On 2015 Oct 06, S Sundar commented:

The conclusion by Nanda et al on hormonal therapy use for prostate cancer and increased mortality is not only based on a small subset (5%) of a retrospective study but the study population consisted of patients whose primary treatment was Brachytherapy(1). By contrast multiple prospective randomised trials, which have shown significant survival benefits for hormone therapy, utilised external radiation (RT) as the primary treatment modality(2)(3). Hence extreme caution is needed before extrapolating the evidence generated by Nanda et al to routine clinical practice.(1.

Radiobiologically, Brachytherapy is different from external RT. Radiation Doses delivered by Brachytherapy are usually far higher than delivered by external RT. Unlike external RT which is given in daily fractions over many weeks, Seed Brachytherapy delivers continuous radiation and affects repair and repopulation of surrounding normal tissues including vascular structures. Furthermore, a significant proportion of Brachytherapy treated patients have distant vascular migration of radioactive seeds.(4) The long term effect of delivering unnecessary vascular radiation at distant places such as lungs remains to be elucidated.

Independent randomised studies combining modest doses of external RT with adjuvant hormonal therapy have shown substantial overall survival benefit. Hence, unless prospective data confirms the results of data mining by Nanda et al, prostate patients with co-morbidity, who are having external RT as their primary therapy, should not be deprived hormone therapy.

References:

1. Nanda A, Chen M-H, Braccioforte MH, Moran BJ, D’Amico AV. Hormonal therapy use for prostate cancer and mortality in men with coronary artery disease-induced congestive heart failure or myocardial infarction. JAMA. 2009 Aug 26;302(8):866–73.

2. Bolla M, Van Tienhoven G, Warde P, Dubois JB, Mirimanoff R-O, Storme G, et al. External irradiation with or without long-term androgen suppression for prostate cancer with high metastatic risk: 10-year results of an EORTC randomised study. Lancet Oncol. 2010 Nov;11(11):1066–73.

3. Brundage M, Sydes MR, Parulekar WR, Warde P, Cowan R, Bezjak A, et al. Impact of Radiotherapy When Added to Androgen-Deprivation Therapy for Locally Advanced Prostate Cancer: Long-Term Quality-of-Life Outcomes From the NCIC CTG PR3/MRC PR07 Randomized Trial. J Clin Oncol Off J Am Soc Clin Oncol. 2015 Jul 1;33(19):2151–7.

4. Eshleman JS, Davis BJ, Pisansky TM, Wilson TM, Haddock MG, King BF, et al. Radioactive seed migration to the chest after transperineal interstitial prostate brachytherapy: extraprostatic seed placement correlates with migration. Int J Radiat Oncol Biol Phys. 2004 Jun 1;59(2):419–25.

On 2015 Oct 06, S Sundar commented:

The conclusion by Nanda et al on hormonal therapy use for prostate cancer and increased mortality is not only based on a small subset (5%) of a retrospective study but the study population consisted of patients whose primary treatment was Brachytherapy(1). By contrast multiple prospective randomised trials, which have shown significant survival benefits for hormone therapy, utilised external radiation (RT) as the primary treatment modality(2)(3). Hence extreme caution is needed before extrapolating the evidence generated by Nanda et al to routine clinical practice.(1.

Radiobiologically, Brachytherapy is different from external RT. Radiation Doses delivered by Brachytherapy are usually far higher than delivered by external RT. Unlike external RT which is given in daily fractions over many weeks, Seed Brachytherapy delivers continuous radiation and affects repair and repopulation of surrounding normal tissues including vascular structures. Furthermore, a significant proportion of Brachytherapy treated patients have distant vascular migration of radioactive seeds.(4) The long term effect of delivering unnecessary vascular radiation at distant places such as lungs remains to be elucidated.

Independent randomised studies combining modest doses of external RT with adjuvant hormonal therapy have shown substantial overall survival benefit. Hence, unless prospective data confirms the results of data mining by Nanda et al, prostate patients with co-morbidity, who are having external RT as their primary therapy, should not be deprived hormone therapy.

References:

1. Nanda A, Chen M-H, Braccioforte MH, Moran BJ, D’Amico AV. Hormonal therapy use for prostate cancer and mortality in men with coronary artery disease-induced congestive heart failure or myocardial infarction. JAMA. 2009 Aug 26;302(8):866–73.

2. Bolla M, Van Tienhoven G, Warde P, Dubois JB, Mirimanoff R-O, Storme G, et al. External irradiation with or without long-term androgen suppression for prostate cancer with high metastatic risk: 10-year results of an EORTC randomised study. Lancet Oncol. 2010 Nov;11(11):1066–73.

3. Brundage M, Sydes MR, Parulekar WR, Warde P, Cowan R, Bezjak A, et al. Impact of Radiotherapy When Added to Androgen-Deprivation Therapy for Locally Advanced Prostate Cancer: Long-Term Quality-of-Life Outcomes From the NCIC CTG PR3/MRC PR07 Randomized Trial. J Clin Oncol Off J Am Soc Clin Oncol. 2015 Jul 1;33(19):2151–7.

4. Eshleman JS, Davis BJ, Pisansky TM, Wilson TM, Haddock MG, King BF, et al. Radioactive seed migration to the chest after transperineal interstitial prostate brachytherapy: extraprostatic seed placement correlates with migration. Int J Radiat Oncol Biol Phys. 2004 Jun 1;59(2):419–25.