treatments for intermediate PC

[Guest guest]

My husband and I are trying to sort out the best treatment

choice for his particular case of intermediate risk cancer.  After talking with quite a number of doctors

and looking at lots of studies, the choices are still confusing—no surprise

there.  Top contenders for us right now

are surgery and brachytherapy + EBRT (or maybe protons).  We would welcome the thoughts from any who

wish to share.  Warning: the following

post is pretty long. 

 

My husband was diagnosed with prostate cancer 5 weeks

ago.  I sent out a letter about his

situation back then.  His biopsy was

originally graded as Gleason 3/3 but a second opinion put it at 3/4.  His CS is T2b (palpable tumor for the last 1

½ years, actually one side just feels sort of different, no real nodule).  His positive cores are 5 out of 9 all one

side, 35% for the highest section (base). 

 

There are several things about his situation that make me

concerned that the cancer might have gotten outside the prostate.  There’s a 30% chance according to the Partin

tables, but I’ve heard from several doctors that they aren’t reliable.  Still, the fact that there’s some Gleason 4,

one side of the prostate felt different for 1 ½ years (same side that was

positive for PC), the smallness of the prostate (31cc) and the number of

positive cores with one core being 35%, makes be concerned, even without

reference to the Partin tables.

 

I realize that having cancer outside the prostate isn’t the

end of the world or life.  Still, it

makes sense to choose the kind of therapy that gives the best chance of

biochemical free recurrence.

 

So, that’s a long preamble to my question, which is:  What treatment gives the best cure rate or

greatest chance of biochemical free recurrence for intermediate grade PC?  OK, that’s a big question which no one can

really answer so here’s some sub questions that might help address it.

 

I’ve approached this question two ways:

1) I’ve tried to find meta studies that analyze success for

various kinds of treatment. 

2)  I’ve tried to find

peer-reviewed studies put out by the some of the best treatment centers and

then have compared their results.

 

Regarding the first, the most comprehensive meta comparison

I’ve found is Grimm’s article in the May 2011 PCRI Insights:  Longterm Outcomes for Prostate Cancer

Therapy Choices (not peer-reviewed).

 

If you’re interested, here are two versions.  The first is the full article published on

Grimm’s website, the second the PCRI article. 

(I’ve attached the full set of slides I got from Grimm’s office.  They tell what the different studies are.)

 

http://www.prostatecancertreatmentcenter.com/ProstateCancer/ProstateCancerResultsStudyGroup.aspx

 

 

http://www.prostate-cancer.org/pcricms/sites/default/files/PDFs/Is14-2_p3-11.pdf

 

Their analysis shows that brachytherapy plus IMRT typically has

the best success rate for intermediate grade PC.   So, here’s my real question…..  Is it fair to compare studies of surgery that

have the > 0.2 ng/ml PSA biochemical criterion for recurrence with studies

of all other forms of treatment with the ASTRO criterion?   This

is what Grimm’s study does.  To me that

seems like comparing apples to oranges, unless there’s some biological reason

that the ASTRO cutoff for radiation would somehow be roughly equivalent to the

> 0.2 PSA criteria.  

 

Maybe the >0.2 criteria for surgery is comparable to

ASTRO for radiation since in surgery the prostate is removed while in radiation

some prostate cells remain behind.  

However, the studies I’ve found for two of the top brachytherapy centers

in the US

(Dattoli and RC Cancer Center) both use the > 0.2 ng/ml PSA criteria for

biochemical recurrence.   RC’s

ProstRcision booklet makes a big deal out of the importance of using the >

0.2 ng/ml criteria.  They convert data

from other centers that use less stringent criteria and their conversions

downgrade the “cure rates” of these other places by quite a bit.  (Which also leaves the question, do they

downgrade too much?) 

 

So I’m confused:  does

it or doesn’t it make sense to compare radiation studies that use the ASTRO

criteria to surgery studies that use the >0.2 PSA criteria?   And if the ASTRO makes for sense for

radiation in general then why does the Dattoli group and the RC Cancer Center

(Dr. Critz) use the >0.2 criteria and do very well with that?   (Dattoli’s data show an 87% (2007) to  89% (2009) cure rate for intermediate grade

cancer.   Dr. Critz’s 2004 paper shows an

80% (2004) cure rate for intermediate. 

Their ProstRcision booklet (2010) claims a 88% cure rate for low and

intermediate risk PC combined.   Again,

these all use the more stringent  0.2

criteria.)

 

Now, another line of thinking is this:  My husband’s prostate is on the small side

for PCa, 31cc.  I think that means it’s

about 1 ½ inches in diameter.   I’ve

heard that radiation (brachytherapy and proton beam) treat the margin around

the prostate.  Loma says they treat

a half inch margin.  So if a half inch

margin is treated in addition to the 1 ½ inch in diameter prostate, that means

that the total area treated is over four times the size of the prostate.   If any cancer has escaped, it makes sense

that increasing the treated area to such a degree would be much more likely to

catch all the cancer than just treating the prostate, which I assume is what

surgery does.  Surgeons can’t cut out a

full half inch margin, can they?   How much extra can they cut off?   On the other hand, surgeons at least have

the advantage of being able to see or feel what they’re treating.

 

So this reasoning points towards the advantage of

brachytherapy plus IMRT or proton beams over surgery.  But I’m sure my thinking is too

simplistic.  So I welcome any thoughts

about this.   How do surgeons make sure

to get any little bits of cancer that has escaped the prostate?  I’ve heard from open surgeons that they can

feel the cancerous tissue and so cut out a bit more and from robotic surgeons

that they can see the cancerous tissue. 

Still, can they really treat as far out as radiation?   How can you compare the success of surgery

vs. brachytherapy plus IMRT for getting rid of cancer just outside the

prostate?   (I say brachy plus only

because that’s what I’ve researched the most, because of Dr. Grimm’s article.)

 

The bottom line is, I’d appreciate any thoughts about the

best treatment for low intermediate risk PC.  

Our priorities are first- treat the cancer so it’s not a problem later

on, second, minimize side effects of treatment. 

 

We welcome any thoughts or opinions.