Radiotherapy for Prostate Cancer: is it 'what you do' or 'the way that you do it'? A UK Perspective on Technique and Quality Assurance.

AIMS: The treatment of prostate cancer has evolved markedly over the last 40 years, including radiotherapy, notably with escalated dose and targeting. However, the optimal treatment for localised disease has not been established in comparative randomised trials. The aim of this article is to describe the history of prostate radiotherapy trials, including their quality assurance processes, and to compare these with the ProtecT trial. MATERIALS AND METHODS: The UK ProtecT randomised trial compares external beam conformal radiotherapy, surgery and active monitoring for clinically localised prostate cancer and will report on the primary outcome (disease-specific mortality) in 2016 following recruitment between 1999 and 2009. The embedded quality assurance programme consists of on-site machine dosimetry at the nine trial centres, a retrospective review of outlining and adherence to dose constraints based on the trial protocol in 54 participants (randomly selected, around 10% of the total randomised to radiotherapy, n = 545). These quality assurance processes and results were compared with prostate radiotherapy trials of a comparable era. RESULTS: There has been an increasingly sophisticated quality assurance programme in UK prostate radiotherapy trials over the last 15 years, reflecting dose escalation and treatment complexity. In ProtecT, machine dosimetry results were comparable between trial centres and with the UK RT01 trial. The outlining review showed that most deviations were clinically acceptable, although three (1.4%) may have been of clinical significance and were related to outlining of the prostate. Seminal vesicle outlining varied, possibly due to several prostate trials running concurrently with different protocols. Adherence to dose constraints in ProtecT was considered acceptable, with 80% of randomised participants having two or less deviations and planning target volume coverage was excellent. CONCLUSION: The ProtecT trial quality assurance results were satisfactory and comparable with trials of its era. Future trials should aim to standardise treatment protocols and quality assurance programmes where possible to reduce complexities for centres involved in multiple trials.

Radiotherapy physics research in the UK: challenges and proposed solutions.

In 2011, the Clinical and Translational Radiotherapy Research Working Group (CTRad) of the National Cancer Research Institute brought together UK radiotherapy physics leaders for a think tank meeting. Following a format that CTRad had previously and successfully used with clinical oncologists, 23 departments were asked to complete a pre-meeting evaluation of their radiotherapy physics research infrastructure and the strengths, weaknesses, opportunities and threats within their own centre. These departments were brought together with the CTRad Executive Group and research funders to discuss the current state of radiotherapy physics research, perceived barriers and possible solutions. In this Commentary, we summarise the submitted materials, presentations and discussions from the meeting and propose an action plan. It is clear that there are challenges in both funding and staffing of radiotherapy physics research. Programme and project funding streams sometimes struggle to cater for physics-led work, and increased representation on research funding bodies would be valuable. Career paths for academic radiotherapy physicists need to be examined and an academic training route identified within Modernising Scientific Careers; the introduction of formal job plans may allow greater protection of research time, and should be considered. Improved access to research facilities, including research linear accelerators, would enhance research activity and pass on developments to patients more quickly; research infrastructure could be benchmarked against centres in the UK and abroad. UK National Health Service departments wishing to undertake radiotherapy research, with its attendant added value for patients, need to develop a strategy with their partner higher education institution, and collaboration between departments may provide enhanced opportunities for funded research.

Clinical application of image-guided radiotherapy in bladder and prostate cancer.

Advances in radiotherapy planning reduced the volumes of irradiated normal tissue and allowed safe dose escalation in prostate cancer. Image-guided radiotherapy solutions to prostate and bladder cancer offer further improvements. The initial process is understanding the causes and extent of internal organ motion, followed by development of equipment and protocols to minimise geographical miss. Further refinements may allow margin reduction and further dose escalation. This paper reviews these issues for bladder and prostate cancer.

Distribution of lymph nodes in men with prostatic adenocarcinoma and lymphadenopathy at presentation: a retrospective radiological review and implications for prostate and pelvis radiotherapy.

AIMS: To describe the distribution of enlarged lymph nodes by nodal group found radiologically in patients presenting with adenocarcinoma of the prostate. This will help to define which nodal groups should be treated during the pelvic radiotherapy of patients with less advanced disease. MATERIALS AND METHODS: The scans of 55 men presenting with prostate cancer and metastases to lymph nodes only were reviewed. Lymph nodes of 8 mm or more in size were considered to be enlarged. RESULTS: The medial external iliac (obturator) nodes were most commonly enlarged (75% of patients) followed by nodes in the para-aortic region (26%) and anterior internal iliac region (24%). Para-aortic lymph-node enlargement was uncommon in the absence of pelvic lymphadenopathy. Midline pre-sacral lymph-node enlargement was not observed. Incidence of enlarged lymph nodes in the lateral external iliac group was 18%, an area which may not be routinely included during radiotherapy. CONCLUSION: There is a case for studying further the role of including lateral external iliac lymph nodes in the pelvic radiotherapy volume, as there may be an appreciable risk of lymph-node spread to this area.