Low-risk Localized Prostate Cancer Research Articles

Stereotactic Radiation Therapy for Localized Prostate Cancer: 10-Year Outcomes From Three Prospective Trials

Background and purposeStereotactic ablative radiotherapy (SABR) is growingly accepted for the treatment of localized prostate cancer with recent randomized trials showing non-inferiority compared to conventional or moderately hypofractionated radiotherapy. The natural history of prostate cancer necessitates extended surveillance for recurrence; however, there are few prospective studies reporting long-term outcomes. Materials and methodsThis study included patients with low and intermediate risk localized prostate cancer from three Canadian clinical trials enrolled from 2006-2013. All patients received SABR to the prostate consisting of 35-40 Gy in 5 fractions over 11-29 days. PSA, distant metastasis, and vital status were prospectively recorded. Occurrence of second malignancy after treatment was assessed by chart review and classified using modified Cahan's criteria. Results267 patients were included. Median follow up was 10.3 years (IQR 7.8 – 12.7). 10-year BF (95% CI) was 7.7% (3.9-11.5). 10-year OS, PCSS, and FFM were 84.1% (79.3 – 89.1%), 99.2% (98.1 – 100), and 98.8% (97.5-100), respectively. 27/267 (10.1%) patients experienced a SM, with 6/27 patients (22.2%) classified as having a SM likely (n=3) or possibly (n=3) related to prior radiotherapy. 10-year freedom from SM was 89.2%. ConclusionSABR shows excellent long-term disease control for low and intermediate risk localized prostate cancer. Patients treated for prostate cancer have a moderate risk of second malignancy, consistent with background rates for the population.

The survival outcomes of localized low-risk prostate cancer, a population-based study using NCDB.

The optimal treatment approach for low-risk prostate cancer (LRPC) remains controversial. While active surveillance is an increasingly popular option, definitive local treatments, including radical prostatectomy (RP), external beam radiotherapy (EBRT), and prostate seed implantation (PSI), are also commonly used. This study aimed to evaluate the survival outcomes of patients with LRPC using a large patient population from the National Cancer Database (NCDB). We analyzed data from 195,452 patients diagnosed with LRPC between 2004 and 2015 using the NCDB. Patients were classified based on their treatment modalities, including RP, EBRT, PSI, or no local treatment (NLT). Only patients with Charlson-Deyo comorbidity scores of 0 or 1 were included to ensure comparability. Propensity score analysis was used to balance the treatment groups, and the accelerated failure time model was used to analyze the survival rates of the treatment groups. After a median follow-up of 70.8 months, 24,545 deaths occurred, resulting in an all-cause mortality rate of 13%. RP demonstrated a survival benefit compared with NLT, particularly in patients younger than 74 years of age. In contrast, radiation treatments (EBRT and PSI) did not improve survival in the younger age groups, except for patients older than 70 years for EBRT and older than 65 years for PSI. Notably, EBRT in patients younger than 65 years was associated with inferior outcomes. This study highlights the differences in survival outcomes among LRPC treatment modalities. RP was associated with improved survival compared to NLT, especially in younger patients. In contrast, EBRT and PSI showed survival benefits primarily in the older age groups. NLT is a reasonable choice, particularly in younger patients when RP is not chosen. These findings emphasize the importance of individualized treatment decisions for LRPC management.

Management outcomes of localized low-risk prostate cancer: A population-based study.

Management outcomes of localized low-risk prostate cancer: A population-based study.

Functional imaging guided stereotactic ablative body radiotherapy (SABR) with focal dose escalation and bladder trigone sparing for intermediate and high-risk prostate cancer: study protocol for phase II safo trial

