Treatment Reference Chart


Select Treatment From List Below to Read Description, Pros, Cons, Published Research & References

Calypso®

Description:

A relatively new radiation program using GPS  technology to focus radiation beam.

Pros:

Can track motion during treatment better than earlier technology.

Cons:

Although motion is tracked, the program is unable to make beam adjustments during treatment.

Published Results:

No long-term studies published.

References:

Sandler, et al; Urology. Vol. 75, 5, 1004-1008, 2010

Cryotherapy, Cryosurgery, Cryoablation

Description:

As primary treatment, uses the process of freezing and thawing to destroy cancer cells.

Pros:

No cutting; performed on outpatient basis. Recent methods reduce risk of rectal injury. Can be repeated.

Cons:

Highest risk of permanent erectile dysfunction; some risk of incontinence, rectal fistula, and urethral sloughing. Cancers return and are frequently more aggressive after recurrence. Not recommended for cases where cancer is known or suspected to have spread beyond the prostate.

Published Research:

Very few studies. Despite dating back to the 80s, there is still a lack of long-term data on cryosurgery.

References:

Long JP, Bahn D, Lee F “Five-year retrospective, multi-institutional pooled analysis of cancer-related outcomes after cyrosurgical ablation of the prostate.” Urol 57:518-523, 2001

 Focal Cryotherapy

Description:

As salvage treatment for recurrent disease identified within the gland, and/or prostate bed.

Pros:

Ability to freeze a clearly identified area of recurrent prostate cancer.

Cons:

Generally recommended for salvage cases, but not as primary therapy based on the risk of complications, and relapse, with the entire gland at risk for cancer – “field effect”.

Published Research:

Latest 10-year follow-up (Cheetham et al, Columbia) indicates overall survival only 56%. Does not report side effects or quality of life, post treatment.

References:

Bahn DK, et al, “Focal Cryoblation…”, J Endourol. 2006, Sept;20(9):688-92

Cyberknife®

Description:

Fancy name, actually a method of external radiation therapy. This involves what is known as “hypo-fractionated” dose delivery (fewer sessions but higher doses of radiation).

Pros:

Treatment usually delivered in only 5 fractions (treatment sessions).

Cons:

All extreme radiation hypofractionated studies to date reveal a high risk of significant complications including high incidence of urethral/rectal fistula, bladder damage, ulcerations, bone necrosis.

Published Research:

No long-term results published (should be reserved for non-curative cases; patients who will not live long enough to suffer harsh complications).

References:

King CR, et al Stanford Univ.Sch of Med, “Stereotactic body radiotherapy for localized prostate cancer: interim results of a prospective phase II clinical trial,” Int J Rad Onc Biol & Physics, 2009 Mar 15; 73(4): 1043-1048.

HIFU
High Intensity Focused Ultrasound

Description:

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.

Pros:

Non-ionizing, non-invasive (no cutting, no blood loss);
treatment can be repeated.

Cons:

Just another form of therapy utilizing heat, known as “hyperthermia” used over 50 years and for the most part abandoned as cancers virtually always return with aggression. Not recommended for cases where cancer is known or suspected to have spread beyond the prostate capsule.

Published Research:

Few studies and no long term results reported.

References:

Misrai V, et al “Oncologic control provided by HIFU therapy as single treatment in men with clinically localized prostate cancer” World J Onc, Springer-Verlag 2008. ”43.7% of patients experienced biochemical recurrence in less than 5 years.”

Hormonal Therapy Androgen Deprivation Therapy(ADT)

Description:

Various types of hormones used to decrease production of testosterone to inhibit growth and progress of cancer. Hormones used as palliative therapy for patients with advanced disease; also used with primary treatments like radiation for localized prostate cancer to enhance effectiveness.

Pros:

Easy oral and/or injection treatment. Offers survival advantages to patients with advanced disease and patients with localized disease undergoing primary treatments, such as radiation therapy. Hormones have a synergistic effect when used with radiation, improving results.

Cons:

Potential side-effects depending on the agent or combination of agents; high risk of erectile dysfunction and menopause-like symptoms (hot flashes, loss of libido, fragile bones, enlarged painful breasts); may cause increased risk of cardiovascular disease. Cancers eventually become resistant to hormonal therapy.

Published Research:

Many studies indicate that hormones are appropriate for late stage patients only when all other options have been expended, since hormonal therapy is non-curative in intent. There are also studies supporting the use of hormones to reduce the size of the prostate with early state patients undergoing primary therapy.

References:

Keating NL, et al, “Diabetes and cardiovascular disease during androgen deprivation therapy for prostate cancer” J Clin Onc, Vol 24, No 27: 4448-4454

RADIATION

Description:

There are different types of radiation and a number of radiation delivery systems used to target and kill cancer cells.

Pros:

No cutting; no blood loss; no risk of infection.

Cons:

In inexperienced hands and without the benefit of the most advanced technology, there is a potential of over-radiation, unwanted outcomes; side effects.

Published Research:

Perhaps most published of all treatment options, along with surgery.

References:

Barringer, JAMA 1917 “because of initial success of radium – no patient with prostate cancer should be operated on.”

