Making Treatment Decisions for Prostate Cancer Robert Miller MD www.aboutcancer.com
Treating prostate cancer Surgery? Radiation?Or Watchful Waiting?
Choices with Prostate Cancer1. Depending on the man’s life expectancy and the nature of the specific cancer (Gleason score) is treatment necessary?2. If treatment is appropriate how to choose between surgery or radiation?
Watchful Waiting or Active Surveillance NCCN appropriate for: 1. Very low risk cancers and life expectancy < 20 y 2. Low Risk and life expectancy < 10 y
Very Low Recurrence Risk1. Stage T1c2. Gleason 6 or lower3. Less than 3 cores positive and none over 50%4. PSA density < 0.15 (so PSA was 5 and volume 35g then density would be 0.14 or 5/35)
Laparoscopic Prostate Surgery The surgeon tries to dissect the prostate away from the rectum, bladder, the neurovascular bundle (nerves) and penile urethra
Radiation Fields with Prostate CancerA 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
Radiation Fields with Prostate CancerA High Dose Large Area (Phase 2) The final, high dose radiation target will be focused very precisely only on the prostate gland
Prostate Cancer Risk Groupscombine all 3 things, the stage, thePSA level and the Gleason score•Low risk: (T1c, T2a Gleason 6, PSA <10)•Intermediate risk: (T2b, T2c, Gleason 7, PSA 10-20)•High risk: (T3, Gleason 8-10 or PSA > 20)
Cure Rates with Radiation versus Surgeryfor Early Stage Prostate Cancer are the same from the Cleveland Clinic. Kupelian. JCO Aug 15 2002: 3376-3385
10 Year Cure Rates for Patients with High Risk Prostate Cancer (PSA >20 or Gleason 8-10 or T3)Treatment Number Cure RateRadical 1,238 92%ProstatectomyRadiation plus 344 92%HormonesRadiation 265 88% Mayo Clinic Study (Cancer Jan 10, 2011)
Prostate Cures Rates by Treatment External beam > 72Gy Surgery or Seeds External beam < 72Gy IJROBP 2004; 58:25 Months
Prostate Cancer Relapse Rate by Radiation Dose < 72Gy 72 - 82Gy 82Gy Years Kupelian. IJROBP 2008:71:16
Cure Rates for High Risk Prostate Cancer Hormones + External + Seeds Surgery Seeds alone IJROBP 2006;66:1092 Months
Quality of Life / Medicare Survey Prostate Cancer PatientsSymptom Surgery RadiationWear 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
Potency Rates after Prostate Cancer TreatmentTreatment Probability RangeSeeds 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
Potency Rates after Surgery can range from 2% to 70%) Did they have a ‘nerve sparing’ prostatectomy? Hold old is the man? How high was the PSA? How good was their sexual function before? JAMA. 2011;306(11):1205-1214
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?
Potency Results after External Radiation can range from 16% to 92%
Potency Results after Seeds can range from 6% to 98% Patient Age? Race? Obese or thin? How good was their sexual function before?
Potency Results after Seeds range from 6% to 98%
Responded to ViagraSurgery: 60%External Radiation: 63%Seeds: 85% JAMA 2011:306:1205
Responded to Viagra Surgery: 43% Radiation: 70 –91% General Population: 80% from other studies in the literature
Choosing Treatment Prostate Cancer Urologist with experience and a good outcome experience with the procedureExperienced RadiationOncologist with ModernTechnology (IGIMRT) andgood outcome data
The experience of the surgeon is a criticalfactor associated with a successful outcomeOpen prostatectomy the learning curve didnot plateau until a surgeon had performed atleast 250 retropubic radical prostatectomiesThe probability of biochemical recurrence atfive years was significantly lower (10.7 versus17.9 percent)
Minimally invasive prostatectomy – In a seriesof 4,702 men who were managed withlaparoscopic prostatectomy by one of 29surgeons at seven centers,the five-year risk of recurrence progressivelydecreased with increasing experience (17, 16,and 9 percent with 10, 250, and 750 priorlaparoscopic procedures)
Understanding Prostate Cancer Robert Miller MD www.aboutcancer.com