… Are we getting things out of proportion?
The CyberKnife® system was initially developed as a method to treat tumors in places like the brain that were inaccessible to physical surgery, and was originally approved by the FDA in 1992. Now it is being touted as “the next thing” in “radiosurgery” for prostate cancer.
In 2003 an article was published by King et al. that reviewed the theoretical potential of the CyberKnife in treatment of prostate cancer. And a Phase II clinical trial has been initiated to explore whether CyberKnife surgery really does have potential in the treatment of prostate cancer. The trial hopes to enroll nearly 300 patients and won’t report outcomes until some time in 2014. This is the sort of thing that can happen when large number of people start to present with a treatable condition: the numbers and types of treatment start to expand, sometimes exponentially.
Of course, because the CyberKnife is already approved, there is nothing to stop CyberKnife users from carrying out such “radiosurgery” today. And some centers clearly are. If you want to get an idea of the marketing that is already in place, have a look at this link (just as an example). This morning in my mail I received an invitation to an “eSymposium” on CyberKnife use in the treatment of prostate cancer, in which one of the speakers is an employee of the manufacturer of the CyberKnife technology.
Here are some questions that need better answers than those offered below:
- Is CyberKnife as effective and as safe as other forms of therapy for the treatment of localized prostate cancer? Answer: We don’t know.
- What is the cost of CyberKnife treatment for localized prostate cancer? Answer: We don’t know, but the equipment alone costs around $4 million.
- Is the average health insurance carrier reimbursing for CyberKnife treatment of prostate cancer? And what about Medicare? Answer: We don’t know, but it would surprise us if they are.
- Would you have considered CyberKnife therapy for prostate cancer, if it had been available when you were treated? Please let us know by posting your comments below.
Please let us be completely clear. CyberKnife therapy may be an absolutely wonderful form of treatment for localized prostate cancer. But what we know at the moment is that:
- Many men who get actively treated for localized disease may not need treatment at all (especially some of the older ones).
- Most men who have treatment for early stage disease do well with available therapies.
- The available data on the short-term (let alone the long-term) outcomes of CyberKnife therapy for prostate cancer are minimal at best.
- There are only three papers on CyberKnife therapy for prostate cancer in the PubMed database (and not one of the three offers peer-reviewed clinical data).
- Several centers are actively promoting this form of therapy, despite the limited outcomes data available.
Finally, so that we are not accused of being out of date curmudgeons (or similar), you may want to read one patient’s view of the situation. We offer the following link to Donn Rosenauer’s decision to go with CyberKnife therapy.
Filed under: Management, Treatment Tagged: | cancer, CyberKnife, localized, prostate, radiosurgery, robotic
Search for new and
ongoing trials on the
CTAG PCa web site
Cyberknife is a radiotherapy device, like many others, that can be used to treat many different conditions. There is nothing Cyberknife-specific about treating some prostate cases with only a few (i.e. five) radiation fractions using a technique called “stereotactic hypofractionation”. “Stereotactic” meaning that the treatment is extremely precisely delivered and “hypofractionated” meaning that the treatment is given in fewer than standard treatment sessions.
Prostate cancer may (or may not) have a theoretical benefit to hypofractionation, but due to the lack of reported data, we can’t confirm or refute this hypothesis.
It seems to me that patients are interested in a treatment approach that employs fewer sessions, but in my opinion that rationale alone shouldn’t be enough for patients to select a less than fully explored treatment regimen for prostate cancer when there are already very successful treatments available, i.e. standard fractionated intensity modulated radiotherapy, brachytherapy, or surgery.
Thanks for the additional insights Dr. Sandler. We appreciate your input.
This is another prime example of financial return driving treatment technology, like proton therapy. Current standard prostate cancer therapy with surgery, IMRT radiation +/- radioactive seed implantation, and radioactive seeds implantation alone are safe and have excellent outcome. While hypofraction may have a biological benefit in treating prostate cancer, the risk of bladder and rectal injury with hypofraction also increases significantly. The current grade 4 rectal injury rate is <0.1%. There is really no reason to put any patient at higher risk without significant survival benefit.
“Is CyberKnife as effective and as safe as other forms of therapy for the treatment of localized prostate cancer? Answer: We don’t know.”
While it is true that the CyberKnife has a more limited track record than some of the other radiotherapeutic methods, due to the relative newness of the technology, there are increasing safety and efficacy data with this method, including a new fully peer-reviewed report from the Stanford group (King et al.) that appeared in the International Journal of Radiotherapy Oncology and Physics “Articles in Press” section. This is the main radiation oncology journal.
