4/15/2014 1 Peter Grimm, DO Prostate Cancer Center of Seattle Comparing Treatment Results Of PROSTATE CANCER Prostate Cancer Results Study Group 2014
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4/15/2014 1
Peter Grimm, DO Prostate Cancer Center of Seattle
Comparing Treatment Results Of
PROSTATE CANCER
Prostate Cancer Results Study Group
2014
4/15/2014 2
Problem: Patients, physicians and carriers need a simple, unbiased means to compare the cancer control rates of modern prostate cancer treatment methods.
4/15/2014 2
4/15/2014
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
4/15/2014 3
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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
4/15/2014 5
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
4/15/2014 6
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. (*1st & 2nd group)
Some treatment methods are under-
represented due to failure to meet
criteria
ABOUT THIS REVIEW STUDY
4/15/2014 7
“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.
4/15/2014 8
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.
4/15/2014 9
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
4/15/2014 10
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
4/15/2014 10
Criteria for Inclusion of Article*
* Expert panel consensus
4/15/2014 11
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]
4/15/2014 11
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RP
EBRT/
IMRT
Cryo Brachy/
HDR
Robot
RP
Proton HIFU
9% 13% 5.4% 21% 5.3% 24% 8%
28/320 40/302 2/37 64/306 4/76 4/17
3/38
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.
4/15/2014 12
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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 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
27
How to Interpret the Results
4/15/2014 14
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
4/15/2014 15
Low Risk Stage: T1 or T2a,b Gleason Sum < 6 PSA < 10 ng/ml
4/15/2014
BJU Int, 2012, Vol. 109(Supp. 1)
7
5
22
← Years from Treatment →
CRYO
• Prostate Cancer Results Study Group
• Numbers within symbols refer to references
1
12
24
14 8
2
HIFU
% P
SA
Pro
gre
ssio
n F
ree
11
15
Protons
4
18
9
10
EBRT &
Seeds
25
Robot RP 26
Prostate Cancer Center of Seattle
27
HDR
28 29 31
32 33
34
19 36
37
LOW RISK RESULTS T
reatm
ent S
uccess 39
35
40
100
101
13
16
103
102
6
16
104
105
106 107
108
Update of
z
20 109
109
110
111 112
113
114
115
7
3
17
4/15/2014
BJU Int, 2012, Vol. 109(Supp. 1)
17
7
60
70
80
90
100
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Seeds
Surgery
EBRT
5
22
← Years from Treatment →
CRYO
• Prostate Cancer Results Study Group
• Numbers within symbols refer to references
1
12
24
14
8
2
HIFU
% P
SA
Pro
gre
ssio
n F
ree
11
15
Protons
4
18
9
10
EBRT &
Seeds
25
Robot RP
26
Prostate Cancer Center of Seattle
27
HDR
28 29 31
32 33
34
19 36
37
LOW RISK RESULTS Weighted
39
35
40
100
101
13 EBRT
Brachy
Surgery
Tre
atm
ent S
uccess
103
102
6
16
104
105
106 107
108
Update of
20 109
110
111 112
113
114
115
7
3
17
109
4/15/2014 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?”
