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Charles Catton

Publications and source records attributed to Charles Catton.

At least 19 recordsLinked to original sources
PubMed2006

Testosterone and erectile function recovery after radiotherapy and long-term androgen deprivation with luteinizing hormone-releasing hormone agonists.

OBJECTIVE: To study the recovery of testosterone levels and erectile function in men who received radiotherapy plus long-term adjuvant androgen deprivation (LTAD) with luteinizing hormone-releasing hormone (LHRH) agonists. PATIENTS AND METHODS: From April 2000 to July 2001, men who had completed prostate radiotherapy with > or = 2 years of LTAD, and had their last LHRH agonist injection at least 6 months before, were invited to participate. At study entry, the men completed the International Index of Erectile Function (IIEF), and their serum total testosterone (TT), prostate-specific antigen, LH, follicle-stimulating hormone, haemoglobin, and body mass were measured. This assessment was repeated at 1 year. RESULTS: In all, 20 men were recruited, with a mean (range) age of 70 (55-81) years. Defining a normal TT level as > or = 8.0 nmol/L, the median time to a normal level was 2.3 years (95% confidence interval (CI), 1.9-4.2). The median duration of castrate TT levels was 8 months (95% CI, 6.2-14.9). LH recovered before TT, suggesting that the rate-limiting step in the recovery of TT may be at the testicular level. The median time to recovery of normal LH levels was 3.8 months, compared to 8.0 months to reach supracastrate TT levels, and 2.3 years to reach normal TT levels. Age and the LH/TT ratio were associated with the time to recovery of both supracastrate and normal levels of TT. The IIEF was completed by 17 men; there were no significant changes in the scores in any domain of the IIEF during the study. CONCLUSIONS: Most men recover supracastrate testosterone levels after LTAD and external beam radiotherapy, but recovery of 'normal' testosterone levels is slow. Few men recover potency and sexual desire. The patients age and LH/TT ratio may be predictive of the time to recovery of both supracastrate and normal testosterone levels.

Aged↗
PubMed2006

High-precision radiotherapy: where are we going and how do we get there?

In January 2006, physicians with an interest in urologic cancers met to discuss patient care at the 4th Annual Current Problems in Urology Conference. A portion of the meeting was focused on technical issues in prostate cancer radiotherapy. This portion of the meeting sought to answer the questions: where are we going? And how can we get there? Work performed at the Princess Margaret Hospital (PMH) and the London Regional Cancer Program (LRCP) served as the basis for discussion and to present examples of options for implementation of new techniques. The response to the first question reviewed the issue of improved outcomes with dose escalation and the preliminary implementation of hypofractionated treatment. The impact on toxicity was reviewed in detail. The response to the second question revolved around the options available to ensure adequate tumor localization. As dose is increased, the need to localize the prostate accurately has become more important in order to ensure tumor control and to avoid toxicity. Selection of appropriate margins around the prostate is determined by a center's ability to localize the target. Options to localize organs including three-dimensional ultrasound, fiducial markers, megavoltage CT and cone beam CT were discussed. The basic research to enable selection and implementation of these options were presented.

Humans↗
PubMed2005

Wound healing morbidity in STS patients treated with preoperative radiotherapy in relation to in vitro skin fibroblast radiosensitivity, proliferative capacity and TGF-beta activity.