In that report of favorable and early intermediate prognosis patients the three-year PSA disease-free survival rate is 100% — obviously not worse compared with other treatment methods. Their reported incidence of grade III toxicity is 5% for urinary complications and 0% for rectal complications — a result that is comparable with other contemporary radiotherapeutic results. The authors have since modified the urethral radiation dose design method to further reduce the incidence of urinary morbidity.
As their median follow-up is 33 months, this result does indeed suggest reasonable safety and efficacy, with the caveat that of course we would like to see a larger number of patients followed for a longer period of time to confirm the findings. The majority of delayed radiation complications manifest by two years post-treatment — particularly rectal complications.
In our own center (CyberKnife Centers of San Diego) we have treated nearly 100 prostate cancer patients with the CyberKnife and although our observations remain preliminary, due to the fact that our center only opened two years ago, there are already two obvious trends in our own patients:
1. PSA response — Our median 18-month PSA level in prostate CyberKnife cases is 0.45 ng/ml and over 90% of the patients have an 18-month PSA level lower than 1.0 ng/ml. This 18-month PSA result is easily competitive with our extensive universe of IMRT and brachytherapy results, and we are particularly encouraged by a very large post-CyberKnife PSA drop-off between the 12-month and the 18-month follow-up interval. In other words, the PSA levels are still dropping impressively at 18 months post-treatment.
2. Toxicity — Thus far our grade III toxicity rate is 1% and the only such case occurred in a high-risk patient that received both CyberKnife and external beam pelvic radiotherapy. Our incidence of grade III complications in CyberKnife monotherapy cases is zero, though again, longer follow-up with a larger number of patients will be required for confirmation.
Finally, to formalize both the efficacy and toxicity observations more definitively, our center is the lead investigator for a multi-institutional CyberKnife prostate monotherapy study with an enrollment target of 253 patients — a study which is accruing well to date.
Our treatment method, incidentally, uses the CyberKnife to noninvasively deliver a radiation dose schedule and dose pattern comparable to that delivered by high dose rate (HDR) brachytherapy — a validated safe and effective prostate cancer approach.
Our “virtual HDR” CyberKnife method in fact has also been peer-reviewed and published in the Red Journal.
Thus far our, pending longer-term confirmation, our safety and efficacy results do indeed resemble HDR brachytherapy very closely ,and yet the patients did not require an invasive hospital-based method to receive it.
Yes, longer-term confirmation of the encouraging preliminary robotic radiosurgery result is necessary before this becomes a “standard” treatment method, but meanwhile, patients who understand the relevent issues are definitely within their rights to consider this treatment method, ideally under the auspices of a clinical trial so that we may formalize the answers as soon as possible.
Thank you for your comments Dr. Fuller. Are you able to provide answers for the second and third questions we originally posed too?
“What is the cost of CyberKnife treatment for localized prostate cancer? Answer: We don’t know, but the equipment alone costs around $4 million.”
There seems to be much confusion about this point and perhaps a misperception that CyberKnife treatment is more expensive. While it is true that the per treament cost of CyberKnife is substantially higher than conventionally fractionated radiation treatment such as IMRT, this difference is offset by the fact that there are far fewer total treatments with the CyberKnife (4-5 treatments) compared with IMRT or other forms of “conventional” radiotherapy (typically 38-45 treatments).
Globally, the cost of CyberKnife prostate treatment is comparable with IMRT or less than IMRT, depending upon the site of service and exact number of treatments applied.
Examples:
- 5 fraction hospital-based CyberKnife cost =~ IMRT course
- 4 fraction physician-office-based CyberKnife cost is significantly lower than a course of IMRT
“Is the average health insurance carrier reimbursing for CyberKnife treatment of prostate cancer? And what about Medicare? Answer: We don’t know, but it would surprise us if they are.”
This has definitely been a problem as many of the private insurers have placed CyberKnife in the “experimental treatment” category. When they do this, typically, the service is not covered.
There has been definite positive insurance movement recently though. To my knowledge, Aetna was the first private insurer to to cover this service, and more recently, Blue Shield of California added prostate cancer to the CyberKnife covered services list. Unquestionably, we are seeing fewer CyberKnife prostate insurance denials now than we were a year ago, though coverage remains insurance company-specific.
