James B. Yu, MD
Since the emergence of new data released in 2017, moderate hypofractionation has proven to be a quicker and efficacious method to administer radiation therapy to patients with prostate cancer.
OncLive: What are the current standards for external beam radiation therapy?
: The hydrogel spacer was an emerging standard last year and has spread rapidly, making it a current standard for prostate radiotherapy to space the rectum away from the prostate. Randomized studies have shown a QOL benefit for not only bowel toxicity, but also urinary and sexual toxicity.
The other standard is moderate hypofractionation. Last year, we spoke about it as an emerging standard. Although there has not been more evidence, I have a feeling that as more people start using it and get comfortable with moderate hypofractionation, it will be an excellent option for patients. Three major large randomized studies have shown that it is equivalent to standard fractionation for intermediate- and low-risk disease.
What are some emerging techniques that seem promising?
Emerging standards are moderate hypofractionation, which is being investigated in the postoperative setting in the NRG GU003 study. That is accruing rapidly and is very promising; I am looking forward to seeing the results of that.
The emerging genomic tests may help differentiate between patients who need postoperative radiation versus those who would not benefit from that. The data for that are strong, and we are using genomic tests more and more to help us with therapeutic decisions. We are also beginning to bring genomic tests into the treatment intensification arena. There was an excellent study out of the University of Michigan on a clinical genomic classifier for prostate cancer rather than just a clinical classifier. [The investigators] incorporated the Decipher prostate cancer test with NCCN criteria and came up with a combined clinical genomic risk. It was very well done and is potentially practice changing.
There is also the concept of oligometastatic disease and our need to define what that is—as well as the use of molecular imaging to help detect metastatic disease that may be occult by standard imaging. We as a field are moving very rapidly in the direction of aggressively treating oligometastatic disease once it has been defined, and potentially curing patients that we previously thought were incurable.
You mentioned genomic testing. Can you expand on that?
The testing that I am talking about is not germline, but testing of the tumor tissue itself. We should all be treating in a multidisciplinary way because genomic testing of the tumor tissue itself has implications for medical oncologists, surgeons, and radiation oncologists.
There are also implications for germline testing—which is testing the patients’ underlying genetics, rather than the tumor. There is a potential “can of worms” that could be opened by discussing that. There also is referral to a genetic counselor. If you are lucky enough, like I am, to have a group that does genetic testing that incorporates counselors, you should refer your patients there if you suspect that they need germline testing.
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