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A Randomized Phase III Study Comparing Androgen Suppression and Elective Pelvic Nodal Irradiation Followed by High Dose 3-D Conformal Boost Versus Androgen Suppression and Elective Pelvic Nodal Irradiation Followed by 125-Iodine Brachytherapy Implant Boost for Patients With Intermediate and High Risk Localized Prostate Cancer


Phase 3
18 Years
N/A
Open (Enrolling)
Male
Prostate Cancer

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Trial Information

A Randomized Phase III Study Comparing Androgen Suppression and Elective Pelvic Nodal Irradiation Followed by High Dose 3-D Conformal Boost Versus Androgen Suppression and Elective Pelvic Nodal Irradiation Followed by 125-Iodine Brachytherapy Implant Boost for Patients With Intermediate and High Risk Localized Prostate Cancer


Patients will be randomly assigned with equal probability to one or two treatment arms, Arm
1 or Arm 2, where the interventions associated with these Arms are as follows:

Arm 1:

Neoadjuvant, concurrent and adjuvant androgen suppression, elective pelvic nodal irradiation
(EPNI), high dose conformal EBRT boost to the prostate, and appropriate secondary
interventions at failure.

Arm 2:

Neoadjuvant, concurrent and adjuvant androgen suppression, elective pelvic nodal irradiation
(EPNI), permanent 125-Iodine brachytherapy boost to the prostate, and appropriate secondary
interventions at failure.

If a patient is assigned to Arm 1, the radiation oncologist will initiate androgen
suppression and monitor clinical and biochemical response. After an 8-month duration of
neoadjuvant androgen suppression, the patient will undergo a course of elective pelvic nodal
irradiation (EPNI) to a volume encompassing the prostate gland, seminal vesicles and
regional lymph nodes. The pelvic irradiation will be followed by a dose-escalated 3-D
conformal EBRT boost to the prostate with appropriate margins. The total radiation dose to
the regional lymphatics is 46 Gy and prostate dose is 78 Gy at the ICRU reference point with
a minimum dose to the PTV of > 74 Gy. Androgen suppression is maintained throughout
radiation therapy and following the completion of radiation therapy until the patient has
received a total duration of androgen suppression of 12 months including the neoadjuvant
phase.

If the patient is assigned to Arm 2, the radiation oncologist will initiate androgen
suppression and monitor clinical and biochemical response. After an 8-month duration of
neoadjuvant androgen suppression, the patient will undergo a course of elective pelvic nodal
irradiation (EPNI) to a volume encompassing the prostate gland, seminal vesicles and
regional lymph nodes. The total radiation dose to the regional lymphatics is 46 Gy. Two
weeks following the completion of the pelvic irradiation, the patient will undergo a
permanent 125-Iodine brachytherapy prostate implant at the facilities of the participating
institution by a team of healthcare professionals lead by a Radiation Oncologist with
experience in prostate brachytherapy. To be eligible to participate, the institution must
have done at least 25 cases of prostate brachytherapy with stranded sources. The minimal
peripheral dose (MPD) to the prostate gland from the implant will be 115 Gy. A modified
peripheral loading technique will be used in an effort to maintain the periurethral dose to
< 150% of the MPD. Androgen suppression is maintained throughout radiation therapy until
the patient has received a total duration of androgen suppression of 12 months including the
neoadjuvant phase.

All patients randomized are part of the analysis. The patient remains on study whether or
not protocol treatment defined for the assigned arm is completed. The end of the primary
intervention is defined as 18 months following the start of neoadjuvant androgen suppression
in both arms.

Secondary Objectives:

Overall survival, metastasis-free survival, pathological local control, incidence of acute
and late side effects and complications associated with the treatment interventions, effect
of the planned interventions on QOL and rate of testosterone recovery.


Inclusion Criteria:



1. Patients must have histologically-proven prostate cancer stage T1c -T3a (UICC 1997).

2. Patients with clinically organ-confined disease must meet the Canadian consensus
definition of intermediate risk disease (i.e any one or more of: CS = T2b [UICC1997
= bilateral palpable intra-capsular disease], GS = 7, or iPSA >10 and 20).

3. Patients with Gleason sum 8 and/or PSA > 20 must have a CT pelvis, and nuclear
medicine bone scan showing no evidence of nodal (N0) or distant metastases (M0).

4. Registration must occur within 36 weeks of biopsy.

5. Patients with clinical or pathological evidence of seminal vesicle invasion (stage
T3b) or involvement of adjacent pelvic organs/structures (stage T4) are not eligible.

6. Pre-intervention PSA must not exceed 40 ng ml-1.

7. Patients must have a chest x-ray and the following blood tests within four weeks of
registration: PSA, PAP, testosterone, CBC, electrolytes, BUN, creatinine, AST, LDH
and alkaline phosphatase. Patients with values for one or more of these tests that
fall outside the normal range will not necessarily be ineligible, however, their
eligibility will need to be reviewed by the study coordinator.

8. Patients must have an ECG within four weeks of registration. Patients with ECGs
judged to be significantly abnormal require a consultation with a cardiologist to
ascertain their suitability for general or spinal anesthesia.

9. Patients judged clinically to have a prostate volume > 65 cm3 prior to starting
androgen suppression must have a transrectal ultrasound for volume estimation.
Patients with TRUS prostate volumes > 75 cm3 prior to starting androgen suppression
are not eligible for the study.

10. Patients may have been started on neoadjuvant androgen suppression prior to
registration provided:

- there is documentation of pre-treatment PSA and

- in the case of patients with iPSA >20 and/or Gleason sum 8, a bone scan and CT
pelvis were done prior to or within 4 weeks after starting neoadjuvant androgen
suppression.

11. Patients must not have received prior surgical treatment for prostate cancer
including transurethral resection of the prostate (TURP), transurethral resection of
the bladder neck (TURB), cryotherapy, laser ablation, or microwave therapy.

12. Patients should have an estimated life expectancy of at least 5 years with an ECOG
performance status of 0-2.

13. Patients may not have received prior radiation therapy to the pelvis.

14. Patients must be fit for general or spinal anesthetic.

15. Patients on Coumadin therapy must be able to stop the therapy safely for at least 12
days. Documentation as to the safety of such an interruption in anticoagulation
therapy must be provided by an appropriate specialist physician (usually a
cardiologist or hematologist).

16. Patients must be judged to have no contraindication to high dose pelvic irradiation
or LHRH agonist therapy.

17. Cancer survivors are eligible providing that all three of the following criteria are
met:

- The patient has undergone potentially curative therapy for all prior
malignancies.

- There has been no evidence of recurrence for at least five years following
potentially curative therapy. (For non-melanoma skin cancer the five-year
requirement does not apply.)

- The patient is considered by the treating physician to be at low risk of
recurrence from prior malignancies.

Type of Study:

Interventional

Study Design:

Allocation: Randomized, Endpoint Classification: Efficacy Study, Intervention Model: Parallel Assignment, Masking: Open Label, Primary Purpose: Treatment

Outcome Measure:

The primary end point of this trial is 5 year actuarial freedom from biochemical recurrence (5 year bNED) using the Houston definition of biochemical failure.

Outcome Time Frame:

5 years

Safety Issue:

No

Principal Investigator

William J Morris, MD

Investigator Role:

Principal Investigator

Investigator Affiliation:

University of British Columbia

Authority:

Canada: Health Canada

Study ID:

R04-0050

NCT ID:

NCT00175396

Start Date:

May 2004

Completion Date:

December 2013

Related Keywords:

  • Prostate Cancer
  • ASCENDE-RT
  • Prostatic Neoplasms

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