Adding 6 months of androgen deprivation therapy to postoperative radiotherapy for prostate cancer: a comparison of short-course versus no androgen deprivation therapy in the RADICALS-HD randomised controlled trial

Background Previous evidence indicates that adjuvant, short-course androgen deprivation therapy (ADT) improves metastasis-free survival when given with primary radiotherapy for intermediate-risk and high-risk localised prostate cancer. However, the value of ADT with postoperative radiotherapy after radical prostatectomy is unclear. Methods RADICALS-HD was an international randomised controlled trial to test the efficacy of ADT used in combination with postoperative radiotherapy for prostate cancer. Key eligibility criteria were indication for radiotherapy after radical prostatectomy for prostate cancer, prostate-specific antigen less than 5 ng/mL, absence of metastatic disease, and written consent. Participants were randomly assigned (1:1) to radiotherapy alone (no ADT) or radiotherapy with 6 months of ADT (short-course ADT), using monthly subcutaneous gonadotropin-releasing hormone analogue injections, daily oral bicalutamide monotherapy 150 mg, or monthly subcutaneous degarelix. Randomisation was done centrally through minimisation with a random element, stratified by Gleason score, positive margins, radiotherapy timing, planned radiotherapy schedule, and planned type of ADT, in a computerised system. The allocated treatment was not masked. The primary outcome measure was metastasis-free survival, defined as distant metastasis arising from prostate cancer or death from any cause. Standard survival analysis methods were used, accounting for randomisation stratification factors. The trial had 80% power with two-sided α of 5% to detect an absolute increase in 10-year metastasis-free survival from 80% to 86% (hazard ratio [HR] 0·67). Analyses followed the intention-to-treat principle. The trial is registered with the ISRCTN registry, ISRCTN40814031, and ClinicalTrials.gov, NCT00541047. Findings Between Nov 22, 2007, and June 29, 2015, 1480 patients (median age 66 years [IQR 61–69]) were randomly assigned to receive no ADT (n=737) or short-course ADT (n=743) in addition to postoperative radiotherapy at 121 centres in Canada, Denmark, Ireland, and the UK. With a median follow-up of 9·0 years (IQR 7·1–10·1), metastasis-free survival events were reported for 268 participants (142 in the no ADT group and 126 in the short-course ADT group; HR 0·886 [95% CI 0·688–1·140], p=0·35). 10-year metastasis-free survival was 79·2% (95% CI 75·4–82·5) in the no ADT group and 80·4% (76·6–83·6) in the short-course ADT group. Toxicity of grade 3 or higher was reported for 121 (17%) of 737 participants in the no ADT group and 100 (14%) of 743 in the short-course ADT group (p=0·15), with no treatment-related deaths. Interpretation Metastatic disease is uncommon following postoperative bed radiotherapy after radical prostatectomy. Adding 6 months of ADT to this radiotherapy did not improve metastasis-free survival compared with no ADT. These findings do not support the use of short-course ADT with postoperative radiotherapy in this patient population

Duration of androgen deprivation therapy with postoperative radiotherapy for prostate cancer: a comparison of long-course versus short-course androgen deprivation therapy in the RADICALS-HD randomised trial

