Transcript Slide 1

Comparing Treatment Results Of
PROSTATE CANCER
Prostate Cancer Results Study Group
2014
Peter Grimm, DO
Prostate Cancer Center of Seattle
7/17/2015
1
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Problem: Patients, physicians and carriers
need a simple, unbiased means to compare
the cancer control rates of modern prostate
cancer treatment methods.
7/17/2015
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To solve this problem, we have
assembled experts from key treating
disciplines: Surgery, External Radiation,
Internal (or Brachytherapy), High
Frequency Ultrasound, and Proton
Therapy
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The purpose of this work is to do a
complete review study of the current
literature on prostate cancer treatment
7/17/2015
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Ignace Billiet, MD F.E.B.U., Urologist Kortrijk, Belgium
David Bostwick, MD Bostwick Laboratories
David Crawford, MD Univ Colorado, Denver
Brian Davis, MD Mayo Clinic Rochester, Minnesota
Adam Dicker, MD Thomas Jefferson U Philadelphia,PA
Steven Frank, MD MD Andersen, Houston Texas
Peter Grimm, DO Prostate Cancer Center of Seattle
Jos Immerzeel, MD De Prostaat Kliniek Netherlands
Stephen Langley, MD St Luke's Cancer Centre, Guildford England
Alvaro Martinez, MD William Beaumont , Royal Oak, Mi
Mira Keyes, MD BC Cancer Agency , Vancouver Canada
Patrick Kupelian, MD UCLA Med Center Los Angeles
Robert Lee , MD Duke University Medical Center
Stefan Machtens, MD University Bergisch, Gladbach Germany
Jyoti Mayadev, UC Davis Davis ,California
Brian Moran, MD Chicago Prostate Institute Chicago
7/17/2015
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Gregory Merrick, MD Schiffler Cancer Center Wheeling West Virginia
Jeremy Millar, MD Alfred Health and Monash University, Melbourne Australia
Mack Roach, MD UCSF San Francisco California
Richard Stock, MD Mt. Sinai New York
Katsuto Shinohara, MD UCSF San Francisco California
Mark Scholz, MD Prostate Cancer Research Institute Marina del Ray California
Edward Weber, MD Prostate Cancer Center of Seattle
Anthony Zietman, MD Harvard Joint Center Boston Ma
Michael Zelefsky, MD Memorial Sloan Kettering New York
Jason Wong, MD UC Irvine California
Robyn Vera, DO Radiant Oncology Lacey Washington
7/17/2015
5
ABOUT THIS REVIEW STUDY
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28,000+ prostate studies were
published between 2000 and June 2013
1,127 of those studies featured
treatment results
233 of those met the criteria to be
included in this review study. (*1 & 2 group)
Some treatment methods are underrepresented due to failure to meet
criteria
st
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7/17/2015
nd
6
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“Will I be cured?” or “Will my treatment
make me cancer free?” are valid patient
questions. However, PSA values (our best
measurement tool today) cannot answer this
absolutely. The current state-of-the-art can
only indicate that the treatment was
“successful” if PSA numbers do not indicate
cancer progression.
7/17/2015
7
After prostate removal, PSA numbers usually
fall rapidly to very low numbers and stay
low.
 After radiation, PSA numbers usually come
down slower, might increase then fall in the
1 to 3 year range (called a “PSA Bump”), and
then usually level out at a higher number
than the surgery patient.
 These different PSA expectations result in
dissimilar ways to review a man’s PSA
history to judge treatment success.
 This study makes no attempt to standardize
those evaluation systems.

