Factors influencing incidence of acute grade 2 morbidity in conformal and standard radiation treatment of prostate cancer.

PURPOSE: The fundament hypothesis of conformal radiation therapy is that tumor control can be increased by using conformal treatment techniques that allow a higher tumor dose while maintaining an acceptable level of complications. To test this hypothesis, it is necessary first to estimate the incidence of morbidity for both standard and conformal fields. In this study, we examine factors that influence the incidence of acute grade 2 morbidity in patients treated with conformal and standard radiation treatment for prostate cancer. METHODS AND MATERIALS: Two hundred and forty-seven consecutive patients treated with conformal technique are combined with and compared to 162 consecutive patients treated with standard techniques. The conformal technique includes special immobilization by a cast, careful identification of the target volume in three dimensions, localization of the inferior border of the prostate using the retrograde urethrogram, and individually shaped portals that conform to the Planning Target Volume (PTV). Univariate analysis compares differences in the incidence of RTOG-EORTC grade two acute morbidity by technique, T stage, age, irradiated volume, and dose. Multivariate logistic regression includes these same variables.
RESULTS: In nearly all categories, the conformal treatment group experienced significantly fewer acute grade 2 complications than the standard treatment group. Only volume (prostate +/- whole pelvis) and technique (conformal vs. standard) were significantly related to incidence of morbidity on multivariate analysis. When dose is treated as a continuous variable (rather than being dichotomized into two levels), a trend is observed on multivariate analysis, but it does not reach significant levels. The incidence of acute grade 2 morbidity in patients 65 years or older is significantly reduced by use of the conformal technique.
CONCLUSION: The conformal technique is associated with fewer grade 2 acute toxicities for all patients. This conclusion is valid irrespective of selection criteria except in a few cases. Older age is associated with increased toxicity only with the standard technique and not then at a statistically significant level. Elderly patients should not be excluded from external beam radiation because of increased morbidity especially if conformal treatment is available. Volume is not significantly related to morbidity in patients with standard treatment, but it is for conformal treatment. Furthermore, it remains significant in a multivariate analysis that also shows the advantage of conformal treatment. Grade 2 acute toxicities are more volume dependent than dose dependent.