In cases where the prostate CyberKnife service was not covered, some of our patients have appealed and had the initial denials overturned, either by higher level review within the insurance company itself, or in some cases, by the State of California Department of Managed Care. Although some insurers still seem to have a “default” no coverage policy, in some cases, with additional information or appeals, their initial denials ave been reversed.
Medicare prostate CyberKnife coverage policy varies by region and almost resembles a blue states versus red states pattern on a presidential electoral map. In other words, it is covered in some regions and not covered in other regions, depending primarily upon their specific “Local Coverage Determination” (LCD) document. An individual patient simply needs to check with their local CyberKnife provider to see whether Medicare covers the service in their state.
The FDA “substantial Equivalence 510(k) approval of Cyberknife K052325 on 9/14/2005 may be found here.
http://www.fda.gov/cdrh/pdf5/K052325.pdf
“The CyberKnife System for Stereotactic Radiosurgery/Radiotherapy is intended to
provide treatment planning and image-guided stereotactic radiosurgery and precision
radiotherapy for lesions, tumors and conditions anywhere in the body when radiation
treatment is indicated.”
–Gerald N. Rogan, MD
Dear Drs Fuller and Rogan: Thank you for this additional and helpful information which certainly will enable interested patients in being fully aware of their therapeutic options.
Can Joseph Chui (8/22/08 above) please elaborate on increased rectal injury w/hypofractionated (CyberKnife) radiotherapy? Is this theoretical or real — because others report no injuries? My Dad is in the midst of deciding on Tx for Gleason 7 prostate cancer. Thank you.
Prostate cancer is the number two cancer killer of men. There is no doubt that millions of dollars are at stake.
What is the motive of CyberKnife critics?
Look at the facts. The medical centers that have treated the majority of patients offer both IMRT and CyberKnife.
What financial benefit is gained by the medical center and the doctor?
1. The medical centers receives less revenue for the 4-5 day of CyberKnife treatment.
2. The doctor receives less pay for 4-5 CyberKnife visits vs 40 IMRT visits.
3. Proton Therapy is the most expensive of all treatments.
4. The patient cost of treatment transportation, food and lodging is much less for the CyberKnife than 40-30 trips or eight weeks in a hotel for IMRT or Proton Therapy
5. The insurer cost is no more for CyberKnife and likely less.
The CyberKnife offers lower cost to all parties, lower income to doctors, easier treatment for patients, in the worst case the side effects are equal to or better than IMRT or Proton Therapy, biological cure is equal or better than IMRT of Proton Therapy. Clearly the CyberKnife is a threat to the market served by IMRT and Proton Therapy.
In my opinion ASTRO is biased against the CyberKnife. And many doctors are not aware of their apparent bias and double standard or may share the same motives. From ASTRO’s website:
“To better educate the patients that our members work so hard to cure, ASTRO works closely with the media to promote accurate articles on scientific breakthroughs involving radiation therapies. We also work with patient advocacy organizations to publish educational materials that keep patients and the public informed about radiation therapy as a safe and effective treatment option.”
The do not mention the CyberKnife as a prostate cancer option in their EB literature and in the clinical trial section no mention of the CyberKnife.
The advertised ASTRO external beam radiation therapies (IMRT and Proton) have not demonstrated superiority for cure or reduced side effects when compared to the CyberKnife in treating early stage prostate cancer. In fact both therapies have higher failure rates at 1, 2, 3 and 4 years. All therapies have varying degrees of urinary and rectal issues at 1, 2, 3 and 4 years. Both IMRT and Proton treatments are more disruptive to the patient’s quality of life and require substantial time away from work when compared to the CyberKnife. And both of these treatments will cost CMS hundreds of millions of dollars if SBRT/CyberKnife treatment is allowed to be removed as a treatment option. ASTRO prostate cancer brochure link follows: http://www.rtanswers.org/brochures/documents/astroprostatebrochure2.pdf
I have additional concerns regarding ASTRO recommendations. When a patient is treated by IMRT the treatment center submits a code for payment. Is the dose received by the patient defined? In fact the dose varies from treatment center to treatment center. Based on the success of treating prostate cancer with higher dose per fraction by the CyberKnife and high dose brachytherapy, IMRT centers are increasing their doses delivered. Do they have short, mid or long term data before treating patients? I would expect these higher doses to be considered experiential treatment, without data proving safety verification or cure rate? There is no specific IMRT treatment plan that corresponds to standard treatment dose. There have been no randomized trials to define what dose is the most effective and the long term risk, or side effects.