7/17/2015
8
Brachy = Seed implantation, either
permanent or temporary seeds
EBRT= External Beam Radiation Therapy includes
IMRT = Intensity Modulated Radiation
RP = Standard open radical prostatectomy
Robot RP = Robotic Radical Prostatectomy
HIFU = High frequency Ultrasound
Cryo= Cryotherapy
Protons = form of External Radiation using Protons
ADT= Hormone Therapy
7/17/2015
9
Criteria for Inclusion of Article*
1. Patients should be separated into Low,
Intermediate, and High Risk
2. Success must be determined by PSA analysis
3. All Treatment types considered: Seeds (Brachy),
Surgery (Standard or Robotic), IMRT (Intensity
Modulated Radiation), HIFU (High Frequency
Ultrasound), CRYO (Cryo Therapy), Protons, HDR
(High dose Rate Brachytherapy)
4.
Article must be in a Peer Reviewed Journal
* Expert panel consensus
7/17/2015
10
5. Low Risk articles must have a minimum of 100
patients
6. Intermediate Risk articles must have a minimum of
100 patients
7. High Risk articles, because of fewer patients, need
only 50 patients to meet criteria
8. Patients must have been followed for a median of 5
years
For additional criteria information contact: [email protected]
7/17/2015
11
RP
EBRT/
IMRT
Cryo
Brachy/
HDR
Robot
RP
9%
13%
5.4%
21%
5.3%
24%
8%
2/37
64/306
4/76
4/17
3/38
28/320 40/302
Proton HIFU
Total of 1,127 Treatment Articles. Some articles addressed several treatments and
were counted as separate articles for each treatment. *A few articles evaluated other/minor treatments
and are not listed here. These calculations only include primary accepted articles, and do not include secondary acceptance totals.
7/17/2015
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How to Interpret the Results
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Each treatment is given a symbol. For example Seed implant
alone (Brachy) is given a blue dot with a number in it.27
The number in the symbol refers to the article. The article
can be found in the notes section below the slide ( go into
“view” in up left corner of PowerPoint and click on note
section, then click on this portion and scroll down to see all
the references)
Treatment Success % = Percent of men, whose PSA numbers
indicate no cancer progression. (progression free) at a
specific point in time
The bottom line indicates the number years the study is out
An example, the blue dot with 27 inside indicates that, as per
article 27, 97% of the patients treated with seeds alone in low
risk patients at 12 years were free of disease progression
according to PSA numbers
7/17/2015
13
How to Interpret the Results
First Establish your clinical risk group* by looking at
the definitions or ask your physician. Refer only to
those slides for your risk group
 Make your own judgment and then ask a doctor in
each discipline ( Seeds, External Radiation Surgery,
etc) to tell you where his/her own peer reviewed
published Treatment Success % would fit on this
plot.

*Next Slide
7/17/2015
14
Low Risk
Stage: T1 or T2a,b
Gleason Sum < 6
PSA < 10 ng/ml
7/17/2015
15
% PSA Progression Free
Treatment Success
LOW RISK RESULTS
25 8
4
22
3 6
31
19 105 24
11314
110
27
13
37
114 35
33
29 101
39103
18
102
2 26
40
1100
7
32
10
28
112
36
5
16
111
115
12
107 106
9
104
EBRT &
Seeds
Robot RP
108
15
109
20
17
7
CRYO
HIFU
34
← Years from Treatment →
Protons
HDR
11109
• Prostate Cancer Results Study Group
• Numbers within symbols refer to references
7/17/2015 Update of
z Vol. 109(Supp. 1)
BJU Int, 2012,
Prostate Cancer Center of Seattle
16
LOW RISK RESULTS
% PSA Progression Free
Treatment Success
Weighted
Brachy
100
EBRT
25
4
22
3 6
31
90
110
37
11314
27
13 8
114 35
33
29 101
18
19 105 24
40
1 100
32
10
28
39103
102
36
2 26
7
111
112
5
16
12
107 106
104
9
80
115
108
15
109
20
17
7
Surgery
70
34
← Years from Treatment →
60
EBRT &
Seeds
Robot RP
Seeds
Surgery
EBRT
CRYO
HIFU
Protons
HDR
11109
1
2 3 4 5 6 7 8 9 10 11 12 13 14 15
• Prostate Cancer Results Study Group
• Numbers within symbols refer to references
7/17/2015 Update of
BJU Int, 2012, Vol. 109(Supp. 1)
Prostate Cancer Center of Seattle
17

