Prostate Cancer Treatment Options “THE FACTS”

TREATMENT NAME(S)	DESCRIPTION	PROS	CONS	PUBLISHED RESULTS	REFERENCES
Cryotherapy Cryosurgery Cryoablation	As primary treatment, uses the process of freezing and thawing to destroy cancer cells.	No cutting; performed on outpatient basis. Recent methods reduce risk of rectal injury. Can be repeated.	Highest risk of incontinence and permanent erectile Dysfunction. Cancers typically return. Despite several resurrections since the 80’s, still a lack of long-term data. Generally recommended for salvage cases, not as primary therapy based on complications, relapse.	Very few. (not recommended for cases where cancer is known or suspected to have spread).	Long, Bahn, Lee Urol 57:518-523, 2001
Cyberknife®	Fancy name, actually a method of radiation; “hypo-fractionated” dose delivery (fewer sessions but higher doses of radiation).	Treatment usually delivered in only 5 fractions.	All extreme radiation hypofractionated studies reveal significant complications including high incidence of urethral/rectal fistula, bladder damage, ulcerations, bone necrosis.	No long-term results published (should be reserved for non-curative cases; patients who will not live long enough to suffer harsh complications).	Prostate Cancer Blog (www.nyprosate.blogspot.com) Dr. Louis Potters 2/14/07
HIFU High Intensity Focused Ultrasound	Uses focused sound waves from a rectal probe to ablate cancer cells. Waves heat the target area to destroy tissue; several hour-long sessions required.	Non-ionizing (treatment can be repeated).	Just another form of “hyperthermia” – heat therapy – used over 50 years and abandoned as cancers virtually always return with aggression. Unwise to use “treatments which can be repeated” as recurrent treatment is challenging. Always best to get rid of cancer “first go round.”	French study reports 30% failures at only 5 years.(not recommended for cases where cancer is known or suspected to have spread beyond the prostate capsule).	Misrai, World J Onc, Springer-Verlag 2008 “43.7% experienced biochemical recurrence in less than 5 years”
Hormonal Therapy	Uses various types of hormones to decrease production of testosterone to inhibit growth and progress of cancer.	Easy oral and/or injection treatment.	Side-effects: complete erectile dysfunction and menopause-like symptoms (hot flashes, fragile bones, enlarged painful breasts) Cancers eventually become resistant. Expensive.	Many studies indicate this is appropriate only when all other options have been expended, since this is non-curative in nature.	Keating, J Clin Onc, Vol 24, No 27: 4448-4454 “Hormonal therapy’s unwelcome side-effects”
Radiation:	Different types of radiation and different delivery systems to kill cancer cells.	No cutting; no blood loss; no risk of infection.	Potential of over-radiation eliminated by experience and expertise – track record!	Perhaps most published of all treatment options.	Barringer, JAMA 1917 “because of initial success of radium - no patient with prostate cancer should be operated on.”
Brachytherapy	Implanting radioactive sources (seeds, pellets) directly into the tumor(-s).	Ability to place radiation source exactly at tumor site.	Results dependent on skill of brachytherapist to place seeds appropriately.	Many approaching 15 years or longer by Dattoli, Wallner, Merrick and Blasko.	Sylvester, Int Journ Rad Onc Bio & Phys, Vol 67, Is 1, Jan 2007: 57-64
Palladium-103	Isotope with short half-life and steep dose fall-off to surrounding anatomy.	Radiation effects diminish by 50% every 17 days; by design, seeds rarely migrate.	If not performed by highly experienced physician may decrease outcome and increase side effects.	Majority by Dattoli, et al (since in clinical use from early 1990’s.)	Dattoli, Urology Vol 70, 2006
Iodine-125	Longer half-life and wider dose fall-off.	Less penetrating than Ir-192 or CS-131 isotope.	Shape of Iodine seeds causes them to migrate from target. Much more penetrating than Pd-103 affecting bladder, urethra, rectum and sexual function.	Yes – often compared to PD-103.	Wallner, The Cancer Journal 2002,8(1):67-73
High Dose Rate (HDR)	Using Iridium-192, highly penetrating,” potentially damaging isotope.	Use of new microprocessors.	Penetrating nature of Iridium causes significant radiation exposure to entire body. Typically delivered over 2-3 sessions (hypofractionated) leading to “late” or long-term damage to healthy surrounding tissues. Not new! Virtually identical to HDR from the 1960’s.	Many, but no studies supporting HDR as sole therapy.	IJ Rad Onc Biol/Phy,Vol 65 No 1, 2006 Large field radiation exposure
COMBINATION THERAPY	Using two or more types of radiation, sometimes with hormones, to defeat cancer. External Beam Radiation uses fractionated	Cancers of all sites proven to respond best to multiple modalities; temporary side effects.	Success dependent on expertise of practitioner, staff and requires sophisticated equipment for integrated treatment plan.	Longest published survival rates – 16 years, using IMRT with PD-103 Brachtherapy.	Dattoli, Cancer, Vol 110, No 3 08/07 pp 551-555 “Longterm Outcomes with Brachy and Radiation …”