Brachytherapy

Description:

Implanting radioactive sources (seeds, pellets) directly into the prostate gland and tumor(-s).

Pros:

Ability to place radiation source exactly at tumor site; to combine seeds with External Beam Radiation to optimize dose with minimal side effects; minimally invasive; performed as out-patient.

Cons:

Results dependent on seed placement skill of brachytherapist. Likelihood of temporary urinary side effects, managed with medications and diet. Appropriate as a single primary therapy for low risk patients only. As a monotherapy, late failure risk.

Published Research:

Many studies reporting 16 years or longer by Dattoli, Wallner, Merrick and Blasko. Note: some of these studies involve combining brachytherapy with External Beam Radiation Therapy.

References:

Dattoli M, et al
Brachytherapy Made Complicated, Smart Med. Press – 1997, 2001, 2008

Palladium-103

Description:

An isotope with short half-life and steep dose fall-off to surrounding anatomy (the radiation is short-lived and surrounding areas are spared).

Pros:

Radiation effects diminish by 50% every 17 days; by design, seeds rarely migrate.

Cons:

If not performed by highly experienced physician there are fewer successful outcomes and an increase in side effects.

Published Research:

Majority of studies by Dattoli, et al (since in clinical use from 1987)

References:

Dattoli M, et al “Long-term prostate cancer control using Palladium-103 brachytherapy and external beam radiation in patients with high likelihood of extracapsular extension” Urology Vol 69, Issue 2006

Iodine-125

Description:

Longer half-life and wider dose fall-off, meaning it takes longer for the radiation to dissipate and there is more exposure to the surrounding tissues.

Pros:

A less penetrating isotope than either Iridium-192 or Cesium-131 isotope.

Cons:

Shape of Iodine seeds can cause them to migrate from target. Much more penetrating than Pd-103, potentially affecting bladder, urethra, rectum and sexual function.

Published Research:

There have been a number of studies comparing Iodine-125 and Palladium-103 in terms of clinical outcomes and complications.

References:

Wallner K, et al “I-125 versus Pd-103 for low-risk prostate cancer: morbidity outcomes from a prospective randomized multi-center trial” The Cancer Journal 2002,8(1):67-73

High Dose Rate (HDR)

Description:

Temporary brachytherapy implants using the highly penetrating isotope, Iridium 192.

Pros:

Use of new microprocessors and imaging techniques.

Cons:

Penetrating nature may cause potentially damaging exposure to entire body. Typically delivered in 2-3 sessions (hypofractionated) May lead to “late” or long-term damage to healthy tissues. Virtually identical to HDR from the 1960’s.

Published Research:

Many, but no long term data supporting HDR as sole therapy, compared to permanent implants and/or combination therapy (permanent implants combined with external beam radiation).

References:

Hall CJ, “Intensity modulated radiation therapy, protons and the risk of second cancers,” Int J Rad Onc Biol Phys, 65 No 1, 2006

Combination Therapy

Description:

Using two or more types of radiation, sometimes with hormones, to defeat cancer.

Pros:

Cancers of all sites proven to respond best to multiple modalities; (i.e. DART with 4D IG-IMRT and brachytherapy). Most patients experience only temporary and manageable side effects.

Cons:

Success dependent on expertise of practitioner, staff and requires sophisticated equipment for integrated treatment plan.

Published Research:

Longest published survival rates – 16 years, using IMRT with PD-103 brachytherapy.

References:

Dattoli M, Wallner K, et al “Long-term outcomes for patients with prostate cancer having intermediate and high-risk disease, treated with combination external beam irradiation and brachytherapy” Journal of Oncology, July 2010 (online)

EBRT

Description:

External Beam Radiation Therapy uses fractionated photon doses.

Pros:

Refers to an early version of the external beam technology.

Cons:

Outdated technology with many side effects.

Published Research:

Many studies historically, but now outdated.

References:

Zelefsky MJ, et al, “High dose radiation delivered by intensity modulated conformal radiotherapy improves the outcome of localized prostate cancer.”J Urol, 166, 2001 876-861

IMRT

Description:

Intensity Modulated Radiation Therapy with photons. An innovative advance over 3D Conformal Radiation Therapy and earlier EBRT. Beware – some centers claim to have IMRT when using 3D CRT.

Pros:

IMRT is a more controlled, accurate and effective version of EBRT and 3D Conformal Radiation Therapy.

Cons:

Early generations of IMRT are now already considered “old” technology.

Published Research:

A number of outdated studies, that nonetheless support the results achieved with more recent innovations with 4D IG-IMRT with DART. (See below.)

References:

(Based on improving, already impressive results of combination therapy above – see Dattoli, et al)

DART

Description:

True Dynamic Adaptive Radiation Therapy made possible only by numerous components of 4D image-guided intensity modulated radiotherapy (4D IG-IMRT)

Pros:

DART provides the most exquisite control of photon beams through SonArray, respiratory gating, cone beam helical tomography, on-board imaging and the “exact couch” functions.

Cons:

This new level of technology in its most advanced “true” state is currently available at only one center – Dattoli Cancer Center.