Background Previous evidence supports androgen deprivation therapy (ADT) with primary radiotherapy as initial treatment for intermediate-risk and high-risk localised prostate cancer. However, the use and optimal duration of ADT with postoperative radiotherapy after radical prostatectomy remains uncertain. Methods RADICALS-HD was a randomised controlled trial of ADT duration within the RADICALS protocol. Here, we report on the comparison of short-course versus long-course ADT. Key eligibility criteria were indication for radiotherapy after previous radical prostatectomy for prostate cancer, prostate-specific antigen less than 5 ng/mL, absence of metastatic disease, and written consent. Participants were randomly assigned (1:1) to add 6 months of ADT (short-course ADT) or 24 months of ADT (long-course ADT) to radiotherapy, using subcutaneous gonadotrophin-releasing hormone analogue (monthly in the short-course ADT group and 3-monthly in the long-course ADT group), daily oral bicalutamide monotherapy 150 mg, or monthly subcutaneous degarelix. Randomisation was done centrally through minimisation with a random element, stratified by Gleason score, positive margins, radiotherapy timing, planned radiotherapy schedule, and planned type of ADT, in a computerised system. The allocated treatment was not masked. The primary outcome measure was metastasis-free survival, defined as metastasis arising from prostate cancer or death from any cause. The comparison had more than 80% power with two-sided α of 5% to detect an absolute increase in 10-year metastasis-free survival from 75% to 81% (hazard ratio [HR] 0·72). Standard time-to-event analyses were used. Analyses followed intention-to-treat principle. The trial is registered with the ISRCTN registry, ISRCTN40814031, and ClinicalTrials.gov , NCT00541047 . Findings Between Jan 30, 2008, and July 7, 2015, 1523 patients (median age 65 years, IQR 60–69) were randomly assigned to receive short-course ADT (n=761) or long-course ADT (n=762) in addition to postoperative radiotherapy at 138 centres in Canada, Denmark, Ireland, and the UK. With a median follow-up of 8·9 years (7·0–10·0), 313 metastasis-free survival events were reported overall (174 in the short-course ADT group and 139 in the long-course ADT group; HR 0·773 [95% CI 0·612–0·975]; p=0·029). 10-year metastasis-free survival was 71·9% (95% CI 67·6–75·7) in the short-course ADT group and 78·1% (74·2–81·5) in the long-course ADT group. Toxicity of grade 3 or higher was reported for 105 (14%) of 753 participants in the short-course ADT group and 142 (19%) of 757 participants in the long-course ADT group (p=0·025), with no treatment-related deaths. Interpretation Compared with adding 6 months of ADT, adding 24 months of ADT improved metastasis-free survival in people receiving postoperative radiotherapy. For individuals who can accept the additional duration of adverse effects, long-course ADT should be offered with postoperative radiotherapy. Funding Cancer Research UK, UK Research and Innovation (formerly Medical Research Council), and Canadian Cancer Society

A mixed methods examination of distress and person-centred experience of head and neck lymphoedema

Purpose: This study aimed to examine the course and nature of distress and quality of life (QoL) during and after head and neck lymphoedema (HNL) treatment in people who developed HNL following treatment for head and neck cancer (HNC).Methods: This study (n = 10) used a mixed method explanatory design to explore distress associated with HNL. Component 1 used a prospective repeated measures design to examine distress during a 22-week HNL program. Component 2 used a qualitative interview approach to understand the patient experience of distress after completion of HNL treatment.Results: During the HNL program distress associated with HNL significantly reduced from baseline to week 6 (p = 0.015), and baseline to week 22 (p = 0.007). There were no significant differences in QoL, body image or fear of cancer progression over time. Self-reported presence of HNL significantly reduced from baseline to week 6 (p = 0.02), week 6 to week 22 (p = 0.026), and from baseline to week 22 (p = 0.001).Qualitative interviews using thematic analysis following HNL treatment, revealed 6 major themes associated with the experiences of distress related to HNL - psychological impact; physical appearance and pattern/timing; experience of receiving treatment; day to day impact; supports that helped manage distress; and adjustment to a new normal.Conclusions: This study found that distress associated with cancer treatment-related HNL may reduce with the delivery of a HNL program. Interview data following completion of the HNL treatment identified several themes related to HNL and its relationship with distress, function and day-to-day life

Patient perceptions of living with head and neck lymphoedema and the impacts to swallowing, voice and speech function

