PROSTATE CANCER:PROSTATE CANCER:RADIATION THERAPYRADIATION THERAPY

APPROACHESAPPROACHESANDREW L. SALNER, MD FACRANDREW L. SALNER, MD FACR

DIRECTORDIRECTORHELEN & HARRY GRAY CANCER CENTERHELEN & HARRY GRAY CANCER CENTER

HARTFORD HOSPITAL, CTHARTFORD HOSPITAL, CT

ARS

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Conventional external beam

Conformal external beam

High-dose conformal

Brachytherapy

Brachytherapy/external beam

Any of the above withandrogen deprivation or chemotherapy

3-D

IMRT

Proton

Ultra-high-doseHigh dose rate

Low dose rate

CHOICES!!!

ProstateConformal therapyConventional therapy

Constraints: Volume rectumVolume of bladderHips

Conformal radiation therapy

Why IMRT?Why IMRT?

TreatedVolume

Tumor TumorTargetVolume

Intensity Modulation

TreatedVolume

Criticalstructure

Target Volume

Collimator

"Classical" Conformation

Criticalstructure

Answer: great for treating donuts and bananas

IMRT

Fontenot, MDACC, IJROBP 2009

Percent of Rectal wall Percent of Rectal wall receiving high doses of receiving high doses of

radiationradiation

0

10

20

30

40

50

60

50 Gray 60 Gray 70 Gray

IMRT3D CRT

Plans run on 23 patients with prostate cancer

Tufts, NEMC

TomotherapyTomotherapy

Contemporary prostate brachytherapy:Trans-perineal approach

HIGH DOSE RATE “TEMPORARY” BRACHYTHERAPY

Quality of life after treatment for early-stage prostate cancer

Talcott et al 2003

Prospective studyBrachytherapyn = 80 Median age 64 years

Max score 100Min score 0

Quality of life after treatment for early-stage prostate cancer

Talcott et al 2003

Prospective studyExternal beam radiationN = 182 Median age 69 years

Max score 100Min score 0

Radiation Therapy ApproachesRadiation Therapy Approaches

Many optionsMany options Must be tailored to meet patient needsMust be tailored to meet patient needs Highly conformal resulting in:Highly conformal resulting in:

Better tumor controlBetter tumor control Fewer side effectsFewer side effects

Comparable to other therapies over 10-15 Comparable to other therapies over 10-15 yearsyears

THANK YOUTHANK YOU

Prostate Cancer Treatment: What’s Best for You

Daniel P. PetrylakProfessor of Medicine

Columbia University Medical Center/NY Presbyterian Hospital

When does a patient see a medical oncologist

• Local disease: As “unbiased” opinion for local therapy

• High Risk Disease: Add hormone or chemotherapy to decrease risk of relapse

• Metastatic disease: Initiation of second line hormones, chemotherapy, radiation therapy

High-Risk CAP: The Options• Surgery

– Standard RP, wide/extended resection RP

– Hormone therapy: NHT, AHT

– ART

– Chemotherapy: Neoadjuvant, adjuvant

• RT

– EBRT with NHT and/or AHT

– Dose escalation

– EBRT with chemohormonal therapy

– Other RT techniques

• HT alone

• New therapies

NHT = neoadjuvant hormone therapy; AHT = adjuvant hormone therapy; ART = adjuvant radiotherapy.Payne, 2009.

Challenges for the Implementation of Multimodality Therapy

• High risk local therapy– Role of chemotherapy not defined– Investigational studies require long follow-

up due to the natural history of disease– By selecting the highest risk patients,

reduce the available patient pool • Clinical trial accrual has been poor.