The Big Picture | What Is It? | Diagnosis | Understanding Risk  | Treatment Options | Prostate Cancer Results Study Group

What is the Best Treatment for Prostate Cancer? The Big Picture

When you or a loved one are diagnosed with prostate cancer, you will be faced with a wide variety of options. Which option is “best” for you is a balance of proven (published) long term cancer control rates of the treatment and the published side effects of this treatment. While it is valuable to know the published results of various treatment options, it is also important to know the results achieved by your physician and center treating you. Upon completing  this section we recommend you review the Prostate Cancer Results Study Groups findings comparing treatment results. See dropdown beneath Prostate Cancer  heading.

The 3 standard treatment options with long term results include:

  • Brachytherapy – Radioactive Seed Implantation  Any procedure in which a source of radioactive material is placed near a tumor. The implantation of radioactive seeds for prostate cancer is a form of brachytherapy in which the seeds emit low energy radiation in order to kill cancer cells inside and immediately surrounding the prostate.
  • External Beam Radiation Therapy (EBRT) Radiation targeted to a specified area and delivered by a special machine (e.g. a linear accelerator). Common forms of EBRT are IMRT, Protons, Cyberknife and Tomotherapy.
  • Radical Prostatectomy  Surgery to remove the entire prostate and usually the seminal vesicles; the three types of radical prostatectomy are retropubic prostatectomy, perineal prostatectomy, and laparoscopic/robotic assisted prostatectomy.

Some treatments currently lack published, long term results. These include:

  • Cryotherapy
  • Cyberknife:  A Robotic Linear Accelerator designed to give External beam radiation. In contrast to the traditional linear accelerator the robotic arm can move in multiple direction rather than simple arc such as with IMRT of other external radiation.
  • HIFU

What Are the Results of the Most Common Treatments?

Will Your Treatment completely rid your body of cancer throughout your lifetime?
Comparing treatments for your specific situation can be extremely difficult. Unfortunately, some of the  treatments (Robotic Radical Prostatectomy, HIFU, and Active Surveillance) have few  published success rates that are long term and comparable to the other treatments. Most of the time centers have followed patients only a short time (less than 5 years) or only report on “good” patients after they have been treated. Randomized trials, which select a treatment for patients and allow accurate comparison of the effectiveness of the various treatments, are few.. Many studies suffer from patient selection problems, which means only the “good” patients (those with favorable features after treatment) are reported on while “poor” patents (those with unfavorable characteristics found after surgery) are not included. These studies make it appear that the treatment is more effective than it actually is as they are only looking at the favorable patients. A common statement given to patients is: “If your cancer is confined to your prostate after surgery, you have a high chance of success.” However, a more important question is: ” OK what is my chance  of it being confined to the prostate before treatment?” Prior to selecting a treatment option, a patient needs to know and ask “If you treat 100 patients just like me what are your personal results?”   If you wish to compare modern treatment results we recommend that you visit the Prostate Cancer Treatment Research Foundation website at www.pctrf.org.

Era of Treatment

The good news is that results of all treatments have improved over the years. However, if a newer study of one treatment, for example, surgery, is compared to an older study of radiation, the improvement in result is very likely only due to the newer patients having better characteristics to begin with. Comparing current results of treatments is important. At PCCS, we will show you only studies that are current and have comparable patients.

“Our New Treatment Has Fewer Side Effects and Better Results!”
More often than not, when one of the “newer” treatments is offered, patients are told that the cancer control will be as good as or better than one of the older treatments but with fewer side effects. This can be true, however, cancer control with newer treatments again involve treating recently diagnosed patients and therefore results are improved simply because the patient has a more favorable disease. In recent years, patients typically actually have less cancer because of the intense screening with PSA blood tests, and, therefore, have an inherently better prognosis than patients from 10 years ago. It is wise not to compare patients from one era to patients of another era. We have recently completed an extensive comparison of treatments performed in the modern era.

Newer Is Not Necessarily Better
It is normal for a person to hope that since a given procedure is “new” it is better. Unfortunately, that is all too often not true. In fact, the largest study comparing open radical prostatectomy to minimally invasive prostatectomy (robotic and laparoscopic prostatectomy) showed that the risk of cancer recurrence in the robotic and laparoscopic prostatectomy patients was 3 times higher than in standard open radical prostatectomy patients. Moreover, robotic prostatectomy patients suffered a higher rate of sexual and urinary side effects than those treated with open prostatectomy. While some of the poor results of robotic surgery are due to learning curve issues, the fact remains that robotic surgery has not been shown to be better in terms of cancer control or side effects than standard open radical prostectomy. And what is published so far suggests results may actually be worse. Reference

Comparing the Results of Modern Treatments
The Prostate Cancer Study Group* performed a large comparative effectiveness study which was published in the British Journal of Urology in 2012 .This study compares the success rates of all prostate cancer treatment options. Over 15,000 published articles were reviewed in this study and was recently updated to include over 318,000 articles.   The results are updated every 6 months and are available at www.pctrf.org The results of this comparison showed that brachytherapy, external beam radiation therapy and open radical prostatectomy were successful in the majority of patients. This was true for all risk groups, but higher dose radiation (EBRT + Brachytherapy) appeared to have better relapse-free survival outcomes in the higher risk and higher grade cancers.

What areas of the Prostate that IMRT, Surgery, Protons  and Seeds treat and don’t treat

Estimating Your Risk of Disease Beyond the Prostate Gland and Treatment Area
Prostate cancer treatment requires consideration of disease inside the gland and disease outside the gland. No matter what stage or PSA you have, there is a risk of microscopic disease beyond the gland. The risk of disease beyond the prostate has been extensively studied and reported. Your risk of microscopic disease beyond the prostate can be found in the Partin Tables. Current imaging tools cannot image this microscopic disease and therefore the risk of disease beyond the gland must be estimated from these tables or other sources.