EBRT	photon doses.	Early version of technology.	Outdated technology with many side effects.	Many studies, now outdated.	Zelefsky, et al, J Urol, 166, 2001
IMRT	Intensity Modulated Radiation Therapy with photons.	More controlled version.	Now “old” technology.	Outdated studies.	(Based on improving already impressive results of combination therapy above – see Dattoli)
4D-IG IMRT	Four-dimensional Image Guided IMRT with	When coupled with DART, the most	Very few Centers offer this new level of technology.	Evolutionary – in process, 2008 (Yet “time-tested” since this is improvement	Lindsley K.L. Cancer Res. 1998; 150: 125-36 and
With DART	Dynamic Adaptive Radiation Therapy.	exquisite control of photon beams.		upon previous successful technology).	Santanam L, Int J Radiat Oncol Biol Phys. 2007 Aug
Neutron Therapy	Using Neutrons to kill cancer cells.	Theoretically might be effective for treating cancer resistant to photon radiation and non-resectable sarcomas.	Any contact with healthy tissue can cause severe damage – high incidence of serious side effects. Unfavorable “therapeutic ratio” - damages both good cells and cancer cells. Not widely available.	Still experimental; studies do not show it as safe or effective as photon radiation.
Proton Therapy	Uses Proton beams to kill cancer cells.	Excellent treatment for tiny tumors of the eyes/brain. Advantages become disadvantages when treating large areas, i.e. prostate.	Risks of radiation “scatter,” not effective for large areas (prostate), risk of secondary tumors from proton by-product – neutrons.	Yes, but all studies combined with Photons.	Hall, IJ Onc, Vol 65, No 1,2006 “When compared to photons, a 10-fold increased total-body dose delivered to patient by neutrons.”
RapidArc®	New product from Varian, using a single radiation rotation.	Shorter treatment time for patient; reduction of staff for Center– no distinct benefit for patient.	Continuous open beam (arc) causes higher integral dose (potentially harmful). Rapid treatment times (accelerated radiation) predicts increased toxicity.	None - no clinical toxicity studies to cite.	Too new – significant concerns about radiation dose rates.
Tomotherapy	Computed tomography guided IMRT	In theory, delivers radiation in helical pattern; best used for small targets.	Problems with consistent movement of couch leading to over-and under-treatment; excessive treatment time causing enormous total body radiation doses resulting in secondary malignancies.	Yes, but no long-term results (less than 5 years).	Too new – no studies, but has been prohibited in treatment of childhood and adolescent malignancies for fear of causing development of another cancer.
Surgery:	The old “Gold” standard.	Perceived as best method to eradicate any cancer.	Misconception of guarantee that all cancer is gone.	Many, however 40 – 80% of cases found to have more cancer after surgery is completed, requiring additional treatment.
Radical	Surgical removal of bulk of the gland by	Physically removes the tumor from the	Most aggressive surgery to be performed on the patient’s body but least aggres-	Results have been reported for many years, as this was the only treatment for	Moul, J Urol,Vol 163, 2000
Prostatectomy	incisions either retropubic or perineal.	body. (A psychological benefit.)	sive treatment to the cancer. Commonly leaves microscopic tumor cells behind and may spread cancer cells into blood stream.	decades.	“30,000 men per year will develop recurrence after radical prostatectomy.”
Robotic “da Vinci”	Uses “sophisticated” robotic equipment to	Possibly easier to tolerate than major	Still surgery with similar outcome and side effects of open surgical procedure.	Recent studies report a 3-fold failure rate at only 6 months, with increased	Blute, J Clin Onc, (Mayo Clinic, Rochester MN)
Laparoscopic	remove gland tissue through small openings in the abdomen.	open surgery.	Success very dependent on operator’s level of experience.	complications compared with standard prostatectomy.	Vol 28, No 14, 2008 “patients have been led to believe ..outcomes are better, but .. not the case.” Just another way to extract the prostate.
Watchful Waiting	No treatment but periodic retesting to assess disease progression.	No treatment is easiest to tolerate as long as cancer does not spread	Difficult for patient – “watchful worrying.” Prostate cancers often become more aggressive and PSAs may even diminish leading to a false sense of security.	Controversial – but suggested for elderly with less than 5 years life expectancy (unless highly aggressive tumor or very high volume tumor).	Lancet Onc. 2008 May 9(5): 407-9 “4-fold increase in mortality without treatment”