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No survival benefit found in routine screening MRI for spinal cord compression in prostate cancer

The Lancet Oncology
Reuters Health - 07/04/2022 - Routine screening MRI and pre-emptive treatment for spinal cord compression (SCC) in patients with asymptomatic castration-resistant prostate cancer is not justified, according to UK-based researchers.

In an open-label randomized controlled trial, they found spinal MRI, followed by treatment as needed, did not significantly reduce the risk of progression from radiological SCC (rSCC) to clinical SCC (cSCC) compared with no screening.

"MRI screen-detected early rSCC does not always progress to cSCC with contemporary systemic management of castration-resistant prostate cancer and observation might be sufficient" for early epidural SCC, Dr. Emma Hall, of The Institute of Cancer Research, in London, and colleagues note in The Lancet Oncology.

They also point out that, despite a substantial incidence of rSCC in the screening group, the rate of cSCC was low in both groups at a median of 22 months of follow-up.

The phase-3 trial took place at 45 National Health Service hospitals in the U.K. Participants were 18 and older, with confirmed diagnoses of castration-resistant prostate adenocarcinoma or prostate cancer with osteoblastic bone metastases.

The study cohort consisted of 420 men with a median age 74. Patients were considered to have radiologic SCC in the absence of neurological symptoms; patients with neurological symptoms in the presence of epidural disease were considered to have clinical SCC.

Radiotherapy (20 Gy in five fractions) was given to radiological SCC sites in 50 of 61 patients identified by screening MRI.

Median overall survival was 22.2 months in the control group and 22.0 months in the surveillance/intervention group (P=0.82).

In an accompanying editorial, Dr. Shankar Siva of the Peter MacCallum Cancer Centre, in Melbourne, Australia, and colleagues write that the study "has highlighted some important clinical practice principles," namely, that adhering to clinical guidelines results in good functional outcomes in patients with clinical suspicion of SCC, that patients diagnosed with SCC are at greater risk of further SCC at other sites and should be considered for closer follow-up, and that "low-dose radiotherapy is effective at preventing radiological and clinical progression of asymptomatic SCC."

In an email to Reuters Health, Dr. Daniel E. Spratt, chair of radiation oncology at UH Seidman Cancer Center, Case Western Reserve University, in Cleveland, noted that although surveillance did not significantly reduce the incidence of progression to clinical SCC, "those in the experimental arm who got the upfront imaging and the low-dose radiation with just five treatments had delays to progression to next systemic therapy and had very few side effects from the radiation." Dr. Spratt were not involved in the study.

Dr. Hall did not respond to a request for comments.

SOURCE: https://bit.ly/3JIxVb6 The Lancet Oncology, online March 10, 2022.

By Scott Baltic

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