Download Comparing Treatment Results Of PROSTATE CANCER Prostate

ComparingTreatmentResultsOf
PROSTATECANCER
ProstateCancerResultsStudyGroup
UpdatedJanuary2017
ProstateCancerTreatmentResearchFoundation
2/11/17
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Problem:Patients,physiciansandprovidersneed
simple,unbiaseddatabywhichtocomparethe
effectivenessofmodernprostatecancer
treatmentmethods.Themosteffective
treatmentsarethoseinwhichthepatient
remainsProstateCancerFree® fortheirlifetime.
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TheStudyGroupisanassemblyofinternationalexperts
fromkeytreatingdisciplines:
Surgery(RP&Robotic)
ExternalBeamRadiationTherapy(EBRT)
Brachytherapy(Seeds)
HighFrequencyUltrasound(HIFU)
ProtonTherapy(Protons)
Cryotherapy(Cryo)
Thepurposeofthisworkistoreviewallofthecurrent
literatureonprostatecancertreatmentandprovide
resultstopatientsandtheirphysicians.
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Ignace Billiet, MD, F.E.B.U.-Urologist, AZ Groeninge Teaching Hospital, Kortrijk, Belgium
David Bostwick, MD, Bostwick Laboratories, Orlando, FL
Luis Campos-Pinheiro, MD, Univ. of Lisbon, Lisbon, Portugal
David Crawford, MD, Univ. Colorado, Denver, CO
Brian Davis, MD, Mayo Clinic, Rochester, MN
D. Jeffrey Demanes, MD, UCLA Medical Center, Santa Monica, CA
Adam Dicker, MD, Thomas Jefferson U., Philadelphia, PA
Steven Frank, MD, MD Andersen, Houston, TX
Peter Grimm, DO, Prostate Cancer Center of Seattle, Seattle, WA (Founder, deceased Feb. 20, 2016)
Gustavo Guimaraes, MD, AC Camargo Cancer Center, São Paulo, Brazil
R. Alex Hsi, MD, Peninsula Cancer Center, Poulsbo, WA
Jos Immerzeel, MD, De Prostaat Kliniek, Netherlands
Mira Keyes, MD, BC Cancer Agency, Vancouver BC, Canada
Patrick Kupelian, MD, UCLA Med Center, Los Angeles, CA
Steven Kurtzman, MD, Western Radiation Oncology, San Francisco, CA
Stephen Langley, MD, St Luke's Cancer Centre, Guildford, England
W. Robert Lee, MD, Duke University Medical Center, Durham, NC
Stefan Machtens, MD, Marien-Krankenhaus Hospital, Bergisch-Gladbach, Germany
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Alvaro Martinez, MD, William Beaumont , Royal Oak, MI
Gregory Merrick, MD, Schiffler Cancer Center, Wheeling, WV
Jeremy Millar, MD, Alfred Health Medical Center & Monash University, Melbourne, Australia
Brian Moran, MD, Chicago Prostate Institute, Chicago, IL
Peter F. Orio, DO, Dana-Farber/Brigham & Women’s Cancer Centers, Boston, MA
Antonio Cassio Pellizzon, MD, Camargo Cancer Center, São Paulo, Brazil
Bradley R. Prestidge, MD, MS, Bon Secours Cancer Institute, Norfolk, VA
Thomas Pugh, MD, University of Colorado School of Medicine, Denver, CO
Mack Roach, MD, UC San Francisco, San Francisco, CA
Mark Scholz, MD, Prostate Cancer Research Institute, Marina del Ray, CA
Katsuto Shinohara, MD, UC San Francisco, San Francisco, CA
Janusz Skowronek, MD, Greater Poland Cancer Center, Poznań, Poland
Richard Stock, MD, Mt. Sinai, New York, NY
Frank Sullivan, MD, College of Medicine, Nursing and Health Sciences, NUI, Galway, Ireland
Jehan Titus, MD, Calvary Hospital, St Josephs Collage, Adelaide, Australia
Robyn Vera, DO, Radiant Oncology, Lacey, WA
Edward Weber, MD, Prostate Cancer Center of Seattle, Seattle, WA
Michael Zelefsky, MD, Memorial Sloan Kettering, New York, NY
Anthony Zietman, MD, Harvard Joint Center, Boston, MA
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AboutThisReviewStudy
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+48,700prostatearticleswerepublishedbetween
2000andJune2016.
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1,502ofthosearticlesfeaturedtreatmentresults.
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223articleshavemetPCRSGcriteriatobeincluded
inthisreviewstudy.
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Sometreatmentmethodsareunder-represented
duetofailuretomeetcriteria.
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“WillIbecured?”or“Willmytreatmentmakemecancer
free?”arevalidpatientquestions.
TheindicatorofbeingProstateCancerFree®isalowPSA
levelwhichdoesnotrise.