BackgroundStereotactic ablative body radiotherapy (SABR) is an emerging treatment alternative for patients with localized low and intermediate risk prostate cancer patients. As already explored by some authors in the context of conventional moderate hypofractionated radiotherapy, focal boost of the index lesion defined by magnetic resonance imaging (MRI) is associated with an improved biochemical outcome. The objective of this phase II trial is to determine the effectiveness (in terms of biochemical, morphological and functional control), the safety and impact on quality of life, of prostate SABR with MRI guided focal dose intensification in males with intermediate and high-risk localized prostate cancer.MethodsPatients with intermediate and high-risk prostate cancer according to NCCN definition will be treated with SABR 36.25 Gy in 5 fractions to the whole prostate gland with MRI guided simultaneous integrated focal boost (SIB) to the index lesion (IL) up to 50 Gy in 5 fractions, using a protocol of bladder trigone and urethra sparing. Intra-fractional motion will be monitored with daily cone beam computed tomography (CBCT) and intra-fractional tracking with intraprostatic gold fiducials. Androgen deprivation therapy (ADT) will be allowed. The primary endpoint will be efficacy in terms of biochemical and local control assessed by Phoenix criteria and post-treatment MRI respectively. The secondary endpoints will encompass acute and late toxicity, quality of life (QoL) and progression-free survival. Finally, the subgroup of high-risk patients will be involved in a prospective study focused on immuno-phenotyping.DiscussionTo the best of our knowledge, this is the first trial to evaluate the impact of post-treatment MRI on local control among patients with intermediate and high-risk prostate cancer undergoing SABR and MRI guided focal intensification. The results of this trial will enhance our understanding of treatment focal intensification through the employment of the SABR technique within this specific patient subgroup, particularly among those with high-risk disease, and will help to clarify the significance of MRI in monitoring local responses. Hopefully will also help to design more personalized biomarker-based phase III trials in this specific context. Additionally, this trial is expected to be incorporated into a prospective radiomics study focused on localized prostate cancer treated with radiotherapy.Trial registrationClinicaltrials.gov identifier: NCT05919524; Registered 17 July 2023.Trial SponsorIRAD/SEOR (Instituto de Investigación de Oncología Radioterápica / Sociedad Española de Oncología Radioterápica).Study settingClinicaltrials.gov identifier: NCT05919524; Registered 17 July 2023.Trial statusProtocol version number and date: v. 5/ 17 May-2023. Date of recruitment start: August 8, 2023. Date of recruitment completion: July 1, 2024.

2440: Ultrahypofractionated radiotherapy in low and favourable intermediate risk localised prostate cancer

2440: Ultrahypofractionated radiotherapy in low and favourable intermediate risk localised prostate cancer

Longitudinal analysis of T2 relaxation time variations following radiotherapy for prostate cancer

Aim of this paper is to evaluate short and long-term changes in T2 relaxation times after radiotherapy in patients with low and intermediate risk localized prostate cancer. A total of 24 patients were selected for this retrospective study. Each participant underwent 1.5T magnetic resonance imaging on seven separate occasions: initially after the implantation of gold fiducials, the required step for Cyberknife therapy guidance, followed by MRI scans two weeks post-therapy and monthly thereafter. As part of each MRI scan, the prostate region was manually delineated, and the T2 relaxation times were calculated for quantitative analysis. The T2 relaxation times between individual follow-ups were analyzed using Repeated Measures Analysis of Variance that revealed a significant difference across all measurements (F (6, 120) = 0.611, p << 0.001). A Bonferroni post hoc test revealed significant differences in median T2 values between the baseline and subsequent measurements, particularly between pre-therapy (M0) and two weeks post-therapy (M1), as well as during the monthly interval checks (M2 - M6). Some cases showed a delayed decrease in relaxation times, indicating the prolonged effects of therapy. The changes in T2 values during the course of radiotherapy can help in monitoring radiotherapy response in unconfirmed patients, quantifying the scarring process, and recognizing the therapy failure.

Can systemic immune-inflammation index and hematologic parameters aid in decision-making for active surveillance or curative treatment in low-risk prostate cancer?

