Evaluación comparativa de los tratamientos de radiación para el cáncer de próstata
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FUENTE: Annals of Internal Medicine
Raveendhara R. Bannuru, MD; Tomas Dvorak, MD; Ndidiamaka Obadan, MD, MSc; Winifred W. Yu, MS, RD; Kamal Patel, MPH, MBA;
Mei Chung, PhD, MPH; and Stanley Ip, MD
Author Affiliations
1. From the Institute of Clinical Research and Health Policy Studies, Tufts University School of Medicine, Tufts Medical Center, and Tufts Clinical and Translational Science Institute, Boston, Massachusetts.
Abstract
Background: Radiation therapy is one of many treatment options for patients with prostate cancer.
Purpose: To update findings about the clinical and biochemical outcomes of radiation therapies for localized prostate cancer.
Data Sources: MEDLINE (2007 through March 2011) and the Cochrane Central Register of Controlled Trials (2007 through March 2011).
Study Selection: Published English-language comparative studies involving adults with localized prostate cancer who either had first-line radiation therapy or received no initial treatment.
Data Extraction: 6 researchers extracted information on study design, potential bias, sample characteristics, interventions, and outcomes and rated the strength of overall evidence. Data for each study were extracted by 1 reviewer and confirmed by another.
Data Synthesis: 75 studies (10 randomized, controlled trials [RCTs] and 65 nonrandomized studies) met inclusion criteria. No RCTs compared radiation therapy with no treatment or no initial treatment. Among the 10 RCTs, 2 compared combinations of radiation therapies, 7 compared doses and fraction sizes of external-beam radiation therapy (EBRT), and 1 compared forms of low-dose rate radiation therapy. Heterogeneous outcomes were analyzed. Overall, moderate-strength evidence consistently showed that a higher EBRT dose was associated with increased rates of long-term biochemical control compared with lower EBRT dose. The body of evidence was rated as insufficient for all other comparisons.
Limitations: Studies inconsistently defined and reported outcomes. Much of the available evidence comes from observational studies with treatment selection biases.
Conclusion: A lack of high-quality comparative evidence precludes conclusions about the efficacy of radiation treatments compared with no treatments for localized prostate cancer.
Primary Funding Source: Agency for Healthcare Research and Quality.
Editors' Notes
Context
Is radiation therapy an effective treatment for localized prostate cancer?
Contribution
This review found inadequate evidence about survival benefits for radiation therapy compared with no treatment for localized prostate cancer. Data regarding the comparative effectiveness of different radiotherapies was also insufficient, except that higher external-beam radiation therapy (EBRT) dose was associated with better long-term biochemical control than was lower EBRT dose. Radiation therapies sometimes caused urinary or bowel problems, and brachytherapy seemed associated with more urinary toxicity than EBRT.
Implication
Whether or which radiation treatments improve clinical outcomes for men with localized prostate cancer is unknown.
—The Editors
Prostate cancer is the most common noncutaneous cancer diagnosed in men in the United States. The American Cancer Society estimates that in 2009 approximately 192 000 men received a prostate cancer diagnosis and approximately 27 000 men died of the disease (1). Widespread prostate-specific antigen (PSA) testing has doubled the incidence of prostate cancer and the lifetime risk for prostate cancer to approximately 16% (2). Prostate cancer is also diagnosed earlier, and the incidence of clinically “silent” T1 tumors has increased from 17% in 1989 to 48% in 2001 (3) since the advent of PSA screening. Overall, the vast majority of patients with prostate cancer diagnoses today have clinically localized prostate cancer (T1-T2N0).
Depending on a patient's risk profile, many treatment options are available, including active surveillance or watchful waiting, surgery, radiation therapy, cryotherapy, high-intensity focused ultrasonography, and androgen deprivation therapy (ADT). In 2008, the Agency for Healthcare Research and Quality published a systematic review comparing all of the treatment options (4), which concluded that no one therapy can be considered the preferred treatment because of limitations in the available evidence and tradeoffs between effectiveness and adverse effects. Recently, the Coverage and Analysis Group at the Centers for Medicare & Medicaid Services commissioned the Agency for Healthcare Research and Quality to update the report. The Agency for Healthcare Research and Quality requested the Tufts Evidence-based Practice Center to conduct an update specifically reviewing the comparative effectiveness of radiation treatments for patients with localized prostate cancer.
Methods
We used methods adapted from the Methods Reference Guide for Effectiveness and Comparative Effectiveness Reviews, version 1.0, published by the Agency for Healthcare Research and Quality (5). A full technical report that describes methods in detail, including literature search strategies, and results, including evidence tables, is available elsewhere (6).
Key Questions
We focused this report on 2 key questions:
1. What are the benefits and harms of radiation therapy for clinically localized prostate cancer compared with no treatment or no initial treatment (watchful waiting, active surveillance, or observation)?
2. What are the benefits and harms of different forms of radiation therapy for clinically localized prostate cancer?
Data Sources and Searches
We searched MEDLINE and the Cochrane Central Register of Controlled Trials from January 2007 to 11 March 2011 for studies in adults with clinically localized prostate cancer who had radiation treatments. We combined search terms or Medical Subject Heading terms for prostate neoplasm and terms relevant to radiation therapy (for example, proton beam, particle beam, external beam, radiotherapy, intensity-modulated radiotherapy, brachytherapy), and we limited our search to English-language reports of primary studies in adults that were published in peer-reviewed journals. We also used the previous review to identify randomized, controlled trials (RCTs) published before 2007 (4).
Study Selection
We included only RCTs and nonrandomized comparative studies. We excluded single-cohort studies, case reports, and conference abstracts.
Patient Populations of Interest
We included studies of men with clinically localized prostate cancer (T1-T2, N0-X, M0-X) regardless of age, histologic grade, or PSA level. We excluded studies in which more than 20% of patients had locally advanced (T3-T4) cancer; adjuvant, salvage, or postprostatectomy radiation therapy studies; and studies specifically evaluating ADT in conjunction with radiation therapy.
Interventions and Comparators of Interest
The intervention of interest was radiation treatment used as first-line treatment of prostate cancer, including external-beam radiation therapy (EBRT) (conformal radiation, intensity-modulated radiotherapy, or proton therapy), stereotactic body radiation therapy (SBRT), and brachytherapy (low-dose rate [permanent seed implantation] brachytherapy [LDRBT] and high-dose rate temporary brachytherapy [HDRBT]). We also included combination radiation therapies, such as EBRT with brachytherapy boost.
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