An ASTRO presentation (2008) confirms the failure of Proton Therapy show a benefit to IMRT.
“Proton radiation has unquestioned value for treatment of certain rare cancers, said Dr. Zietman. However, the technology has yet to demonstrate any advantages over other forms of radiation therapy for common malignancies, such as lung and prostate cancer, where proton radiation centers would recoup the capital investment.
“The problem is that most patients in the United States treated with proton beam are treated for prostate cancer,” he said. “It’s the economic driver of the proton avalanche.” (http://www.medpagetoday.com/MeetingCoverage/ASTRO/11076)
Without any patient benefit from proton therapy, why does ASTRO promote this therapy which is the most expensive of all options?
I find the ASTRO position for treatment by SBRT/CyberKnife unconscionable and without cause!
As a cancer patient I want all treatment options not the just the ones ASTRO advertises. I feel very strongly about a patients right to make an informed choice for their treatment. Every treatment has risk and from my research every other option has higher risk of death, infection or biological failure. It is the cancer patient’s quality of life that is at risk. It must be our choice in consultation with our doctors to select the treatment that best meets our specific limitations or medical needs.
Do doctors still take and follow the Hippocratic Oath? Do the CyberKnife critics care about their patients’ quality of life? It would seem they are more concerned with the money deposited to their pockets than a man’s urinary function, ED function, cure potential, and/or ease of treatment?
Editorial comment: Fred Kinder (like others) clearly has strong opinions on this subject. On some of these issues we would back him 100 percent. On others, we think he needs to do a little more research. However, we respect his right to express his opinions.
Thank you for all the information provided. My husband just completed three CyberKnife treatments for advanced prostate cancer that had spread to his spine and we are currently in a “wait and see” mode. Your insight is very encouraging.
Will soon have a prostate biopsy — definitely appears to be cancer with a PSA of 14 — Live at South Lake Tahoe and CyberKnife is at Carson City — I am very wary of surgery — Does Cyberknife at Carson do prostates? If so; what is the outcome? Have Medicare with AARP — Does it cover? Please send whatever info avail. — Thanx
Dear Nils: Most of these questions are ones you need to ask the CyberKnife facilty in Carson City. We cannot answer questions like this on a facility by facility and state by state basis.
What we can tell you is that CyberKnife therapy is only considered to be appropriate for men with low- and perhaps some intermediate-risk prostate cancers. Until you have biopsy data you will not know if your meet those criteria.
Thank you for the detailed information so far. We notice that in all places, a Gleason score is very important consideration for treatment using the CyberKnife method. Why is that such a big consideration? Can’t a treatment using HK + CK be sufficient enough to treat prostate cancer? My father has been recently diagnosed to have prostate cancer with a Gleason score of 9. His MRI and PET scan were clear of any spread to other parts of the body and he does not have any sign of bone metastasis. His PSA level is 8.81. He was a CABG patient too in 2002.
Any advice will be very welcome
Dear Raj:
The importance of the Gleason score is not limited to CyberKnife radiation. The Gleason score is important when assessing the potential value of any form of treatment for potentially localized prostate cancer, along with several other factors, including the patient’s age, his PSA level, and the amount of cancer in the prostate (based on number of positive biopsy cores and amount of cancer in each core).
Your father has high-risk prostate cancer because he has Gleason 9, regardless of any other information. While it is possible that he can be cured of his prostate cancer by CyberKnife radiation, there are few data to support this possibility based on the use of CyberKnife radiation in the treatment of prostate cancer to date. We are aware of only one published study that included data (from 29 men) on the use of CyberKnife radiation in the treatment of high-risk prostate cancer assumed to be localized to the prostate. That study only has 5-year follow-up data.
Futhermore, in a man with high-risk (Gleason 9) prostate cancer, the fact that his MRI, PET scan, and bone scan are all negative means only that these scans are not showing gross signs of extraprostatic cancer. These scans are not capable of showing early stage, micrometastatic prostate cancer that could already have escaped from the prostate into his seminal vesicles, his lymph nodes, and even his bone marrow. There are no available tests today that can clearly and accurately identify the presence of such very small (micrometastatic) foci of prostate cancer outside the prostate, but such foci are relatively common among men who have Gleason 9 disease at the time of diagnosis.