IntroductionPathologic Gleason Score (GS) upgrading is common in patients with low-risk localized prostate cancer (PCa) who are followed by active surveillance (AS) or undergo radical prostatectomy (RP). This fact raises concerns about inadequate treatment, especially in AS patients. We aimed to analyze the association of preoperative neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR), and systemic immune-inflammation (SII) index with GS upgrading. Materials and methodsThis study was approved by the Ethical Review Committee of Afyonkarahisar Health Sciences University. Data of the patients who underwent RP for PCa at three different centers between 2018 and 2023 were retrospectively analyzed. The patients were divided into 2 groups based on GR upgrading status as “upgrading” and “non-upgrading”. Among the patients who underwent RP, 77 patients who fully met the criteria for AS were identified. The patients eligible for AS were divided into “non-upgrading” and “upgrading” groups. These groups were compared regarding NLR, PLR, and SII index values. ResultsOverall, data from 250 patients were reviewed. Among these, 147 had GS upgrading, while 103 had no upgrading. Seventy-seven patients were eligible for AS. Among these patients, 30 had upgrading, while 47 were in the “non-upgrading” group. Our analysis revealed that an NLR of 1.85 and above was associated with a 2.238-fold increase in the risk of GS upgrading (p = 0.009). Also, a PLR of 115.7 and above was affiliated with a 2.992-fold increase in the GS upgrading risk (p < 0.001). The analysis regarding patients who underwent RP but were eligible for AS revealed that an NLR of ≥1.68 was associated with a 3.25-fold risk increase in GS upgrading. On the other hand, a PLR≥134.5 and an SII index≥630.7 were affiliated with a 12.303-fold and 6.562-fold increase in the risk of upgrading (p = 0.019, p = 0.018). ConclusionThe decision of AS should be carefully reappraised, and treatment methods such as RP or radiotherapy should be considered in patients with high NLR, PLR, or SII index values.

Transperineal focal diode laser ablation for low and intermediate risk localized prostate cancer. A five years pilot prospective study

Transperineal focal diode laser ablation for low and intermediate risk localized prostate cancer. A five years pilot prospective study

Active surveillance of patients with low and intermediate risk prostate cancer

Aim to analyze the survival of patients with localized low and intermediate risk prostate cancer receiving various types of treatment and active surveillance in the Samara region.&#x0D; Material and methods. The study included 1474 patients with newly diagnosed localized prostate cancer in the Samara region for the period 2010-2016.&#x0D; Results. In the Samara region, the radical prostatectomy proved to be the most effective treatment method. At the same time, the active surveillance was comparable to other treatment methods in men older than 75 years.&#x0D; Conclusion. The active surveillance can improve the managing of prostate cancer patients by reducing overtreatment of its clinically insignificant forms, reducing treatment costs and reducing the number of side effects of radical treatment. At the same time, the possibility of radical treatment remains in case of malignant neoplasm progression.

AI-Based Isotherm Prediction for Focal Cryoablation of Prostate Cancer

Focal therapies have emerged as minimally invasive alternatives for patients with localized low-risk prostate cancer (PCa) and those with postradiation recurrence. Among the available focal treatment methods for PCa, cryoablation offers several technical advantages, including the visibility of the boundaries of frozen tissue on the intraprocedural images, access to anterior lesions, and the proven ability to treat postradiation recurrence. However, predicting the final volume of the frozen tissue is challenging as it depends on several patient-specific factors, such as proximity to heat sources and thermal properties of the prostatic tissue. This paper presents a convolutional neural network model based on 3D-Unet to predict the frozen isotherm boundaries (iceball) resultant from a given a cryo-needle placement. Intraprocedural magnetic resonance images acquired during 38 cases of focal cryoablation of PCa were retrospectively used to train and validate the model. The model accuracy was assessed and compared against a vendor-provided geometrical model, which is used as a guideline in routine procedures. The mean Dice Similarity Coefficient using the proposed model was 0.79±0.08 (mean+SD) vs 0.72±0.06 using the geometrical model (P<.001). The model provided an accurate iceball boundary prediction in less than 0.4second and has proven its feasibility to be implemented in an intraprocedural planning algorithm.

Comparison of Outcomes of Active Surveillance in Intermediate-Risk Versus Low-Risk Localised Prostate Cancer Patients: A Systematic Review and Meta-Analysis.

Currently, there is no clear consensus regarding the role of active surveillance (AS) in the management of intermediate-risk prostate cancer (IRPC) patients. We aim to analyse data from the available literature on the outcomes of AS in the management of IRPC patients and compare them with low-risk prostate cancer (LRPC) patients. A comprehensive literature search was performed, and relevant data were extracted. Our primary outcome was treatment-free survival, and secondary outcomes were metastasis-free survival, cancer-specific survival, and overall survival. The DerSimonian-Laird random-effects method was used for the meta-analysis. Out of 712 studies identified following an initial search, 25 studies were included in the systematic review. We found that both IRPC and LRPC patients had nearly similar 5, 10, and 15 year treatment-free survival rate, 5 and 10 year metastasis-free survival rate, and 5 year overall survival rate. However, cancer-specific survival rates at 5, 10, and 15 years were significantly lower in IRPC compared to LRPC group. Furthermore, IRPC patients had significantly inferior long-term overall survival rate (10 and 15 year) and metastasis-free survival rate (15 year) compared to LRPC patients. Both the clinicians and the patients can consider this information during the informed decision-making process before choosing AS.

