Comparing Treatment Results Of
PROSTATE CANCER
Prostate Cancer Results Study Group
2012
Peter Grimm, DO
Prostate Cancer Center of Seattle
4/8/2015
1
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Problem: Patients need a simple means to
compare the cancer control rates of
modern prostate cancer treatment
methods.
4/8/2015
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To solve this problem, we have
assembled experts from key treating
disciplines: Surgery, External Radiation,
Internal (or Brachytherapy), High
Frequency Ultrasound, and Proton
Therapy

The purpose of this work is to do a
complete review study of the current
literature on prostate cancer treatment
4/8/2015
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Ignace Billiet, MD F.E.B.U., Urologist Kortrijk, Belgium
David Bostwick, MD Bostwick Laboratories
David Crawford, MD Univ Colorado, Denver
Adam Dicker, MD Thomas Jefferson U Philadelphia,PA
Steven Frank, MD MD Andersen, Houston Texas
Peter Grimm, DO Prostate Cancer Center of Seattle
Jos Immerzeel, MD De Prostaat Kliniek Netherlands
Stephen Langley, MD St Luke's Cancer Centre, Guildford England
Alvaro Martinez, MD William Beaumont , Royal Oak, Mi
Mira Keyes, MD BC Cancer Agency , Vancouver Canada
Patrick Kupelian, MD UCLA Med Center Los Angeles
Robert Lee , MD Duke University Medical Center
Stefan Machtens, MD University Bergisch, Gladbach Germany
Jyoti Mayadev, UC Davis Davis ,California
Brian Moran, MD Chicago Prostate Institute Chicago
4/8/2015
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Gregory Merrick, MD Schiffler Cancer Center Wheeling West Virginia
Jeremy Millar, MD Alfred Health and Monash University, Melbourne Australia
Mack Roach, MD UCSF San Francisco California
Richard Stock, MD Mt. Sinai New York
Katsuto Shinohara, MD UCSF San Francisco California
Mark Scholz, MD Prostate Cancer Research Institute Marina del Ray California
Edward Weber, MD Prostate Cancer Center of Seattle
Anthony Zietman, MD Harvard Joint Center Boston Ma
Michael Zelefsky, MD Memorial Sloan Kettering New York
Jason Wong, MD UC Irvine Irvine California
Stacy Wentworth, MD Piedmont Radiation Oncology Greensboro , NC
Robyn Vera, DO Medical College of Virginia Richmond Virginia
4/8/2015
5
ABOUT THIS REVIEW STUDY
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21,000+ prostate studies were
published between 2000 and 2011
917 of those studies featured
treatment results
145 of those met the criteria to be
included in this review study.
Some treatment methods are underrepresented due to failure to meet
criteria
4/8/2015
6
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“Will I be cured?” or “Will my treatment
make me cancer free?” are valid patient
questions. However, PSA numbers (our best
measurement tool today) cannot answer this
absolutely. The current state-of-the-art can
only indicate that the treatment was
“successful” if PSA numbers do not indicate
cancer progression.
4/8/2015
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After prostate removal, PSA numbers usually
fall rapidly to very low numbers and stay
low.
 After radiation, PSA numbers usually come
down slower, might increase then fall in the
1 to 3 year range (called a “PSA Bump”), and
then usually level out at a higher number
than the surgery patient.
 These different PSA expectations result in
dissimilar ways to review a man’s PSA
history to judge treatment success.
 This study makes no attempt to standardize
those evaluation systems.

