Hypofractionated Accelerated Pelvic Nodal Radiotherapy (GCC 2048)

Study Overview
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Brief Summary
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A phase I trial to determine the safety of delivering three sequentially shorter RT schedules (20, 16, and 12 fractions) of HypoFx pelvic nodal RT in combination with a HypoFx, simultaneous integrated boost (SIB) to the prostate that have been designed to incrementally increased the biological equivalent dose (BED) to prostate cancer, while maintaining a constant BED to normal tissue toxicity.

Detailed Description
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Outcomes for patients with unfavorable intermediate-risk and high-risk prostate cancer (PC) have been historically poor and are now known to require multimodality treatment. A standard non-surgical treatment option for patients with localized, intermediate and high-risk PC is radiation therapy (RT) in combination with short- or long-term androgen deprivation therapy (ADT). The benefit of pelvic nodal RT in this setting is unclear, previous studies have been equivocal. There is a growing body of evidence to demonstrate that use of hypofractionated (HypoFx) RT may be a safe method for increasing the dose of RT, while also decreasing normal tissue toxicity.

Official Title
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A Phase I Dose Escalation Study of Hypofractionated Accelerated Pelvic Nodal Radiotherapy Delivered With A Simultaneously Integrated Prostate Boost For Patients With Localized, Intermediate- And High-Risk Prostate Cancer (GCC 2048)

Conditions
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Prostate Cancer, Prostate Adenocarcinoma

Intervention / Treatment
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* Radiation: Hypofractionated Radiation Therapy


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Patient age is ≥ 18 years Pathologically (histologically or cytologically) proven diagnosis of prostatic adenocarcinoma within 180 days of registration. Patient's with intermediate to high risk prostate cancer and must be recommended to undergo pelvic as well as prostatic irradiation. History/physical examination (to include at a minimum digital rectal examination of the prostate and examination of the skeletal system and abdomen) within 90 days prior to registration. Clinically negative lymph nodes as established by imaging (pelvic ± abdominal CT or MR), (but not by nodal sampling, or dissection) within 120 days prior to registration. • Patients with lymph nodes equivocal or questionable by imaging are eligible if the nodes are ≤ 1.5 cm. No evidence of bone metastases (M0) on bone scan within 120 days prior to registration. • Equivocal bone scan findings are allowed if plain films (or CT or MRI) are negative for metastasis. Baseline serum PSA value performed within 12 weeks (90 days) prior to registration. ECOG Performance Status 0-1 Patient must be able to provide study specific informed consent prior to study entry. Exclusion Criteria: Evidence of distant metastases Regional lymph node involvement Previous radical surgery (prostatectomy), cryosurgery, or HIFU (High-intensity focused ultrasound) for prostate cancer Previous pelvic irradiation or prostate brachytherapy Planned prostate brachytherapy boost Previous or concurrent cytotoxic chemotherapy for prostate cancer Severe acute or chronic medical or psychiatric condition or laboratory abnormality that may increase the risk associated with study participation or study drug administration, or may interfere with the interpretation of study results, and in the judgment of the investigator would make the subject inappropriate for entry into this study. Patients are excluded if they have a history of autoimmune disease that, in the opinion of the treating physician would be a contraindication to pelvic radiation (e.g., active systemic lupus, progressive scleroderma) Patients receiving full-dose anticoagulation or clopidogrel • Patients taking 81 mg Aspirin po daily may are still eligible for the study Patients with a history of prior small bowel ulceration

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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Male