“The PCRSG criteria is pretty strict and not a
lot of studies fit. What happens if you include
articles with only 40 months of follow up or
have a long follow up but less than 100
patients?”
7/17/2015
18
LOW RISK RESULTS
% PSA Progression Free
Treatment Success
>40 months follow-up or less than 100 patients
100
68 51 50
46 11314
97
96
110
66 25 22
8
13
75
48
37
2014 816 6286
11435
44
3
60
41 82
33
32
203 n 6985
1067
39103
9865 3171
112
101
72
99
29
28
8489
94 95
42
61 93
18 88 102
54
36
105 24
73
1947
43 55
78
2 26
64
12 83
40
20258
1 100 7 87
76 56
107 106
77
9
70 80
41
15 45
57 74 79
20
10959
17
90
53
90
80
+
27
111
5
16
52
104
108
63
70
7
34
← Years from Treatment →
91
60
1
49
11
2 3 4 5 6 7 8 9 10 11 12 13 14 15
• Prostate Cancer Results Study Group
• Numbers within symbols refer to references
7/17/2015 Update of
BJU Int, 2012, Vol. 109(Supp 1)
Prostate Cancer Center of Seattle
Seeds &
ADT
EBRT &
ADT
EBRT &
Seeds
Robot RP
Seeds
Surgery
EBRT
CRYO
HIFU
Protons
Hypo EBRT
HDR
19
LOW RISK RESULTS
Weighted
% PSA Progression Free
Treatment Success
>40 months follow-up or less than 100 patients
100
EBRT
Brachy
68 51 50
92
46 11314
96
110
97 66 25
22
8
13
75
48
37
2014 816 6286
11435
44
3
60
41 82
33
32
203 6985
71
6584 3172 99 29 101 39103 11228 1067
98 89
42 94 95
61 93
18 88102
38
54
36
105 24
73
1947
43 55
78
2 26
64
12 83
40
20258
1 100 7 87
76 56
107 106
77
9
70 80
41
15 45
57 74 79
20
10959
17
90
53
90
80
+
27
111
5
16
115
52
104
108
Surgery
63
70
7
34
← Years from Treatment →
91
60
49
11
1
2 3 4 5 6 7 8 9 10 11 12 13 14 15
• Prostate Cancer Results Study Group
Seeds &
ADT
EBRT &
ADT
EBRT &
Seeds
Robot RP
Seeds
Surgery
EBRT
CRYO
HIFU
Protons
Hypo EBRT
HDR
• Numbers within symbols refer to references
7/17/2015 Update of
BJU Int, 2012, Vol. 109(Supp 1)
Prostate Cancer Center of Seattle
20

Zelefsky definition
 Only 1 factor
▪ Clinical Stage T2c
▪ Gleason score > 7
▪ PSA > 10 ng/ml

