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1/26/20141 Peter Grimm, DO Prostate Cancer Center of Seattle Comparing Treatment Results Of PROSTATE CANCER Prostate Cancer Results Study Group 2013.

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Presentation on theme: "1/26/20141 Peter Grimm, DO Prostate Cancer Center of Seattle Comparing Treatment Results Of PROSTATE CANCER Prostate Cancer Results Study Group 2013."— Presentation transcript:

1 1/26/20141 Peter Grimm, DO Prostate Cancer Center of Seattle Comparing Treatment Results Of PROSTATE CANCER Prostate Cancer Results Study Group 2013

2 1/26/20142 Problem: Patients, physicians and carriers need a simple, unbiased means to compare the cancer control rates of modern prostate cancer treatment methods. 1/26/20142

3 Prostate Cancer Results Study Group 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 1/26/20143

4 4 Prostate Cancer Results Study Group Ignace Billiet, MD F.E.B.U., Urologist Kortrijk, Belgium David Bostwick, MD Bostwick Laboratories David Crawford, MD Univ Colorado, Denver Brian Davis, MD Mayo Clinic Rochester, Minnesota 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

5 1/26/20145 Prostate Cancer Results Study Group 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 California Robyn Vera, DO Radiant Oncology Lacey Washington

6 1/26/20146 25,000+ prostate studies were published between 2000 and 2012 1,066 of those studies featured treatment results 218 of those met the criteria to be included in this review study. (*1 st & 2 nd group) Some treatment methods are under- represented due to failure to meet criteria ABOUT THIS REVIEW STUDY

7 1/26/20147 About This Study Will I be cured? or Will my treatment make me cancer free? are valid patient questions. However, PSA values (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.

8 1/26/20148 About This Study 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 mans PSA history to judge treatment success. This study makes no attempt to standardize those evaluation systems.

9 1/26/20149 Abbreviations Brachy = Seed implantation, either permanent or temporary seeds EBRT= External Beam Radiation Therapy (includes IMRT- Intensity Modulated Radiation) RP = Standard open radical prostatectomy Robot RP = Robotic Radical Prostatectomy HIFU = High frequency Ultrasound Cryo= Cryotherapy Protons = form of External Radiation using Protons ADT= Hormone Therapy

10 1/26/201410 1.Patients should be separated into Low, Intermediate, and High Risk groups 2.Success must be determined by PSA analysis 3.All Treatment types considered: Seeds (Brachy), Surgery (Standard or Robotic), EBRT (External beam radiation therapy & IMRT (Intensity Modulated Radiation therapy), HIFU (High Frequency Ultrasound), CRYO (Cryo Therapy), Protons, HDR (High dose Rate Brachytherapy) 4. Article must be in a Peer Reviewed Journal 1/26/201410 Criteria for Inclusion of Article* * Expert panel consensus

11 1/26/201411 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.comlisa@prostatecancertc.com 1/26/201411

12 1/26/201412 RP EBRT/ IMRT CryoBrachy/ HDR Robot RP ProtonHIFU 9%12%6%20%6%25%3% 26/30334/2842/3460/2994/704/161/36 Total of 1,066 Treatment Articles. Some articles addressed several treatments and were counted as separate articles for each treatment. *A few articles evaluated other/minor treatments and are not listed here. These calculations only include primary accepted articles, and do not include secondary acceptance totals. 1/26/201412

13 1/26/201413 Each treatment is given a symbol. For example Seed implant alone (Brachy) is given a blue dot with a number in it. The number in the symbol refers to the article reference number. The article references can be found in the notes section below the slides (Click on the view tab in upper left corner of PowerPoint and select notes page, you can then scroll down to see all the references below the graphs) Treatment Success % = Percent of men, whose PSA numbers indicate no cancer progression (progression free) at a specific point in time The bottom line of the graph indicates the number of years the study is out. An example, the blue dot with #27 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 27 How to Interpret the Results

14 1/26/201414 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. How to Interpret the Results (cont.) *Next Slide

15 1/26/201415 LOW Risk Group Definition Low Risk Stage: T1 or T2a,b Gleason Sum < 6 PSA < 10 ng/ml Stage: T1 or T2a,b Gleason Sum < 6 PSA < 10 ng/ml

