Transcript from our site here - Prostate Cancer Support Group

Comparing Treatment Results Of
PROSTATE CANCER
Prostate Cancer Results Study Group
- Version: 15_01_2013(3)
Peter Grimm, DO
Prostate Cancer Center of Seattle
15_01_2013(3)
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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.
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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

The purpose of this work is to do a
complete review study of the current
literature on prostate cancer treatment
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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
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
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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 Irvine California
Stacy Wentworth, MD Piedmont Radiation Oncology Greensboro , NC
Robyn Vera, DO Medical College of Virginia Richmond Virginia
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ABOUT THIS REVIEW STUDY
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23,000+ prostate studies were
published between 2000 and 2012
989 of those studies featured
treatment results
195 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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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.
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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.

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Brachy = Seed implantation either
permanent or temporary seeds
IMRT = Intensity Modulated Radiation
Therapy a form of External Radiation
RP = Standard open radical prostatectomy
Robot RP = Robotic Radical Prostatectomy
HIFU = High frequency Ultrasound
Cryo= Cryotherapy
Protons = form of External Radiation using Protons
EBRT= External Beam Radiation Therapy
ADT= Hormone Therapy
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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
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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]
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RP
EBRT/
IMRT
Cryo
Brachy/
HDR
Robot
RP
Proton HIFU
8.7%
10.6%
6%
19%
6%
23%
3%
25/285 28/263
2/33
51/275
4/65
3/13
1/33
Total of 989 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.
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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
do not indicate 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
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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
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Low Risk
Stage: T1 or T2a,b
Gleason Sum < 6
PSA < 10 ng/ml
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% PSA Progression Free
Treatment Success
LOW RISK RESULTS
100
23
25
4
22
30 6
37
3
33
29 101
31
90
19
14 21
13 8
24
38
39103
18
102
2 26
40
1 100
7
27
35 17
32
10
28
36
12
107 106
9
80
EBRT &
Seeds
5 16
104
108
15
Robot RP
Seeds
Surgery
EBRT
CRYO
HIFU
70
34
← Years from Treatment →
60
Protons
HDR
11
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
15_01_2013(3)
Prostate Cancer Center of Seattle
16
LOW RISK RESULTS
% PSA Progression Free
Treatment Success
Weighted
Brachy
100
EBRT
23
25
4
22
30 6
37
3
31
90
19
14 21
13 8
24
33
29 101
39103
18
102
38
40
1 100
2 26
7
27
35 17
32
10
28
36
5 16
12
107 106
104
9
80
108
15
Surgery
70
34
← Years from Treatment →
60
EBRT &
Seeds
Robot RP
Seeds
Surgery
EBRT
CRYO
HIFU
Protons
HDR
11
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
15_01_2013(3)
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?”
