Does the presence of a connective tissue disorder such as lupus or scleroderma modify your radiation dose or technique for prostate cancer?
Here another article that may be of interest. It's actually a hometown favorite at VCU since the lead author is on our faculty.
Irradiation in the setting of collagen vascular disease: acute and late complications.
PURPOSE:
Based on reports of greater toxicity from radiation therapy, collagen vascular diseases (CVDs) have been considered a contraindication to irradiation. We assessed the complications of radiation therapy in patients with CVD.
PATIENTS AND METHODS:
A total of 209 patients with documented CVD were irradiated between 1960 and 1995. One hundred thirty-one had rheumatoid arthritis (RA), 25 had systemic lupus erythematosus (SLE); 17 had polymyositis or dermatomyositis; 16 had scleroderma; eight had ankylosing spondylitis; five had juvenile RA; three had discoid lupus erythematosus; and four had 4 mixed connective tissue disorders (MCTD). The mean follow-up duration of curative cases was more than 6 years. Doses ranged from 10 to 87.6 Gy, with a median of 45 Gy.
RESULTS:
Overall, 263 sites were assessable in 209 patients. Significant (> or = grade 3) acute toxicity was seen in 10% of irradiated sites. Severe late effects were associated with significant acute reactions and with non-RA CVDs (6% v 21% at 5 years). No difference was seen in late effects according to timing of CVD onset, presence of concurrent vascular insults, radiation dose, or other technical factors, or by measures of disease activity.
CONCLUSION:
RA does not appear to have an elevated rate of late toxicity. While non-RA CVD is significantly associated with increased radiation late effects at standard doses, radiation-related mortality remains exceedingly rare. The choice of therapeutic modality in this radiosensitive group of patients should be made on a case-by-case basis.
Concerns about irradiating patients with connective tissue disorders (CTD) stem from a combination of radiobiologically sound science, frightening case reports, and teaching (or folklore, depending on your perspective) from our mentors. As with many longstanding beliefs in medicine, this one is pervasive among radiation oncologists as well as our colleagues who refer patients to us. Consequently, the number of patients with CTD referred for radiation is relatively low (we only know who we see; we don't know who isn't even being sent) and thus the data on their outcomes is limited. There are a few published reports (Patel et al Rad Onc 2012 and abstract from Chang et al. IJROBP 2014) on CTD pts who were actually referred for and received radiation, comprising a combination of diagnoses including prostate cancer. These data suggest that RT is well-tolerated with limited acute and chronic toxicities in this population. These are retrospective single-institution data and limited in generalizability, but do suggest that CDT does not have to be an absolute contraindication to radiotherapy. Interestingly, there was a trend towards greater rate of grade 2 and 3 toxicity development in women compared to men (all P>0.23), perhaps in line with greater prevalence of lupus in women. Having said that, lupus patients (discoid and systemic) did not experience more severe toxicities compared to patients with scleroderma. Older age also did not appear to predict for higher grade toxicities (all P>0.77). Caveats notwithstanding, these observations at least suggest that evaluating prostate cancer patients with CTD for suitability for radiation is appropriate, and radiation should not be summarily excluded as an option. Among prostate cancer patients where the genotypic gender of the patient is uniform but age can be variable, data suggest that perhaps the latter is not that critical a factor to consider. Consultation with the patient's rheumatologist, assessment of how "active" the CTD is, and the patient's personal preferences are all critical however, and should be part of the rad onc evaluation and shared decision-making conversation.