16 1/26/2014 BJU Int, 2012, Vol. 109(Supp. 1) 7 7 5 5 22 Years from Treatment CRYO Prostate Cancer Results Study Group Numbers within symbols refer to references 1 1 12 24 14 8 8 2 2 HIFU % PSA Progression Free 11 15 Protons 4 4 18 9 9 10 EBRT & Seeds 25 Robot RP 26 Prostate Cancer Center of Seattle 27 HDR 28 29 31 32 33 34 19 36 37 LOW RISK RESULTS Treatment Success 39 35 40 100 101 13 16 103 102 6 6 16 104 105 106 107 108 Update of z 20 109 110 111111 112 113 114 115

17 1/26/2014 BJU Int, 2012, Vol. 109(Supp. 1) 17 7 7 5 5 22 Years from Treatment CRYO Prostate Cancer Results Study Group Numbers within symbols refer to references 1 1 12 24 14 8 8 2 2 HIFU % PSA Progression Free 11 15 Protons 4 4 18 9 9 10 EBRT & Seeds 25 Robot RP 26 Prostate Cancer Center of Seattle 27 HDR 28 29 31 32 33 34 19 36 37 LOW RISK RESULTS Weighted 39 35 40 100 101 13 EBRT Brachy Surgery Treatment Success 103 102 6 6 16 104 105 106 107 108 Update of 20 109 110 111 112 113 114 115

18 1/26/201418 Question about the Criteria 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?

19 1/26/2014 BJU Int, 2012, Vol. 109(Supp 1) 19 7 7 5 5 22 Years from Treatment CRYO Prostate Cancer Results Study Group Numbers within symbols refer to reference s 1 1 12 24 14 8 8 2 2 HIFU % PSA Progression Free 11 15 Protons 4 4 18 9 9 10 EBRT & Seeds 25 Robot RP 26 Prostate Cancer Center of Seattle 27 HDR 28 29 31 32 33 34 19 36 37 LOW RISK RESULTS >40 months follow-up or less than 100 patients Treatment Success 39 35 40 41 100 101 13 65 49 76 80 56 59 63 41 75 51 71 72 90 73 74 70 42 57 85 84 66 43 64 44 EBRT & ADT 53 82 81 62 54 79 Hypo EBRT 86 87 88 45 58 69 7878 77 4646 4848 91 + + Seeds & ADT 93 89 50 67 68 95 94 55 5252 8383 47 61 96 103 102 97 98 60 6 6 16 104 105 106 99 107 108 Update of 20 109 110 201 202 111 112 113 114

20 1/26/2014 BJU Int, 2012, Vol. 109(Supp 1) 20 7 7 5 5 22 Years from Treatment CRYO Prostate Cancer Results Study Group Numbers within symbols refer to references 1 1 12 24 14 8 8 2 2 HIFU % PSA Progression Free 11 15 Protons 4 4 18 9 9 10 EBRT & Seeds 25 Robot RP 26 Prostate Cancer Center of Seattle 27 HDR 28 29 31 32 33 34 19 36 37 38 LOW RISK RESULTS Weighted >40 months follow-up or less than 100 patients Treatment Success 39 35 40 41 100 101 13 65 49 76 80 56 59 63 41 75 51 71 72 90 73 74 70 42 57 85 84 66 43 64 44 EBRT & ADT 53 82 81 62 54 79 86 87 88 45 58 69 7878 77 4646 4848 91 + + Seeds & ADT 93 92 89 50 67 68 95 94 55 5252 8383 47 61 BrachyEBRT Surgery Hypo EBRT 96 103 102 97 98 60 6 6 16 104 105 106 99 107 108 Update of 20 109 110 201 202 111 112 113 114 115

21 1/26/201421 Intermediate Risk Patient Definition Zelefsky definition Only 1 factor Clinical Stage T2c Gleason score > 7 PSA > 10 ng/ml DAmico definition PSA 10-20 Gleason Score 7 or Stage T2b

22 1/26/2014 BJU Int, 2012, Vol. 109(Supp 1) 22 29 22 21 5 5 % PSA Progression Free 18 12 28 17 10 9 9 8 8 2 2 1 1 13 Protons EBRT & Seeds HDR Years from Treatment Prostate Cancer Results Study Group Numbers within symbols refer to references 15 4 4 36 Prostate Cancer Center of Seattle 37 EBRT, Seeds + ADT 38 + + Seeds Alone Seeds + ADT 40 Robot RP 41 42 44 43 45 46 Hypo EBRT INTERMEDIATE RISK RESULTS Treatment Success 7 7 11 14 20 35 34 39 23 24 16 6 6 26 30 27 47 48 49 150 151 31 Update of 152 153 154 155 156 157 EBRT + ADT 158 159