Published Research:

Evolutionary – in process, since 2008 (yet already “time-tested” since this is a dramatic improvement upon previous successful technology).

References:

Cash, J; Dattoli, M et al Radiology Nursing, vol 28, # 3; 87-95; Combined Modality Treatment for Prostate Cancer with Dynamic Adaptive Radiation Therapy. 2009

Neutron Therapy

Description:

Using Neutrons to kill cancer cells.

Pros:

Theoretically might be effective for treating cancer resistant to photon radiation and non-resectable sarcomas.

Cons:

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.

Published Research:

Still experimental; studies do not show it as safe or effective as photon radiation.

References:

Santanam L, “Intensity modulated neutron radiotherapy for the treatment of adenocarcinoma of the prostate,” Int J Radiat Onc Biol Phys, 2007 Aug.

Proton Therapy

Description:

Uses Proton beams to kill cancer cells.

Pros:

Non-invasive, excellent treatment for tiny tumors of the eyes/brain. However advantages become disadvantages when treating large areas, i.e. prostate plus margins and lymph nodes.

Cons:

Risks of radiation “scatter,” not effective for targeting large areas (such as the prostate), a likely risk of secondary tumors from proton by-product – neutrons. Unable to adjust targeting to account for organ motion; unproven, expensive, Dose to surrounding organs is higher than represented; excessive hip fractures.

Published Research:

No studies longer than 10 years and most are devoted to protons combined with photons.

References:

Hall, IJ, et al “Intensity modulated radiation therapy, protons, and the risk of second cancers,” IJ Rad Onc Biol Physics, Vol 65 No 1, 2006
“When compared to photons, a 10-fold increased total body dose is delivered to the patients by neutrons.”

RapidArc®

Description:

New product from Varian, using a single radiation rotation.

Pros:

Shorter treatment time for patient; reduction of staff for Center– no distinct clinical benefit for patient.

Cons:

Continuous open beam (arc) causes higher integral dose (potentially harmful). Rapid treatment times (accelerated radiation) predicts increased toxicity.

Published Research:

None – no clinical toxicity studies to cite.

References:

Too new – significant concerns about high radiation dose rates which have never been studied.

Tomotherapy

Description:

Computed tomography guided IMRT

Pros:

In theory, delivers radiation in helical pattern; best used for small targets.

Cons:

Problems with consistent movement of couch leading to over- and under-treatment; excessive treatment time causing enormous total body radiation doses resulting in future secondary malignancies.

Published Research:

Yes, but no long-term results (less than 5 years).

References:

Too new – no studies, but has been prohibited in treatment of childhood and adolescent malignancies for fear of causing development of another cancer.

Surgery

Description:

The old “Gold Standard.”

Pros:

Previously perceived as best method to eradicate any cancer.

Cons:

Misconception of guarantee that all cancer is gone.

Published Research:

Many, however 40 – 80% of cases found to have more cancer after surgery is completed, requiring additional treatment.

References:

Pierorazio PM, et al, “Long-term Survival After [RP]…”, Urology 2010 Mar 27, shows an 80% failure rate with high risk patients

Radical Prostatectomy

Description:

Surgical removal of bulk of the gland by incisions either retropubic or perineal.

Pros:

Physically removes the tumor from the body. (A psychological benefit.)

Cons:

Most aggressive surgery to be performed on the patient’s body but least aggressive treatment to the cancer. Commonly leaves microscopic tumor cells behind, may spread cancer cells to blood stream.

Published Research:

Results have been reported for many years, as this was the only treatment for decades.

References:

Moul, J Urol,Vol 163, 2000
“30,000 men per year will develop recurrence after radical prostatectomy.”

Robotic “da Vinci” Laparoscopic

Description:

Uses “sophisticated” robotic equipment to remove gland tissue through small openings in the abdomen.

Pros:

Possibly easier to tolerate than major open surgery.

Cons:

Still surgery with similar outcome and side effects of open surgical procedure. Success very dependent on operator’s level of experience.

Published Research:

Recent studies report a 3-fold failure rate at only 6 months, with increased complications compared with standard prostatectomy.

References:

Blute, J Clin Onc, (Mayo Clinic, Rochester MN)
Vol 28, No 14, 2008
“patients have been led to believe ..outcomes are better, but is not the case.” Just another way to extract the prostate.

Watchful Waiting

Description:

No treatment but periodic retesting to assess disease progression.

Pros:

No treatment is easier to tolerate as long as cancer does not spread.

Cons:

Difficult for patient – sometimes called “watchful worrying.” Prostate cancers often become more aggressive and PSAs may even diminish leading to a false sense of security.

Published Research:

Controversial – but suggested for elderly with less than 5 years of life expectancy (unless patient has a highly aggressive or very high volume tumor, where treatment would be indicated)

References:

Etzioni R, Feuer E, “Studies of prostate cancer mortality, caution advised.” Lancet Onc. 2008 May 9(5): 407-9. This study reports a “4-fold increase in mortality without treatment.”

Expectant Surveillance

Description:

Similar to watchful waiting but taking complementary medicines and homeopathics believed to have cancercidal effects on prostate.


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