The primary goal of radical radiation therapy in men with localized prostate carcinoma is cure and a secondary but important goal is to achieve cure without treatment related sequelae, such as loss of continence, rectal injury, loss of potency and the need for castration. A literature review of 2,611 men undergoing irradiation for all stages of localized prostatic carcinoma documented a 0.2% incidence of treatment related mortality, 1.9% severe complications, 0.9% incontinence and 33 to 60% maintenance of full potency 5 or more years after treatment. A separate analysis was made of 331 patients with only early tumors (stages T1 and T2) treated with conventional external beam radiation therapy to doses of 63 to 74 Gy. from 2 individual centers (Massachusetts General Hospital and M.D. Anderson Hospital) and 1 multi-institutional group (Radiation Therapy Oncology Group). Median followup was 6.1 years; however, in 2 series followup ranged to 14 years. This analysis revealed frequencies of treatment associated sequelae of 0% for mortality, 0% severe complications, 0.4% urinary incontinence, 5.4% genitourinary structures (1.2% persisting), 5.1% hematuria (0.9% persisting) and 5.4% rectal bleeding (0.6% persisting). This composite analysis of men undergoing irradiation for stages T1 and T2 tumors with conventional fractionation and doses indicates that acute morbidity is minor and usually transient, severe injury is rare, most late gastrointestinal and genitourinary symptoms of radiation injury are neither permanent nor debilitating, and few symptoms of radiation injury develop beyond 5 years from treatment. These data, combined with the low progression rates (using prostate specific antigen criteria) following irradiation of men with early tumors, further substantiate the primary role of radical radiotherapy in the treatment of surgical risk adversive patients.

We studied the evolution of treatment philosophy for testicular seminoma, by means of a questionnaire mailed to radiation oncologists practising in the United States. Of the 600 respondents 65% indicated a change in treatment policy since 1982. In patients with stage IIA disease the mediastinum is no longer treated by 62% of physicians, whereas 38% omit such treatment in Stage IIB patients. A trend towards the use of lower doses of radiation in areas treated was also noted. Omission of mediastinal irradiation in some stage II patients may be associated with an increased risk of failure in this site. Patients who do not receive treatment to the mediastinum must be carefully followed for recurrent tumour.

We studied the effect of patient age on treatment decisions related to radiation therapy using data obtained through the Patterns of Care Study. Definitive treatment given for breast cancer (191 patients) and palliative therapy given for a variety of symptoms (784 patients) were investigated using data collected from 49 facilities selected on a random basis to reflect fairly the national practice of radiotherapy. Elderly (aged 70 or older) patients accounted for 28.6% of the palliatively treated patients and 19.5% of the definitively treated breast patients. No correlation was found between patient age and the dose or number of days used in palliative therapy. Older patients were more likely to have the "boost" dose of radiation to the tumor bed delivered through external rather than implant techniques. While statistically significant, this difference is not felt to be clinically important. We conclude that once a patient is selected for a course of radiation therapy, age per se, is not a basis for prejudicial treatment.

Three hundred and thirteen patients with UICC T-1 N-0 M-0 prostate cancer were treated with external beam irradiation in 1973 and 1974 or in 1978, and their outcome determined 3–10 years after treatment. Survival over the first 5 years was comparable to that expected for a group of age matched normal males (77% vs. 81%), but during the second 5-year interval, there was a decrease in survival below that expected (51% vs 62%), a reflection of death in patients who developed metastasis as a first recurrence (18%). Overall, 72% of patients were free of any recurrence at 5 years and, 88% free of infield recurrence. The development of metastatic recurrence was significantly related to grade; at 5 years 87% of grade I, 79% of grade II and 69% of grade III patients were free of metastasis. There was a trend for increased local recurrence with increasing grade, but it was not statistically significant. There was a dose/response relation for complications, and radiation doses above 6500 cGy are associated with an increase in complication from 6% to 11% (p = .09). Complications requiring hospitalization for evaluation or management occurred in 30 (10%) of 313 patients. There were no deaths from complications and less than 2% of patients required surgical correction of complications. External beam radiation offers the patient with early prostate cancer a favorable opportunity for cure without the morbidity of impotence, incontinence, and occasional death experienced following LND and radical prostatectomy. Lymph node dissection does not seem necessary for most patients with T-1 prostate cancer as the positive yield in those with Grades I and II cancers is less than the complications of the procedure, and extensive involvement can be detected by non-invasive means.