D’Amico definition
 PSA 10-20 Gleason Score 7 or Stage T2b
7/17/2015
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% PSA Progression Free
Treatment Success
INTERMEDIATE RISK RESULTS
100
24 2313
35
14
49
80
160
16 4
5
152 7 155
70
9 26
41
1
10 11
60
40
38
27
39
156 31
43
18 47
+
34
153
160 30 36 45 25
152 6 12
37
158
156
151
161
15 44
90
EBRT + ADT
Robot RP
42
32
28
Hypo EBRT
17
157
150
157
29
8
33
154
48
Seeds + ADT
EBRT & Seeds
159
32
2 19
46
Brachy
Seeds Alone
Surgery
EBRT
CRYO
HIFU
20
HDR
50
155
← Years from Treatment
→
21
40
1
2
3
4
5
6
EBRT, Seeds +
ADT
7
22
8
9 10 11 12 13 14 15
Protons
• Prostate Cancer Results Study Group
• Numbers within symbols refer to references
7/17/2015 Update of
BJU Int, 2012, Vol. 109(Supp 1)
Prostate Cancer Center of Seattle
22
INTERMEDIATE RISK RESULTS
% PSA Progression Free
Treatment Success
Weighted
EBRT & Seeds
Brachy
100
24 2313
35
14
49
156
153
151
161
15 44
90
160 30 36 45 25
152 6 12
80
160
43
18 47
5
7 155
152
70
Robot RP
37
158
16 4
41
27
42
32 3
28
8
33
60
EBRT
Brachy
Seeds
Alone
157
29
154
48
159
2
32
19
46
Surgery
20
50
Seeds + ADT
EBRT & Seeds
Hypo EBRT
17
150
1
10 11
40
38
39
156 31
9 26
+
34
Surgery
EBRT
CRYO
HIFU
HDR
155
← Years from Treatment
→
40
EBRT, Seeds +
ADT
21
22
1
2
3
4
5
6
7
8
9 10 11 12 13 14 15
Protons
• Prostate Cancer Results Study Group
• Numbers within symbols refer to references
7/17/2015 Update of
BJU Int, 2012, Vol. 109(Supp 1)
Prostate Cancer Center of Seattle
23
 Favorable
▪ Single feature
▪ Gleason 3+4=7
▪ < 50% of biopsy cores +

Unfavorable
 All other Intermediate
*Zumsteg et al (MSKCC) New Risk Classification system for therapeutic decision making PCA pts undergoing dose escalated EBRT
European Urology 64 p 895-902 2013 Favorable vs Unfavorable
7/17/2015
24
INTERMEDIATE RISK
% PSA Progression Free
Treatment Success
Favorable Vs Unfavorable*
Weighted
EBRT & Seeds
Brachy
24 2313
35
14
49
151
15 44
160 30 36 45 25
152 6 12
156
16 4
F33
39
31
156
152
7 155
9 26
41
1
10 11
EBRT
28
40
38
42
32 3
160
5
+
34
153
43
18 47
Robot RP
37
158
Seeds + ADT
EBRT & Seeds
Hypo EBRT
17 27
Seeds Alone
150
157
29 U33
154
48
8
159
2
32
19
46
Surgery
20
HDR
155
← Years from Treatment
→
21
22
EBRT, Seeds +
ADT
Protons
• Prostate Cancer Results Study Group
• Numbers within symbols refer to references
7/17/2015 Update of
BJU Int, 2012, Vol. 109(Supp 1)
Prostate Cancer Center of Seattle
25
INTERMEDIATE RISK RESULTS
% PSA Progression Free
100
10459
EBRT + ADT
54 56
59 55
66
24 23 13
14
35
79
49
59
158
92
156
98
151
34
153
161 1544 96
4
57
16
38 58
68 69
1093036 45 25
160
10599 77 12
39
83
152
107
82
97 6106
42 73
156 3191
108
51
160
32 3 72
62 18 6393 4347
71
86
81 95
28
74 67 50
150
90 92652
5
65
152 78 70 7 155
103
29
76 102
154
41
1
60100
48
32
8 87
85 88 53
2
19
10101 11 33
75
46
84
90
80
70
Robot RP
37
+
40
60
89 94
Seeds + ADT
EBRT & Seeds
27
17
110
Treatment Success
>40 months follow-up or less than 100 patients
64
Hypo EBRT
Brachy
Seeds
Alone
157
159
20
Surgery
EBRT
CRYO
HIFU
HDR
50
155
← Years from Treatment
→
40
21
80
1
2
3
4
5
EBRT, Seeds +
ADT
22
6
7
8
9 10 11 12 13 14 15
Protons
• Prostate Cancer Results Study Group
• Numbers within symbols refer to references
7/17/2015 Update of
BJU Int, 2012, Vol. 109(Supp 1)
Prostate Cancer Center of Seattle
26
INTERMEDIATE RISK RESULTS weighted
% PSA Progression Free
>40 months follow-up or less than 100 patients
Brachy
10459
66 55
24 23 13
14
35
79
49
158
92
156
98
151
34
153
161 1544 96
4
57
16
38 58
68 69
30 36 45
109
99 77
39
83
105 152
107
82
97 612
42 73
156 31 91
108
51
160
3 72
62 18 6393 4347
71
86
81
95
28
74 67 50
150
90 92652
5
65
152 78 70 7 155
103
29
76 102
154
41
1
60100
48
32
8 87
85 88 53
2
19
10101 11
75
46
84
Robot RP
EBRT
90
25
80
70
60
89 94
+
40
27
17
64
157
159
Surgery
20
50
155
← Years from Treatment
→
40
21
80
1
2
3
4
EBRT + ADT
37
110
Treatment Success
100
54 56
5
22
6
7
8
9 10 11 12 13 14 15
Seeds + ADT
EBRT & Seeds
Hypo EBRT
Brachy
Seeds Alone
Surgery
EBRT
CRYO
HIFU
HDR
EBRT, Seeds +
ADT
Protons
• Prostate Cancer Results Study Group
• Numbers within symbols refer to references
7/17/2015 Update of
BJU Int, 2012, Vol. 109(Supp 1)
Prostate Cancer Center of Seattle
27


