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Peter Grimm, DOProstate Cancer Center of Seattle
Comparing Treatment Results Of PROSTATE CANCER
Prostate Cancer Results Study Group 2012
11/04/14 2
Problem: Patients need a simple 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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21,000+ prostate studies were published between 2000 and 2011
917 of those studies featured treatment results
145 of those met the criteria to be included in this review study.
Some treatment methods are under-represented due to failure to meet criteria
ABOUT THIS REVIEW STUDY
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“Will I be cured?” or “Will my treatment make me cancer free?” are valid patient questions. However, PSA numbers (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 prostatectomyRobot RP = Robotic Radical ProstatectomyHIFU = High frequency Ultrasound Cryo= Cryotherapy Protons = form of External Radiation using ProtonsEBRT= External Beam Radiation Therapy ADT= Hormone Therapy
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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
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Criteria for Inclusion of Article*
* 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] 11/04/14 11
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RP
EBRT/IMRT
Cryo Brachy/HDR
Robot RP
Proton HIFU
7.4% 10% 16% 19% 3.2% 23% 3%
20/272 26/241 2/32 44/236 2/62 3/13 1/31
Total of 917 Treatment Articles. Some articles addressed several treatments and were counted as separate articles for each treatment.
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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.
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
27 27
How to Interpret the Results
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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.
How to Interpret the Results
*Next Slide
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Low Risk Low Risk Stage: T1 or T2a,b Stage: T1 or T2a,b Gleason Sum Gleason Sum << 6 6 PSA PSA << 10 ng/ml 10 ng/ml
11/04/14BJU Int, 2012, Vol. 109(Supp. 1)
77
60
70
80
90
100
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Seeds
Surgery
EBRT
5 5
22 22
← Years from Treatment →
CRYO
• Prostate Cancer Results Study Group • Numbers within symbols refer to references
11
12 12 24 24
14 14
8 8
22
23 23
HIFU
% P
SA
Progression F
ree
1111
1515
Protons
21 21
4 4
1818
9 9
10 10
EBRT & Seeds
2525
Robot RP 26 26
Prostate Cancer Center of Seattle
27 27
HDR
28282929
3030
313132323333
34 34
1919 36 36
37 37
3838
LOW RISK RESULTST
reatment S
uccess
3 3 3939
35
4040
100100
101101
1313
16
103103
102 102
66
16 16
104104
105105
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17
77
60
70
80
90
100
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Seeds
Surgery
EBRT
5 5
22 22
← Years from Treatment →
CRYO
• Prostate Cancer Results Study Group • Numbers within symbols refer to references
11
12 12 24 24
14 14
8 8
22
23 23
HIFU
% P
SA
Progression F
ree
1111
1515
Protons
21 21
4 4
1818
9 9
10 10
EBRT & Seeds
2525
Robot RP
26 26
Prostate Cancer Center of Seattle
27 27
HDR
28282929
3030
313132323333
34 34
1919 36 36
37 37
3838
LOW RISK RESULTS Weighted
3 3 3939
35
4040
100100
101101
1313EBRT
Brachy
Surgery
Tre
atm
ent