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LOW RISK RESULTS
% PSA Progression Free
Treatment Success
>40 months follow-up or less than 100 patients
100
68 51 50
97
96
23 46
14 21
66 25 22
8
13
48
4 8175 62
37
35
44 86
17
3069641
3
60
82
33
32
71
85
1067
9865 3172 99 29 101 39103
28 94
8489
95
42
61 93
18 88 102
38
54
36
73
1947 24
43 55
78
2 26
64
12 83
40
58
1 100 7 87
76 56
107 106
77
9
70 80
41
15 45
57 74 79
59
90
53
90
80
+
27
5 16
52
104
108
34
← Years from Treatment →
91
60
1
15_01_2013(3)
Seeds
Surgery
EBRT
CRYO
HIFU
63
70
Seeds &
ADT
EBRT &
ADT
EBRT &
Seeds
Robot RP
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
Prostate Cancer Center of Seattle
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
96
23 46
14 21
97 66 25
22
8
13
48
4 8175 62
37
35
44 86
17
3069641
3
60
82
33
32
71
85
1067
39103
65
28 94
98 84893172 99 29 101
95
42
61 93
18 88102
38
54
36
73
1947 24
43 55
78
2 26
64
12 83
40
58
1 100 7 87
76 56
107 106
77
9
70 80
41
15 45
57 74 79
59
90
53
90
80
+
27
5 16
52
104
108
Surgery
63
70
34
← Years from Treatment →
91
60
49
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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
15_01_2013(3)
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
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% PSA Progression Free
Treatment Success
INTERMEDIATE RISK RESULTS
100
33
14
24 2313
35
49
151
90
16 4
38
31
42
3
40
32
Seeds + ADT
EBRT & Seeds
39
6 12
43
18
28
9 26
25
29
41
1
8
10 11
19 5
7
70
+
34
15 44
30 36 45
80
Robot RP
37
60
Hypo EBRT
17 27
150
48
2
46
20
Brachy
Seeds
Alone
Surgery
EBRT
CRYO
HIFU
HDR
50
← 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
15_01_2013(3)
Prostate Cancer Center of Seattle
22
INTERMEDIATE RISK RESULTS
% PSA Progression Free
Treatment Success
Weighted
EBRT & Seeds
Brachy
100
33
14
24 2313
35
49
151
90
16 4
38
31
42
3
40
32
43
18
28
9 26
25
29
41
1
8
10 11
19 5
7
60
EBRT
20
Hypo EBRT
17 27
150
48
2
46
Surgery
50
← Years from Treatment
→
40
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2
3
4
5
6
21
7
8
Brachy
Seeds Alone
Surgery
EBRT
CRYO
HIFU
HDR
EBRT, Seeds +
ADT
22
1
Seeds + ADT
EBRT & Seeds
39
6 12
70
+
34
15 44
30 36 45
80
Robot RP
37
9 10 11 12 13 14 15
Protons
• Prostate Cancer Results Study Group
• Numbers within symbols refer to references
Prostate Cancer Center of Seattle
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INTERMEDIATE RISK RESULTS
% PSA Progression Free
Treatment Success
>40 months follow-up or less than 100 patients
100
10459
EBRT + ADT
54 56
33
59 55
66
24 23 13
14
35
79
49
59
92
98
151
34
1544 96
4
57
16
38 58
68 69
1093036 45
10599 77 12
39
83
107
82
97 6106
42 73
3191
108
51
3 72
62 18 6393 43
71
86
81
95
28
74 67 50
150
90
5
92652
19
65
78 70 7
25
103
29
76 102
41
1
60100
48
8 87
85 88 53
2
10101 11
75
46
84
90
80
70
60
89 94
Robot RP
37
+
40
EBRT & Seeds
32
17 27
Seeds + ADT
64
20
Hypo EBRT
Brachy
Seeds Alone
Surgery
EBRT
CRYO
HIFU
HDR
50
← Years from Treatment
→
40
21
80
1
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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
Prostate Cancer Center of Seattle
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INTERMEDIATE RISK RESULTS weighted
Treatment Success
% PSA Progression Free
>40 months follow-up or less than 100 patients
Brachy
100
10459
33
66 55
24 23 13
14
35
79
49
92
98
151
34
1544 96
4
57
16
38 58
68 69
30 36 45
109
99 77
39
83
105 82
107
97 612
42 73
31 91
108
51 106
3 72
62 18 6393 43
71
86
81
95
28
74 67 50
150
90
5
92652
19
65
78 70 7
25
103
29
76 102
41
1
60100
48
8 87
85 88 53
2
10101 11
75
46
84
Robot RP
37
EBRT
90
80
70
60
89 94
20
+
40
32
17 27
64
Surgery
50
← Years from Treatment
