Prostate Cancer

Smoking and Prostate Cancer Radiation Outcomes: #RadOnc Journal Club 11/21-23

The November #RadOnc Journal Club will be discussing the following article:

 

 Cigarette smoking during external beam radiation therapy for prostate cancer is associated with an increased risk of prostate cancer-specific mortality and treatment-related toxicity. Steinberger E, Kollmeier M, McBride S, Novak C, Pei X, Zelefsky MJ. BJU Int 2014 [in press]

 

The authors will be joining us for the journal club. Live chat is scheduled for Sunday evening at 8PM Central Standard Time.

 

The chat moderators will lead the discussion with these questions:

 

T1a.     What is the current role of external beam radiation in prostate cancer?

T1b.     What are some of the main ways to optimize cure and lessen side effects of prostate radiotherapy?

T2.  What comorbidities, habits affect the risk/benefit discussion for prostate cancer radiation?

T3a.  What were the results of the study?

T3b.  What are its limitations and strengths?

T4a. What are the implications for current and future research?

T4b. What are the practical points for doctors and prostate cancer patients?

 

The journal club will begin on Friday 11/21 with everyone sharing and discussion their thoughts about the article and by including #RadOnc in their tweets. The live-tweet chat will in the journal club discussion.

 

Thanks to Scott Millar and Dr. Prokar Dasgupta at BJU International, the article is available for free until November 26th.

 

Here is the link: http://onlinelibrary.wiley.com/doi/10.1111/bju.12969/abstract

 

Please tweet thank you to Dr. Dasgupta and BJUI and consider following them for making the article available for our journal club.

1 Comment

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  • As people get excited about obesity and HPV and genetic signatures this paper pulls us up short and shows how much we still have to do about the old old enemy; the cigarette.

    This paper shows (in a very large cohort) highly statistically different outcomes in smokers compared to non-smokers after prostate cancer radiotherapy.

    This joins a literature which has demonstrated similar outcomes in head and neck cancer:
    http://www.ncbi.nlm.nih.gov/pubmed/20399030

    In thoracic radiotherapy concurrent smoking is a strong predictor for pneumonitis and poor outcomes as a result:
    http://www.hoajonline.com/jctr/2049-7962/1/6

    So – smoking and RT means worse side effects, worse outcomes – double trouble.
    What is not clear (to this reader at least) however if the increase in acute toxicity is at least partly causation for the poor outcomes. In head and neck cancer relatively minor increases in toxicity can greatly increase failure to stick to fractionation schedule (because we are already at the top of the dose-response curve for side effects) and we know that extended treatment time compromises outcomes. In the head and neck setting then increased toxicity may explain poor outcomes. Is the same true in prostate?

    The authors of the paper don’t give us any data on interruptions to schedule and therefore we cannot draw any conclusion over whether the toxicity influenced the delivery of treatment. Furthermore I’m not persuaded that prostate cancer is as susceptible to changes in overall treatment time as head and neck due to lower repopulation.

    So is a smoker’s prostate cancer just, well, badder? We’ve seen this too in HPV and smoking in head and neck. Kian Ang’s “Good, The Bad and The Ugly” describes the poor outcome smoker’s tonsillar cancer with the much better HPV associated non smoker (the smoking HPV positive tumour is bad but not ugly!).
    It is plausible that increased p53 mutation in a smoker’s cancer will lead to worse outcomes although but if this is the case we cannot expect outcomes to improve if the patient stops smoking during treatment – so should we make the efforts to improve smoking cessation? Yes – because toxicity will be reduced, there is a lower chance of second malignancy (as we have seen in breast)
    http://onlinelibrary.wiley.com/doi/10.1002/cncr.11669/pdf

    and head and neck

    http://www.uptodate.com/contents/second-primary-malignancies-in-patients-with-head-and-neck-cancers

    and yes because we may be oncologists but we have a duty to use this ‘teachable moment’ to protect the patient from all the other harms that smoking may bring and save them from future visits to the chest and cardiology clinics.

    Most smoking patients will not stop smoking just on the diagnosis of cancer alone

    http://www.ncbi.nlm.nih.gov/pubmed/22008174

    but can be encouraged to do so with a supportive intervention
    http://www.ncbi.nlm.nih.gov/pubmed/18302647

    We should all deliver smoking interventions – after all it only takes 30 seconds (Page 2)
    http://www.sor.org/system/files/article/201311/speaker_abstracts_health_improvement_14_november_2013.pdf

    Perhaps the best way I have seen to enshrine this change is daily positive reinforcement by the radiographers / RTs whilst setting up the patient – instead of a brief chat about the weather and the drive to the cancer centre how about cut the small talk and ask “How’s the quitting going?”

    http://diss.kib.ki.se/2006/91-7140-619-0/thesis.pdf

    Looking forward to the discussion!

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