Impact of Advanced Radiotherapy on Second Primary Cancer Risk in Prostate Cancer Survivors: A Nationwide Cohort Study.

Marie-Christina Jahreiß,Carel Hoekstra,Floris J Pos,Chris H Bangma,Maarten Dirkx,Inge M Van Oort,Andre Dekker,Robert J Smeenk,Tomas Janssen,Bo Van Santvoort,Ben Vanneste,Andre Minken,Wilma D Heemsbergen,Luca Incrocci,Mischa Hoogeman,Katja K H Aben

doi:10.3389/fonc.2021.771956

Abstract

PurposeExternal Beam Radiotherapy (EBRT) techniques dramatically changed over the years. This may have affected the risk of radiation-induced second primary cancers (SPC), due to increased irradiated low dose volumes and scatter radiation. We investigated whether patterns of SPC after EBRT have changed over the years in prostate cancer (PCa) survivors.Materials and MethodsPCa survivors diagnosed between 1990-2014 were selected from the Netherlands Cancer Registry. Patients treated with EBRT were divided in three time periods, representing 2-dimensional Radiotherapy (RT), 3-dimensional conformal RT (3D-CRT), and the advanced RT (AdvRT) era. Standardized incidence ratios (SIR) and absolute excess risks (AER) were calculated to estimate relative and excess absolute SPC risks. Sub-hazard ratios (sHRs) were calculated to compare SPC rates between the EBRT and prostatectomy cohort. SPCs were categorized by subsite and anatomic region.ResultsPCa survivors who received EBRT had an increased risk of developing a solid SPC (SIR=1.08; 1.05-1.11), especially in patients aged <70 years (SIR=1.13; 1.09-1.16). Pelvic SPC risks were increased (SIR=1.28; 1.23-1.34), with no obvious differences between the three EBRT eras. Non-pelvic SPC were only significantly increased in the AdvRT era (SIR=1.08; 1.02-1.14), in particular for the 1-5 year follow-up period. Comparing the EBRT cohort to the prostatectomy cohort, again an increased pelvic SPC risk was found for all EBRT periods (sHRs= 1.61, 1.47-1.76). Increased non-pelvic SPC risks were present for all RT eras and highest for the AdvRT period (sHRs=1.17, 1.06-1.29).ConclusionSPC risk in patients with EBRT is increased and remained throughout the different EBRT eras. The risk of developing a SPC outside the pelvic area changed unfavorably in the AdvRT era. Prolonged follow-up is needed to confirm this observation. Whether this is associated with increased irradiated low-dose volumes and scatter, or other changes in clinical EBRT practice, is the subject of further research.

Highlights

Prostate Cancer (PCa) is the second most commonly diagnosed cancer in men
For pelvic second primary cancer (SPC) a significant increased risk was observed (SIR=1.08 (1.05-1.11); absolute excess risks (AER)=3.40). This was mainly attributed to a significant increase in SPCs in the bladder (SIR=1.08 (1.04-1.11); AER=1.95) and rectum (SIR=1.10 (1.05-1.15); AER=1.17)
In PCa patients treated with External Beam Radiotherapy (EBRT) an 8% increased risk of developing a solid SPC was observed, which corresponds with an absolute excess number of 14.5 patients diagnosed with a second cancer per 10.000, compared to the Dutch male general population

Summary

Introduction

Prostate Cancer (PCa) is the second most commonly diagnosed cancer in men. The worldwide PCa burden is expected to grow to almost 2.3 million new cases by 2040 [1]. A rare but severe long-term adverse event is a radiation-induced second primary cancer (SPC) [2, 3]. Large cohort studies exploring SPC risk after PCa have confirmed that RT is associated with increased SPC risk [2, 5,6,7,8,9,10]. The majority of these large cohort studies are based on data from national cancer registries in which details on treatment, such as type of External Beam Radiotherapy (EBRT), are typically not registered

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