Validating the total cancer location density metric for stratifying patients with low-risk localized prostate cancer at higher risk of grade group reclassification while on active surveillance.

To validate a previously proposed prognostic metric, Total Cancer Location (TCLo) density, in a contemporary cohort of men with grade group (GG) 1 prostate cancer (PCa) on active surveillance (AS). We evaluated 123 patients who entered AS with maximum GG1 PCa at diagnostic and/or confirmatory biopsy. TCLo was defined as the total number of PCa locations identified on both biopsy sessions. TCLo density was calculated as TCLo / prostate volume [ml]. Primary endpoint was progression-free survival (PFS), defined as time from confirmatory biopsy to grade group reclassification (GGR) on repeat biopsy or prostatectomy. Optimal cut-point for TCLo density was predefined in a previously reported cohort and applied to this contemporary cohort. Kaplan-Meier and multivariable Cox regression analysis were used to estimate the association of predictors with PFS. During median follow-up of 7.8 years, (IQR 7.3-8.2) 34 men had GGR. Using previously defined cut-points, PFS at 5-years was 60% (95% CI: 44%-81%) vs. 89% (95% CI: 83%-96%) in men with high (≥0.06 ml-1) vs. low (<0.06 ml-1) TCLo density, and 63% (95% CI: 48%-82%) vs. 90% (95% CI: 83%-96%) in men with high (≥3) vs. low (≤2) TCLo (log-rank test: P < 0.0001, respectively). Adjusting for age, prostate volume, percent of positive cores and PSA, both higher TCLo density (HR [per 0.01 ml-1 increase]: 1.18, 95% CI: 1.05-1.33, P = 0.005) and TCLo (HR: 1.69, 95% CI: 1.20-2.38, P = 0.002) were associated with shorter PFS. The previously suggested prognostic value of TCLo density was confirmed in this validation cohort. TCLo alone performed similarly well. Patients with high TCLo density (≥0.06 ml-1) or TCLo (>2) were at greater risk of GGR while on AS. With external validation, these metric may help guide risk-adapted surveillance protocols.

Economic value of knowing BRCA status: BRCA testing for prostate cancer prevention and optimal treatment

ABSTRACT Background We aimed to estimate the incremental lifetime effects, costs, and net-monetary-benefit (NMB) of knowing BRCA information by testing of patients with low-risk localized prostate cancer (PCa) in the US and guiding subsequent screening and treatment, and the cumulative savings or losses of yearly cohort testing over 16 years. We compared two strategies: (1)‘with BRCA information’ and (2)‘without BRCA information.’ We also estimated the expected value of perfect information. Methods The incremental NMB (INMB) quantified the monetized benefit per person of knowing BRCA status. The net-monetized-value of knowing BRCA information was estimated by multiplying the INMB with the eligible population. Results The INMBs of knowing BRCA information were $43,357 (payer) and $43,487 (society). in payer and societal perspectives, respectively. Escalated to the eligible patients in 2020, knowing BRCA status resulted in net monetized lifetime value of $1.7 billion (payer and society) for the 2020 cohort; and yielded accumulated net-monetized-value of $28.0 billion (payer) and $28.1 billion (society) over 16 yearly cohorts of eligible PCa patients. Conclusions The economic value of knowing BRCA status for all low-risk localized PCa patients in the US provides short-term and long-term evidence for BRCA testing to screen early and optimize treatment.

Genetic Aspects and Molecular Testing in Prostate Cancer: A Report from a Dutch Multidisciplinary Consensus Meeting

