1. Radiation therapy for Early Stage Prostate Cancer
John A. Kalapurakal MD
Professor, Radiation Oncology
Northwestern University Medical School
Chicago, IL

2. ARS
?1-B

3. It is estimated that 217,730 men will be diagnosed with and 32,050 men will die of cancer of the prostate in (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 Indian/Alaska Native
77.7 per 100,000 men
20.0 per 100,000 men
Hispanic
125.8 per 100,000 men
18.8 per 100,000 men

4. Anatomy

6. Risk stratification of Prostate Cancer
Low risk
T1c-T2a and PSA<10 and Gleason score <6
Intermediate risk
T2b-T2c or PSA or Gleason score 7
High risk
T3-T4 or PSA >20 or Gleason score 8-10

7. Low-risk Prostate Cancer
External beam RT: (x-rays, protons)
70.2Gy-79.2Gy in sessions (5 treatments/week, 8-9 weeks)
3D Conformal, Intensity Modulated RT, Protons
Brachytherapy: I-125 (Iodine), Pd-103 (Palladium)
144Gy in single session

8. Intermediate-risk Prostate Cancer
External beam RT: (x-rays, protons)
Gy 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), Pd-103 (Palladium)
45 Gy in 25 sessions (5 weeks) + brachytherapy (seeds, HDR)

10. 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)

11. 3D conformal versus IMRT versus Protons

12. Prostate Seed Implantation: Indications, Techniques and Outcomes

15. Post Implant CT scan dosimetry

16. Long-term results: Brachytherapy alone (Low-risk) and RT+Brachytherapy in intermediate-risk Prostate Cancer
IJROBP 2010
IJROBP 2007

17. 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

18. Harvard Study: Adding 6 months of hormones to RT improved survival in intermediate-risk and high-risk disease
Intermediate-risk
High-risk
IJROBP 2010

19. MD Anderson Study: Higher RT dose (78 Gy) for intermediate-risk patients resulted in better PSA control and cancer–specific survival
IJROBP 2010

20. 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

21. Radiation-related Side Effects
Likely
Increased urinary frequency, burning and urgency
Increased bowel frequency, burning and urgency
Fatigue
Less likely
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

22. Hormone-related Side Effects

23. 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

24. Radiation therapy for Early Stage Prostate Cancer
John A. Kalapurakal MD
Professor, Radiation Oncology
Northwestern University Medical School
Chicago, IL