Impact of Rectal Spacer on Toxicity Reduction in Men Treated With Proton Versus Photon Therapy

Vishal R Dhere; Subir Goyal; Jun Zhou; Nikhil T Sebastian; Ashish B Patel; Sheela Hanasoge; Pretesh R Patel; Joseph Shelton; Karen D Godette; Bruce W Hershatter; Ashesh B Jani; Sagar A Patel

doi:10.1016/j.ijpt.2024.100111

Impact of Rectal Spacer on Toxicity Reduction in Men Treated With Proton Versus Photon Therapy

Int J Part Ther. 2024 Jun 20:13:100111. doi: 10.1016/j.ijpt.2024.100111. eCollection 2024 Sep.

Affiliations

¹ Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia, USA.
² Department of Biostatistics and Bioinformatics, Emory University, Atlanta, Georgia, USA.

Abstract

Purpose: Rectal toxicity after prostate cancer (PCa) radiation therapy (RT) may be greater with protons compared with photon intensity-modulated RT, perhaps due to lateral penumbra and end-of-range uncertainty. Rectal spacers (RSs) have been shown to mitigate RT-associated acute/late rectal toxicity in men treated with photons. The relative benefit of RS in men treated with protons versus photons is unknown. We hypothesize that RS will confer greater bowel toxicity benefits in PCa treated with protons versus photons.

Materials and methods: We conducted a single institution, retrospective review of men receiving photon intensity-modulated RT or pencil-beam scanning proton RT for localized PCa. Four cohorts were compared: photon with or without RS, and proton with or without RS. Acute (<3 months), late (≥3 months), and most recent toxicity were compared among the 4 cohorts. The cumulative incidence of physician-reported grade 1 to 2 gastrointestinal (GI) toxicity (common terminology criteria for adverse events V5.0) was compared using χ² or Fisher exact test. Patient-reported toxicity was evaluated using the International Prostate Expanded Prostate Composite Index-Clinical Practice and compared using linear mixed modeling.

Results: In total, 164 patients were eligible for analysis: 38 photons without RS, 50 photons with RS, 26 protons without RS, and 50 protons with RS. The median follow-up was 17.6 months. In proton patients, acute (6.12% vs 30.77%, P = .009) and most recent (4.26% vs 26.09%, P = .01) G1-2 GI toxicity was lower with versus without RS. In photon patients, there were no significant differences in toxicity with versus without RS. No significant differences in patient-reported outcomes were observed with versus without RS in photon or proton groups.

Conclusion: The rectal spacer was associated with lower G1-2 acute and most recent GI toxicity in men treated with protons; this difference was not observed in men treated with photons. While this study is limited by sample size, a relatively greater benefit of RS with proton versus photon therapy was observed.

Keywords: Late toxicity; Prostate radiation; Proton versus photon; Rectal spacer; Rectal toxicity.