Fivetotenyearsaftertreatment,alowPSAlevel
indicatescanceriscontrolledandthereisahighlikelihood
thecancerwillnotreturn.
Resultsgreaterthanfiveyearsarenecessarytobeableto
comparetreatmentresults.
SuccessisdefinedasPSAatalowlevelandnotrising
duringthelifetimeofapatient“ProstateCancerFree®.”
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Afterprostatesurgery,PSAnumbersusuallyfallrapidlyto
verylownumbersandstaylow.
Afterradiation,PSAnumbersusuallycomedownslower,
andmayincreasebriefly,thensubsequentlyfall(thisis
calleda“PSABump.”)
ThesedifferentPSAexpectationsresultindissimilarways
toreviewaman’sPSAhistorytojudgetreatmentsuccess.
AconsistentriseinPSAafterfiveyearsisgenerally
consideredatreatmentfailure.
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Brachy=SeedImplantation(Brachytherapy,either
permanentortemporaryseeds)
EBRT=ExternalBeamRadiationTherapy(includes
IMRT=IntensityModulatedRadiationTherapy)
RP=StandardOpenRadicalProstatectomy
RobotRP=RoboticRadicalProstatectomy
HIFU=HighIntensityFocusedUltrasound
Cryo=Cryotherapy
Protons=formofExternalRadiationusingProtons
ADT=HormoneTherapy
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Theexpertpanelagreedunanimouslyonthecriteriaan
articlehastomeettobeacceptedforcomparison
purposes.
EveryProstateCancerarticlewrittenbetween2000and
June2016wasreviewed.Firsttodetermineifitwasa
treatmentarticle,andsecondlyifitmettheexpertpanel's
inclusioncriteria.
Theresultsoftheacceptedtreatmentarticleswere
plottedtogetheraccordingtoeachriskgroup’s“Prostate
CancerFree®”status(intheprofessionalliteraturethisis
knownasPSAProgressionFreestatus,meaningno
evidenceofarisingPSA.)
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Allarticleevaluationsandgraphplottingsarereviewedby
theArticleReviewCommitteeandthensubmittedtothe
ExpertPanelforconfirmationpriortoallstudyupdates.
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Alldatarecipients,includingpatientsandphysicians,are
invitedtocritiquethedataandsubmitarticlesforthe
PCRSGreviewprocess.
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CriteriaforInclusionofArticle*
1. 
ArticlesmustbepublishedinaMajorMedicalJournal.
2. 
PatientsshouldbeseparatedintoLow-,Intermediate-,and
High-RiskGroups.
3. 
SuccessmustbedeterminedbyPSAanalysis.
4. 
Allmajortreatmenttypesconsidered:Seeds(Brachy),
Surgery(StandardorRobotic),EBRT(includingIMRT),
HIFU(HighIntensityFrequencyUltrasound),CRYO
(Cryotherapy),Protons,HDR(HighdoseRate
Brachytherapy)
* Expert panel consensus
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5. 
Low-Riskarticlesaminimumof100patients.
6. 
Intermediate-Riskarticlesaminimumof100patients.
7. 
High-Riskarticles,becauseoffewerpatients,aminimumof
50patients.
8. 
Patientsneedtobefollowedforamedianof5years.
Foradditionalcriteriainformationcontact:[email protected]
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RP
EBRT/
IMRT
Cryo
Brachy/
HDR
Robot
RP
9%
16%
6%
24.8%
5.1%
20%
12.7%
3/50
100/403
5/98
5/20
6/47
37/410 68/427
Proton HIFU
Total of 1,502* Treatment Articles. Some articles addressed several treatments and
were counted as separate articles for each treatment. *Some articles evaluated other/minor treatments
that are not listed here and are therefore not included in these calculations.
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HowtoInterprettheGraphs
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EachTreatmentisgivenasymbol.ForexampleSeed
implantalone(Brachytherapy)isgivenabluedot.
EachSymbolisadifferentarticleforthattreatment.At
thewebsiteyoucanputacursoroverthesymboland
actuallyretrievethatarticle.
TreatmentSuccess=PercentofmenwhosePSAnumbers
indicateaProstateCancerFree®Status(PSAprogression
free)ataspecificpointintime.
Thebottomlineindicatesthenumberyearsthestudyis
out.
Anexample,abluedotpositionedat12yearsalongthe
97%lineindicatesthat,97%ofthepatients,treatedwith
seedsaloneinlow-riskpatientsat12yearswerefreeof
diseaseprogressionandwereProstateCancerFree®.
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HowtoInterprettheGraphs
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Thecoloredellipsesoutlinetheresultsofmultiple
articlesinthesametreatment.Thesewerecreatedbyour
statisticiansusingstandardstatisticalmethods.
Theseellipsesdemonstrate2things:
§  1.dividingtheellipsesinhalfwillgiveyoutheaverage
resultofthetreatment.
