Slides that accompany the video on radiation for prostate cancer

1. Radiation Therapy for Prostate
Cancer
Robert Miller MD
www.aboutcancer.com

2. NCCN.org

4. Prostate Guidelines
1. Low risk of extracapsular spread, then
external beam or seeds alone
2. Intermediate risk then some (or all) of the
radiation should be by external
3. High risk then hormone therapy should be
added to the radiation
4. External beam should be daily image
guided intensity modulated (IGRT)
5. Need high dose radiation (75 to 81 Gy)

5. The prostate
gland has a
capsule around
it, and cancers
arise close to
the capsule, the
cancer may
invade through
the capsule

6. Age: 67 / Stage T1c / Gleason 6 / PSA 5 =
27.6% risk of extracapsular spread
Age: 67, Stage T2b, Gleason 7/ PSA 12 =
86.2% risk of extracapsular spread

7. Laparoscopic Prostate Surgery
The surgeon
tries to dissect
the prostate
away from the
rectum,
bladder, the
neurovascular
bundle (nerves)
and penile
urethra

8. Radiation Fields with Prostate Cancer
A Low Dose Large Area (Phase 1)
With radiation it is
possible to include
a wider area
around the
prostate to cover
any cells that may
have escaped
After the highest
safe dose is
reached, the
radiation target
will be made
smaller

9. Radiation Fields with Prostate Cancer
A High Dose Large Area (Phase 2)
The final, high
dose radiation
target will be
focused very
precisely only
on the prostate
gland

10. Prostate Cures Rates by Treatment and Dose
External beam > 72Gy
Surgery or Seeds
External beam < 72Gy
IJROBP 2004; 58:25
Months

11. Prostate Cancer Relapse Rate by
Radiation Dose
< 72Gy
72 - 82Gy
82Gy
Years
Kupelian. IJROBP 2008:71:16

12. Salvage (postOp) radiation works best if
the radiation dose is high

13. Survival
Hormone Therapy plus
Radiation by Gleason Score
95 5 year cure rate radiation
radiation plus hormones
90
85
80
75
70
65
60
3+3 3+4 4+4 4+5 5+5
Gleason Score

14. Cure Rates for High Risk Prostate Cancer
Hormones + External + Seeds
Surgery
Seeds alone
IJROBP 2006;66:1092
Months

15. 10 Year Cure Rates for Patients with High
Risk Prostate Cancer
(PSA >20 or Gleason 8-10 or T3)
Treatment Number Cure Rate
Radical 1,238 92%
Prostatectomy
Radiation plus 344 92%
Hormones
Radiation 265 88%
Mayo Clinic Study (Cancer Jan 10, 2011)

16. Typical PSA Decline after External Beam
Months Since Completing Radiation

17. Declining PSA Levels after Seed Implant
PSA bounce
Years

18. Evolving
Radiation
Technology

19. CT scan is obtained at the time of the
Simulation
Fiducials may be inserted
before this step. CT images are
then imported into the
treatment planning computer

20. Goal = radiation zone precisely around
the prostate cancer with small margin
bladder prostate
Radiation zone rectum

21. IMRT (intensity
modulated
radiation therapy)
using 7 different beams
to target the prostate
The computer can
determine the optimal
number of beams to
deliver the radiation
dose to hit the target and
avoid other structures

22. After IMRT was established then IGRT
(image guided) was introduced

23. Lower Risk of Side Effects with Image Guided
IMRT compared to IMRT

24. Better Cure Rates with Image Guided IMRT
compared to IMRT for Prostate
Intermediate Risk High Risk

25. The most sophisticated technique for
image guided IMRT is Tomotherapy.
Combine a CT scan and linear accelerator to ultimate in
targeting (IGRT) and ultimate in delivery (dynamic, helical
IMRT) ability to daily adjust the beam (ART or adaptive
radiotherapy)

26. There is significant movement of the
prostate gland based on daily gas in rectum
Planned
target
No Rectal
gas
Planned target,
missed badly if
rectal gas pushes
the prostate Rectal gas
forward

27. Significant movement of the prostate gland
based on daily gas in rectum
Initial computer target for prostate (red circle) would have badly
missed the target if no adjustments were made based on the amount
of rectal gas

28. Importance of daily CT targeting on
Tomotherapy and adjusting the treatment daily
Very little bowel gas on initial study and the dose (red)
targets the prostate gland closely
large bowel gas on later treatment day and the dose (red) will cover
half the rectum if an adjustment is Not made

29. If no
adjustment
was made
Actual
treatment on
Tomotherapy

30. Using Tomotherapy to tightly target the
prostate with very little radiation hitting
the bladder or rectum

32. Radiosurgery for Cancer

33. Cyberknife Radiosurgery

34. Non Isocentric Delivery with CK Beams

35. Conformality: Dose Painting

36. SBRT Prostate Cancer / Naples-Tampa
Experience
 Feb 2005 – Apr 2008 (Naples,
FL)
• 164 monotherapy, 35 Gy
• 168 monotherapy, 36.25 Gy
• 59 EBRT + CK boost
 Jul 2008 – Dec 2011 (Tampa,
FL)
• 121 monotherapy, 36.25 Gy
• 10 monotherapy, 38 GY
• 12 EBRT + CK boost