4/15/2014
BJU Int, 2012, Vol. 109(Supp 1) 19
7
60
70
80
90
100
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Seeds
Surgery
EBRT
5
22
← Years from Treatment →
CRYO
• Prostate Cancer Results Study Group
• Numbers within symbols refer to references
1
12
24
14 8
2
HIFU
% P
SA
Pro
gre
ssio
n F
ree
11
15
Protons
4
18
9
10
EBRT &
Seeds
25
Robot RP 26
Prostate Cancer Center of Seattle
27
HDR
28 29 31
32 33
34
19 36
37
LOW RISK RESULTS
>40 months follow-up or less than 100 patients
Tre
atm
ent S
uccess 39
35
40
41
100
101
13
65
49
76
80
56
59
63
41
75
51
71 72
90
73
74
70
42
57
85 84
66
43 64
44 EBRT &
ADT
53
82 81
62
54
79
Hypo EBRT
86
87
88
45
58
69
78
77
46
48
91
+ Seeds &
ADT
93 89
50
67
68
95 94
55 52 83
47
61
96
103
102
97
98
60 6
16
104
105
106
99
107
108
Update of
20 109
110
201
202
111 112
113
114
7
3
17
203 n
4/15/2014
BJU Int, 2012, Vol. 109(Supp 1) 20
7
60
70
80
90
100
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Seeds
Surgery
EBRT
5
22
← Years from Treatment →
CRYO
• Prostate Cancer Results Study Group
• Numbers within symbols refer to references
1
12
24
14 8
2
HIFU
% P
SA
Pro
gre
ssio
n F
ree
11
15
Protons
4
18
9
10
EBRT &
Seeds
25
Robot RP 26
Prostate Cancer Center of Seattle
27
HDR
28 29 31
32 33
34
19 36
37
38
LOW RISK RESULTS Weighted
>40 months follow-up or less than 100 patients
Tre
atm
ent S
uccess 39
35
40
41
100
101
13
65
49
76
80
56
59
63
41
75
51
71 72
90
73
74
70
42
57
85 84
66
43 64
44 EBRT &
ADT
53
82 81
62
54
79
86
87
88
45
58
69
78
77
46
48
91
+ Seeds &
ADT
93
92
89
50
67
68
95 94
55 52 83
47
61
Brachy EBRT
Surgery
Hypo EBRT
96
103
102
97
98
60 6
16
104
105
106
99
107
108
Update of
20 109
110
201
202
111 112
113
114
115
7
3
17
203
4/15/2014 21
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
4/15/2014
BJU Int, 2012, Vol. 109(Supp 1) 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
22
21
5
% P
SA
Pro
gre
ssio
n F
ree
18
12
28 17
10
9
8 2
1
13
Protons
EBRT & Seeds
HDR
← Years from Treatment
→
• Prostate Cancer Results Study Group
• Numbers within symbols refer to references
15
4 36
Prostate Cancer Center of Seattle
37
EBRT, Seeds +
ADT
38
+
Seeds Alone
Seeds + ADT 40
Robot RP
41
42
44
43
45
46
Hypo EBRT
INTERMEDIATE RISK RESULTS
Tre
atm
ent S
uccess
7
11
14
20
35
34
39
23 24
16
6
26
30 27
47
48
49
150
151
31
Update of
152
152
153
154
155
155
156
157
157
EBRT + ADT
158
159
19
25
32
32 160
160
33
161
156
4/15/2014
BJU Int, 2012, Vol. 109(Supp 1) 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
22
21
5
% P
SA
Pro
gre
ssio
n F
ree
18
12
28
3 17
10
9
8 2
1
13
Protons
HDR
← Years from Treatment
→
• Prostate Cancer Results Study Group
• Numbers within symbols refer to references
15
4 36
37
38
+
Seeds Alone
Seeds + ADT 40
Robot RP
41
42
44
43
45
46
INTERMEDIATE RISK RESULTS Weighted
7
11
14
20
35
34
39
23 24
16
6
26
EBRT & Seeds
EBRT Surgery
Brachy
EBRT & Seeds
Hypo EBRT
EBRT, Seeds +
ADT
Tre
atm
ent S
uccess
Prostate Cancer Center of Seattle
30
27
47
48
49
150
151
31
Update of
152
152
153
154
155
155
156
157
158
159
19
25
32
32 160
160
33
161 156
Favorable ▪ Single feature
▪ Gleason 3+4=7
