CYBERKNIFE SBRT FOR THE TREATMENT OF PROSTATE CANCER: 5 VS. 44 FRACTIONS THE PHILADELPHIA CYBERKNIFE CENTER EXPERIENCE

CYBERKNIFE SBRT FOR THE TREATMENT OF PROSTATE CANCER: 5 VS. 44 FRACTIONS THE PHILADELPHIA CYBERKNIFE CENTER EXPERIENCE Olusola Obayomi-Davies M.D. Philadelphia CyberKnife Center September 26 th, 2017

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Background-Localized Prostate Cancer Estimated 160,000 men will be affected in 2017 27,000 deaths #1 cancer diagnosis in men #3 cause of cancer related mortality Typically detected by PSA screening USPSTF D-Recommendation (2012) C Recommendation 2017 (55-69) Cancer Facts & Figures ACS 2017 Screening for Prostate Cancer: U.S. Preventive Services Task Force Recommendation Statement, 2012, 2017.

Treatment Options-Localized Prostate Cancer Surgery-Prostatectomy Radiation Therapy IMRT Conventional Fractionation (40-48) IMRT Moderate Hypofractionation (20-28) Proton Therapy Brachytherapy HDR or LDR CyberKnife SBRT (5 treatments)

The New England Journal of Medicine October 13, 2016 Vol. 375 No. 15 10-Year Outcomes after Monitoring, Surgery, or Radiotherapy for Localized Prostate Cancer F.C. Hamdy, J.L. Donovan, J.A. Lane, M. Mason, C. Metcalfe, P. Holding, M. Davis, T.J. Peters, E.L. Turner 1643 men (50-69) randomized to AS, Surgery or Radiation therapy between 1999-2009. Primary outcome: Prostate cancer specific mortality at 10 years N Engl J Med 2016;375:1415-24

IMRT-Localized Prostate Cancer Daily radiation therapy for 8-9 weeks (40-48) Hypofractionated regimen (20-38) fractions Rectal and Bladder sparing Significant dose escalation from 3D-CRT Popular, high penetration in radiation oncology community Effective Sveistrup et al. Radiation Oncology 2014, 9:44

External Beam Radiation 5yr BDFS Low 95% Inter. 82% High 62% 1988-2004, 2047 patients 3D or IMRT (1996) 66-86.4 Gy in 33-48 fractions. Zelefsky, Int. J. Radiation Oncology Biol. Phys., Vol. 71, No. 4, pp. 1028 1033, 2008

IMRT-81 Gy 8yr BRFS Favorable 85% Intermediate 76% Unfavorable 72% 1996-2000, 561 patients 81 Gy Low rates of rectal and urinary toxicity Zelefsky, J. Urology Vol. 176, 1415-1419, October 2006

IMRT-For Localized Prostate Cancer: Concerns Radiation Dose: Is 80-86 Gy high enough? Further dose escalation required? Normal Structures: Bowel, Bladder Opportunity cost: 8-9 weeks of daily therapy Other: Prostate motion, rectal and bladder filling

CyberKnife SBRT-Rationale Radiobiology: Low αβ ratio of prostate cancer Favors larger fractionation schemes Normal Structure sparing Rectum, Bladder, Penile bulb Opportunity cost: 5 days versus 8-9 weeks of treatment Technology: Prostate motion management

CyberKnife Prostate SBRT Rationale: αβ ratio (2 Gy x 37 fx) bned (5 year) 75% SBRT (7.25 Gy x 5 fx) bned (5 year), 94% Fowler, Acta Oncol, 2005

CyberKnife SBRT: αβ ratio Wallace, Radiation Biology 2014

Prostate Motion: Where is the target? Kupelian et al, IJROBP, 2007

CyberKnife SBRT For Localized Prostate Cancer: Overview Robotic Radiosurgery Platform Deliver high dose radiation in 5 treatments 8 weeks of daily radiation equivalent Sparing of normal Structures from high dose radiation 3-5mm margins Live target tracking with gold fiducials CyberKnife.com, accessed 7/2017

CyberKnife SBRT For Localized Prostate Cancer Chen L. et al Rad. Onc., 2013

CyberKnife SBRT-Concerns Long term data maturing Few prospective comparisons to more established techniques Concerns about late bladder and GU toxicity Healthcare Costs: Shrinking healthcare $$

Published Prostate SBRT Series

Predicting Biochemical Disease-Free Survival after Prostate Stereotactic Body Radiotherapy: Risk-Stratification and Patterns of Failure Alan Katz, Silvia C. Formenti and Josephine Kang 515 patients between 2006-2010 treated with CyberKnife SBRT, 35-36.25 Gy, daily. NCCN Risk Stratification Low risk-324 Intermediate risk-153 High Risk-38 Median Follow-up 84 months