Head and neck lymphoedema (HNL) is common following head and neck cancer (HNC) treatment, and may contribute to numerous physical, functional and psychological symptoms. However, its impact on swallowing, voice and speech is less well understood. The aim of this study was to use interpretive description to explore patient perceptions relating to the impact of HNL on swallowing, voice and speech. Twelve participants, >3\ua0months post HNC treatment and experiencing some form of HNL, participated in individual, semi-structured interviews. Transcribed interviews underwent thematic analysis using an inductive approach, with subsequent member checking. Most participants felt their HNL impacted their swallowing and some had impacts on speech; although the impact on voice was less clear. Four themes emerged, including three themes relating to HNL and its impact on swallowing and speech: "it feels tight;" "it changes throughout the day;" "it requires daily self-monitoring and management;" and a fourth general theme "it affects me in other ways." Participants perceived direct impacts from HNL to swallowing and speech. They often experienced daily symptom fluctuations that required additional strategies during times of increased difficulty. Findings highlight the need to improve patient education regarding the functional impacts of HNL and the importance of self-management

Association between external and internal lymphedema and chronic dysphagia following head and neck cancer treatment

Background: To examine the relationship between chronic external and internal head and neck lymphedema (HNL) and swallowing function in patients following head and neck cancer (HNC) treatment.Methods: Seventy‐nine participants, 1‐3 years post treatment were assessed for external HNL using the MD Anderson Cancer Centre Lymphedema Rating Scale, and internal HNL using Patterson's Radiotherapy Edema Rating Scale. Swallowing was assessed via instrumental, clinical and patient‐reported outcome measures.Results: HNL presented as internal only (68%), combined external/internal (29%), and external only (1%). Laryngeal penetration/aspiration was confirmed in 20%. Stepwise multivariable regression models, that accounted for primary site, revealed that a higher severity of external HNL and internal HNL was associated with more severe penetration/aspiration (P

Solid–Liquid–Solution Phases in Poly(diallyldimethylammonium)/Poly(acrylic acid) Polyelectrolyte Complexes at Varying Temperatures

The coacervation and complexation of oppositely charged polyelectrolytes are dependent on numerous environmental and preparatory factors, but temperature is often overlooked. Temperature effects remain unclear because the temperature dependence of both the dielectric constant and polymer–solvent interaction parameter can yield lower and/or upper critical solution phase behaviors for PECs. Further, secondary interactions, such as hydrogen bonding, can affect the temperature response of a PEC. That is, mixtures of oppositely charged polyelectrolytes can exhibit phase separation upon lowering and/or increasing the mixture’s temperature. Here, the phase behavior of poly(diallylmethylammonium)/poly(acrylic acid) (PDADMA/PAA) complexes under varying KBr ionic strengths, mixing ratios, and temperatures at a fixed pH (in which PAA hydrogen bonding can occur) is examined. At room temperature, the PDADMA/PAA PECs exhibit four different phase states: precipitate, coexisting precipitate and coacervate, solid-like gel, and coacervate. Variable-temperature optical microscopy reveals the upper critical solution temperature (UCST) at which each phase transitioned to a solution state. Interestingly, the UCST value is highly dependent on the original phase of the PEC, in which solid-like precipitates exhibit higher UCST values. Large-scale all-atom molecular dynamics (MD) simulations support that precipitates exhibit kinetic trapping, which may contribute to the higher UCST values observed in the experiment. Taken together, this study highlights the significance of temperature on the phase behavior of PECs, which may play a larger role in stimuli-responsive materials, membraneless organelles, and separations applications

Solid–Liquid–Solution Phases in Poly(diallyldimethylammonium)/Poly(acrylic acid) Polyelectrolyte Complexes at Varying Temperatures

The coacervation and complexation of oppositely charged polyelectrolytes are dependent on numerous environmental and preparatory factors, but temperature is often overlooked. Temperature effects remain unclear because the temperature dependence of both the dielectric constant and polymer–solvent interaction parameter can yield lower and/or upper critical solution phase behaviors for PECs. Further, secondary interactions, such as hydrogen bonding, can affect the temperature response of a PEC. That is, mixtures of oppositely charged polyelectrolytes can exhibit phase separation upon lowering and/or increasing the mixture’s temperature. Here, the phase behavior of poly(diallylmethylammonium)/poly(acrylic acid) (PDADMA/PAA) complexes under varying KBr ionic strengths, mixing ratios, and temperatures at a fixed pH (in which PAA hydrogen bonding can occur) is examined. At room temperature, the PDADMA/PAA PECs exhibit four different phase states: precipitate, coexisting precipitate and coacervate, solid-like gel, and coacervate. Variable-temperature optical microscopy reveals the upper critical solution temperature (UCST) at which each phase transitioned to a solution state. Interestingly, the UCST value is highly dependent on the original phase of the PEC, in which solid-like precipitates exhibit higher UCST values. Large-scale all-atom molecular dynamics (MD) simulations support that precipitates exhibit kinetic trapping, which may contribute to the higher UCST values observed in the experiment. Taken together, this study highlights the significance of temperature on the phase behavior of PECs, which may play a larger role in stimuli-responsive materials, membraneless organelles, and separations applications