4/8/2015
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Brachy = Seed implantation either
permanent or temporary seeds
IMRT = Intensity Modulated Radiation
Therapy a form of External Radiation
RP = Standard open radical prostatectomy
Robot RP = Robotic Radical Prostatectomy
HIFU = High frequency Ultrasound
Cryo= Cryotherapy
Protons = form of External Radiation using Protons
EBRT= External Beam Radiation Therapy
ADT= Hormone Therapy
4/8/2015
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Criteria for Inclusion of Article*
1. Patients should be separated into Low,
Intermediate, and High Risk
2. Success must be determined by PSA analysis
3. All Treatment types considered: Seeds (Brachy),
Surgery (Standard or Robotic), IMRT (Intensity
Modulated Radiation), HIFU (High Frequency
Ultrasound), CRYO (Cryo Therapy), Protons, HDR
(High dose Rate Brachytherapy)
4.
Article must be in a Peer Reviewed Journal
* Expert panel consensus
4/8/2015
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5. Low Risk articles must have a minimum of 100
patients
6. Intermediate Risk articles must have a minimum of
100 patients
7. High Risk articles, because of fewer patients, need
only 50 patients to meet criteria
8. Patients must have been followed for a median of 5
years
For additional criteria information contact: lisa@prostatecancertc.com
4/8/2015
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RP
EBRT/
IMRT
Cryo
Brachy/
HDR
Robot
RP
7.4%
10%
16%
19%
3.2%
23%
3%
2/32
44/236
2/62
3/13
1/31
20/272 26/241
Proton HIFU
Total of 917 Treatment Articles. Some articles addressed several
treatments and were counted as separate articles for each treatment.
4/8/2015
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How to Interpret the Results
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Each treatment is given a symbol. For example Seed implant
alone (Brachy) is given a blue dot with a number in it.27
The number in the symbol refers to the article. The article
can be found in the notes section below the slide ( go into
“view” in up left corner of PowerPoint and click on note
section, then click on this portion and scroll down to see all
the references)
Treatment Success % = Percent of men whose PSA numbers
do not indicate cancer progression. (progression free) at a
specific point in time
The bottom line indicates the number years the study is out
An example, the blue dot with 27 inside indicates that, as per
article 27, 97% of the patients treated with seeds alone in low
risk patients at 12 years were free of disease progression
according to PSA numbers
4/8/2015
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How to Interpret the Results
First Establish your clinical risk group* by looking at
the definitions or ask your physician Refer only to
those slides for your risk group
 Make your own judgment and then ask a doctor in
each discipline ( Seeds, External Radiation Surgery,
etc) to tell you where his/her own peer reviewed
published Treatment Success % would fit on this
plot.

*Next Slide
4/8/2015
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Low Risk
Stage: T1 or T2a,b
Gleason Sum < 6
PSA < 10 ng/ml
4/8/2015
15
% PSA Progression Free
Treatment Success
LOW RISK RESULTS
100
25
4
22
30 6
31
90
19 105 24
23
37
39103
18
102
2 26
40
1 100
27
35
3
33
29 101
38
14 21
13 8
32
10
28
36
EBRT &
Seeds
5 16
12
7
104
9
80
15
Robot RP
Seeds
Surgery
EBRT
CRYO
HIFU
70
34
← Years from Treatment →
60
Protons
HDR
11
1
2 3 4 5 6 7 8 9 10 11 12 13 14 15
• Prostate Cancer Results Study Group
• Numbers within symbols refer to references
4/8/2015
BJU Int, 2012, Vol. 109(Supp. 1)
Prostate Cancer Center of Seattle
16
LOW RISK RESULTS
% PSA Progression Free
Treatment Success
Weighted
Brachy
100
EBRT
25
4
22
30 6
31
90
19 105 24
23
37
39103
18
102
40
1 100
2 26
27
35
3
33
29 101
38
14 21
13 8
32
10
28
36
5 16
12
7
104
9
80
15
Surgery
70
34
← Years from Treatment →
60
EBRT &
Seeds
Robot RP
Seeds
Surgery
EBRT
CRYO
HIFU
Protons
HDR
11
1
2 3 4 5 6 7 8 9 10 11 12 13 14 15
• Prostate Cancer Results Study Group
• Numbers within symbols refer to references
4/8/2015
BJU Int, 2012, Vol. 109(Supp. 1)
Prostate Cancer Center of Seattle
17

