Making Treatment Decisions for Prostate Cancer

Robert Miller MDwww.aboutcancer.com

Treating prostate cancer

Surgery?

Radiation?

Or Watchful Waiting?

Choices with Prostate Cancer

1. 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 y2. Low Risk and life expectancy < 10 y

Very Low Recurrence Risk

1. Stage T1c

2. Gleason 6 or lower

3. 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)

Low Recurrence Risk

1. Stage T1 – T2a

2. Gleason 6 or lower

3. PSA < 10

Median Life Expectancy in Men by Health (poor, average or excellent)

Age Expectancy

50 29

55 25

60 21

65 17

70 14

75 11

80 7.9

85 5.7

Life Tables for Men in the US (2007 data)

Watchful Waiting? Mortality if Untreated

Gleason Score Death by 15 Years

2 – 4 4 – 7%

5 6 – 11%

6 18 – 30%

7 42 – 70%

8 – 10 60 – 87%

Watchful Waiting, the odds that untreated prostate cancer would cause death related to the age and the Gleason Score

Laparoscopic Prostate Surgery

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

NCCN.org

Prostate Cancer Risk Groups combine all 3 things, the stage, the PSA 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 Surgery for 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)

Mayo Clinic Study (Cancer Jan 10, 2011)

Treatment Number Cure Rate

Radical Prostatectomy

1,238 92%

Radiation plus Hormones

344 92%

Radiation 265 88%

External beam > 72Gy

External beam < 72Gy

Surgery or Seeds

Prostate Cures Rates by Treatment

Months

IJROBP 2004; 58:25

Years

Prostate Cancer Relapse Rate by Radiation Dose

< 72Gy

72 - 82Gy

82Gy

Kupelian. IJROBP 2008:71:16

Cure Rates for High Risk Prostate Cancer

Months

IJROBP 2006;66:1092

Seeds alone

Surgery

Hormones + External + Seeds

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 movements

3% 10%

J Clin Oncol 14 (8): 2258-65, 1996

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 2002:54:1063

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 surgery from 2% to 70%)

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 External Radiation can range from 16% to 92%

Patient Age? Race? Obese or thin? How good was their sexual function

before?

Potency Results after Seeds can range from 6% to 98%

Potency Results after Seeds range from 6% to 98%

Responded to Viagra

Surgery: 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 procedure

Experienced Radiation Oncologist with Modern Technology (IGIMRT) and good outcome data

The experience of the surgeon is a critical factor associated with a successful outcome

Open prostatectomy the learning curve did not plateau until a surgeon had performed at least 250 retropubic radical prostatectomies The probability of biochemical recurrence at five years was significantly lower (10.7 versus 17.9 percent)

Minimally invasive prostatectomy – In a series of 4,702 men who were managed with laparoscopic prostatectomy by one of 29 surgeons at seven centers,

the five-year risk of recurrence progressively decreased with increasing experience (17, 16, and 9 percent with 10, 250, and 750 prior laparoscopic procedures) 

Understanding Prostate Cancer

Robert Miller MDwww.aboutcancer.com