BackgroundGermline and tumour genetic testing in prostate cancer (PCa) is becoming more broadly accepted, but testing indications and clinical consequences for carriers in each disease stage are not yet well defined. ObjectiveTo determine the consensus of a Dutch multidisciplinary expert panel on the indication and application of germline and tumour genetic testing in PCa. Design, setting, and participantsThe panel consisted of 39 specialists involved in PCa management. We used a modified Delphi method consisting of two voting rounds and a virtual consensus meeting. Outcome measurements and statistical analysisConsensus was reached if ≥75% of the panellists chose the same option. Appropriateness was assessed by the RAND/UCLA appropriateness method. Results and limitationsOf the multiple-choice questions, 44% reached consensus. For men without PCa having a relevant family history (familial PCa/BRCA-related hereditary cancer), follow-up by prostate-specific antigen was considered appropriate. For patients with low-risk localised PCa and a family history of PCa, active surveillance was considered appropriate, except in case of the patient being a BRCA2 germline pathogenic variant carrier. Germline and tumour genetic testing should not be done for nonmetastatic hormone-sensitive PCa in the absence of a relevant family history of cancer. Tumour genetic testing was deemed most appropriate for the identification of actionable variants, with uncertainty for germline testing. For tumour genetic testing in metastatic castration-resistant PCa, consensus was not reached for the timing and panel composition. The principal limitations are as follows: (1) a number of topics discussed lack scientific evidence, and therefore the recommendations are partly opinion based, and (2) there was a small number of experts per discipline. ConclusionsThe outcomes of this Dutch consensus meeting may provide further guidance on genetic counselling and molecular testing related to PCa. Patient summaryA group of Dutch specialists discussed the use of germline and tumour genetic testing in prostate cancer (PCa) patients, indication of these tests (which patients and when), and impact of these tests on the management and treatment of PCa.

Healthcare Professionals' Experiences and Perspectives of Facilitating Self-Management Support for Patients with Low-Risk Localized Prostate Cancer via mHealth and Health Coaching.

Introduction: Self-monitoring of self-management interventions with the use of mobile health (mHealth) can enhance patients' well-being. Research indicates that mHealth and health coaching act symbiotically to providing a more constructive outcome. Nurse coaches seem to have a significant role in translating the patients' tracked data. Objective: The objective was to explore healthcare professionals' experiences of an intervention offering self-management support through mHealth and health coaching for patients with prostate cancer. Methods: We used the interpretive description methodology, combining semi-structured individual and focus group interviews and participant observations of patient-coach interactions and use of mHealth in coaching sessions. The study was conducted between June 2017 and August 2020. Results: The nurse coaches experienced motivation and autonomy when possessing the right competences for coaching. Furthermore, the nurse coaches experienced conflicting expectations of their roles when having to integrate mHealth. Conclusion: The experience of being competent, autonomous, and confident is important for the nurse coaches to be mentally present during the coaching sessions. On the other hand, the findings indicate that having the sense of not being confident in one's own ability to perform leads to reduced motivation.

Impact of active surveillance for prostate cancer on the risk of depression and anxiety

Active surveillance (AS) is a standard treatment option for low risk localized prostate cancer. However, the risk of anxiety and depression compared to other curative strategies, namely radical prostatectomy (RP) and radiotherapy (RT), is controversial. This study consisted in a French representative sample of 4174 5-years cancer survivors. Self-reported data, including quality-of-life assessment, were prospectively collected through telephone interviews. Among the 447 survivors with PC, we selected 292 patients with localized prostate cancer, T1–T2 stage, Gleason score ≤ 7 and we compared anxiety and depressive symptoms according to treatment strategy. Among patients on AS, 14.9% received curative treatment during the 5 years of follow-up. Anxiety was reported in 34.3% of cases in the AS group versus 28.6% in the RP group and 31.6% in the RT group (p = 0.400), while depressive symptoms were reported in 14.9% of cases in the AS group versus 10.7% in the RP group and 22.8% in the RT group (p = 0.770). Consumption of anxiolytics reported did not vary significantly between the 3 groups (p = 0.330). In conclusion, patients managed with AS for localized prostate cancer do not report more anxiety or depressive symptoms than patients managed with curative treatment, encouraging the extended use of active surveillance.

The evolving landscape of practice pattern and survival outcomes in the management of localized low-risk prostate cancer.