“The PCRSG criteria is pretty strict and not a
lot of studies fit. What happens if you include
articles with only 40 months of follow up or
have a long follow up but less than 100
patients?”
4/8/2015
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LOW RISK RESULTS
% PSA Progression Free
Treatment Success
>40 months follow-up or less than 100 patients
100
68 51 50
97
66 25 22
4 8175 62
44 86
3069641
82
71
9865 85
31
72
8489
61 93
105 24
1947
90
58
76 56
77
70 80
15 45
59
80
53
23 46
96
37
33
29 101
38
78
14 21
13 8
18
40
1 100
48
3 60
39103
88 102
54
73
2 26
+
27
35
32
1067
28 94
42 95
36
43 55
64
12 83
5 16
7 87
52
104
9
41
57 74 79
90
34
← Years from Treatment →
91
60
1
49
11
2 3 4 5 6 7 8 9 10 11 12 13 14 15
• Prostate Cancer Results Study Group
• Numbers within symbols refer to references
4/8/2015
BJU Int, 2012, Vol. 109(Supp 1)
Seeds
Surgery
EBRT
CRYO
HIFU
63
70
Seeds &
ADT
EBRT &
ADT
EBRT &
Seeds
Robot RP
Prostate Cancer Center of Seattle
Protons
Hypo EBRT
HDR
19
LOW RISK RESULTS
Weighted
% PSA Progression Free
Treatment Success
>40 months follow-up or less than 100 patients
100
EBRT
Brachy
68 51 50
92
97 66 25
22
4 8175 62
44 86
3069641
82
71
6584 85
31
72
98 89
61 93
105 24
1947
90
58
76 56
77
70 80
15 45
59
80
53
23 46
96
37
33
29 101
38
78
14 21
13 8
18
40
1 100
48
3 60
39103
88102
54
73
2 26
+
27
35
32
1067
28 94
42 95
36
43 55
64
12 83
5 16
52
7 87
104
9
41
57 74 79
90
Surgery
63
70
34
← Years from Treatment →
91
60
49
11
1
2 3 4 5 6 7 8 9 10 11 12 13 14 15
• Prostate Cancer Results Study Group
Seeds &
ADT
EBRT &
ADT
EBRT &
Seeds
Robot RP
Seeds
Surgery
EBRT
CRYO
HIFU
Protons
Hypo EBRT
HDR
• Numbers within symbols refer to references
4/8/2015
BJU Int, 2012, Vol. 109(Supp 1)
Prostate Cancer Center of Seattle
20

Zelefsky definition
 Only 1 factor
▪ Clinical Stage T2c
▪ Gleason score > 7
▪ PSA > 10 ng/ml