BACKGROUND AND PURPOSE: In a recent study, we demonstrated that the ability of dermal fibroblasts, obtained from soft tissue sarcoma (STS) patients, to undergo initial division in vitro following radiation exposure correlated with the development of wound healing morbidity in the patients following their treatment with preoperative radiotherapy. Transforming growth factor beta (TGF-beta) is thought to play an important role in fibroblast proliferation and radiosensitivity both of which may impact on wound healing. Thus, in this study we examined the interrelationship between TGF-beta activity, radiosensitivity and proliferation of cultured fibroblasts and the wound healing response of STS patients after preoperative radiotherapy to provide a validation cohort for our previous study and to investigate mechanisms. PATIENTS AND METHODS: Skin fibroblasts were established from skin biopsies of 46 STS patients. The treatment group consisted of 28 patients who received preoperative radiotherapy. Eighteen patients constituted a control group who were either irradiated postoperatively or did not receive radiation treatment. Fibroblast cultures were subjected to the colony forming and cytokinesis-blocked binucleation assays (low dose rate: approximately 0.02 Gy/min) and TGF-beta assays (high dose-rate: approximately 1.06 Gy/min) following gamma-irradiation. Fibroblast radiosensitivity and initial proliferative ability were represented by the surviving fraction at 2.4 Gy (SF(2.4)) and binucleation index (BNI), respectively. Active and total TGF-beta levels in fibroblast cultures were determined using a biological assay. Wound healing complication (WHC), defined as the requirement for further surgery or prolonged deep wound packing, was the clinical endpoint examined. RESULTS: Of the 28 patients treated with preoperative radiotherapy, 8 (29%) had wound healing difficulties. Fibroblasts from patients who developed WHC showed a trend to retain a significantly higher initial proliferative ability after irradiation compared with those from individuals in the treatment group with normal wound healing, consistent with the results of our previous study. No link was observed between fibroblast radiosensitivity and WHC. Neither active nor total TGF-beta levels in cultures were significantly affected by irradiation. Fibroblast proliferation in unirradiated and irradiated cultures, as well as radiosensitivity, was not influenced by TGF-beta content. TGF-beta expression in fibroblast cultures did not reflect wound healing morbidity. CONCLUSIONS: These data are consistent with our previous study and combined the results suggest that in vitro fibroblast proliferation after irradiation may be a useful predictor of wound healing morbidity in STS patients treated with preoperative radiotherapy. TGF-beta levels in culture do not predict WHC, suggesting that the role of TGF-beta in wound healing is likely controlled by other in vivo factors.

Adolescent↗
PubMed2005

Histologic assessment of peritumoral edema in soft tissue sarcoma.

PURPOSE: To evaluate whether satellite tumor cells can be identified histologically in the tissues surrounding a soft tissue sarcoma and whether their presence correlates with increased T(2)-weighted signal intensity on MRI. METHODS AND MATERIALS: Fifteen patients with a high-grade extremity or truncal soft tissue sarcoma underwent preoperative MRI. The extent of high T(2)-weighted signal changes in the tissues surrounding tumor, thought to represent peritumoral edema/reactive changes, was determined. Twelve patients received i.v. gadolinium, and contrast enhancement was determined. All patients underwent surgical resection in the absence of preoperative chemotherapy or radiotherapy. The presence of tumor cells in the surrounding tissues was determined histologically in representative paraffin-embedded sections and correlated with the MRI findings. RESULTS: The extent of peritumoral T(2)-weighted MRI signal changes ranged from 0 to 7.1 cm (mean, 2.5 cm); contrast enhancement ranged from 0 to 5.3 cm (mean, 1.1 cm). Sarcoma cells were identified histologically in the tissues beyond the tumor in 10 of 15 cases. In 6 cases, tumor cells were located within 1 cm of the tumor margin, and in 4 cases, malignant cells were found at a distance >1 cm and up to a maximum of 4 cm. The location of tumor cells beyond the margin did not correlate with tumor size nor did it correlate with the location or extent of peritumoral changes. CONCLUSION: The ability to identify tumor cells beyond the margin of a soft tissue sarcoma has important implications in planning appropriate targets for treatment. This could influence the use of new radiotherapy technologies such as intensity-modulated radiotherapy that aim to minimize treatment volumes through conformal planning.

Adult↗
PubMed2005

Late radiation morbidity following randomization to preoperative versus postoperative radiotherapy in extremity soft tissue sarcoma.