▪ < 50% of biopsy cores +
Unfavorable
All other Intermediate
4/15/2014 24
*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
4/15/2014
BJU Int, 2012, Vol. 109(Supp 1) 25
29
22
21
5
% P
SA
Pro
gre
ssio
n F
ree
18
12
28
3 17
10
9
8 2
1
13
Protons
HDR
← Years from Treatment
→
• Prostate Cancer Results Study Group
• Numbers within symbols refer to references
15
4 36
37
38
+
Seeds Alone
Seeds + ADT 40
Robot RP
41
42
44
43
45
46
INTERMEDIATE RISK Favorable Vs Unfavorable* Weighted
7
11
14
20
35
34
39
23 24
16
6
26
EBRT & Seeds
EBRT Surgery
Brachy
EBRT & Seeds
Hypo EBRT
EBRT, Seeds +
ADT
Tre
atm
ent S
uccess
Prostate Cancer Center of Seattle
30
27 47
48
49
150
151
31
Update of
152
152
153
154
155
155
156
157
158
159
19
25
32
32
F33
U33
160
160
156
4/15/2014
BJU Int, 2012, Vol. 109(Supp 1) 26
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
22
21
5
% P
SA
Pro
gre
ssio
n F
ree
18
12
28
3 17
10
9
8 2
1
13
Protons
EBRT & Seeds
HDR
← Years from Treatment
→
• Prostate Cancer Results Study Group
• Numbers within symbols refer to references
15 4
36
Prostate Cancer Center of Seattle
37
EBRT, Seeds +
ADT
38
+
Seeds Alone
Seeds + ADT 40
Robot RP
41
42
44
43
45
46
INTERMEDIATE RISK RESULTS >40 months follow-up or less than 100 patients
Tre
atm
ent S
uccess
7
11
14
20
35
34
39
23 24
16
6
26
82
66
88
67
70
97
63
65
102 103
101
86
87 85
58 68
71 81 50
EBRT + ADT
94
93
92
77
91 51
69
Hypo EBRT
99
75
90
89
56
55
54
80
57
83
60
73
72
98
53
52
79
95
64
100
84
78
59
62
74
96
76
104 59
59
105
30
27
47
48
49
150
151
106 107
31
109
108
Update of
152
152
153
154
155
155
156
11
0
157
158
159
19
25
32
32 160
160
33
161
156
4/15/2014
BJU Int, 2012, Vol. 109(Supp 1) 27
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
22
21
5
% P
SA
Pro
gre
ssio
n F
ree
18
12
28
3 17
10
9
8 2
1
13
Protons
HDR
← Years from Treatment
→
• Prostate Cancer Results Study Group
• Numbers within symbols refer to references
15 4
36
Prostate Cancer Center of Seattle
37
38
+
Seeds Alone
Seeds + ADT 40
Robot RP
41
42
44
43
45
46
INTERMEDIATE RISK RESULTS weighted
>40 months follow-up or less than 100 patients
7
11
14
20
35
34
39
23 24
16
6
26
82
66
88
67
70
97
63
65
102 103
101
86
87 85
58 68
71 81 50
EBRT + ADT
94
93
92
77
91 51
69
Hypo EBRT
99
75
90
89
56
55
54
80
57
83
60
73
72
98
53
52
79
95
64
100
84
78
59
62
74
96
76
EBRT
Brachy
Surgery
EBRT & Seeds
EBRT, Seeds +
ADT
Tre
atm
ent S
uccess
104
105
30
27
47
48
49
150
151
107 31
109
108
Update of
152
152
153
154
155
155
156
11
0
157
158
159
19
25
32
160
161
156
4/15/2014 28
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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BJU Int, 2012, Vol. 109(Supp 1) 29
6
11
25
15
5
EBRT Seeds +
ADT
19
30
16 20
18
29
% P
SA
Pro
gre
ssio
n F
ree
17
21
8 24
26
37
41
12
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
42
43
46
47
Robot RP
48
49
101
102
103
104
105
106
Hypo EBRT
107
109
HIGH RISK RESULTS T
reatm
ent S
uccess
23
35
108
4
2
39
33
34
7
1
110
27
3
13
14
28
40
10
111
112
113
114
115
Surg & ADT
116
118
117
119 121
122
Hypo EBRT
+ADT
123
124
120 120
HDR + ADT
120
Update of
125
125