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Non-Randomized
Intervention Model: Sequential Assignment
Interventional Model Description: A modified 3+3 study design will be employed to determine the dose-fractionation schedule that results in less than 33% dose limiting toxicity. One de-escalation will be allowed if the initial dose-fractionation schedule results in too high a frequency of dose limiting toxicities. A total of 6 patients will be treated following the dose-fractionation schedule that is recommended for further study.
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Dose Level 1<br>Dose schedules were calculated to maintain similar BED for late normal tissue injury (α/β= 3.0 Gy), with an increased BED for PC (α/β= 1.5Gy). Patients be treated with 20 fractions. A total of 6 patients will be treated at the dose that is determined to be Maximum Tolerated Dose. | Radiation: Hypofractionated Radiation Therapy<br>* All patients RT will be delivered utilizing pencil beam scanning proton therapy. Radiation treatment will be delivered 4 days per week.<br>|
| Experimental: Dose Level 2<br>Dose schedules were calculated to maintain similar BED for late normal tissue injury (α/β= 3.0 Gy), with an increased BED for PC (α/β= 1.5Gy). Patients be treated with 16 fractions. A total of 6 patients will be treated at the dose that is determined to be Maximum Tolerated Dose. | Radiation: Hypofractionated Radiation Therapy<br>* All patients RT will be delivered utilizing pencil beam scanning proton therapy. Radiation treatment will be delivered 4 days per week.<br>|
| Experimental: Dose Level 3<br>Dose schedules were calculated to maintain similar BED for late normal tissue injury (α/β= 3.0 Gy), with an increased BED for PC (α/β= 1.5Gy). Patients be treated with 12 fractions. A total of 6 patients will be treated at the dose that is determined to be Maximum Tolerated Dose. | Radiation: Hypofractionated Radiation Therapy<br>* All patients RT will be delivered utilizing pencil beam scanning proton therapy. Radiation treatment will be delivered 4 days per week.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| HypoFx RT schedule that results in <33% acute dose-limiting toxicity with accelerated, HypoFx pelvic nodal RT | The frequency of all observed acute GI, GU, hematologic, and neurologic dose limiting toxicities by CTCAE v5 grade will be tabulated. DLT is defined as treatment-related: Grade ≥3 GI (small bowel or rectal) toxicity, Grade ≥3 GU toxicity, Grade ≥3 hematologic, Grade ≥3 neurologic toxicity, or any grade 5 treatment-related adverse events. | Within 90 days of completing RT | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Frequency of acute and late GI, GU, hematologic, and neurologic toxicity for each dose cohort | The frequency of the maximum grade acute (within 90 days completing RT) and late (occurring > 90 days from treatment) GI (small bowel and rectal), GU, hematologic, and neurologic toxicities at 3-months, 6 months, 1-year and 2 years for each dose cohort using National Cancer Institute Common Terminology Criteria v.5.0 (NCI CTCAE v5). | Acute (within 90 days completing RT), Late (occurring > 90 days from treatment), 3-months, 6 months, 1-year and 2 years | 
| Dose volume histogram (DVH) parameters | A dose-volume histogram is a histogram relating radiation dose to tissue volume in radiation therapy planning. | Within 90 days of completing RT | 
| Evaluate the duration of biochemical progression-free survival | The duration of bPFS will be measured from the end of RT until either PSA recurrence or death due to any cause and summarized for the expanded cohort of patients treated at the maximum total dose (MTD). PSA recurrence is defined by the Phoenix definition of biochemical failure (PSA nadir + 2 ng/mL). | 2 years after completing RT | 
| Patient Reported Outcomes (PROs) related to urinary and bowel function | Quality of life will be assessed with the validated Expanded Prostate Cancer Index Composite (EPIC) questionnaire. | 1 month after completion of treatment, every 3 months for year 1, and every 6 months during Year 2 | 
| Patient Reported Outcomes (PROs) related to urinary function | The International Prostate System Score (IPSS) questionnaire will be used for urinary function. | 1 month after completion of treatment, every 3 months for year 1, and every 6 months during Year 2 | 
| Patient Reported Outcomes (PROs) related to urinary and bowel function | The PRO-CTCAE questionnaire measures patient-reported bowel, urinary and sexual function. | 1 month after completion of treatment, every 3 months for year 1, and every 6 months during Year 2 | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Prostate, Hypofractionated Radiation Therapy, Prostate Cancer, Radiotherapy, Proton Therapy