Solid–Liquid–Solution Phases in Poly(diallyldimethylammonium)/Poly(acrylic acid) Polyelectrolyte Complexes at Varying Temperatures

The coacervation and complexation of oppositely charged polyelectrolytes are dependent on numerous environmental and preparatory factors, but temperature is often overlooked. Temperature effects remain unclear because the temperature dependence of both the dielectric constant and polymer–solvent interaction parameter can yield lower and/or upper critical solution phase behaviors for PECs. Further, secondary interactions, such as hydrogen bonding, can affect the temperature response of a PEC. That is, mixtures of oppositely charged polyelectrolytes can exhibit phase separation upon lowering and/or increasing the mixture’s temperature. Here, the phase behavior of poly(diallylmethylammonium)/poly(acrylic acid) (PDADMA/PAA) complexes under varying KBr ionic strengths, mixing ratios, and temperatures at a fixed pH (in which PAA hydrogen bonding can occur) is examined. At room temperature, the PDADMA/PAA PECs exhibit four different phase states: precipitate, coexisting precipitate and coacervate, solid-like gel, and coacervate. Variable-temperature optical microscopy reveals the upper critical solution temperature (UCST) at which each phase transitioned to a solution state. Interestingly, the UCST value is highly dependent on the original phase of the PEC, in which solid-like precipitates exhibit higher UCST values. Large-scale all-atom molecular dynamics (MD) simulations support that precipitates exhibit kinetic trapping, which may contribute to the higher UCST values observed in the experiment. Taken together, this study highlights the significance of temperature on the phase behavior of PECs, which may play a larger role in stimuli-responsive materials, membraneless organelles, and separations applications

Solid–Liquid–Solution Phases in Poly(diallyldimethylammonium)/Poly(acrylic acid) Polyelectrolyte Complexes at Varying Temperatures

The coacervation and complexation of oppositely charged polyelectrolytes are dependent on numerous environmental and preparatory factors, but temperature is often overlooked. Temperature effects remain unclear because the temperature dependence of both the dielectric constant and polymer–solvent interaction parameter can yield lower and/or upper critical solution phase behaviors for PECs. Further, secondary interactions, such as hydrogen bonding, can affect the temperature response of a PEC. That is, mixtures of oppositely charged polyelectrolytes can exhibit phase separation upon lowering and/or increasing the mixture’s temperature. Here, the phase behavior of poly(diallylmethylammonium)/poly(acrylic acid) (PDADMA/PAA) complexes under varying KBr ionic strengths, mixing ratios, and temperatures at a fixed pH (in which PAA hydrogen bonding can occur) is examined. At room temperature, the PDADMA/PAA PECs exhibit four different phase states: precipitate, coexisting precipitate and coacervate, solid-like gel, and coacervate. Variable-temperature optical microscopy reveals the upper critical solution temperature (UCST) at which each phase transitioned to a solution state. Interestingly, the UCST value is highly dependent on the original phase of the PEC, in which solid-like precipitates exhibit higher UCST values. Large-scale all-atom molecular dynamics (MD) simulations support that precipitates exhibit kinetic trapping, which may contribute to the higher UCST values observed in the experiment. Taken together, this study highlights the significance of temperature on the phase behavior of PECs, which may play a larger role in stimuli-responsive materials, membraneless organelles, and separations applications