23 1/26/2014 BJU Int, 2012, Vol. 109(Supp 1) 23 29 22 21 5 5 % PSA Progression Free 18 12 28 3 3 17 10 9 9 8 8 2 2 1 1 13 Protons HDR Years from Treatment Prostate Cancer Results Study Group Numbers within symbols refer to references 15 4 4 36 37 38 + + Seeds Alone Seeds + ADT 40 Robot RP 41 42 44 43 45 46 INTERMEDIATE RISK RESULTS Weighted 7 7 11 14 20 35 34 39 23 24 16 6 6 26 EBRT & Seeds EBRT Surgery Brachy EBRT & Seeds Hypo EBRT EBRT, Seeds + ADT Treatment Success Prostate Cancer Center of Seattle 30 27 47 48 49 150 151 31 Update of 152 153 154 155 156 157 158 159

24 1/26/2014 BJU Int, 2012, Vol. 109(Supp 1) 24 29 22 21 5 5 % PSA Progression Free 18 12 28 3 3 17 10 9 9 8 8 2 2 1 1 13 Protons EBRT & Seeds HDR Years from Treatment Prostate Cancer Results Study Group Numbers within symbols refer to references 15 4 4 36 Prostate Cancer Center of Seattle 37 EBRT, Seeds + ADT 38 + + Seeds Alone Seeds + ADT 40 Robot RP 41 42 44 43 45 46 INTERMEDIATE RISK RESULTS >40 months follow-up or less than 100 patients Treatment Success 7 7 11 14 20 35 34 39 23 24 16 6 6 26 82 66 88 67 70 97 63 65 102 103 101 86 87 85 58 68 71 81 50 EBRT + ADT 94 93 92 77 91 51 69 Hypo EBRT 99 75 90 89 56 55 54 80 57 83 60 73 72 98 53 52 79 95 64 100 84 78 59 62 74 96 76 104 59 105 30 27 47 48 49 150 151 106 107 31 109 108 Update of 152 153 154 155 156 110 157 158 159

25 1/26/2014 BJU Int, 2012, Vol. 109(Supp 1) 25 29 22 21 5 5 % PSA Progression Free 18 12 28 3 3 17 10 9 9 8 8 2 2 1 1 13 Protons HDR Years from Treatment Prostate Cancer Results Study Group Numbers within symbols refer to references 15 4 4 36 Prostate Cancer Center of Seattle 37 38 + + Seeds Alone Seeds + ADT 40 Robot RP 41 42 44 43 45 46 INTERMEDIATE RISK RESULTS weighted >40 months follow-up or less than 100 patients 7 7 11 14 20 35 34 39 23 24 16 6 6 26 82 66 88 67 70 97 63 65 102 103 101 86 87 85 58 68 71 81 50 EBRT + ADT 94 93 92 77 91 51 69 Hypo EBRT 99 75 90 89 56 55 54 80 57 83 60 73 72 98 53 52 79 95 64 100 84 78 59 62 74 96 76 EBRT Brachy Surgery EBRT & Seeds EBRT, Seeds + ADT Treatment Success 104 105 30 27 47 48 49 150 151 106\\\\\\0\\\\\ 107 31 109 108 Update of 152 153 154 155 156 110 157 158 159

26 1/26/201426 High Risk Patient Definition Zelefsky definition 2 or more factors Gleason > 7 PSA 10-20 Clinical Stage T1c- T2b D'Amico Gleason Score 8-10 PSA >20

27 1/26/2014 BJU Int, 2012, Vol. 109(Supp 1) 27 6 6 11 25 15 5 5 EBRT Seeds + ADT 19 30 16 20 18 29 % PSA Progression Free 17 21 8 8 24 26 37 41 12 Protons EBRT & Seeds HDR EBRT & ADT Years from Treatment Prostate Cancer Results Study Group Numbers within symbols refer to references Prostate Cancer Center of Seattle 42 43 46 47 Robot RP 48 49 101 102 103 104 105 106 Hypo EBRT 107 109 HIGH RISK RESULTS Treatment Success 23 35 108 4 4 2 2 31 39 33 34 7 7 1 1 110 27 3 3 13 14 28 40 10 111 112 113 114 115 Surg & ADT 116 118 117 119 121 122 Hypo EBRT +ADT 123 124 120 HDR + ADT 120 Update of 125 126 127 128 129 130 131 Surg & EBRT 132 133