Treatment related morbidity, recorded in patients entered onto a RTOG phase III study (testing the value of periaortic irradiation in locally advanced carcinoma of the prostate), has been correlated with radiotherapeutic parameters to identify and quantify the relationship with treatment volumes, doses, and techniques. Between 1976 and 1983 a total of 526 analyzable cases were entered onto the study. The study design entailed randomization to either pelvic irradiation followed by a prostate boost or pelvic and periaortic irradiation followed by a prostate boost. Periaortic irradiation was not associated with a significantly increased incidence of bowel injuries manifested by diarrhea. No correlation between the total dose to the regional lymphatics (ranging from 4400 to 5100 cGy) and the incidence of bowel and bladder injuries could be established. Doses to the prostate in excess of 7000 cGy have not resulted in a significantly increased incidence of bladder injuries, but have been associated with a significant increase in the incidence of bowel injuries manifested by diarrhea. The techniques of pelvic irradiation did not seem to significantly influence the incidence of bowel or bladder complications. The technique of delivery of the prostatic boost did seem to influence the incidence of bowel injuries. This refers to the lateral boost technique and the perineal boost technique which have been associated with a higher incidence of diarrhea. All of the conclusions based on this analysis are applicable only to treatment volumes and dose ranges used in this study and to conventional fractionation of 180 to 200 cGy per day.

Evaluation of the efficacy of radical prostatectomy versus radiotherapy in carcinoma of the prostate has been compromised by the scarcity of data in comparable populations. A nationwide search was conducted to compile the available data on the use of radiotherapy in lymphadenectomy-staged patients. The assessed population consists of patients with tumor confined to the gland (Stages A 2 and B), negative staging lymphadenectomy, negative bone scan, and normal serum acid phosphatase level who received external beam radiotherapy with curative intent. To provide a broad spectrum of experiences, the search included patients from a large number of institutions including Stanford University, Washington University (St. Louis), those participating in the Radiation Therapy Oncology Group, and a broad range of radiotherapy practices surveyed by the PCS (Patterns of Care Study). A total of 209 patients were identified. No selection criteria other than the aforementioned were applied. The patients were treated consecutively during the survey period. In sharp contradistinction to the reported results of the VA Uro-Oncology Group the analysis indicates a less than 10 per cent probability of progression within the first five years after completion of treatment. Nationwide, the outcome of radiotherapy-treated patients appears to be equivalent to the comparable surgically treated population.

This paper reports the results of the PCS Outcome Surveys for radiation therapy treatment in six disease sites: cervix, Hodgkin's disease, seminoma of the testis, anterior two-thirds of tongue and floor of mouth, larynx and prostate. The survey reflects data obtained for patients treated in 1973. Results for early stages of disease are generally favorable in cancer of the cervix, prostate, testis, larynx and Hodgkin's disease. Control of disease in anterior two-thirds of tongue and floor of mouth was less favorable, but data suggest that more aggressive radiation therapy may contribute to better outcome for this site.

Cancer of the ovary has been treated postoperatively at Stanford with uniform megavoltage radiotherapy technics since 1956. This study was undertaken to evaluate the efficacy of this therapy and to introduce the use of lymphangiography as an aid in staging and treatment planning. Patients and Staging One hundred twenty-nine patients with cancer of the ovary were referred by private gynecologists or the Stanford University Department of Gynecology to the Division of Radiation Therapy for evaluation between January 1956 and December 1965 (table I). All patients were followed either in the Radiation Therapy-Gynecology Tumor Clinic or in collaboration with their private physicians; none was lost. The dual classification staging system proposed by Rubin was used (13). In his system each tumor is classified according to both its anatomic extent and histologic appearance (table II). One hundred three of the patients were untreated at the time of referral and had tumors limited to the abdomen. See Figure 1 and table III for age and staging data. Treatment Program Surgical Treatment Complete resection of the primary tumor with hysterectomy and bilateral salpingooophorectomy was attempted in all cases. Whenever possible, metastases beyond these organs were resected grossly and the sites identified with silver clips. All patients were treated with either the 4.8 MeV Stanford Medical Linear Accelerator or the 6 MeV Varian Clinac. The fractionation was at the rate of 1,000 rads/week absorbed in the midfrontal plane unless symptoms of radiation enteritis were such as to dictate either a reduction of daily dose or a one- or two-week hiatus in the treatment regimen. Radiotherapy Anatomic Stage I carcinomas {complete removal with no microscopic invasion): No postoperative radiotherapy was given. Anatomic Stage II carcinomas (gross total removal of an invasive cancer): A dose of 5,500–6,000 rads was delivered to the midplane of the lower abdomen in six weeks by anterior and posterior opposed portals encompassing the entire peritoneal surface from the pelvic floor to the level of the umbilicus (Fig. 2).