D’Amico definition
 PSA 10-20 Gleason Score 7 or Stage T2b
4/8/2015
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% PSA Progression Free
Treatment Success
INTERMEDIATE RISK RESULTS
100
33
14
90
24 2313
35
16 4
30 36 45
40
38
32
Seeds + ADT
EBRT & Seeds
39
6 12
43
18 47
19 5
7
70
+
34
15 44
80
Robot RP
37
42
3
28
9 26
25
29
41
1
8
10 11
60
Hypo EBRT
17 27
2
46
20
Brachy
Seeds Alone
Surgery
EBRT
CRYO
HIFU
HDR
50
← Years from Treatment
→
40
EBRT, Seeds +
ADT
21
22
1
2
3
4
5
6
7
8
9 10 11 12 13 14 15
Protons
• Prostate Cancer Results Study Group
• Numbers within symbols refer to references
4/8/2015
BJU Int, 2012, Vol. 109(Supp 1)
Prostate Cancer Center of Seattle
22
INTERMEDIATE RISK RESULTS
% PSA Progression Free
Treatment Success
Weighted
EBRT & Seeds
Brachy
100
33
14
90
24 2313
35
16 4
30 36 45
40
38
32
43
18 47
19 5
7
42
3
28
9 26
25
29
41
1
8
10 11
60
EBRT
20
Hypo EBRT
17 27
2
46
Surgery
50
← Years from Treatment
→
40
2
3
4
5
6
21
7
8
Brachy
Seeds Alone
Surgery
EBRT
CRYO
HIFU
HDR
EBRT, Seeds +
ADT
22
1
Seeds + ADT
EBRT & Seeds
39
6 12
70
+
34
15 44
80
Robot RP
37
9 10 11 12 13 14 15
Protons
• Prostate Cancer Results Study Group
• Numbers within symbols refer to references
4/8/2015
BJU Int, 2012, Vol. 109(Supp 1)
Prostate Cancer Center of Seattle
23
INTERMEDIATE RISK RESULTS
% PSA Progression Free
Treatment Success
>40 months follow-up or less than 100 patients
100
10459
EBRT + ADT
54 56
33
59 55
66
14
79
59
92
98
1544 96
16 4
3036 57
68 69
45
99
77
105
39
82 97 612
51
91
62 18 6393 4347
86
28
74 67 50
90
5
92652
19
78 70 7
25
103
29
76 102
41
100
1
60
8 87
85 88 53
10101 11
75
84
90
80
70
60
89 94
24 23 13
35
Robot RP
37
+
34
40
38 58
83
42 73
3 72
71
81 95
65
EBRT & Seeds
32
17 27
Seeds + ADT
64
2
46
20
Hypo EBRT
Brachy
Seeds Alone
Surgery
EBRT
CRYO
HIFU
HDR
50
← Years from Treatment
→
40
21
80
1
2
3
4
5
EBRT, Seeds +
ADT
22
6
7
8
9 10 11 12 13 14 15
Protons
• Prostate Cancer Results Study Group
• Numbers within symbols refer to references
4/8/2015
BJU Int, 2012, Vol. 109(Supp 1)
Prostate Cancer Center of Seattle
24
INTERMEDIATE RISK RESULTS weighted
Treatment Success
% PSA Progression Free
>40 months follow-up or less than 100 patients
Brachy
100
10459
33
66 55
14
79
92
98
1544 96
57
16 4
68 69
30 36 45
99 77
39
105 82 97 612
51
91
62 18 6393 4347
86
28
74 67 50
90
5
92652
19
78 70 7
25
103
29
76 102
41
100
1
60
8 87
85 88 53
10101 11
75
84
EBRT
90
80
70
60
89 94
20
24 23 13
35
Robot RP
37
+
34
40
38 58
83
42 73
3 72
71
81 95
65
32
17 27
64
2
46
Surgery
50
← Years from Treatment
→
40
2
3
4
5
22
6
7
8
Seeds + ADT
EBRT & Seeds
Hypo EBRT
Brachy
Seeds Alone
Surgery
EBRT
CRYO
HIFU
HDR
EBRT, Seeds +
ADT
21
80
1
EBRT + ADT
54 56
9 10 11 12 13 14 15
Protons
• Prostate Cancer Results Study Group
• Numbers within symbols refer to references
4/8/2015
BJU Int, 2012, Vol. 109(Supp 1)
Prostate Cancer Center of Seattle
25


Zelefsky definition
2 or more factors
 Gleason > 7
 PSA 10-20 Clinical Stage T1c- T2b