§  2.Thedirectionoftheellipsewillgiveyouanideaofthelongterm
success.Adownwarddirectionoftheellipseindicatesthat
somepatientsarefailingovertime.
§  Ideally,ifatreatmentreachesapointwherenoorfewpatientsfail,
theellipsepatternwilllooklikethis.
§  Thereareinteractiveversionsofthegraphsonthewebsite:
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www.pctrf.org/comparing-treatments/Youcanchoosewhich
treatmentsandellipsestoviewbycheckingandun-checkingthe
boxesinthekeyontheright.
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Ellipsesarenotavailableforalltreatments.Theycanonly
bedoneifthereare4ormoreacceptedstudieswithinthat
treatment,sosometreatmentsmaynotappearonthe
slidesasellipsesonlydatapoints.
Ingeneral:Brachytherapysymbolsareblue
EBRT/IMRTsymbolsaregreen
Protonssymbolsareyellow
Surgerysymbolsarered
Cryotherapysymbolsarepurple
HIFUsymbolsaregray
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Brachytherapy
• Brachytherapyalone
• Brachytherapy&EBRT
• Brachytherapy,EBRT,&ADT
• HDR(Brachytherapy)
• HDR&ADT(Brachytherapy)
EBRT/IMRT
• EBRTalone
• EBRT&ADT
• HypoEBRT
Protons
• Protons
Surgery
• RPSurgery
• RoboticSurgery
• RPSurgery&EBRT
Cryotherapy
• Cryotherapy
HIFU
• HIFU
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HowtoInterprettheResults
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TheRiskgroupsaredefinedbyacombinationoffactors.
Thesefactorsareprovidedbythediagnosingphysician
andincludethestageofthecancer,theGleasonScore,
andPSAlevel.Seeslides20,23,and26forspecific
definitionsforeachrisk-group.
Firstestablishyourclinicalriskgroup*bylookingatthe
definitions(youcanalsoaskyourphysicianforhelpin
determiningyouriskgroup.)Referonlytothoseslidesfor
yourriskgroup.
Makeyourownjudgmentandthenaskadoctorineach
discipline(Seeds,ExternalRadiation,Surgery,etc.)totell
youwherehis/herownpeerreviewedpublishedTreatment
*Next Slide
Success%wouldfitonthisplot.
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Thelow-riskgroupisdefinedbyacombinationoffactors.
Thesefactorsareprovidedbythediagnosingphysicianand
includethestageofthecancer,theGleasonScore,andPSA
level.Thelow-riskgroupisdefinedby:
§ ClinicalStage:T1orT2a,b
§ GleasonScore<6
§ PSA<10ng/ml
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Theintermediate-riskgroupisdefinedbyacombinationof
factors.Thesefactorsareprovidedbythediagnosingphysician
andincludethestageofthecancer,theGleasonScore,andPSA
level.Theintermediate-riskgrouphas2definitionsthatcanbe
used:
¡  Zelefskydefinition
§  Only1factor
▪  ClinicalStageT2c
▪  GleasonScore>7
▪  PSA>10ng/ml
¡  D’Amicodefinition
§  PSA10-20,GleasonScore7,orClinicalStageT2b
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Thehigh-riskgroupisdefinedbyacombinationoffactors.These
factorsareprovidedbythediagnosingphysicianandincludethe
stageofthecancer,theGleasonScore,andPSAlevel.Thehighriskgrouphas2definitionsthatcanbeused:
¡  Zelefskydefinition
§  2ormorefactors
▪  GleasonScore>7
▪  PSA10-20
▪  ClinicalStageT1c-T2b
¡  D'Amicodefinition
§  GleasonScore8-10,PSA>20,ClinicalStage>T2c
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Observations
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Formostlow-riskpatients,mosttherapieswillbe
successful.
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Treatmentsatthetopoftheresultscomparisongraphs
forthelongperiodsofyears,indicatethatpatients
treatedwiththesemethodsdidnotexperiencean
increaseinPSAaftertreatment.Thesepatientsaremore
likelytoremainProstateCancerFree®.Patientsare
encouragedtolookatgraphsanddeterminefor
themselves.
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Seriousside-effectratesmustbeconsideredforany
treatment.
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LowRisk
Stage:T1orT2a,b
GleasonScore<6
PSA<10ng/ml
IntermediateRisk
StageT1orT1-2StageT1-2
GleasonScore7orGleasonScore6
PSA<10PSA10-20
HighRisk
StageT2corT3
GleasonScore≥8
PSA>20ng/mL
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ProstateCancerTreatmentResearchFoundation
website:www.pctrf.org
ContacttheProstateCancerTreatmentResearch
Foundation:[email protected]
AdditionalinformationforStudyGroupmembers:
www.pctrf.org/study-group-members/
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