Most Prostate Cancer treatments are effective. Besides controlling the cancer, side effects and recovery times are also important.

Historically, the most effective treatment has been open surgery. However, whenever therapies are compared, the person doing the comparing usually chooses the playing field. For instance, surgeons do not usually take cases where the prostate cancer has spread. These are, of course, the tough ones, typically candidates for radiation. The outcomes will be poorer. Does this mean surgery is better? With the pre-selection, it is no longer so clear.

Further, many comparison measure things like 5-year survival. This is also a bit of a problem. Many of us would like to know about 10-year survival or longer.

I was put in the position of having to decide about treatments a year ago. I blogged about that drama here and here.

Comparison Of The Treatments

In 2012, a very interesting paper, found here, was published which cut through a lot of the apples to oranges problems. The paper was the result of a huge project led by Dr. Peter Grimm, and 24 other practitioners, including Dr. Mark Scholz from a previous post. However, the lead author is effectively the “father” of brachytherapy, and most of the others come from radiation type treatments rather than surgery, so quite possibly surgeons would not agree with the results. Nonetheless, the paper compares many methods, and interestingly, examines PSA recurrence. This is a key measure, because if PSA begins to rise, it usually means the cancer is again growing.

Close to 50,000 cases from over 800 papers were compared.

The paper divides the cases into Low, Intermediate, and High Risk and produces plots. Here is the low risk plot. The ovals surround the various sort of therapies give a good idea of their effectiveness as well as how well they hold up with time. As can be seen, fives year out, all the procedures are very effective, with success rates (measure by lack of PSA increase) of about 80%. However, ten years out, a spread has developed, with surgery and radiation (EBRT) not looking quite so good. The two most effective treatments were brachytherapy and HDR (which is a variant of brachytherapy).

Now there could be some claims that the fox is guarding the henhouse here, as there are a lot of brachytherapists among the authors, but the paper, nonetheless, seems pretty solid. I could find only one “letter to the editor” which addressed some minor issues with the paper selection, none of which, it seemed to me, would significantly affect the conclusions. I did not find any criticisms by advocates of the surgical procedures.

Brachytherapy clearly wins on the chart. Its oval is quit high up (low rate of relapse) and doesn’t seem to get worse with time. What is a little surprising is that EBRT radiation treatment seems to lose a lot of its potency after ten years. This was true, to a lesser extent, for surgery. As surgery has been considered the Gold Standard for decades, I did a bit of independent searching for literature that might contradict this, but it does seem that the above numbers are in the right ballpark.

Outcomes and plots for intermediate risk (me) and high risk are also found in the paper.

To Sort Out Some of the Options

For the above graph, brachytherapy, HDR and seeds are essentially the same thing. Radioactive seeds are implanted in the prostate using a rather horrid looking hypodermic needle. In fact 60 to 120 seeds, each about the size of a grain of rice, are delivered to the prostate in 20 or 30 “shots.” This is done under anesthesia and takes about two hours. The radiation from the seeds lasts a couple of months and is more intense than external radiation methods. The nature of the radiation is such that it extends ¼ to ½ inch beyond the prostate.

 

EBRT and Protons are external radiation. As these effect all the organs they traverse, they need to be much weaker than the brachytherapy. Normally they “shoot” from several angles so that the prostate always gets a dose, but the other organs are spared when they are not in the line of fire. Typically several sessions are required over a several week period. Other than the radiation itself, this procedure is completely non-invasive, and it is painless.

 

Surgery and robot are both surgeries, and the “robot” terminology is misleading. A flesh and blood surgeon is controlling gadgets that do the snipping and stitching. The gadgets are inserted via small incisions, which make the recovery much faster. On the other hand, the surgeon’s access and view is limited compared to open surgery. In surgery, they attempt to peel off and save the nerves that control potency. These nerves run around the prostate and are fairly tightly attached to it, so this takes considerable skill. There is frequently some damage to the nerves.

ADT(Androgen Deprivation Therapy) is sometimes combined with the other procedures. This therapy will shrink the prostate to a small size, and kill a lot of the cancer in and of itself.

Cryotherapy is a relatively new procedure that injects cold liquid into the prostate and kills it that way.

Surgery has the benefit of completely removing the prostate, and hence the cancer within it. This is completely successful, if, and this is a big if, 100% of the cancer is contained within the prostate gland and some nearby lymph nodes. Radiation, on the other hand, can kill a tumor that may have escaped the prostate, or protrudes from it. As more advanced cancers typically have spread, the radiation results tend to overtake the surgery results.

Impotence and incontinence are the most common side effects and the numbers in the literature vary (a lot). As always, in the hands a top practitioner, the odds are a lot better. A quick review of the medical literature yielded results something like these, but don’t take these numbers as gospel. There was quite a spread.

For surgery, incontinence occurs around 10% of the time, and impotence 50%, perhaps higher.

For cryotherapy, incontinence is around 3%, but impotence almost 90%.

For EBRT, about 40% are impotent, and 5% to 20% incontinent

For brachytherapy, the impotence rate is lower still, being around 25%, with incontinence being around 15%.

For those eligible, brachytherapy seems the best of all worlds. Best outcomes, fewest side effects, and a two-hour procedure.

I was convinced, but two hurdles remained: 1) was I eligible—was my case treatable with brachytherapy? And 2) how could we get a top doc to do it?

The top doctor was Peter Grimm, located in Seattle. Dr. Mike had referred patients to him for years and had already sent my data. I was able to get a consultative appointment. So I then gathered up all the scans and blood tests and booked a plane to Seattle for a consultative appointment with Dr. Grimm himself. This will be covered in the final post in this series.