Image-guided Hypofractionated Radiotherapy as an Alternative to Radical Prostatectomy in Localized Prostate Cancer in Elderly Patients with Low Life Expectancy.

Abstract

Introduction: Radical prostatectomy is appropriate for any patient whose cancer appears clinically localised to prostate. However because of potential perioperative morbidity, radical prostatectomy is generally reserved for patients whose life expectancy is more than ten years. Moderate hypofractionation for localized prostate cancer is safe and effective. There is a growing body of evidence in support of extreme hypofractionation for localized prostate cancer. Hypofractionation for prostate cancer was originally carried out in the pursuit of efficiency and convenience, but has now attracted greatly renewed interest based upon a hypothesis that prostate cancers have a higher sensitivity to fraction size, reflected in a low α/β ratio, then do late responding organs at risk such as the rectum or bladder.

Material and methods: From January 2017 to December 2020 we treated 112 patients of localised Prostate Cancer with Image Guided Radiotherapy (IGRT). They were in range of 75-85 years. They were of stage T1-T3, N0 or N1. There were significant comborbidities. ECOG performance status was 0-1. They were given 3 months of Androgen Deprivation Therapy (ADT) before starting IGRT. Patients were immobilised with casts and subject to CT simulation. CBCT was taken daily. Dose was 70 Gy @ 250 cGy per fraction at a frequency of 5 fractions per week. Complete blood counts were done weekly for assessment of haematological toxicity. Androgen Deprivation Therapy was continued post IGRT.

Results: All the patients were able to complete the treatment. Evaluation was done at one month, three month and six months post treatment. 104 out of 112 patients achieved complete response. Other 8 had near complete response. There were no acute grade 3-4 toxicities. Grade 1-2 toxicities like skin desquamation, diarrhoea, burning micturition were managed conservatively. Late toxicity was rectal bleeding seen after one year of completion of treatment and was managed with steroid enemas. 23 patients required argon plasma laser therapy.

Conclusion: Image guided radiotherapy is well tolerated, easy to implement and an effective alternative to radical prostatectomy in elderly patients with comorbidities and low life expectancy.