04/10/23 1
Peter Grimm, DOProstate Cancer Center of Seattle
Comparing Treatment Results Of PROSTATE CANCER
Prostate Cancer Results Study Group 2013
04/10/23 2
Problem: Patients, physicians and carriers need a simple, unbiased means to compare the cancer control rates of modern prostate cancer treatment methods.
04/10/23 2
04/10/23
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
04/10/23 3
04/10/23 4
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
04/10/23 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
04/10/23 6
25,000+ prostate studies were published between 2000 and 2012
1,066 of those studies featured treatment results
218 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
04/10/23 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.
04/10/23 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.
04/10/23 9
Brachy = Seed implantation, either permanent or
temporary seedsEBRT= External Beam Radiation Therapy
(includes IMRT- Intensity Modulated Radiation) RP = Standard open radical prostatectomyRobot RP = Robotic Radical ProstatectomyHIFU = High frequency Ultrasound Cryo= Cryotherapy Protons = form of External Radiation using
ProtonsADT= Hormone Therapy
04/10/23 10
1. Patients should be separated into Low, Intermediate, and High Risk groups
2. Success must be determined by PSA analysis
3. All Treatment types considered: Seeds (Brachy), Surgery (Standard or Robotic), EBRT (External beam radiation therapy & IMRT (Intensity Modulated Radiation therapy), HIFU (High Frequency Ultrasound), CRYO (Cryo Therapy), Protons, HDR (High dose Rate Brachytherapy)
4. Article must be in a Peer Reviewed Journal
04/10/23 10
Criteria for Inclusion of Article*
* Expert panel consensus
04/10/23 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]
04/10/23 11
04/10/23 12
RP
EBRT/IMRT
Cryo Brachy/HDR
Robot RP
Proton HIFU
9% 12% 6% 20% 6% 25% 3%
26/303 34/284 2/34 60/299 4/70 4/16 1/36
Total of 1,066 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.
04/10/23 12
04/10/23 13
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 reference number. The article references can be found in the notes section below the slides (Click on the “view” tab in upper left corner of PowerPoint and select notes page, you can then scroll down to see all the references below the graphs)
Treatment Success % = Percent of men, whose PSA numbers indicate no cancer progression (progression free) at a specific point in time
The bottom line of the graph indicates the number of years the study is out. An example, the blue dot with #27 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
04/10/23 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 (cont.)
*Next Slide
04/10/23 15
Low Risk Low Risk Stage: T1 Stage: T1 or T2a,b or T2a,b Gleason Gleason Sum Sum << 6 6 PSA PSA << 10 10 ng/mlng/ml
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77
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
HIFU
% P
SA
Pro
gres
sion
Fre
e
1111
1515
Protons
4 4
1818
9 9
10 10
EBRT & Seeds
2525
Robot RP 26 26
Prostate Cancer Center of Seattle
27 27
HDR
28282929313132323333
34 34
1919 36 36
37 37
LOW RISK RESULTST
reat
men
t S
ucce
ss
3939
35
4040
100100
101101
1313
16
103103
102 102
66
16 16
104104
105105
106106107107
108 108
Update of z
2020109109
109109
110110
111111111111112 112
113 113
114 114
115 115
04/10/23BJU Int, 2012, Vol. 109(Supp. 1)
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
HIFU
% P
SA
Pro
gres
sion
Fre
e
1111
1515
Protons
4 4
1818
9 9
10 10
EBRT & Seeds
2525
Robot RP
26 26
Prostate Cancer Center of Seattle
27 27
HDR
28282929313132323333
34 34
1919 36 36
37 37
LOW RISK RESULTS Weighted
3939
35
4040
100100
101101
1313EBRT
Brachy
Surgery
Tre
atm
ent
Suc
cess
103103
102 102
66
16 16
104104
105105
106106107107
108 108
Update of
2020109109
110110
111 111 112 112
113 113
114 114
115 115
04/10/23 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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19
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
HIFU
% P
SA
Pro
gres
sion
Fre
e
1111
1515
Protons
4 4
1818
9 9
10 10
EBRT & Seeds
2525
Robot RP 26 26
Prostate Cancer Center of Seattle
27 27
HDR
28282929 31 3132323333
34 34
1919 36 36
37 37
LOW RISK RESULTS >40 months follow-up or less than 100 patients
Tre
atm
ent
Suc
cess
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
83838383
47476161
96 96
103103
102 102
97 97
989860 60 66
16 16
104104
105105
106106
9999
107107
108 108
Update of
2020109109
110110
201201
202 202
111 111 112 112
113 113
114 114
04/10/23BJU Int, 2012, Vol. 109(Supp 1)
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
HIFU
% P
SA
Pro
gres
sion
Fre
e
1111
1515
Protons
4 4
1818
9 9
10 10
EBRT & Seeds
2525
Robot RP 26 26
Prostate Cancer Center of Seattle
27 27
HDR
28282929 31 3132323333
34 34
1919 36 36
37 37
3838
LOW RISK RESULTS Weighted
>40 months follow-up or less than 100 patients
Tre
atm
ent
Suc
cess
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
83838383
47476161
BrachyEBRT
Surgery
Hypo EBRT
96 96
103103
102 102
97 97
9898
60 60 66
16 16
104104
105105
106106
9999
107107
108 108
Update of
2020109109
110110
201201
202 202
111 111 112 112
113 113
114 114
115 115
04/10/23 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
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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
% P
SA
Pro
gres
sion
F
ree
1818
12 12
2828 17 17
10 10
99