e17057 Background: The majority of patients with low-risk prostate cancer (LRPC) are candidates for active surveillance (AS) or definitive local treatment, which may include radical prostatectomy (RP), external beam radiotherapy (EBRT), or prostate seed implant (PSI). In the recent edition of the National Comprehensive Cancer Network (NCCN) guidelines, the “preferred” status was removed for AS, which rekindled a debate and interest in the management of LRPC. In this study, we analyzed the treatment pattern and impact of various treatment modalities on the survival of patients with LRPC using a large patient population provided by the National Cancer DataBase (NCDB). Methods: Patients with LRPC, as defined by the NCCN criteria, between 2004 and 2015 from NCDB were analyzed. Patients are categorized by treatment modalities, including RP, EBRT, PSI, and those who received no local therapy (NLT). Only patients with low Charlson-Deyo comorbidity score, 0 or 1 were included to ensure comparability between treatment groups. A multivariable Cox regression model was developed to determine the adjusted odds of patients' survival. The Kaplan Meier survival plots stratified by treatment were generated to establish the median overall survival (OS). The log-rank test was used to determine significance between treatment groups. Cox regression models were used to produce parameter estimates and hazard ratio (HR) for each age group. Results: A total of 195,452 patients with LRPC were identified from 2004 to 2015. There was a significant practice pattern change with increased utilization of NLT over time, from 11.3% in 2004 to 53.5% in 2015, with a turning point in 2009. The utilization was peaked for RP at 41.6% in 2008, EBRT at 24.3% in 2006, and PSI at 35.3% in 2004, but dropped to 17.6%, 18.1%, and 10.8%, respectively, in 2015. Of different treatment modalities, compared to NLT, RP provided a superior OS with a HR of 0.662, p &lt; .0001; PSI also improved OS with an HR of 0.795, p &lt; .0001. However, EBRT did not improve OS and was potentially detrimental, HR = 1.049, p = 0.01. With age-matched subgroup analysis, the survival advantage based on HR of RP relative to NLT favors RP until the age of 74 but diminishes as age increases. In patients younger than 70, NLT provided comparable survival to EBRT or PSI. The survival advantage of EBRT or PSI is only seen in older patients, at age of 75 or older for EBRT and 70 or older for PSI. Conclusions: There has been a significant treatment pattern change between 2004 and 2015. AS, as represented by the NLT in this study, has become the dominant choice of treatment for LRPC. However, of different treatment modalities, both RP and PSI improve OS. The patients managed with AS had comparable OS to those who received EBRT. The survival benefit of RP is mostly seen in younger patients. Only older patients benefit from PSI or EBRT. This study is limited by its retrospective nature and inherent bias in NCDB.

Cryotherapy As Treatment of Curative Intent for Localized Adenocarcinoma of The Prostate Gland with A Focus on Low-risk and Medium – (Intermediate-) Risk Localized Adenocarcinoma of The Prostate Gland: A Review and Update

Cryotherapy As Treatment of Curative Intent for Localized Adenocarcinoma of The Prostate Gland with A Focus on Low-risk and Medium – (Intermediate-) Risk Localized Adenocarcinoma of The Prostate Gland: A Review and Update

Impact of the COVID-19 outbreak on prostate cancer care in the Netherlands

IntroductionThe COVID-19 outbreak has affected care for non-COVID diseases like cancer. We evaluated the impact of the COVID-19 outbreak on prostate cancer care in the Netherlands. MethodsProstate cancer diagnoses per month in 2020–2021 versus 2018–2019 were compared based on preliminary data of the Netherlands Cancer Registry (NCR) and nationwide pathology network. Detailed data was retrieved from the NCR for the cohorts diagnosed from March-May 2020 (first COVID-19 wave) and March-May 2018–2019 (reference). Changes in number of diagnoses, age, disease stage and first-line treatment were compared. ResultsAn initial decline of 17% in prostate cancer diagnoses during the first COVID-19 wave was observed. From May onwards the number of diagnoses started to restore to approximately 95% of the expected number by the end of 2020. Stage at diagnosis remainedstable over time. In low-risk localised prostate cancer radical prostatectomy was conducted more often in week 9–12 (21% versus 12% in the reference period; OR=1.9, 95% CI; 1.2–3.1) and less active surveillance was applied (67% versus 78%; OR=0.6, 95% CI; 0.4–0.9). In the intermediate-risk group, a similar change was observed in week 13–16. Radical prostatectomy volumes in 2020 were comparable to 2018–2019. ConclusionDuring the first COVID-19 wave the number of prostate cancer diagnoses declined. In the second half of 2020 this largely restored although the number remained lower than expected. Changes in treatment were temporary and compliant with adapted guidelines. Although delayed diagnoses could result in a less favourable stage distribution, possibly affecting survival, this seems not very likely.

Radiation therapy cost-effective option for low-risk localised prostate cancer in Australia

Radiation therapy cost-effective option for low-risk localised prostate cancer in Australia