126
127
128
130
131
Surg & EBRT
132 133
9
32
32
36
36
44
31
45
134
135
136
136
9
22
112
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BJU Int, 2012, Vol. 109(Supp 1) 30
6
11
25
15
5
EBRT Seeds +
ADT
19
30
16 20
18
29 % P
SA
Pro
gre
ssio
n F
ree
17
21
8
22
24
26
37
41
12
Protons
HDR
← Years from Treatment
→
• Prostate Cancer Results Study Group
• Numbers within symbols refer to references
Prostate Cancer Center of Seattle
42
43
46
47
Robot RP
48
49
101
102
103
104
105
106
107
109
HIGH RISK RESULTS Weighted
23
35
108
4
2
39
33
34
EBRT, Seeds & ADT
Brachy
EBRT Surgery
EBRT & ADT
EBRT & Seeds
Hypo EBRT
Tre
atm
ent S
uccess
1
7
110
27
3
13
14
28
40
10
111
112
112
113
114
115
116
Surg & ADT
118
117
119 121
HDR + ADT
122
123
124
120 120
Update of
125
125
126
127
128
130
131
132
Surg & EBRT
133 9
32
32
36
36
44
31
45
134
135
136
136
9
4/15/2014
BJU Int, 2012, Vol. 109(Supp 1) 31
6
11
25
15
5
EBRT Seeds +
ADT
19
30
16 20
18
29 % P
SA
Pro
gre
ssio
n F
ree
17
21
8 24
26
37
41
12
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
42
43
46
47
Robot RP
48
49
101
102
103
104
105
106
Hypo EBRT
107
109
HIGH RISK RESULTS >40 months follow-up or less than 100 patients
Tre
atm
ent S
uccess
35
108
4
2
39
33
34
50
51
52
53
54
55
HIFU
56
86 87
57
58
59
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
88
79
80
81
89
84
83 82
85
1
7
90
91
110
27
3
13
14
28
40
92
10
23 111
112
112
113
114
115
116
Surg & ADT
118
117 119 119 121
60
122
123
124
120 120
HDR + ADT
Update of
125
125
93 126
127
128
94
95
96
97 98
130
131
132
Surg & EBRT
133 9
32
32
36
36
44
31
45
134
135
99
136
136
22
9
4/15/2014
BJU Int, 2012, Vol. 109(Supp 1) 32
6
11
25
15
5
19
30
16 20
18
29 % P
SA
Pro
gre
ssio
n F
ree
17
21
8
22
24
26
37
41
12
Protons
← Years from Treatment
→
• Prostate Cancer Results Study Group
• Numbers within symbols refer to references
42
43
46
47
48
49
101
102
103
104
105
106
107
109
HIGH RISK RESULTS Weighted
>40 months follow-up or less than 100 patients
Tre
atm
ent S
uccess
10
23
35
108
4
2
39
33
34
50
51
52
53
54
55
HIFU
56
86 87
57
58
59
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
88
79
80
81
89
84
83 82
85
Surgery
Brachy
EBRT
EBRT & ADT
EBRT & Seeds
Hypo EBRT
HDR
EBRT Seeds +
ADT
Robot RP
Prostate Cancer Center of Seattle
1
7
90
91
110
27
3
13
14
28
40
92
111
112
112
113
114
115
116
Surg & ADT
118 119
60
122
123
123
124
120
HDR + ADT
Update of
125
125
93 126
127
128
94
95
96 98
130
131
132
Surg & EBRT
133 9
32
32
36
36
44
31
45
134
135
99
136
136
9
4/15/2014 33
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
4/15/2014 33
OBSERVATIONS
4/15/2014 34
= 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
4/15/2014 35
= “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
+
4/15/2014 36
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
Low Risk Stage: T1 or T2a,b Gleason Sum < 6 PSA < 10 ng/ml
4/15/2014 37
Peter Grimm, DO
Lisa Grimm, Research Coordinator
Or ProstateCancerTC.com
Or contact PCRSG member Prostate Cancer Center of Seattle website
www.Prostatecancertreatmentcenter.com
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