Surgery
The majority of robotic surgery in this country is done with a nerve sparing technique. This nerve lies within millimeters of the prostate and provides the stimulation for erectile function. Therefore, surgeons, reluctant to make you impotent, often leave these nerves behind. Unfortunately, the studies which have looked at microscopic disease beyond the prostate have shown that disease beyond the prostate is almost always located around these nerves. Therefore, with surgery, which does an excellent job of removing the cancer in the prostate, cancer recurrence is almost always due to the failure to remove this microscopic diseases near the nerves.

IMRT
Intensity Modulated Radiation Therapy is sophisticated radiation designed to achieve a higher dose to the gland than was previously achievable with older techniques. Why give a higher dose? Because a higher dose has been shown to improve cancer control rates. The IMRT treatment area includes the prostate and a small margin around the gland to treat possible microscopic disease just outside the gland. It does an excellent job of treating disease beyond the gland. Cancer control rates, however have not been as good as reported with seed implantation, particularly with higher risk disease.

Why might IMRT not be as effective in some cases? It is likely that in some patients the radiation dose is insufficient to control the amount of disease. Recently, very high doses of IMRT for low risk disease have reached similar results to seed implantation however the results are early (5 years). Also, the long term risks, especially to hips of these high doses has not yet been assessed adequately.

Protons  Proton treatment  form of external beam radiation that delivers a unique form of radiation , protons to a fairly defined area. The proste is positined in the filed so that, as the protons slow down , radiation is emitted which kills the cells similar to IMRT. Despite claims of better treatment, the dose to the prostate is identical to IMRT and the fields are similar. To date there is no proof that protons are superior to either IMRT or seed imlantaiton

Seed Implantation (Brachytherapy/Brachysurgery )
Seed Implantation delivers as much as two times the dose that IMRT can deliver to the prostate without delivering this high dose to the surrounding normal tissues. In addition, Seed Implantation can be tailored to the prostate and deliver high doses to the region of microscopic spread. It is extremely unusual for cancer to recur in the prostate region after Seed Implantation. It does require a surgical and radiation team  expertise to be done well.

Comparing Side Effects of the Various Treatments

Multiple studies have been published that compare the side effects of the 3 standard treatment options. The best of these studies are Health Related Quality Of Life studies (HRQOL), in which patients answer questionnaires that are validated by expert panels. Multiple HRQOL studies have been performed with the 3 standard treatment options. Unfortunately, none of these studies are randomized, thus patients in the surgical (radical prostatectomy) arms are typically younger and healthier before treatment than those in the EBRT or brachytherapy arms. This is because many patients that are not candidates for surgery are still good candidates for EBRT or brachytherapy. So, the average age and health of the surgically treated patient (before surgery) is more favorable than the average age and health EBRT or brachytherapy patient. Multiple studies prove that younger, healthier patients recover from virtually any type of treatment better than older, sicker patients. So, all these studies have a built-in bias favoring the surgically treated patients.

In general, those patients treated with surgery suffer higher rates of incontinence and impotency than those treated with either seed implantation or IMRT radiation. Those treated with radiation have higher rates of (usually temporary) increased urinary frequency and bowel frequency. Prostatectomy patients face a small risk of stroke, blood clots to the lung (pulmonary embolus), cardiac or pulmonary complications, significant infections, Peyronies Disease**, bleeding, or death. These risks are not seen in either Seed implantation or IMRT radiation.

Quality of Life
The side effects from treatment affect the quality of your life. Each treatment option has a slightly different side effect profile. In addition, these side effects can vary, depending on the patient’s individual condition, technique used and the skill of the treating physician. The quality of life is an important aspect of treatment outcome. Quality of life begins with an understanding of your current status and how treatment will affect you, personally. At PCCS, you will fill out a detailed questionnaire that will help us individualize your side effect profile.You will receive a full explanation of the potential effects on bowel, urinary and sexual function from the experience we have had performing these treatments in over 7,000 patients during the past 25 years. As most patients with prostate cancer will lead relatively normal lives without recurrence after treatment, our research efforts at PCCS focus on technical improvements and therapeutic interventions that help minimize the risk of cancer recurrence and maximize your quality of life after treatment. The studies we conduct provide information that benefit your and the next patient’s experience.

* The PCRSG expert panel consists of: Ignace Billiet,MD, Europe, David Bostwick, MD, Bostwick Laboratories, David Crawford, MD, Univ Colorado, Peter Grimm, DO, Prostate Cancer Center of Seattle, Jos Immerzeel, Netherlands, Mira Keyes, MD, BC Cancer Agency, Patrick Kupelian, MD, UCLA, Robert Lee, Duke University Medical Center, Stefan Machtens, MD, Europe, Brian Moran, MD, Chicago Prostate Institute, Greg Merrick, MD, Schiffler Cancer Center, Jeremy Millar, MD, Australia, Mack Roach, MD, UCSF, Richard Stock, MD, Mt. Sinai New York, Katsuto Shinohara, MD, UCSF, John Sylvester, MD, Prostate Cancer Center of Seattle, Mark Scholz, MD, Prostate Cancer Research Institute, Ed Weber, MD, Prostate Cancer Center of Seattle, Anthony Zietman, MD, Harvard Joint Center, Michael Zelefsky, MD, Memorial Sloan Kettering, Jason Wong, MD, ts: Jyoti Mayadev, MD, Stacy Wentworth, MD, Robyn Vera, DO, Medical College of Virginia
** Peyronie’s Disease: Curvature of the penis is an abnormal bend in the penis that occurs during erection. Symptoms: Bend in the penis with erection; Narrowing of the penis with erection.