Comparative analysis of prostate-specific antigen free survival outcomes for patients with low, intermediate and high risk prostate cancer treatment by radical

therapy. Results from the Prostate Cancer Results Study Group Updated study available from Lisa@pccseattle.com) BJUI 2011

Peter Grimm 1 , Ignace Billiet 2 , David Bostwick 3 , Adam P. Dicker 4 ,Steven Frank 5 , Jos Immerzeel 6 , Mira Keyes 7 , Patrick Kupelian 8 ,W. Robert Lee 9 , Stefan Machtens 10 , Jyoti Mayadev 11 ,

Brian J. Moran 12 , Gregory Merrick 13 , Jeremy Millar 14 , Mack Roach 15 ,Richard Stock 16 , Katsuto Shinohara 15 , Mark Scholz 17 , Ed Weber 18 ,Anthony Zietman 19 , Michael Zelefsky 20 , Jason Wong 21 ,

Stacy Wentworth 22 , Robyn Vera 23 and Stephen Langley 24

1 Prostate Cancer Center of Seattle, WA, USA, 2 Urology Centre Kortrijk, Belgium , 3 Bostwick Laboratories,Glen Allen, VA, USA , 4 J efferson Medical College of Thomas Jefferson University, Philadelphia, PA, USA, 5 MDAndersen Center, Houston, TX, USA , 6 The Prostate Clinic, Utrecht, The Netherlands , 7 BC Cancer AgencyVancouver Center, Vancouver, BC, Canada, 8 UCLA, Los Angeles, CA, USA , 9 D uke University Medical Center, Durham, NC, USA , 1 0D epartment of Urology, Marien-Krankenhaus, Bergisch Gladbach, Germany, 11 University of California, Davis, CA, USA , 1 2 Chicago Prostate Center, Westmont, IL, USA , 1 3 Urologic Research Institute, Wheeling Jesuit University, WV, USA , 1 4A lfred Health and Monash Univeristy, Melbourne, Australia , 1 5U niversity of California, San Francisco, CA, USA, 1 6M t Sinai Medical Center, New York, USA, 1 7Prostate Cancer Research Institute, Los Angeles, CA, USA, 1 8P rostate Cancer Center of Seattle, WA, USA, 1 9 Harvard Medical School, Boston, MA, USA , 2 0M emorial Sloan Kettering Cancer Center, New York, USA, 21 University of California, Irvine, CA, USA , 2 2 Piedmont Radiation Oncology, Greensboro, NC, USA , 2 3 Virginia Commonwealth University, Richmond, VA, USA , and 24 Department of Urology, Royal Surrey County

Hospital, Guildford, UK

What ’ s known on the subject? and What does the study add?

Very few comparative studies to date evaluate the results of treatment options for prostate cancer using the most sensitive measurement tools. PSA has been identifi ed as the most sensitive tool for measuring treatment effectiveness. To date, comprehensive unbiased reviews of all the current literature are limited for prostate cancer. This is the fi rst large scale comprehensive review of the literature comparing risk stratifi ed patients by treatment option and with long-term follow-up. The results of the studies are weighted, respecting the impact of larger studies on overall results. The study identifi ed a lack of uniformity in reporting results amongst institutions and centers.

A large number of studies have been conducted on the primary therapy of prostate cancer but very few randomized controlled trials have been conducted. The comparison of outcomes from individual

studies involving surgery (radical prostatectomy or robotic radical prostatectomy), external beam radiation (EBRT) (conformal, intensity modulated radiotherapy, protons), brachytherapy,

cryotherapy or high intensity focused ultrasound remains problematic due to the non-uniformity of reporting results and the use of varied disease outcome endpoints. Technical advances in these treatments

have also made long-term comparisons diffi cult. The Prostate Cancer Results Study Group was formed to evaluate the comparative effectiveness of prostate cancer treatments. This international group

conducted a comprehensive literature review to identify all studies involving treatment of localized prostate cancer published during 2000 – 2010. Over 18 000 papers were identifi ed and a further

selection was made based on the following key criteria: minimum/median follow-up of 5 years; stratification into low-, intermediate- and high-risk groups; clinical Comparative analysis of prostate-specifi c

antigen free survival outcomes for patients with low, intermediate and high risk prostate cancer treatment by radical therapy. Results from the Prostate Cancer Results Study Group

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C A N C E R C O N T R O L R AT E S : C O M P A R I S O N O F T R E AT M E N T O P T I O N S

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INTRODUCTION

The evaluation of treatment options for low-, intermediate- and high-risk prostate cancer has remained diffi cult primarily because of the lack of randomized trials. In the absence of such studies, patients and

physicians have used individual institution treatment results to evaluate the effectiveness of modern treatments. Despite a relatively large number of these retrospective studies, the comparison of

surgery (radical prostatectomy [ RP ] or robotic RP), external beam radiation (EBRT) (conformal, intensity modulated radiotherapy, protons), brachytherapy (low dose rate and high dose rate), cryotherapy

or high intensity focused ultrasound is complicated by the non-uniformity of reporting results and the use of varied disease outcome endpoints. Technical advances in these treatments have also

made long-term comparisons difficult. The Prostate Cancer Results Study Group (PCRSG) was formed to evaluate the comparative effectiveness of prostate cancer treatments using current modern literature

results as a basis. The ongoing task of the group is to fi nd comparable studies and present these studies and outcomes in an easily understandable form to interested groups. This initiative is designed to provide

physicians, their patients and healthcare providers such as Medicare with comprehensive, evidence-based prostate cancer treatment comparisons in an understandable form. Importantly, uniform

pretreatment staging criteria are used (rather than the postoperative stage) as this is the information that the patients and clinicians rely on when choosing between the different options. The following is a

report of the PCRSG fi ndings. and pathological staging; accepted standard defi nitions for prostate-specifi c antigen failure; minimum patient number of 100 in each risk group (50 for high-risk

group). A statistical analysis (standard deviational ellipse) of the study outcomes suggested that, in terms of biochemicalfree progression, brachytherapy provides superior outcome in patients with low-risk

disease. For intermediate-risk disease, the combination of EBRT and brachytherapy appears equivalent to brachytherapy alone. For high-risk patients, combination therapies involving EBRT and

brachytherapy plus or minus androgen deprivation therapy appear superior to more localized treatments such as seed implant alone, surgery alone or EBRT. It is anticipated that the study will assist

physicians and patients in selecting treatment for men with newly diagnosed prostate cancer. For updated results see under Prostate Cancer

Prostate Cancer Results Study Group  or contact Lisa@pccseattle.com and ask for complete slide set and original paper