Suc
cess
103103
102 102
66
16 16
104104
105105
11/04/14 18
“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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77
60
70
80
90
100
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Seeds
Surgery
EBRT
5 5
22 22
← Years from Treatment →
CRYO
• Prostate Cancer Results Study Group • Numbers within symbols refer to references
11 12 12
24 24
14 14 8 8
22
23 23
HIFU
% P
SA
Progression F
ree
1111
1515
Protons
21 21
4 4
1818
9 9
10 10
EBRT & Seeds
2525
Robot RP 26 26
Prostate Cancer Center of Seattle
27 27
HDR
28282929
3030
31 3132323333
34 34
1919 36 36
37 37
3838
LOW RISK RESULTS >40 months follow-up or less than 100 patients
Treatm
ent Success
3 3 3939
35
4040
4141
100100
101101
1313
6565
4949
7676
8080
5656
59 59
63 63
4141
75 75
51 51
71717272
90 90
7373
7474
7070
4242
5757
85 858484
6666
43436464
44 44EBRT & ADT
5353
82828181 6262
5454
7979
Hypo EBRT
86 86
8787
8888
4545
5858
6969
78787878
77 77
46464646
48484848
91 91
++ Seeds & ADT
93938989
5050
6767
68 68
95959494
555552525252
838383834747
6161
96 96
103103
102 102
97 97
989860 60 66
16 16
104104
105105
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20
77
60
70
80
90
100
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Seeds
Surgery
EBRT
5 5
22 22
← Years from Treatment →
CRYO
• Prostate Cancer Results Study Group • Numbers within symbols refer to references
11 12 12
24 24
14 14 8 8
22
23 23
HIFU
% P
SA
Progression F
ree
1111
1515
Protons
21 21
4 4
1818
9 9
10 10
EBRT & Seeds
2525
Robot RP 26 26
Prostate Cancer Center of Seattle
27 27
HDR
28282929
3030
31 3132323333
34 34
1919 36 36
37 37
3838
LOW RISK RESULTS Weighted
>40 months follow-up or less than 100 patients
Treatm
ent Success
3 3 3939
35
4040
4141
100100
101101
1313
6565
4949
7676
8080
5656
59 59
63 63
4141
75 75
51 51
71717272
90 90
7373
7474
7070
4242
5757
85 858484
6666
43436464
44 44EBRT & ADT
5353
82828181 6262
5454
7979
86 86
8787
8888
4545
5858
6969
78787878
77 77
46464646
48484848
91 91
++ Seeds & ADT
9393
9292
8989
5050
6767
68 68
95959494
555552525252
838383834747
6161
BrachyEBRT
Surgery
Hypo EBRT
96 96
103103
102 102
97 97
9898
60 60 66
16 16
104104
105105
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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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22
40
50
60
70
80
90
100
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Brachy
Surgery
EBRT
CRYO
HIFU
29 29
2222
2121
5 5 1919
% P
SA
Progression F
ree
1818
12 12
2828
3 3 17 17
10 10
32 32
99
88 2 2
2525
1 1
13 13
Protons
EBRT & Seeds
HDR
← Years from Treatment →
• Prostate Cancer Results Study Group • Numbers within symbols refer to references
1515
443636
Prostate Cancer Center of Seattle
37 37
EBRT, Seeds + ADT
3838
++
Seeds Alone
Seeds + ADT40 40
Robot RP
4141
42 42
44 44
4343
4545
46 46
Hypo EBRT
INTERMEDIATE RISK RESULTST
reatment S
uccess
77
11 11
14 14
2020
35 35
34 34
39 39
23232424
1616
66
2626
3333
3030
27 27 47 47
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23
40
50
60
70
80
90
100
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Brachy
Surgery
EBRT
CRYO
HIFU
29 29
2222
2121
5 5 1919
% P
SA
Progression F
ree
1818
12 12
2828
3 3 17 17
10 10
32 32
99
88 2 2
2525
1 1
13 13
Protons
HDR
← Years from Treatment →
• Prostate Cancer Results Study Group • Numbers within symbols refer to references
