peter grimm, do prostate cancer center of seattle
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Peter Grimm, DO Prostate Cancer Center of Seattle. Comparing Treatment Results Of PROSTATE CANCER Prostate Cancer Results Study Group 2012. Prostate Cancer Results Study Group . - PowerPoint PPT PresentationTRANSCRIPT
04/22/23 1
Peter Grimm, DOProstate Cancer Center of Seattle
Comparing Treatment Results Of PROSTATE CANCER
Prostate Cancer Results Study Group 2012
04/22/23 2
Problem: Patients need a simple means to compare the cancer control rates of modern prostate cancer treatment methods.
04/22/23 2
04/22/23
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
04/22/23 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 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
04/22/23 6
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 analysis3. 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]
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RP
EBRT/IMRT
Cryo Brachy/HDR
Robot RP
Proton HIFU
7.4% 10% 6% 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
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 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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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
23
HIFU
% P
SA
Pro
gres
sion
Fre
e
11
15
Protons
21
4
18
9
10
EBRT & Seeds
25
Robot RP 26
Prostate Cancer Center of Seattle
27
HDR
2829
30
313233
34
19 36
37
38
LOW RISK RESULTSTr
eatm
ent
Suc
cess
3 39
35
40100
101
13
16
103
102
6
16
104
105
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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
23
HIFU
% P
SA
Pro
gres
sion
Fre
e
11
15
Protons
21
4
18
9
10
EBRT & Seeds
25
Robot RP 26
Prostate Cancer Center of Seattle
27
HDR
2829
30
313233
34
19 36
37
38
LOW RISK RESULTS Weighted
3 39
35
40100
101
13EBRTBrachy
Surgery
Trea
tmen
t Suc
cess
103
102
6
16
104
105
04/22/23 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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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
23
HIFU
% P
SA
Pro
gres
sion
Fre
e
11
15
Protons
21
4
18
9
10
EBRT & Seeds
25
Robot RP 26
Prostate Cancer Center of Seattle
27
HDR
2829
30
313233
34
19 36
37
38
LOW RISK RESULTS >40 months follow-up or less than 100 patients
Trea
tmen
t S
ucce
ss
3 39
35
40
41
100
101
13
65
49
76
80
56
59
63
41
75
51
7172
90
73
74
70
42
57
8584
66
4364
44EBRT & ADT
53
8281 62
54
79
Hypo EBRT
86
87
88
45
58
69
7878
77
4646
4848
91
+ Seeds & ADT
9389
50
67
68
9594
5552528383
4761
96
103
102
97
9860 6
16
104
105
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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
23
HIFU
% P
SA
Pro
gres
sion
Fre
e
11
15
Protons
21
4
18
9
10
EBRT & Seeds
25
Robot RP 26
Prostate Cancer Center of Seattle
27
HDR
2829
30
313233
34
19 36
37
38
LOW RISK RESULTS Weighted >40 months follow-up or less than 100 patients
Trea
tmen
t S
ucce
ss
3 39
35
40
41
100
101
13
65
49
76
80
56
59
63
41
75
51
7172
90
73
74
70
42
57
8584
66
4364
44EBRT & ADT
53
8281 62
54
79
86
87
88
45
58
69
7878
77
4646
4848
91
+ Seeds & ADT
93
92
89
50
67
68
9594
5552528383
4761
BrachyEBRT
Surgery
Hypo EBRT
96
103
102
97
98
60 6
16
104
105
04/22/23 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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40
50
60
70
80
90
100
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
BrachySurgeryEBRTCRYOHIFU
29
22
21
5 19
% P
SA
Pro
gres
sion
Fr
ee
18
12
28
3 17
10
32
9
8 2
25
1
13
Protons
EBRT & Seeds
HDR
← Years from Treatment →
• Prostate Cancer Results Study Group • Numbers within symbols refer to references
154
36
Prostate Cancer Center of Seattle
37
EBRT, Seeds + ADT
38
+
Seeds Alone
Seeds + ADT40
Robot RP
41
42
44
43
45
46
Hypo EBRT
INTERMEDIATE RISK RESULTSTr
eatm
ent
Suc
cess
7
11
14
20
35
34
39
2324
16
6
26
33
30
27 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
BrachySurgeryEBRTCRYOHIFU
29
22
21
5 19
% P
SA
Pro
gres
sion
Fr
ee
18
12
28
3 17
10
32
9
8 2
25
1
13
Protons
HDR
← Years from Treatment →
• Prostate Cancer Results Study Group • Numbers within symbols refer to references
154
36
37
38
+
Seeds Alone
