Wednesday, December 17, 2008

3 articles on Lancet Online First

Three article of interest in this week's Lancet online:

1. Publication of the SPCG-7/SFUO-3 trial of androgen deprivation +/- radiation therapy in locally advanced prostate cancer. This trial was presented at ASTRO 2008, and was one of the highlights of the plenary session. 873 patients with largely T3 tumors were treated with indefinite ADT, and were subsequently randomized to RT or no further intervention. They demonstate a biochemical, cancer-specific and overall survival benefit.

While to believers this is a "tell us something we don't already know" moment, there are plenty of non-believers out there, and this trial fits into a much needed gap in the literature in the treatment of high-risk prostate cancer.

Then there is publication of two components of the MRC - ASTEC trial in Endometrial cancer-

2. The first is a question of lymphadenectomy. This is a randomized trial of TAH-BSO + washings and palpation of the PA nodes +/- Lymphadenectomy, with a sizable sample size (n=1408). Contrary to prior non-randomized reports (particularly out of Duke), this trial finds no benefit to lymphadenctomy beyond TAH-BSO. In fact, the HR is in the wrong direction, and was worse in the subsets where more nodes were harvested.

While there are significant differences with the surgical approach in the US and Europe, this trial seriously challenges this approach.

3. The second question is one of radiotherapy. This is actually a report of the ASTEC trial and a canadian trial (NCIC
CTG EN.5). Again a sizeable sample (n=905), randomized patients with intermediate to high risk, early stage endometrial cancer (any stage grade 3, IC any grade) to TAH-BSO to EBRT vs Observation. An important consideration is that a sizeable proportion (53%) received a brachytherapy boost to the vaginal cuff, outside of the randomization.

Not surprising, given findings from the PORTEC 1 and 2 trials, in addition to GOG 99, there was no survival difference. Local control was not formally evaluated in an actuarial fashion, however did seem to be improved. While there are no perfect studies examining this issued (at least from the rad onc's perspective), this again suggests that vaginal brachytherapy alone may be enough for the majority of early stage endometrial cancers.

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