88 2 2 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
reat
men
t S
ucce
ss
77
11 11
14 14
2020
35 35
34 34
39 39
23232424
1616
66
2626
3030
27 27 47 47
48 48
49 49
150150
151151
31 31
Update of
152152
152152
153153
154154155155
155155
156156
157 157
157 157
EBRT + ADT
158 158
159 159
04/10/23BJU 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 29
2222
2121
5 5
% P
SA
Pro
gres
sion
F
ree
1818
12 12
2828
3 3 17 17
10 10
99
88 2 2 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
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
48 48
49 49
150150
151151
31 31
Update of
152152
152152
153153
154154155155
155155
156156
157 157
158 158
159 159
04/10/23BJU Int, 2012, Vol. 109(Supp 1)
24
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
% P
SA
Pro
gres
sion
F
ree
1818
12 12
2828
3 3 17 17
10 10
99
88 2 2 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
Tre
atm
ent
Suc
cess
77
11 11
14 14
2020
35 35
34 34
39 39
23232424
1616
6 6
2626
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
95956464
100100
8484
7878
5959
62 62
7474
9696
7676
1041045959
5959
1051053030
27 27 47 47
48 48
49 49
150150
151151
106106 107 107 31 31
109109
108108
Update of
152152
152152
153153
154154155155
155155
156156
11
0 1
10
157 157
158 158
159 159
04/10/23BJU Int, 2012, Vol. 109(Supp 1)
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
% P
SA
Pro
gres
sion
F
ree
1818
12 12
2828
3 3 17 17
10 10
99
88 2 2 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
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
95956464
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
48 48
49 49
150150
151151
106\\\\\\0\\\\\106\\\\\\0\\\\\ 107 107 31 31
109109
108108
Update of
152152
152152
153153
154154155155
155155
156156
11
0 1
10
157 157
158 158
159 159
04/10/23 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
25 25
15 15
55
EBRT Seeds +ADT
19 19
3030
16 16 20 20
18 18
2929
% P
SA
Pro
gres
sion
Fre
e
17
21 21
8824 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
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
reat
men
t S
ucce
ss
2323
3535
108 108 44
22
3131
39393333
3434
77
11
110110
2727
33
1313
1414
28 28
4040
10 10
111 111
112112
113113
114 114
115115
Surg & ADT
116 116
118118
117 117 119 119 121121
122122
Hypo EBRT +ADT
123123
124124
120 120 120 120
HDR + ADT
120120
Update of
125125
125
126126
127 127
128128
129129
130130
131 131
Surg & EBRT
132 132 133133
04/10/23BJU Int, 2012, Vol. 109(Supp 1)
28
66 11 11
25 25
15 15
55
EBRT Seeds +ADT
19 19
3030
16 16 20 20
18 18
2929% P
SA
Pro
gres
sion
Fre
e
17
21 21
88
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
4646
47 47
Robot RP
48 48
4949
101101
102102
103103
104 104
105 105
106106
107 107
109 109
HIGH RISK RESULTSWeighted
2323
3535
108 108 44
22
3131
39393333
3434
EBRT, Seeds & ADTEBRT, 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
10 10
111 111
112112
112112
113113
114 114
115115
116 116
Surg & ADT
118118
117 117 119 119 121121
HDR + ADT
122122123123
124124
120 120 120120
Update of
125125
125
126126
127 127
128128
129129
130130
131 131
132 132
Surg & EBRT
133133
04/10/23BJU Int, 2012, Vol. 109(Supp 1)
29
66 11 11
25 25
15 15
55
EBRT Seeds +ADT
19 19
3030
16 16 20 20
18 18
2929% P
SA
Pro
gres
sion
Fre
e
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
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
Tre
atm
ent
Suc
cess
3535
108 108 44
22
3131
39393333
3434
5050
5151
5252
53
5454
55
HIFU
5656
8686 8787
57
5858
5959
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
10 10
2323 111 111
112112
112112
113113
114 114
115115
116 116
Surg & ADT
118118
117 117 119 119 119 119 121121
6060
122122123123
124124
120 120 120120
HDR + ADT
Update of
125125
125
93126126
127 127
128128
129129
94
95 95
96 96
97 979898
130130
131 131
132 132
Surg & EBRT
133133
04/10/23BJU Int, 2012, Vol. 109(Supp 1)
30
66
11 11
25 25
15 15
55
19 19
3030
16 16 20 20
18 18
2929% P
SA
Pro
gres
sion
Fre
e
17
21 21
88
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
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
Tre
atm
ent
Suc
cess
10 10
2323
3535
108 108 44
22
3131
39393333
3434
5050
5151
5252
53
5454
55
HIFU
5656
8686 8787
57
5858
5959
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
111 111
112112
112112
113113
114 114
115115
116 116
Surg & ADT
118118119 119
6060
122122123123
123123
124124
120120
HDR + ADT
Update of
125125
125
93126126
127 127
128128
129129
94
95 95
96 96 9898
130130
131 131
132 132
Surg & EBRT
133133
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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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OBSERVATIONS
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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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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 Score 6Gleason Score 7 or Gleason Score 6PSA < 10 ng/ml PSA 10-20 PSA < 10 ng/ml PSA 10-20
ng/mlng/mlHigh Risk High Risk Stage T2c or T3Stage T2c or T3 Gleason Score ≥ 8 Gleason Score ≥ 8 PSA > 20 ng/mLPSA > 20 ng/mL
Low Risk Low Risk Stage: Stage: T1 or T2a,b T1 or T2a,b Gleason Gleason Score Score << 6 6 PSA PSA << 10 10 ng/mlng/ml
04/10/23 35
Peter Grimm, DO [email protected]
Lisa Grimm, Research Coordinator [email protected]
Or contact a PCRSG member Prostate Cancer Center of Seattle
(website & email)
www.Prostatecancertreatmentcenter.com [email protected]