→
40
15_01_2013(3)
2
3
4
5
22
6
7
8
Seeds + ADT
EBRT & Seeds
Hypo EBRT
Brachy
Seeds Alone
Surgery
EBRT
CRYO
HIFU
HDR
EBRT, Seeds +
ADT
21
80
1
EBRT + ADT
54 56
9 10 11 12 13 14 15
Protons
• Prostate Cancer Results Study Group
• Numbers within symbols refer to references
Prostate Cancer Center of Seattle
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
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Zelefsky definition
2 or more factors
 Gleason > 7
 PSA 10-20 Clinical Stage T1c- T2b

D'Amico
 Gleason Score 8-10
 PSA >20
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% PSA Progression Free
Treatment Success
HIGH RISK RESULTS
20
19 18
3
8
16
45
109
112 4
108
Surg & ADT
EBRT & ADT
17
40
3 34
9 41
13 36
25
101 113
106
118
EBRT & Seed
112
44
43 32
2
48
1
33 111
21
10 114
12
14
46
28
42
8
110
31
Hypo EBRT
104
24
5
12139 119
115 11 26
76
103
35
37
47
117
Protons
HDR
3011627
107
102 15
105
23 29
← Years from Treatment
→
49
EBRT Seeds +
ADT
Robot RP
• Prostate Cancer Results Study Group
• Numbers within symbols refer to references
15_01_2013(3)
Prostate Cancer Center of Seattle
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HIGH RISK RESULTS
% PSA Progression Free
Treatment Success
Weighted
EBRT, Seeds & ADT
20
Brachy
16
109
45
19 18
3
22
8
112 4
Surg & ADT
EBRT & ADT
108
17
40
3 34
9 41
13 36
25
101 113
106
118
EBRT
EBRT & Seeds
112
44
43 32
2
48
1
33 111
21
10
114
12
14
28
42
8
110
46
31
Hypo EBRT
104
24
5
12139 119
115 11 26
76
103
35
37
47
117
Surgery
3011627
107
102 15
105
HDR
23 29
← Years from Treatment
→
Protons
49
EBRT Seeds +
ADT
Robot RP
• Prostate Cancer Results Study Group
• Numbers within symbols refer to references
15_01_2013(3)
Prostate Cancer Center of Seattle
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HIGH RISK RESULTS
% PSA Progression Free
Treatment Success
>40 months follow-up or less than 100 patients
92 65
81
20
19 18
80
74
78
67
55 40 75
3 85 60
72 54
34
91 66 41
9 7968
71 136436
50
53 25
101
23 62113
106
118
← Years
→
3
22
8
1645
109
112 4
108
Surg & ADT
EBRT & ADT
17
4376
EBRT & Seed
112
57
48 59 10
42
56 1
12 114
8 61
90
110 89
33 111
5
21
14
39
121
70
119 119
11
115
103
83 7 8226
6
35
52 63
84
116
73
31
58 27
77 46
107
86 87
88
102 15
105
51
29
from 69
Treatment
2
28
Hypo EBRT
104
24
117
Protons
30
49
HDR
EBRT Seeds +
ADT
Robot RP
• Prostate Cancer Results Study Group
• Numbers within symbols refer to references
15_01_2013(3)
37
47
32
44
Prostate Cancer Center of Seattle
HIFU
29
HIGH RISK RESULTS
Weighted
>40 months follow-up or less than 100 patients
% PSA Progression Free
Treatment Success
Brachy
92 65
81
20
19 18
80
74
78
67
4075
3 85 60
72 54
91 66 34
941 68
71 13643679
50
53 25
101 113
62 106
118
3
22
8
16 45
109
112 4
108
Surg & ADT
EBRT & ADT
17
55
4376
EBRT & Seed
112
57
48 59 10 114
42
56 1
12
8 61
90
110 89
33 111
5
21
14
39
119
70
11
115
103
83 7 8226
35
6
52 63
84
73
31
30116
58 27
77 46
107
86 87
88
102 15
105
51
23 29
from 69
Treatment
2
28
Hypo EBRT
104
24
EBRT
← Years
→
Protons
HDR
Surgery 49
EBRT Seeds +
ADT
Robot RP
• Prostate Cancer Results Study Group
• Numbers within symbols refer to references
15_01_2013(3)
37
47
32
44
Prostate Cancer Center of Seattle
HIFU
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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
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= 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
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+
= “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
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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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