BACKGROUND AND PURPOSE: This study compared late radiation morbidity in patients with extremity soft tissue sarcoma randomized to treatment by pre- (50 Gy) or postoperative (66 Gy) radiotherapy in combination with surgery. The morbidities evaluated included fibrosis, joint stiffness and edema at 2 years following treatment. The impact of morbidity on patient function as measured by the Musculoskeletal Tumor Rating Scale (MSTS) and the Toronto Extremity Salvage Score (TESS) was also evaluated. PATIENTS AND METHODS: 129 patients were evaluated. Toxicity rates were compared by treatment arm using the Fisher's exact test. Function scores by toxicity were analyzed using the Wilcoxon rank sum test. Multivariate logistic regression was used to evaluate the joint effect of treatment arm, field size, and dose on subcutaneous tissue fibrosis, joint stiffness and edema. RESULTS: 27 of 56 patients (48.2%) in the postoperative arm compared to 23 of 73 (31.5%) in the preoperative arm had grade 2 or greater fibrosis (P = 0.07). Although not statistically significant, edema was more frequent in the postoperative arm, 13 of 56 (23.2%) versus 11 of 73 (15.5%) in the preoperative arm, as was joint stiffness, 13 of 56 (23.2%) versus 13 of 73 (17.8%). Patients with significant fibrosis, joint stiffness or edema had significantly lower function scores on both measures (all P-values < 0.01). Field size was predictive of greater rates of fibrosis (P = 0.002) and joint stiffness (P = 0.006) and marginally predictive of edema (P = 0.06). CONCLUSIONS: Patients treated with postoperative radiotherapy tended to have greater fibrosis. Fibrosis, joint stiffness and edema adversely affect patient function.

Adolescent↗
PubMed2005

A phase II study of localized prostate cancer treated to 75.6 Gy with 3D conformal radiotherapy.

BACKGROUND AND PURPOSE: To prospectively evaluate toxicity, biochemical failure-free survival (bFFS) and biopsy-proven local control for prostate cancer patients treated with 75.6 Gy in 42 fractions using 6-field conformal radiotherapy to prostate alone. PATIENTS AND METHODS: From 1997 to 1999, 140 patients with T1-2NxM0, Gleason score or=grade 2: 2%, and GU>or=grade 2: 1%. The 3-year bFFS of patients failure-free before biopsy was 93% (95% CI: 83-100) from a negative biopsy and 22% (95% CI: 0-56) from a positive biopsy (P=0.001). Patients reported significantly more late toxicity than physicians (GI: P=0.003, GU: P<0.001). At 5.0 years median follow-up, cause-specific survival was 98% (95% CI: 96-100), overall survival was 91% (95% CI: 86-97), and bFFS was 55% (95% CI: 45-64). CONCLUSIONS: 75.6 Gy caused modest levels of acute and late toxicity. Three-year biopsies predicted subsequent biochemical outcome.

Adenocarcinoma↗
PubMed2005

Cardiac tumours: diagnosis and management.

Primary cardiac tumours are rare, with an autopsy incidence ranging from 0.001% to 0.030%. Three-quarters of these tumours are benign and nearly half of the benign tumours are myxomas. Metastases to the heart are far more common than primary cardiac tumours. Primary cardiac tumours present with one or more of the symptoms of the classic triad of: cardiac symptoms and signs resulting from intracardiac obstruction; signs of systemic embolisation; and systemic or constitutional symptoms. They are diagnosed by use of transthoracic and transoesophageal echocardiograms, MRI, and CT scan. Whereas surgery is indicated in patients with benign tumours, systemic chemotherapy is indicated in those who have widespread or unresectable malignant disease, and chemotherapy and radiotherapy are usually combined in treatment of patients with primary cardiac lymphomas. The prognosis after surgery is usually excellent in the case of benign tumours but is unfortunately still limited in localised malignant diseases. Patients with sarcomas live for a mean of 3 months to 1 year, and those with lymphomas live up to 5 years if treated, but usually die within 1 month if untreated.