D'Amico
 Gleason Score 8-10
 PSA >20
4/8/2015
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% PSA Progression Free
Treatment Success
HIGH RISK RESULTS
20
16
19 18
3
22
8
45
109
4
108
EBRT & ADT
17
40
3 34
9 41
13 36
25
101
106
44
EBRT & Seed
43 32
2
48
1
33 21
10
12
14
28
42
8
110
31
Hypo EBRT
104
24
5
39
11
7 6 26
103
35
46
37
47
Protons
HDR
30 27
107
102 15
105
23 29
← Years from Treatment
→
49
EBRT Seeds +
ADT
Robot RP
• Prostate Cancer Results Study Group
• Numbers within symbols refer to references
4/8/2015
BJU Int, 2012, Vol. 109(Supp 1)
Prostate Cancer Center of Seattle
27
HIGH RISK RESULTS
% PSA Progression Free
Treatment Success
Weighted
EBRT, Seeds & ADT
20
Brachy
16
109
45
19 18
4
3
22
8
EBRT & ADT
108
17
40
3 34
9 41
13 36
25
101
106
EBRT
44
EBRT & Seeds
43 32
2
48
1
33 21
10
12
14
28
42
8
110
46
31
Hypo EBRT
104
24
5
39
11
7 6 26
103
35
37
47
Surgery
30 27
107
102 15
105
HDR
23 29
← Years from Treatment
→
Protons
49
EBRT Seeds +
ADT
Robot RP
• Prostate Cancer Results Study Group
• Numbers within symbols refer to references
4/8/2015
BJU Int, 2012, Vol. 109(Supp 1)
Prostate Cancer Center of Seattle
28
HIGH RISK RESULTS
% PSA Progression Free
Treatment Success
>40 months follow-up or less than 100 patients
92 65
81
20
19 18
80
74
78
3
22
8
67
55 40 75
3 85
72 54
34
91 66 41
9 7968
71 136436
50
53 25
101
62 106
45
109
4
108
EBRT & ADT
17
EBRT & Seed
4376
2
48 59
56 1
90
33 21
103
35
52 63
73
77 46
88
51
23 29
from 69
Treatment
10
12
14
31
86 87
57
42
8 61
110 89
5
28
Hypo EBRT
104
24
39
11
83 7 8226
6
84
30 58 27
107
102 15
105
60
Protons
HDR
49
EBRT Seeds +
ADT
Robot RP
• Prostate Cancer Results Study Group
• Numbers within symbols refer to references
4/8/2015
BJU Int, 2012, Vol. 109(Supp 1)
37
47
32
44
70
← Years
→
16
Prostate Cancer Center of Seattle
HIFU
29
HIGH RISK RESULTS
Weighted
>40 months follow-up or less than 100 patients
% PSA Progression Free
Treatment Success
Brachy
92 65
81
20
19 18
80
74
78
3
22
8
67
4075
3 85
72 54
91 66 34
941 68
71 13643679
50
53 25
101
62 106
← Years
→
45
109
4
108
EBRT & ADT
17
55
EBRT
16
EBRT & Seed
4376
2
48 59
56 1
90
33 21
70
103
35
52 63
73
77 46
88
51
23 29
from 69
Treatment
10
12
14
31
86 87
57
42
8 61
110 89
5
28
Hypo EBRT
104
24
39
11
83 7 8226
6
84
30 58 27
107
102 15
105
60
Protons
HDR
Surgery 49
EBRT Seeds +
ADT
Robot RP
• Prostate Cancer Results Study Group
• Numbers within symbols refer to references
4/8/2015
BJU Int, 2012, Vol. 109(Supp 1)
37
47
32
44
Prostate Cancer Center of Seattle
HIFU
30
OBSERVATIONS




For most low risk patients, most therapies
will be successful.
There appears to be a higher cancer control
success rate for Brachy over EBRT and
Surgery for all groups. Patients are
encouraged to look at graphs and determine
for themselves
Serious side effect rates must be considered
for any treatment
Relaxing the report selection criteria doesn’t
seem to impact the results substantially
4/8/2015
31
= Seeds alone
= EBRT & Seeds
= Surgery = Standard Radical Prostatectomy
= “Robot” =Robotic Prostatectomy
= “HIFU” = High Frequency Ultrasound
= “HDR”= High Dose Rate Brachytherapy +/-EBRT
= EBRT alone
= Hypo EBRT
= Protons
4/8/2015
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+
= “CRYO” Cryo Therapy
= EBRT, Seeds, & ADT
= Seeds & ADT
= EBRT & ADT
= “Brachy” = all seed implant treatments
= all Surgery treatments
= all EBRT treatments
= all EBRT & Seeds
= all EBRT, Seeds & ADT
4/8/2015
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Low Risk
Stage: T1 or T2a,b
Gleason Sum < 6
PSA < 10 ng/ml
Intermediate Risk
Stage T1 or T1-2
Stage T1-2
Gleason Score 7 or Gleason 6
PSA < 10
PSA 10-20
High Risk
Stage T2c or T3
Gleason score ≥ 8
PSA > 20 ng/mL
4/8/2015
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
Peter Grimm, DO
 peter@grimm.com

Lisa Grimm, Research Coordinator
 lisa@prostatecancertc.com
 Or ProstateCancerTC.com


Or contact PCRSG member
Prostate Cancer Treatment Center website
 www.Prostatecancertreatmentcenter.com
4/8/2015
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