Seeds + ADT40
Robot RP
41
42
44
43
45
46
INTERMEDIATE RISK RESULTS Weighted
7
11
14
20
35
34
39
2324
16
6
26
33
EBRT & Seeds
EBRT Surgery
Brachy
EBRT & Seeds Hypo EBRT
EBRT, Seeds + ADT
Trea
tmen
t Suc
cess
Prostate Cancer Center of Seattle
30
27 47
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24
40
50
60
70
80
90
100
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
BrachySurgeryEBRTCRYOHIFU
29
22
21
5 19
% P
SA
Pro
gres
sion
Fr
ee
18
12
28
3 17
10
32
9
8 2
25
1
13
Protons
EBRT & Seeds
HDR
← Years from Treatment →
• Prostate Cancer Results Study Group • Numbers within symbols refer to references
154
36
Prostate Cancer Center of Seattle
37
EBRT, Seeds + ADT
38
+
Seeds Alone
Seeds + ADT40
Robot RP
41
42
44
43
45
46
INTERMEDIATE RISK RESULTS>40 months follow-up or less than 100 patients
Trea
tmen
t S
ucce
ss
7
11
14
20
35
34
39
2324
16
6
26
33
82
66
88
67
70
97
63
65102103
101
86
8785
5868
718150
EBRT + ADT
94
93
92
77
9151
69
Hypo EBRT99
75
90
89
5655
54
80
57
83
60
7372
98
53
52
79
9564
100
84
78
59
62 74
96
76
10459
59
10530
27 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
BrachySurgeryEBRTCRYOHIFU
29
22
21
5 19
% P
SA
Pro
gres
sion
Fr
ee
18
12
28
3 17
10
32
9
8 2
25
1
13
Protons
HDR
← Years from Treatment →
• Prostate Cancer Results Study Group • Numbers within symbols refer to references
154
36
Prostate Cancer Center of Seattle
37
38
+
Seeds Alone
Seeds + ADT40
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
2324
16
6
26
33
82
66
88
67
70
97
63
65102103
101
86
8785
5868
718150
EBRT + ADT
94
93
92
77
9151
69
Hypo EBRT99
75
90
89
5655
54
80
57
83
60
7372
98
53
52
79
9564
100
84
78
59
62 74
96
76
EBRT
Brachy
Surgery
EBRT & Seeds
EBRT, Seeds +ADT
Trea
tmen
t Suc
cess
104
105
30
27 47
04/22/23 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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6 11
36
25
15
5
EBRT Seeds +ADT
19
30
16 20 18
29% P
SA
Pro
gres
sion
Fre
e
17
21
8
9
22
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
4344
45
46
47
Robot RP
48
49
101
102
103
104
105
106
Hypo EBRT
107
109
HIGH RISK RESULTSTr
eatm
ent
Suc
cess
10
23
35
108 4
2
31
39
32
33
34
38
7
1110
27
3
13
14
28
40
100
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28
6 11
36
25
15
5
EBRT Seeds +ADT
19
30
16 20 18
29% P
SA
Pro
gres
sion
Fre
e
17
21
8
9
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
4344
45
46
47
Robot RP
48
49
101
102
103
104
105
106
107
109
HIGH RISK RESULTSWeighted
10
23
35
108 4
2
31
39
32
33
34
38
EBRT, Seeds & ADTBrachy
EBRT Surgery
EBRT & ADT EBRT & Seeds
Hypo EBRT
Trea
tmen
t Suc
cess
1
7
110
27
3
13
14
28
40
100
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29
6 11
36
25
15
5
EBRT Seeds +ADT
19
30
16 20 18
29% P
SA
Pro
gres
sion
Fre
e
17
21
8
9
22
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
4344
45
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
Trea
tmen
t S
ucce
ss
10
23
35
108 4
2
31
39
32
33
34
38
50
51
52
53
54
55
HIFU
56
86 87
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
7576
77
78
88
79
8081
89
84
83 82
85
1
7
90
91
110
27
3
13
14
28
40
92
100
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30
6
11
36
25
15
5
19
30
16 20 18
29% P
SA
Pro
gres
sion
Fre
e
17
21
8
9
22
24
26
37
41
12
Protons
← Years from Treatment →
• Prostate Cancer Results Study Group • Numbers within symbols refer to references
42
4344
45
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
Trea
tmen
t S
ucce
ss
10
23
35
108 4
2
31
39
32
33
34
38
50
51
52
53
54
55
HIFU
56
86 87
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
7576
77
78
88
79
8081
89
84
83 82
85
Surgery
Brachy
EBRT
EBRT & ADT EBRT & Seeds
Hypo EBRT
HDREBRT Seeds +ADT
Robot RP
Prostate Cancer Center of Seattle
1
7
90
91
110
27
3
13
14
28
40
92
100
04/22/23 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
04/22/23 31
OBSERVATIONS
04/22/23 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
04/22/23 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
+
04/22/23 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: Stage: T1 or T2a,b T1 or T2a,b Gleason Gleason Sum Sum << 6 6 PSA PSA << 10 10 ng/mlng/ml
04/22/23 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