Echocardiography↗
PubMed2005

Fractures following radiotherapy and limb-salvage surgery for lower extremity soft-tissue sarcomas. A comparison of high-dose and low-dose radiotherapy.

BACKGROUND: The purpose of the present retrospective study was to determine the correlation between radiation therapy and the risk of postradiation fracture following combined therapy for the treatment of soft-tissue sarcomas of the lower extremity. METHODS: Three hundred and sixty-four patients with lower extremity sarcomas that had been treated with combined external beam radiation therapy and limb-salvage surgery were evaluated on the basis of a combined chart and data-base review. For the purposes of analysis, high-dose radiation was defined as 60 or 66 Gy and low-dose radiation was defined as 50 Gy. The timing of irradiation was defined as preoperative, postoperative, or preoperative followed by a postoperative boost. Univariate and multivariate analyses were used to determine which factors were associated with fracture risk. RESULTS: Twenty-seven fractures occurred in twenty-three patients. Twenty-four fractures occurred in twenty patients who had been managed with high-dose radiation. Seventeen of these patients had received postoperative radiation (with fifteen patients receiving 66 Gy and two receiving 60 Gy), and three had received preoperative radiation with a postoperative boost (total dose, 66 Gy). Three fractures occurred in three patients who had received preoperative, low-dose radiation (50 Gy). Of the twenty-three patients who sustained a pathologic fracture, eighteen were female and five were male. The crude median time to fracture was forty-three months. Most fractures occurred in the femoral shaft (thirteen) or the femoral neck (eight). High-dose radiation was associated with a greater risk of fracture when compared with low-dose radiation (p = 0.007). CONCLUSIONS: Women more than fifty-five years of age who are managed with removal of a thigh sarcoma combined with radiation therapy have a higher risk of pathologic fracture. The frequency of pathologic fractures associated with higher doses (60 or 66 Gy) of radiation is significantly higher than that associated with lower doses (50 Gy).

Adolescent↗
PubMed2005

Prostate cancer radiotherapy 2002: the way forward.

In November 2000, the GU Radiation Oncologists of Canada had their first meeting, "Controversies in prostate cancer radiotherapy: consensus development". The success of this meeting prompted a second meeting, held in December 2002 to discuss "The Way Forward" in prostate radiotherapy. Radiation oncologists from across Canada were brought together and integrated with key opinion leaders in prostate cancer treatment from throughout North America. The group debated current controversies including: intensity modulated radiotherapy (IMRT), external beam hypofractionation, high dose-rate brachytherapy, and hormone therapy in the management of prostate cancer. The meeting also sought to identify and prioritize clinical trial opportunities and to highlight steps required to achieve these research goals. In summary, advances involving IMRT have enabled the use of higher radiation doses without increasing morbidity. With renewed interest in hypofractionated radiation schedules, the value of hypofractionation using IMRT was discussed and initial results from ongoing clinical trials were presented. The emerging role for high dose-rate brachytherapy in higher risk patients was also discussed. Based on existing preliminary evidence the group expressed enthusiasm for further investigation of the role for brachytherapy in intermediate to high-risk patients. Despite significant advances in radiotherapy, hormone therapy continues to play an important role in prostate cancer treatment for patients with intermediate and high-risk disease. Although evidence supports the effectiveness of hormone therapy, the optimal timing, and duration of hormonal treatment are unclear. Results from ongoing clinical trials will provide insight into these questions and will assist in the design of future clinical trials.

Clinical Trials as Topic↗
PubMed2004

Polarographic electrode study of tumor oxygenation in clinically localized prostate cancer.

