelial
Neoplasms by Histologic Type
Neoplasms
Genital Neoplasms, Male
Urogenital Neoplasms
Neoplasms by Site
Genital Diseases, Male
Prostatic Diseases

ClinicalTrials.gov processed this record on August 21, 2014