Quality of Life and Decision Regret After Postoperative Radiation Therapy to the Prostatic Bed Region With or Without Elective Pelvic Nodal Radiation Therapy.

PURPOSE: To evaluate patient-reported health-related quality of life (HRQOL) and decision regret (DR surgery or DR radiation therapy) after radiation therapy to the prostatic bed (PBRT) with or without whole pelvic radiation therapy (WPRT). METHODS AND MATERIALS: Patients received 79.29 Gy (n = 78; R1/detectable tumors) or 71.43 Gy (n = 56; R0/undetectable tumors) equivalent dose in 2-Gy fractions (EQD-2). Out of 134 patients, 51 had received additional WPRT with 44 Gy. Decision regret was reported using a 5-item instrument (best/worst scores: 0-100); European Organization for Research and Treatment of Cancer QLQ-C30 and QLQ-PR25 questionnaires were used for HRQOL evaluation. RESULTS: At a median follow-up of 53 months, 134 valid questionnaires were returned. Most patients had locally advanced, node-positive (T3-4/N0 = 54.5%; N1 = 17.2%) or high-risk tumors (27.6%). Mean DR surgery was 17.61 and not associated with positive margins, salvage strategy, or radiation therapy regimen. Mean DR radiation therapy was 18.64 and better in patients who had PBRT compared with WPRT (P = .034; 24.39 vs. 15.24). Patient-reported bowel and urinary symptoms were worse after WPRT compared with PBRT (both P < .05); general HRQOL was numerically but not significantly better after PBRT without WPRT (P = .055). Subset analyses identified increased bowel and urinary symptom scores after WPRT irrespective of higher or lower dose cohorts (all P < .05). CONCLUSIONS: WPRT was associated with increased symptom burden and decision regret compared with PBRT. It is uncertain if the results can be extrapolated to lower-dose (<70 Gy) regimens. Further research is required to evaluate if specific decision support tools or treatment modifications according to the individual risk situation may be beneficial in this setting.

Postoperative elective pelvic nodal irradiation compared to prostate bed irradiation in locally advanced prostate cancer - a retrospective analysis of dose-escalated patients.

BACKGROUND: It is uncertain if whole-pelvic irradiation (WPRT) in addition to dose-escalated prostate bed irradiation (PBRT) improves biochemical progression-free survival (bPFS) after prostatectomy for locally advanced tumors. This study was initiated to analyze if WPRT is associated with bPFS in a patient cohort with dose-escalated (> 70 Gy) PBRT. METHODS: Patients with locally advanced, node-negative prostate carcinoma who had PBRT with or without WPRT after prostatectomy between 2009 and 2017 were retrospectively analyzed. A simultaneous integrated boost with equivalent-doses-in-2-Gy-fractions (EQD-2) of 79.29 Gy or 71.43 Gy to the prostate bed was applied in patients with margin-positive (or detectable) and margin-negative/undetectable tumors, respectively. WPRT (44 Gy) was offered to patients at an increased risk of lymph node metastases. RESULTS: Forty-three patients with PBRT/WPRT and 77 with PBRT-only were identified. Baseline imbalances included shorter surgery-radiotherapy intervals (S-RT-Intervals) and fewer resected lymph nodes in the WPRT group. WPRT was significantly associated with better bPFS in univariate (p = 0.032) and multivariate models (HR = 0.484, p = 0.015). Subgroup analysis indicated a benefit of WPRT (p = 0.029) in patients treated with rising PSA values who mostly had negative margins (74.1%); WPRT was not associated with a longer bPFS in the postoperative setting with almost exclusively positive margins (96.8%). CONCLUSION: We observed a longer bPFS after WPRT compared to PBRT in patients with locally advanced prostate carcinoma who underwent dose-escalated radiotherapy. In subset analyses, the association was only observed in patients with rising PSA values but not in patients with non-salvage postoperative radiotherapy for positive margins.

Minimum Volume Discussion in the Treatment of Colon and Rectal Cancer: A Review of the Current Status and Relevance of Surgeon and Hospital Volume regarding Result Quality and the Impact on Health Economics.

BACKGROUND: To answer the question whether minimum caseloads need to be stipulated in the German S3 (or any other) guidelines for colorectal cancer, we analyzed the current representative literature. The question is important regarding medical quality as well as health economics and policy. METHODS: A literature research was conducted in PubMed for papers concerning 'colon cancer' (CC), 'rectal cancer' (RC), and 'colorectal cancer' (CRC), with 'results', 'quality', and 'mortality' between the years 2000 and 2016 being relevant factors. We graded the recommendations as 'pro', 'maybe', or 'contra' in terms of a significant correlation between hospital volume (HV) or surgeon volume (SV) and treatment quality. We also listed the recommended numbers suggested for HV or SV as minimum caseloads and calculated and discussed the socio-economic impact of setting minimum caseloads for CRC. RESULTS: The correlations of caseloads of hospitals or surgeons turned out to be highly controversial concerning the influence of HV or SV on short- and long-term surgical treatment quality of CRC. Specialized statisticians made the point that the reports in the literature might not use the optimal biometrical analytical/reporting methods. A Dutch analysis showed that if a decision towards minimum caseloads, e.g. >50 for CRC resections, would be made, this would exclude a lot of hospitals with proven good treatment quality and include hospitals with a treatment quality below average. Our economic analysis envisioned that a yearly loss of EUR <830,000 might ensue for hospitals with volumes <50 per year. CONCLUSIONS: Caseload (HV, SV) definitely is an inconsistent surrogate parameter for treatment quality in the surgery of CC, RC, or CRC. If used at all, the lowest tolerable numbers but the highest demands for structural, process and result quality in the surgical/interdisciplinary treatment of CC and RC must be imposed and independently controlled. Hospitals fulfilling these demands should be medically and socio-economically preferred concerning the treatment of CC and RC patients.