37. PSA Response to CyberKnife
Mean PSAi 6.8ng/ml
Mean PSAp 0.78ng/ml
97% biochemical control at 30 months median follow-up

38. Cure Rate after Cyberknife
N = 515, Alan Katz in New York

39. PSA Response after Cyberknife
 Follow-up median 54 months (range, 7 -
78)
7
 Median PSA 6
35 Gy
36.25 Gy
– 36 m 0.20 ng/ml 5
– 60 m 0.10 ng/ml PSA ng/ml 4
3
 By 48 months 2
– 290 of 329 pts 1
PSA < 0.5 0
0 12 24 36 48 60 72
Months

40. Prostate Seed Implants

41. A grid or template with holes every 5mm are
used to line up the needles

42. The needles are distributed

43. The Mick ‘Gun’ is used to push the radioactive
seeds into the gland

44. The seeds are left behind, distributed through
the gland and slowly radiate the cancer

45. CT scans of the prostate
will show the seeds and
the studies will be used
to calculate the
radiation dose

46. Side Effects of Prostate Radiation

47. Side Effects of
Prostate Radiation
Is related to the size
and area of normal
structures that are
over lapped by the
radiation zone…the
goal is to keep the
radiation zone as
small as possible

48. Side Effects of Prostate Radiation
With IMRT and
image guided
techniques the
goal is to shape
the radiation zone
very precisely ,
based on the type
of cancer (high
Gleason might
require a larger
margin around the
gland)

49. Side Effects of Prostate Radiation
Radiation
zone
The structures that will get hit by radiation
and have inflammation or irritation:
bladder, urethra and rectum

50. Radiation
zone
Short Term Side Effects:
Irritation of bladder, urethra
and rectum
1. Urinary frequency (getting up at night very few hours,
take NSAID’s, or may benefit from medication)
2. Slight burning or stinging with urination (drink cranberry
juice)
3. Diarrhea or more frequent, softer bowel movements,
rectal soreness (take Imodium)
4. Mild skin irritation is now rarely seen
5. Fatigue is common

51. Radiation
zone
Long Term Side Effects:
Irritation of bladder, urethra
and rectum
Chronic radiation cystitis or proctitis: about 6% of the
men will have occasional episodes of blood in the urine or
with bowel movements, this usually responds to
medication (e.g. cortisone suppositories) The risk of
serious damage to the bladder and rectum is now less than
1%
Impotence: about 30% of men have problems after
radiation (see the next slides)

52. GETUG Dose Trial for Prostate Cancer,
Long Term Side Effects
Score 70Gy 80Gy
GI grade 3 1.9% 5.9%
GU grade 3,4 2.6% 1.9%
IJROBP 2011:80;1056

53. Long Term Side Effects from MD Anderson Dose
Trial
Grade 70Gy 80Gy
GI grade 2 13% 26%
GI grade 3 1% 7%
GU grade 2 8% 13%
GU grade 3 5% 4%
IJROBP 2008:70:67

54. Long Term Side Effects in 9 Trials of SBRT for
Prostate Cancer
Grade Percent
GI Grade 3 0 – 7%
GI Grade 4 0 – 1.5%
GU Grade 3 1.6 – 13%
GU Grade 4 0%
IJROBP 2012:82:877

55. Quality of Life / Medicare Survey
Prostate Cancer Patients
Symptom Surgery Radiation
Wear Pads 30% 7%
Potent (< 70y) 11% 33%
Potent (>70y) 12% 27%
More frequent bowel 3% 10%
movements
J Clin Oncol 14 (8): 2258-65, 1996

56. Potency Rates after Prostate Cancer Treatment
Treatment Probability Range
Seeds 80% 64 – 96%
Seeds + External 69% 51 – 86%
External 68% 51 – 95%
Radical Prostatectomy
Nerve Sparing 22% 0 – 53%
Standard 16% 0 – 37%
Cryotherapy 11% 0 - 53%
IJROBP

57. Potency Results after External Radiation
can range from 16% to 92%
 Did they get hormone therapy along
with the radiation?
 How high was the PSA prior to
radiation?
 How good was their sexual function
before?

58. Potency Results after External Radiation
can range from 16% to 92%

59. Potency Results after Seeds
can range from 6% to 98%
 Patient Age?
 Race?
 Obese or thin?
 How good was their sexual function
before?

60. Potency Results after Seeds range from 6% to 98%

61. Responded to Viagra
Surgery: 60%
External Radiation: 63%
Seeds: 85%
JAMA 2011:306:1205

62. Responded to Viagra
Surgery: 43%
Radiation: 70 –
91%
General Population: 80%
from other studies in the literature

63. Understanding Prostate Cancer
Robert Miller MD
www.aboutcancer.com