Prostate SBRT: Quality of Life Urinary quality of life Bowel quality of life Sexual Function

Prostate SBRT QOL: GI/GU Toxicity Meier, R. Front. Oncol, 2015

Prostate SBRT QOL: GU/ED Meier, R. Front. Oncol, 2015

Potency preservation following stereotactic body radiation therapy for prostate cancer Olusola Obayomi-Davies, Leonard N Chen, Aditi Bhagat, Henry C Wright, Sunghae Uhm, Joy S Kim, Thomas M Yung, Siyuan Lei, Gerald P Batipps, John Pahira, Kevin G McGeagh, Brian T Collins, Keith Kowalczyk, Gaurav Bandi, Deepak Kumar, Simeng Suy, Anatoly Dritschilo, John H Lynch, Sean P Collins 97 Hormone naive men (aged 48-82) Adequate erectile function pre-treatment Firm enough for penetration 35-36.25 Gy in 5 fractions Minimum 24 month follow-up Assessments: SHIM, EPIC and Medication/Device Questionaires Obayomi-Davies et al. Radiation Oncology 2013, 8:256

The Philadelphia CyberKnife First CyberKnife System facility in Philadelphia region Opened in 2006 Pioneers Luther Brady/Jack Fowler Rachelle Lanciano John Lamond Experience

Stereotactic Body Radiation Therapy for Treatment of Intermediate-and High-Risk Prostate Cancer Mark Dziemianowicz MD, Rachelle Lanciano MD, Olusola Obayomi-Davies MD, Steven Arrigo MD, John Lamond, MD, Jun Yang PhD, Jing Feng MS, Michael Mooreville MD, Bruce Garber MD, Michael Good, Luther Brady MD. Philadelphia CyberKnife, Havertown, PA 100 consecutive patients with NCCN intermediate or high risk prostate cancer treated with definitive SBRT were identified. Patients with <2 years biochemical follow-up were excluded (n=26). Biochemical failure was defined as prostate-specific antigen (PSA) rise > 2ng/ml above nadir (Phoenix definition) Analyses performed using the Kaplan Meier method, with differences compared using log-rank test.

Stereotactic Body Radiation Therapy for Treatment of Intermediate-and High-Risk Prostate Cancer Mark Dziemianowicz MD, Rachelle Lanciano MD, Olusola Obayomi-Davies MD, Steven Arrigo MD, John Lamond, MD, Jun Yang PhD, Jing Feng MS, Michael Mooreville MD, Bruce Garber MD, Michael Good, Luther Brady MD. Philadelphia CyberKnife, Havertown, PA Risk classification: Zumsteg et al. criteria for favorable intermediate-risk (FIR) and unfavorable intermediate risk (UIR) disease FIR: NCCN intermediate risk with a single NCCN intermediate risk factor (ct2b-c, PSA 10-20 or Gleason score 7), Gleason < 3+4, and <50% of biopsy cores positive for cancer UIR: NCCN intermediate risk with 2 intermediate risk factors (ct2b-c, PSA 10-20 or Gleason score 7), primary Gleason pattern 4, or >50% biopsy cores positive for cancer High risk (HR) patients classified per NCCN guidelines Zumsteg et al. Eur Urol Dec;64(6):895-902

Philadelphia CyberKnife: Treatment Planning All patients received CyberKnife SBRT Dose: 35-37.5 Gy/5 fractions CTV: Defined as prostate plus seminal vesicles PTV: 5mm, 3mm posteriorly (Now 3mm superiorly)

Philadelphia CyberKnife: Results

Philadelphia CyberKnife: Results 1 1 PSA brfs 0.8 0.6 0.4 0.2 5yr brfs FIR-100%, p=0.007 UIR-83.3%, p=0.07 HR-92.3% Overall Survival 0.8 0.6 0.4 0.2 5yr OS FIR-96.2%, p=0.08 UIR-71.4%, p=0.52 HR-89.5% 0 0 1 2 3 4 5 6 7 8 Time (years) Number at risk 74 51 40 27 13 8 0 0 1 2 3 4 5 6 7 8 Time (years) 5-year brfs: 89.7% 5 failures: 3 distant, 2 biochemical only 5-year OS: 87.3% 7 deaths: none caused by prostate cancer