28 1/26/2014 BJU Int, 2012, Vol. 109(Supp 1) 28 6 6 11 25 15 5 5 EBRT Seeds + ADT 19 30 16 20 18 29 % PSA Progression Free 17 21 8 8 22 24 26 37 41 12 Protons HDR Years from Treatment Prostate Cancer Results Study Group Numbers within symbols refer to references Prostate Cancer Center of Seattle 42 43 46 47 Robot RP 48 49 101 102 103 104 105 106 107 109 HIGH RISK RESULTS Weighted 23 35 108 4 4 2 2 31 39 33 34 EBRT, Seeds & ADT Brachy EBRT Surgery EBRT & ADT EBRT & Seeds Hypo EBRT Treatment Success 1 1 7 7 110 27 3 3 13 14 28 40 10 111 112 113 114 115 116 Surg & ADT 118 117 119 121 HDR + ADT 122 123 124 120 Update of 125 126 127 128 129 130 131 132 Surg & EBRT 133

29 1/26/2014 BJU Int, 2012, Vol. 109(Supp 1) 29 6 6 11 25 15 5 5 EBRT Seeds + ADT 19 30 16 20 18 29 % PSA Progression Free 17 21 8 8 9 9 22 24 26 37 41 12 Protons EBRT & Seeds HDR EBRT & ADT Years from Treatment Prostate Cancer Results Study Group Numbers within symbols refer to references Prostate Cancer Center of Seattle 42 43 46 47 Robot RP 48 49 101 102 103 104 105 106 Hypo EBRT 107 109 HIGH RISK RESULTS >40 months follow-up or less than 100 patients Treatment Success 35 108 4 4 2 2 31 39 33 34 50 51 52 53 54 55 HIFU 56 86 87 57 58 59 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 88 79 80 81 89 84 83 82 85 1 1 7 7 90 91 110 27 3 3 13 14 28 40 92 10 23 111 112 113 114 115 116 Surg & ADT 118 117 119 121 60 122 123 124 120 HDR + ADT Update of 125 93 126 127 128 129 94 95 96 97 98 130 131 132 Surg & EBRT 133

30 1/26/2014 BJU Int, 2012, Vol. 109(Supp 1) 30 6 6 11 25 15 5 5 19 30 16 20 18 29 % PSA Progression Free 17 21 8 8 22 24 26 37 41 12 Protons Years from Treatment Prostate Cancer Results Study Group Numbers within symbols refer to references 42 43 46 47 48 49 101 102 103 104 105 106 107 109 HIGH RISK RESULTS Weighted >40 months follow-up or less than 100 patients Treatment Success 10 23 35 108 4 4 2 2 31 39 33 34 50 51 52 53 54 55 HIFU 56 86 87 57 58 59 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 88 79 80 81 89 84 83 82 85 Surgery Brachy EBRT EBRT & ADT EBRT & Seeds Hypo EBRT HDR EBRT Seeds + ADT Robot RP Prostate Cancer Center of Seattle 1 1 7 7 90 91 110 27 3 3 13 14 28 40 92 111 112 113 114 115 116 Surg & ADT 118 119 60 122 123 124 120 HDR + ADT Update of 125 93 126 127 128 129 94 95 96 98 130 131 132 Surg & EBRT 133

31 1/26/201431 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 doesnt seem to impact the results substantially 1/26/201431 OBSERVATIONS

32 1/26/201432 Slide Symbols & Abbreviations = 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

33 1/26/201433 Slide Symbols & Abbreviations (cont.) = CRYO Cryo Therapy = EBRT, Seeds, & ADT = Seeds & ADT = EBRT & ADT = Surgery & ADT = Brachy = all seed implant treatments = all Surgery treatments = all EBRT treatments = all EBRT & Seeds = all EBRT, Seeds & ADT + +

34 1/26/201434 Risk Group Definitions Intermediate Risk Stage T1 or T1-2 Stage T1-2 Stage T1 or T1-2 Stage T1-2 Gleason Score 7 or Gleason Score 6 PSA < 10 ng/ml PSA 10-20 ng/ml High Risk Stage T2c or T3 Stage T2c or T3 Gleason Score 8 Gleason Score 8 PSA > 20 ng/mL PSA > 20 ng/mL Low Risk Stage: T1 or T2a,b Gleason Score < 6 PSA < 10 ng/ml Stage: T1 or T2a,b Gleason Score < 6 PSA < 10 ng/ml

35 1/26/201435 For More Information Peter Grimm, DO peter@grimm.com Lisa Grimm, Research Coordinator lisa@pccseattle.com Or contact a PCRSG member Prostate Cancer Center of Seattle (website & email) www.Prostatecancertreatmentcenter.com info@pccseattle.com


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