1515
443636
37 37
3838
++
Seeds Alone
Seeds + ADT40 40
Robot RP
4141
42 42
44 44
4343
4545
46 46
INTERMEDIATE RISK RESULTS Weighted
77
11 11
14 14
2020
35 35
34 34
39 39
23232424
1616
66
2626
3333
EBRT & Seeds
EBRT Surgery
Brachy
EBRT & Seeds
Hypo EBRT
EBRT, Seeds + ADT
Tre
atm
ent
Suc
cess
Prostate Cancer Center of Seattle
3030
27 27 47 47
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40
50
60
70
80
90
100
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Brachy
Surgery
EBRT
CRYO
HIFU
29 29
2222
2121
5 5 1919
% P
SA
Progression F
ree
1818
12 12
2828
3 3 17 17
10 10
32 32
99
88 2 2
2525
1 1
13 13
Protons
EBRT & Seeds
HDR
← Years from Treatment →
• Prostate Cancer Results Study Group • Numbers within symbols refer to references
151544
3636
Prostate Cancer Center of Seattle
37 37
EBRT, Seeds + ADT
3838
++
Seeds Alone
Seeds + ADT40 40
Robot RP
4141
42 42
44 44
4343
4545
46 46
INTERMEDIATE RISK RESULTS>40 months follow-up or less than 100 patients
Treatm
ent Success
77
11 11
14 14
2020
35 35
34 34
39 39
23232424
1616
6 6
2626
3333
8282
6666
8888
6767
7070
9797
6363
6565
102102103103
101 101
8686
87878585
58586868
717181815050
EBRT + ADT
9494
9393
9292
7777
919151
6969
Hypo EBRT99 99
7575
9090
8989
5656
5555
5454
8080
5757
8383
60 60
7373
7272
9898
5353
5252
7979
9595
6464
100100
8484
7878
5959
62 62
7474
9696
7676
1041045959
5959
1051053030
27 27 47 47
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25
40
50
60
70
80
90
100
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Brachy
Surgery
EBRT
CRYO
HIFU
29 29
2222
2121
5 5 1919
% P
SA
Progression F
ree
1818
12 12
2828
3 3 17 17
10 10
32 32
99
88 2 2
2525
1 1
13 13
Protons
HDR
← Years from Treatment →
• Prostate Cancer Results Study Group • Numbers within symbols refer to references
151544
3636
Prostate Cancer Center of Seattle
37 37
3838
++
Seeds Alone
Seeds + ADT40 40
Robot RP
4141
42 42
44 44
4343
4545
46 46
INTERMEDIATE RISK RESULTS weighted
>40 months follow-up or less than 100 patients
77
11 11
14 14
2020
35 35
34 34
39 39
23232424
1616
6 6
2626
3333
8282
6666
8888
6767
7070
9797
6363
6565
102102103103
101 101
8686
87878585
58586868
717181815050
EBRT + ADT
9494
9393
9292
7777
919151
6969
Hypo EBRT99 99
7575
9090
8989
5656
5555
5454
8080
5757
8383
60 60
7373
7272
9898
5353
5252
7979
9595
6464
100100
8484
7878
5959
62 62
7474
9696
7676
EBRT
Brachy
Surgery
EBRT & Seeds
EBRT, Seeds +ADT
Tre
atm
ent
Suc
cess
104104
1051053030
27 27 47 47
11/04/14 26
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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27
66 11 11
3636
25 25
15 15
55
EBRT Seeds +ADT
19 19
3030
16 16 20 20
18 18
2929% P
SA
Progression F
ree
17
21 21
88
99
22 22
24 24
26 26
37 37
4141
1212
Protons
EBRT & Seeds
HDR
EBRT & ADT
← Years from Treatment →
• Prostate Cancer Results Study Group • Numbers within symbols refer to references
Prostate Cancer Center of Seattle
4242
43 43
4444
45 45
4646
47 47
Robot RP
48 48
4949
101101
102102
103103
104 104
105 105
106106
Hypo EBRT
107 107
109 109
HIGH RISK RESULTST
reatment S
uccess
10 10
2323
3535
108 108 44
22
3131
3939
3232
3333
3434
38
77
11
110110
2727
33
1313
1414
28 28
4040
11/04/14BJU Int, 2012, Vol. 109(Supp 1)
28
66 11 11
3636
25 25
15 15
55
EBRT Seeds +ADT
19 19
3030
16 16 20 20
18 18
2929% P
SA
Progression F
ree
17
21 21
88
99
22 22