PURPOSE: To describe the oxygenation of clinically localized prostate cancer. METHODS AND MATERIALS: Intraprostatic oxygen tension was measured using the Eppendorf electrode in 55 unanesthetized men with localized prostate cancer before radiotherapy. Measurements were made along two tracks through regions of suspected tumor in the prostate, and core needle biopsies were then obtained from the same regions. RESULTS: The median pO(2) ranged from 0.2 to 57.3 mm Hg, and the grand median pO(2) was 4.5 mm Hg. The percentage of oxygen readings <5 mm Hg (HP(5)) ranged from 0% to 100% (median 60%). The track 1 oxygen readings were greater than those from track 2. Statistically significant heterogeneity was found in the individual oxygen readings: the between- and within-tumor components accounted for 32% and 68% of the total variability, respectively. However, the between-tumor variability in HP(5) significantly exceeded the within-tumor variability (61% vs. 39%). No association was found between oxygen values and clinical factors, including age, T stage, Gleason score, prostate-specific antigen level, hemoglobin concentration, or prior hormonal treatment. No difference was noted in the oxygenation between regions of tumor and normal prostate tissue, as determined from the core biopsies. CONCLUSION: Localized prostate cancer is characterized by marked hypoxia and significant heterogeneity in oxygenation, similar to other human tumors. The normal prostate may contain regions of low oxygen concentration. HP(5), as determined in this study, should adequately discriminate among patients with prostate cancer and allow the independent prognostic significance of oxygenation to be evaluated once the study matures.

Aged↗
PubMed2004

The role of hemoglobin concentration in clinically localized prostate cancer treated with radical radiotherapy +/- neoadjuvant androgen deprivation.

PURPOSE: Serum hemoglobin level (Hb) is a significant determinant of treatment outcome after radical radiotherapy (RT) for several cancer types, but its importance in prostate cancer is not well established. METHODS AND MATERIALS: Two treatment-specific cohorts of men with localized prostate cancer (T1-4, Nx/N0, M0) were analyzed. Seven hundred six men who received radical RT at Princess Margaret Hospital between 1987 and 2000 comprise the RT-alone cohort, of whom 536 had a pre-RT Hb. Six hundred fifty-eight men received 3-6 months' neoadjuvant androgen deprivation (NAD) and radical RT at Royal Marsden Hospital between 1989 and 2000 and comprise the NAD + RT cohort, of whom 475 had a pre-NAD Hb and 513 a pre-RT Hb. Time to biochemical failure (TTBF) was the primary end point. Univariate and multivariate analyses using the Cox proportional hazards regression model were used for each data set independently to study the prognostic role of pre-RT Hb, pre-NAD Hb, nadir Hb (lowest Hb during RT), Hb decrement (pre-NAD Hb - pre-RT Hb), Gleason score, presenting PSA, and T stage. RESULTS: On univariate analysis, no significant association was seen between TTBF and any of the Hb variables for either data set. On multivariate analysis, TTBF was associated with presenting PSA (p < 0.001), Gleason score (p < 0.01), and (for the NAD + RT data set) T stage (p < 0.001), but not pre-NAD Hb (p = 0.24) or pre-RT Hb (p > 0.3). CONCLUSION: Hemoglobin level is not an important determinant of RT outcome in localized prostate cancer.

Aged↗
PubMed2004

Clonogenic survival and cytokinesis-blocked binucleation of skin fibroblasts and normal tissue complications in soft tissue sarcoma patients treated with preoperative radiotherapy.

