Radiation therapy for Early
Stage Prostate Cancer
John A. Kalapurakal MD
Professor, Radiation Oncology
Northwestern University Medical
School
Chicago, IL
ARS
1-B
It is estimated that 217,730 men will be diagnosed with
and 32,050 men will die of cancer of the prostate in
2010 (SEER DATA)
RACE/ETHNICITY
INCIDENCE
MORTALITY
All Races
156.9 per 100,000
men
24.7 per 100,000
men
White
150.4 per 100,000
men
22.8 per 100,000
men
Black
234.6 per 100,000
men
54.2 per 100,000
men
Asian/Pacific
Islander
90.0 per 100,000
men
10.6 per 100,000
men
American
77.7 per 100,000
Indian/Alaska Native men
20.0 per 100,000
men
Hispanic
125.8 per 100,000
men
18.8 per 100,000
men
Anatomy
Risk stratification of Prostate Cancer
• Low risk
T1c-T2a and PSA<10 and Gleason score
<6
• Intermediate risk
T2b-T2c or PSA 10-20 or Gleason score 7
•
High risk
T3-T4 or PSA >20 or Gleason score 8-10
Low-risk Prostate Cancer
• External beam RT: (x-rays, protons)
–
–
•
70.2Gy-79.2Gy in 39-45 sessions (5 treatments/week, 8-9 weeks)
3D Conformal, Intensity Modulated RT, Protons
Brachytherapy: I-125 (Iodine), Pd-103 (Palladium)
–
144Gy in single session
Intermediate-risk Prostate Cancer
•
External beam RT: (x-rays, protons)
–
–
75.6-79.2Gy in 42 sessions (5 treatments/week, 8-9 weeks)
3D Conformal, Intensity Modulated RT (IMRT), Protons
•
External beam RT + Short term Hormone therapy (6-8
months)
•
External beam RT + Brachytherapy: I-125 (Iodine), Pd103 (Palladium)
–
45 Gy in 25 sessions (5 weeks) + brachytherapy (seeds, HDR)
Image Guided RT (IGRT)
• ALL MODERN RT DELIVERY SHOULD BE IGRT
• Improve accuracy of treatment
• Track daily position of the prostate before delivering RT
• Fiducial markers (x-rays), ultrasound scans,
electromagnetic tracking, CT scans (cone beam CT,
fiducials), endorectal balloon (x-rays, CT scan)
3D conformal versus IMRT versus Protons
Prostate Seed Implantation:
Indications, Techniques and
Outcomes
Post Implant CT scan dosimetry
Long-term results: Brachytherapy alone (Low-risk) and
RT+Brachytherapy in intermediate-risk Prostate Cancer
IJROBP 2010
IJROBP 2007
Higher RT dose (79.2Gy) resulted in higher PSA control in
low and intermediate-risk prostate cancer without any increase
in toxicity
Low risk
Intermediate-risk
JCO 2010
Harvard Study: Adding 6 months of hormones to RT improved
survival in intermediate-risk and high-risk disease
Intermediate-risk
High-risk
IJROBP 2010
MD Anderson Study: Higher RT dose (78 Gy) for
intermediate-risk patients resulted in better PSA control and
cancer–specific survival
IJROBP 2010
Low-intermediate risk Prostate Cancer:
RTOG 94-08 Study
•
•
•
•
•
•
•
•
T1b-T2b, PSA <20
RT: 66.6Gy + 4 months of hormone therapy
1979 patients randomized
Overall survival significantly better RT+ hormones (51%
vs. 4%)
PSA control significantly higher with RT+ hormones in
low and intermediate risk patients
Subset analysis: survival benefit mainly for higher GS
and PSA
Final results awaited
IJROBP 2009
Radiation-related Side Effects
• Likely
–
–
–
•
Less likely
–
–
–
•
Increased urinary frequency, burning and urgency
Increased bowel frequency, burning and urgency
Fatigue
Rectal bleeding, urinary bleeding
Chronic bowel/bladder symptoms
Temporary blockage of urination requiring a catheter
Rare but serious
–
Permanent Rectal and Bladder injury requiring surgery
Hormone-related Side Effects
Conclusions – RT for Early Prostate
Cancer
•
•
•
•
•
•
Best Results: Higher tumor RT doses with improved
technology treatments (Brachytherapy, IMRT, Proton
therapy)
Role of hormone therapy with RT in low and
intermediate-risk patients remains to be defined
Stereotactic Body Radiotherapy (SBRT): Cyberknife,
Linear Accelerator, Tomotherapy
Role of hypofractionated RT (70 Gy in 28 fractions,
50Gy in 5 fractions) ?
Role of protons
PATIENT’S CHOICE: Surveillance vs. Surgery vs.
Radiation* vs. Seeds
Radiation therapy for Early
Stage Prostate Cancer
John A. Kalapurakal MD
Professor, Radiation Oncology
Northwestern University Medical
School
Chicago, IL