Pelvic radiotherapy in prostate cancer: an unresolved question
Mené sur 1 322 patients atteints d'un cancer localisé de la prostate de stade précoce à risque intermédiaire ou élevé de récidive (durée médiane de suivi : 8,8 ans), cet essai multicentrique de phase III compare, du point de vue de la survie sans progression, l'efficacité de trois protocoles thérapeutiques combinant de façon séquentielle une radiothérapie ciblant la région pelvienne ou uniquement la prostate et une hormonothérapie néo-adjuvante ou adjuvante
The question of whether to irradiate the pelvis or not in primary prostate cancer is essential to daily practice and subject to many discussions in every radiation oncology department. Until now, most clinicians who treated the pelvis with radiotherapy did so mostly on the basis that important, multicentre, randomised trials in favour of combining androgen deprivation therapy (ADT) and external beam radiotherapy (EBRT) over a control group often included pelvic radiotherapy in the EBRT field. 1
With time, treatment for the pelvis became more sophisticated with the realisation that nodes at risk were often excluded from preventive treatment fields. Several consensuses have since been developed, which indicated the nodes to include in treatment fields. 2
Furthermore, the use of intensity-modulated radiotherapy is now common and results in a smaller dose of radiation being delivered to healthy tissue, improving delivery and tolerance of pelvic radiotherapy. Until the results of NRG Oncology (NRG)/Radiation Therapy Oncology Group (RTOG) 9413 trial were first published, no randomised trials showed an advantage of pelvic radiotherapy in combination with ADT versus radiotherapy delivered to the prostate alone. In this issue of The Lancet Oncology, Mack Roach and colleagues 3
present a long-term follow-up of the trial, 11 years after the publication of the previous update. The trial included 1270 eligible patients treated in four groups. Patients received either whole pelvis radiotherapy (WPRT) or prostate only radiotherapy (PORT) and either neoadjuvant and concomitant hormonal therapy (NHT) or adjuvant hormonal therapy (AHT) for a total of 4 months. All patients received a radiotherapy dose of 70 Gy in 1·8 Gy per fraction, which would be considered as insufficient nowadays. The primary outcome was progression-free survival, defined as the first occurrence of local or regional progression, metastatic disease, biochemical failure, or death from any cause.
The Lancet Oncology , commentaire, 2017