BACKGROUND AND PURPOSE: To evaluate the clonogenic and cytokinesis-blocked assays in skin fibroblast cultures for their utility as tools for predicting normal tissue responses in soft tissue sarcoma (STS) patients treated with preoperative radiotherapy. PATIENTS AND METHODS: Dermal fibroblast strains were established from skin biopsies of 26 STS patients who received preoperative radiotherapy. Cultures were subjected to the colony forming and cytokinesis-blocked assays after low (approximately 0.02 Gy/min) dose-rate 60Co -irradiation. Fibroblast radiosensitivity was expressed as the dose for 1% clonogenic survival, D0.01, based on colonies/clusters with >or=10 cells. Fibroblast proliferative capability was represented by binucleation index (BNI) and genomic damage was expressed in terms of micronucleus frequency. Wound healing complications (WHC) and subcutaneous fibrosis were the clinical endpoints examined. The ability of each in vitro parameter to detect patients at high risk of a given normal tissue complication was assessed using receiver operating characteristic (ROC) analysis. RESULTS: While fibroblasts from patients without WHC were marginally more radiosensitive than fibroblasts from patients with WHC (P=0.08), the reduction in BNI following a dose of 2.4 Gy was significantly higher in strains from patients without WHC compared to those from patients with WHC (P=0.01). The area under the ROC curve (c-index) is indicative of the power of discrimination of D0.01 and BNI for WHC, and was found to be 0.68 and 0.79, respectively. Subcutaneous fibrosis was not associated with D0.01 (rs=0.09, P=0.66) and the percent reduction in BNI after 2.4 Gy (rs=-0.19, P=0.36). Micronucleus frequency did not reflect differences in normal tissue responses. CONCLUSION: These data suggest that it is the ability of fibroblasts to undergo one-three divisions in vitro following radiation treatment that may reflect the development of wound healing morbidity or subcutaneous fibrosis in this population of patients.

Adult↗
PubMed2003

Salvage radiotherapy following radical prostatectomy.

Biochemical relapse will occur in 17-64% of men who undergo radical prostatectomy, and up to a third of men with biochemical relapse will progress to develop metastatic disease and ultimately die of prostate cancer. Postoperative salvage radiotherapy (RT) to the prostatic fossa is well-tolerated and potentially curative treatment and should be considered for all men who have biochemical relapse following prostatectomy. Gleason score <8, prostate-specific antigen (PSA) doubling time >10 months and PSA re-emergence >2 years following surgery predict for a low risk of early metastatic failure, but even men with no favourable prognostic factors may have a long-term durable response to RT and should not be excluded from consideration of treatment on the basis of these factors alone. Positive surgical margin status and a positive anastomotic biopsy do not predict response to RT, and routine biopsy is not recommended. PSA level at time of RT is a strong indicator of durable response to RT. No one PSA cutpoint level appears to be more significant, and early RT is likely more effective than late. Contemporary PSA assays can detect biochemical relapse in the 0.01-0.2 range, and this may provide additional therapeutic advantage if treatment can be given when tumour burden is smallest. There is an urgent need for prospective data from randomised trials to optimally select patients for salvage RT, to determine the optimal time to initiate treatment and to determine the role of adjuvant hormone therapy, and all patients should be considered for entry into ongoing and future clinical trials.

Humans↗
PubMed2003

Preoperative radiotherapy for adult head and neck soft tissue sarcoma: assessment of wound complication rates and cancer outcome in a prospective series.

Combination surgery and radiotherapy (RT) is frequently used in soft tissue sarcoma (STS). Because lower doses and smaller irradiation volumes are possible in preoperative RT (pre-op RT), this approach can be especially valuable in anatomic settings where critical organs are in close proximity to the RT target area. A recent multicenter phase III trial (SR.2 trial of the National Cancer Institute of Canada Clinical Trials Group) comparing pre-op RT against post-op RT for extremity STS has shown significantly higher major wound complication rates (35%) with pre-op RT. We postulated that wound complication rates may be less frequent in the head and neck with better vascularity and wider use of secondary wound reconstruction. Using a prospective database, we identified 40 consecutive patients with head and neck STS treated with pre-op RT (50 Gy) and subsequent (4 to 6 weeks later) resection between 1/89 and 8/99 in a single institution setting. Major wound complications (MWC) were classified by the identical criteria used in the SR.2 trial. Intracranial extension was evident in 5 patients, whereas 50% of the patients had large tumors (> 5 cm). Deep tumor was present in 34 (85%), and 6 (15%) were superficial to fascia. In this series, 31 patients (77.5%) had secondary reconstruction of the acquired soft tissue deficit. The actuarial 2-year local relapse-free rate was 80%, and the metastatic relapse-free rate was 85%. Major wound complications occurred in 8 of 40 patients (20%) within 120 days of surgery according to the SR.2 criteria: secondary wound surgery (3), readmission or prolonged hospital admission for wound care (2), deep packing (0), prolonged dressing changes (2), and invasive procedure for wound care (1). The latter was a minor wound management problem (a single outpatient drainage of a seroma) for the combined rate of 8/20 or 20%. Our findings show that (1) pre-op RT in head and neck STS is associated with lower rates of major wound complications compared to extremity cases; (2) pre-op RT provides high rates of local control in an adverse group of cases of adult head and neck STS; (3) the choice of scheduling of RT should be based on anatomic issues with emphasis on the trade-offs between RT doses and volumes versus wound morbidity for individual patients. This is especially important when tumor may be adjacent to critical head and neck structures which may be protected from the high-dose RT area.