24 24
26 26
37 37
4141
1212
Protons
HDR
← Years from Treatment →
• Prostate Cancer Results Study Group • Numbers within symbols refer to references
Prostate Cancer Center of Seattle
4242
43 43
4444
45 45
4646
47 47
Robot RP
48 48
4949
101101
102102
103103
104 104
105 105
106106
107 107
109 109
HIGH RISK RESULTSWeighted
10 10
2323
3535
108 108 44
22
3131
3939
3232
3333
3434
38
EBRT, Seeds & ADTBrachy
EBRT Surgery
EBRT & ADT
EBRT & Seeds
Hypo EBRT
Tre
atm
ent
Suc
cess
11
77
110110
2727
33
1313
1414
28 28
4040
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29
66 11 11
3636
25 25
15 15
55
EBRT Seeds +ADT
19 19
3030
16 16 20 20
18 18
2929% P
SA
Progression F
ree
17
21 21
88
99
22 22
24 24
26 26
37 37
4141
1212
Protons
EBRT & Seeds
HDR
EBRT & ADT
← Years from Treatment →
• Prostate Cancer Results Study Group • Numbers within symbols refer to references
Prostate Cancer Center of Seattle
4242
43 43
4444
45 45
4646
47 47
Robot RP
48 48
4949
101101
102102
103103
104 104
105 105
106106
Hypo EBRT
107 107
109 109
HIGH RISK RESULTS>40 months follow-up or less than 100 patients
Treatm
ent Success
10 10
2323
3535
108 108 44
22
3131
3939
3232
3333
3434
38
5050
5151
5252
53
5454
55
HIFU
5656
8686 8787
57
5858
5959
6060
6161
6262
6363
6464
65
6666
6767
6868
6969
7070
7171
7272
7373
74
7576
77
78
8888
79
80
81
8989
8484
8383 8282
85
11
77
9090
9191
110110
2727
33
1313
1414
28 28
4040
9292
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30
66
11 11
3636
25 25
15 15
55
19 19
3030
16 16 20 20
18 18
2929% P
SA
Progression F
ree
17
21 21
88
99
22 22
24 24
26 26
37 37
4141
1212
Protons
← Years from Treatment →
• Prostate Cancer Results Study Group • Numbers within symbols refer to references
4242
43 43
4444
45 45
4646
47 47
48 48
4949
101101
102102
103103
104 104
105 105
106106
107 107
109 109
HIGH RISK RESULTS Weighted
>40 months follow-up or less than 100 patients
Treatm
ent Success
10 10
2323
3535
108 108 44
22
3131
3939
3232
3333
3434
38
5050
5151
5252
53
5454
55
HIFU
5656
8686 8787
57
5858
5959
6060
6161
6262
6363
6464
65
6666
6767
6868
6969
7070
7171
7272
7373
74
7576
77
78
8888
79
80
81
8989
8484
8383 8282
85
Surgery
Brachy
EBRT
EBRT & ADT
EBRT & Seeds
Hypo EBRT
HDR
EBRT Seeds +ADT
Robot RP
Prostate Cancer Center of Seattle
11
77
9090
9191
110110
2727
33
1313
1414
28 28
4040
9292
11/04/14 31
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
11/04/14 31
OBSERVATIONS
11/04/14 32
= 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
11/04/14 33
= “CRYO” Cryo Therapy = EBRT, Seeds, & ADT = Seeds & ADT= EBRT & ADT = “Brachy” = all seed implant treatments = all Surgery treatments= all EBRT treatments= all EBRT & Seeds= all EBRT, Seeds & ADT
++
11/04/14 34
Intermediate Risk Intermediate Risk Stage T1 or T1-2 Stage T1-2 Stage T1 or T1-2 Stage T1-2
Gleason Score 7 or Gleason 6Gleason Score 7 or Gleason 6PSA < 10 PSA 10-20PSA < 10 PSA 10-20
High Risk High Risk Stage T2c or T3 Gleason score ≥ 8 PSA > 20 ng/mL
Low Risk Low Risk Stage: T1 or T2a,b Stage: T1 or T2a,b Gleason Sum Gleason Sum << 6 6 PSA PSA << 10 ng/ml 10 ng/ml
11/04/14 35
Peter Grimm, DO [email protected]
Lisa Grimm, Research Coordinator [email protected] Or ProstateCancerTC.com
Or contact PCRSG member Prostate Cancer Treatment Center website
www.Prostatecancertreatmentcenter.com
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