Zelefsky definition
2 or more factors
 Gleason > 7
 PSA 10-20 Clinical Stage T1c- T2b

D'Amico
 Gleason Score 8-10
 PSA >20
7/17/2015
28
% PSA Progression Free
Treatment Success
HIGH RISK RESULTS
20
19 18
32 22
136123
122
40
125 44
3
9 124 34135
125
13
46
108
17
43
48 128
103
35
4
112
Surg & EBRT
Surg & ADT
EBRT & ADT
109
EBRT & Seed
112 131
41
25
101 113
106
118
16
127
2
10 114
42
1 13412
8 132136
32
110 9
36
45
33 111
5 120
21
120
120
126
14
39
121 119
115 11 26
31
76
36
3011627
107
102 15
105
37
47
104
24 28
133
117
130
23 29
← Years from Treatment
→
• Prostate Cancer Results Study Group
• Numbers within symbols refer to references
7/17/2015 Update of
BJU Int, 2012, Vol. 109(Supp 1)
Prostate Cancer Center of Seattle
Hypo EBRT
49
Protons
HDR
EBRT Seeds +
ADT
Robot RP
Hypo EBRT
+ADT
HDR + ADT
29
HIGH RISK RESULTS
% PSA Progression Free
Treatment Success
Weighted
EBRT, Seeds & ADT
20
Brachy
16
109
4
19 18
32 22
123
136 122
40
125 44
3
9 124 34135
125
13
EBRT
46
108
17
43
EBRT & Seeds
37
47
127
2
10
114
42
1 13412
8 132136
32
110 9
36
45
33 111
5 120120
21
126
14
39
121 119
115 11 26
31
76
36
3011627
107
102 15
105
48 128
103
35
112
112131
41
25
101 113
106
118
Hypo EBRT
104
24 28
133
117
Surgery
130
• Prostate Cancer Results Study Group
• Numbers within symbols refer to references
Prostate Cancer Center of Seattle
Protons
HDR
23 29
← Years from Treatment
→
7/17/2015 Update of
BJU Int, 2012, Vol. 109(Supp 1)
Surg & EBRT
Surg & ADT
EBRT & ADT
49
EBRT Seeds +
ADT
Robot RP
HDR + ADT
30
HIGH RISK RESULTS
92 65
99 94 81
80
74
78
123
136 12267
55 40 75
125 44 85
3
60
12454
972
34
91 66 41135
125
68
71 1364 79
50
53 25
101
23 62113
106
118
20
16
19 18
22
32
4
112
17
4376
112
← Years
→
108
EBRT & Seed
131
57
48 128
59 10
42
56 1
12 114
8 61
132136
90
110 9 89
36
33 111
5 120120
21 93 32
126
14
39
121
70
45
119 119
97
11
95
115
98
103
83 7 8226
31
6 96
35
52 63
84
116
73
58 27
36
77 46
107
86 87
88
102 15
105
51
29
from 69
Treatment
127
2
37
47
Hypo EBRT
104
24 28
133
117
130
30
49
Protons
HDR
EBRT Seeds +
ADT
Robot RP
• Prostate Cancer Results Study Group
• Numbers within symbols refer to references
7/17/2015 Update of
BJU Int, 2012, Vol. 109(Supp 1)
Surg & EBRT
Surg & ADT
EBRT & ADT
109
134
% PSA Progression Free
Treatment Success
>40 months follow-up or less than 100 patients
Prostate Cancer Center of Seattle
HIFU
HDR + ADT
31
HIGH RISK RESULTS
Weighted
>40 months follow-up or less than 100 patients
% PSA Progression Free
Treatment Success
Brachy
92 65
20
16
99 94 81
109
4
18
19
80
74
112
108
32
22
78
123
67
136 122
17
123
55
131
75
112
40
125 44 85
76
43
3
60
127
12454
972
34 135
91 66 41
125
68
57
2
134
71 1364 79
48 128
59 10 114
42
50
56 1
24 28
12
8 61
132136
53 25
90
32
110 9 89
101 113
36
93
33
5 120
111
62 106
21
126
118
4514
39
119 95
70
98 31
11
96
115
103
83 7 8226
35
6
52 63
84
36
73
30116
58 27
77 46
107
86 87
88
102 15
105
51
23 29
Years from 69
Treatment
Surg & EBRT
Surg & ADT
EBRT & ADT
EBRT & Seed
37
47
Hypo EBRT
104
133
EBRT
←
→
Surgery 49
Protons
HDR
EBRT Seeds +
ADT
Robot RP
• Prostate Cancer Results Study Group
• Numbers within symbols refer to references
7/17/2015 Update of
BJU Int, 2012, Vol. 109(Supp 1)
130
Prostate Cancer Center of Seattle
HIFU
HDR + ADT
32
OBSERVATIONS