Adolescent↗
PubMed2003

Recent advances in radiotherapy for soft-tissue sarcoma.

The use of radiotherapy in soft-tissue sarcoma continues to evolve. This review focuses on how current management is influenced by the most recent publications in the field. In particular, experience of patients treated without radiotherapy permits guidelines to be established that define a subset of patients who do not need radiotherapy to achieve sarcoma cure with good function. Strategies for radiotherapy delivery are discussed, including the most recent prospective results from a trial of preoperative and postoperative radiotherapy, with particular emphasis on randomized data. Also, the definitions for adequacy of surgical excision and the ability to achieve high rates of local control when margins are minimally positive are integrated into a planned approach. The difficult problem of retroperitoneal sarcoma is discussed, as are chemoradiotherapy protocols that may enhance local and systemic outcome. Finally, the potential for image-guided radiotherapy, enhanced targeting, and better radiotherapy delivery in the contemporary era is addressed.

Combined Modality Therapy↗
PubMed2003

Recurrent prostate cancer following external beam radiotherapy: follow-up strategies and management.

All patients who undergo curative therapy for prostate cancer should be followed for a prolonged period of time to determine tumor control and treatment toxicity for quality assurance purposes. Follow-up duties may be reasonably shared between the oncologist and the family doctor or urologist: however, it is probable that some follow-up information specific to the irradiated patient will be lost unless the oncologist maintains regular contact with the patient, especially in the first 5 years of follow-up when late radiation effects are most likely to appear. There is no strong evidence that patients stop being at risk for recurrence at any time after treatment, and because PSA testing is an accurate, simple, and inexpensive method of determining post-RT tumor status, it is recommended that periodic PSA measurements be continued for life. In the absence of a rising PSA, all other tests and visits are unnecessary to determine post-RT tumor control. Because DRE has been shown to be of limited utility in follow-up of irradiated patients, it should be possible to effectively follow patients remotely. This could be done by asking patients to have PSA tests done, forward the results to their physicians, and report treatment toxicity when it occurs. Only abnormal results would trigger an office visit. This strategy is being evaluated in clinical trials. The alternative is to delegate the follow-up to the primary-care physician with guidelines as to when referral back is required. Follow-up frequency, and the most beneficial follow-up investigations vary from scenario to scenario, and are influenced by the likelihood of relapse, time to relapse, and planned intervention. These decisions are influenced in turn by the initial presentation--either with high or low risk factors--and by the patient's general state of health at completion of EBRT. Effective follow-up also requires active patient cooperation that only can be achieved after discussion of the goals of follow-up with the patient and with the patient's full understanding of the process. The follow-up strategy proposed in Fig. 1 is most suitable for a fit patient with low or intermediate risk factors who wishes to consider all salvage options should he relapse, or for the high-risk individual in situations in which the probability of systemic relapse is of major concern. Young patients with very adverse risk factors may benefit from even closer follow-up in the early years after EBRT and the elderly or frail may require only occasional visits to record or treat treatment toxicity and to ensure clinical non-progression.

Biopsy↗