Philadelphia CyberKnife: Results PSA brfs 1 0.9 0.8 0.7 0.6 0.5 0.4 0.3 0.2 0.1 0 0 1 2 3 4 5 6 7 8 5-year brfs < 3+4 100% 4+3 75% > 4+4 80% 4+3 3+4 4+4 Time (years) Log-rank p=0.019

Philadelphia CyberKnife: Results 1 0.8 5-year BRFS ADT 100% No ADT 83.4% PSA brfs 0.6 0.4 ADT Patients receiving ADT n (%) FIR 13 (37.1%) UIR 3 (17.6%) HR 8 (36.4%) 0.2 No ADT Log-rank p=0.403 0 0 1 2 3 4 5 6 7 8 Time (years) Number at risk ADT 24 18 16 12 4 2 No ADT 50 33 24 15 9 6

Philadelphia CyberKnife: Toxicity Late GU Toxicity N=74 % Grade 1 10 14% Grade 2 19 26% Grade 3 1 1% Grade 4 0 0% Late GI Toxicity Grade 1 2 3% Grade 2 0 0% Grade 3 0 0% Grade 4 0 0% Late Erectile Dysfunction Grade 1 15 20% Grade 2 24 32% Grade 3 8 11%

The Comparison of Stereotactic Body Radiation Therapy and Intensity-Modulated Radiation Therapy for Prostate Cancer by NCCN Risk Groups Anthony Ricco, 1 Genevieve Manahan, 1,2 Rachelle Lanciano, 1,2,* Alexandra Hanlon, 3 Jun Yang, 1,2 Stephen Arrigo, 1 John Lamond, 1,2 Jing Feng, 1 Michael Mooreville, 1 Bruce Garber, 1 and Luther Brady 1,2 1 Philadelphia Cyberknife, Delaware County Memorial Hospital, Havertown, PA, USA 2 Drexel University College of Medicine, Philadelphia, PA, USA 3 University of Pennsylvania, Philadelphia, PA, USA Front. Oncol., 23 August 2016

Philadelphia CyberKnife Experience Between 2007 and 2012, 270 consecutive men were treated for organ confined prostate cancer with either IMRT (n=120) or SBRT (n=150) Charts were abstracted for pretreatment and treatment factors as well as outcome and toxicity NCCN Risk Group Guidelines V. 2.2015 were used to stratify patients into Very Low, Low, Intermediate, High and Very High risk groups. Dose: IMRT: 75.6-78 Gy in 39-42 fractions SBRT: 36.25-37.5 Gy in 5 fractions

Philadelphia CyberKnife Experience Late toxicity was graded by RTOG grading system at last follow up Nadir +2 considered Biochemical failure Statistical analysis included Fisher s Exact Test and Two- Sample Independent T-Test for comparison of pretreatment factor distribution between IMRT and SBRT, Kaplan Meier for comparison of curves Propensity Score matched comparison

Philadelphia CyberKnife Experience 6-year FFBF 91.9% for SBRT 88.9% for IMRT

Philadelphia CyberKnife Experience

Propensity Score Matched Comparison of Intensity Modulated Radiation Therapy vs Stereotactic Body Radiation Therapy for Localized Prostate Cancer: A Survival Analysis form the National Cancer Database Anthony Ricco, Alexandra Hanlon and Rachelle Lanciano Propensity score matched (PSM) analysis with the National Cancer Database (NCDB) for the comparison of stereotactic body radiation therapy (SBRT) and intensity modulated radiation therapy (IMRT) for organ confined prostate cancer Men with localized prostate cancer treated with IMRT to a dose 72 Gy and 35 Gy for SBRT to the prostate only Men treated with previous surgery, brachytherapy, or proton therapy were excluded. Matching was performed to eliminate confounding variables via PSM. Simple 1 1 nearest neighbor matching resulted in a matched sample of 5,430 (2,715 in each group). Ricco et al, Front. Oncol. August 2017

Philadelphia CyberKnife: NCBD Ricco et al, Front. Oncol. August 2017

Philadelphia CyberKnife: NCDB Ricco et al, Front. Oncol. August 2017

Ongoing Trials

CyberKnife SBRT for Localized Prostate Cancer: Summary Excellent outcomes from published data Similar to existing techniques Short duration Opportunity cost Dose escalation compared to conventional fractionation Low toxicity profile with excellent QOL outcomes Lower health care costs

Conclusion CyberKnife Prostate SBRT offers an excellent radiation therapy alternative to existing techniques. The increased convenience, cost-effectiveness and unique radiobiology of prostate cancer offer advantages compared to existing treatment platforms. Clinical outcomes are at least equivalent compared to existing techniques.