For most low risk patients, most therapies
will be successful.
There appears to be a higher cancer control
success rate for Brachy over EBRT and
Surgery for all groups. Patients are
encouraged to look at graphs and determine
for themselves
Serious side effect rates must be considered
for any treatment
Relaxing the report selection criteria doesn’t
seem to impact the results substantially
7/17/2015
33
= Seeds alone
= EBRT & Seeds
= Surgery = Standard Radical Prostatectomy
= “Robot” =Robotic Prostatectomy
= “HIFU” = High Frequency Ultrasound
= “HDR”= High Dose Rate Brachytherapy +/-EBRT
= EBRT alone
= Hypo EBRT
= Protons
7/17/2015
34
+
7/17/2015
= “CRYO” Cryo Therapy
= EBRT, Seeds, & ADT
= Seeds & ADT
= EBRT & ADT
= Surgery & ADT
= “Brachy” = all seed implant treatments
= all Surgery treatments
= all EBRT treatments
= all EBRT & Seeds
= all EBRT, Seeds & ADT
35
Low Risk
Stage: T1 or T2a,b
Gleason Sum < 6
PSA < 10 ng/ml
Intermediate Risk
Stage T1 or T1-2
Stage T1-2
Gleason Score 7 or Gleason 6
PSA < 10
PSA 10-20
High Risk
Stage T2c or T3
Gleason score ≥ 8
PSA > 20 ng/mL
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
Peter Grimm, DO
 [email protected]

Lisa Grimm, Research Coordinator
 [email protected]
 Or ProstateCancerTC.com


Or contact PCRSG member
Prostate Cancer Center of Seattle website
 www.Prostatecancertreatmentcenter.com
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