Low and Intermediate Risk Prostate Cancer – Comparative Effectiveness of Brachytherapy, Cryotherapy, External Beam Radio Therapy, HIFU, Proton Therapy, Radical Prostatectomy and Robot Assisted Radical Prostatectomy
Accepted for future publication of the 51st ASTRO Annual Meeting Nov. 1-5, 2009
Authors: Peter D. Grimm, John E. Sylvester, The Prostate Cancer Results Study Group
Purpose/Objective(s): Currently there are no randomized studies comparing treatment modalities for prostate cancer. The Prostate Cancer Results Study Group (PCRSG) was formed to continuously evaluate clinical endpoints from peer reviewed prostate cancer studies that met minimum reporting requirements.
Materials/Methods: An Elsevier, Google Scholar, Medline and PubMed search from 2000-2009 of >15,000 prostate cancer articles identified 603 prostate cancer treatment related articles. The PCRSG (D. Bostwick, D. Crawford, P. Grimm, M. Keyes, P. Kupelian, R. Lee, J. Mayadev, G. Merrick, J. Millar, B. Moran, M. Roach, M. Scholz, K. Shinohara, R. Stock, J. Sylvester, E. Weber, S. Wentworth, R. Vera, J. Wong, M. Zelefsky, A. Zietman) established the following criteria for articles to be included in the analysis: peer-reviewed journal published since 2000 with a minimum of 100 patients and a median follow-up of >5 years; low or intermediate pre-treatment risk group classification; ASTRO, Phoenix, or >0.2ng/ml PSA definitions of biochemical relapse- free survival (BRFS); clinical staging, no pathological exclusions; external beam radiotherapy (EBRT) dose >72Gy.
Results: Number of articles that met these inclusion criteria: Overall 31/603 (5%), brachytherapy (Brachy) 29/157 (18%), cryotherapy (Cryo) 2/26 (7.7%), EBRT 14 /165 (8.5%), high intensity focused ultrasound (HIFU) 1/27 (3%), proton therapy (Proton) 1/9 (11%), radical prostatectomy (RP) 13/206 (6.3%) and Robot RP 0/ 53 (0%). 21,066 evaluated treatments from 1983-2005 met criteria. 5-10 year BRFS stratified by modality for the low risk group was: Brachy 84-98 %, RP 77-90%, EBRT 72-84%, Proton 79%, Cryo 85%. No HIFU or Robot RP met criteria. 5-10 year BRFS stratified by modality for the intermediate risk group was: Brachy 70-96 %, Cryo 83%, EBRT 52-82%, HIFU 54%, Proton 79%, and RP 60-63%. No Robot RP met criteria. Relaxing the criteria to > 40 months median follow up or less than 100 pts did not affect overall results in either risk group.
Conclusions: Brachytherapy, Cryotherapy, EBRT, Proton therapy and RP are effective treatments for low and intermediate risk prostate cancer in the majority of patients. The current literature largely fails to report results using minimum and comparable criteria. The large number of studies that fail to stratify patients preoperatively into risk groups or fail to meet a median follow up of 5 years represents a challenge to the oncology community to exact stricter criteria for reporting results which are meaningful, comparable and understandable to physicians, patients and interested parties.