Finally, given your father’s prior CABG in 2002, and depending upon his age and other health factors, there are serious questions about whether treatment will have any impact on his life expectancy because he may well be at higher risk of death from cardiovascular disease than he is at risk from his prostate cancer. Certainly if he is 70 or more years of age, the value of interventional treatment is open to considerable question, because the complications of treatment may come at higher risk than any risk of death from prostate cancer. These are all factors that need careful discussion between your father, your family, and his doctors.
Question to SiteMaster for Raj’s reply — I am not clear what you are advising Raj. Are you saying that if a person is 70+ and is having heart complications along with prostate cancer with Gleason score = 9 then we should not consider any treatment for such patients? If not, then can you please be more specific as to what type of treatments would you recommend? I agree that I guess any form of surgical procedures are ruled out but what other forms of treatment can we use on such patients? My father too is in similar state as Raj and so I too am interested in knowing the recommendations. Thank you.
As you also wanted to know how many cores are affected … For my dad all 4 cores seems to be affected. The bottles submitted had the following markings: Right Upper Lobe, Right Mid Lobe, Right Lower Lobe, Left Upper Lobe, Left Mid Lobe, Left Lower Lobe, and the Conclusion reads as follows:
– Sextant trucut biopsies from prostate – prostatic adenocarinoma, composite Gleason score 4 + 5 = 9.
– Present in nearly all the cores that were submitted
– Occupying about 70% of the areas of the cores
Thank you in advance for your recommendation. Appreciate it.
Dear Smashkick:
First and most importantly, please understand that I am not a doctor and I am in no position to make any individual recommendation about an individual patient. What I was trying to say to Raj, and I believe that the same information is relevant to the care of your father (based on the data you have provided), is that in older men with a diagnosis of prostate cancer and one or more other co-morbid conditions (such as a history of heart disease) one needs to be careful to balance the risk of the prostate cancer against risk of death from all other causes. In particular, in the case of older men with Gleason 9 diease, there is a significant risk for micrometastatic prostate cancer — even when MRIs, CT scans, bone scans, and PET scans are all negative.
It is important in such cases to have a serious discussion with one’s doctors about what can be expected from localized treatment, and whether such treatment can really be given with curative intent or whether what is really being done is attempting to delay the progression of the disease. While surgery (and other localized therapies such as various forms of radiation therapy) for men with Gleason 9 disease can most certainly be curative, it is customary in many younger men with Gleason 9 disease for surgery to be followed by adjuvant radiation therapy with or without hormone therapy. That is a very aggressive form of treatment for someone in their 70s whose life expectancy may only be another 5 to 10 years, and whose symptoms of prostate cancer (if any) can be managed with hormone therapy and radiation therapy as and when they occur, and who may never die from his prostate cancer.
But then there are “young” 70-year-olds and not so young ones. Some 70-year-olds (even some with a co-morbid condition) may be good candidates for surgery. Others clearly aren’t. Such other patients may be better managed with some form of radiation therapy with or without adjuvant hormone therapy.
What I am trying to tell you (and Raj) is that everyone’s expectations need to be carefully assessed. No one lives for ever. All treatments for prostate cancer come with significant risks for adverse effects. Some of those adverse effects can be highly debilitating for older men, and life without quality of life is surely not what you are likely to want for your father or what he is going to want for himself. The doctors need to be encouraged to think about treating the whole patient, not just the cancer in his prostate (and very possibly outside it too). Unfortunately, all too often, the prostate cancer surgeon (and the radiation oncologist) can over-estimate his or her ability to eliminate the cancer and under-estimate the impact of treatment on the quality of life of the patient. The older the patient, the more important it becomes to look really hard at the potential risks and benefits of every type of treatment.
Now having said that, it is very likely that your and Raj’s fathers will need and should have some form of treatment to address the fact that they bnoth have high-risk disease. The much harder question is what form of treatment is appropriate and what expectations everyone has from such treatment. Is CyberKnife therapy a possibility? Certainly. Should you ex[pect that to be curative? That is not a question I can answer, although your doctors might be able to give you estimates of probabilities based on all of the data available to them. What I can tell you is the following:
Based on the Kattan pre-treatment nomogram, a 70-year-old man with 4/12 positive biopsy cores, a PSA of 7, clinical stage T2b disease (i.e., significant cancer that can be felt or observed on an ultrasound), and a Gleason score of 4 + 5 = 9 and who had his prostate surgically removed by a skilled surgeon has the following probabilities:
– Probability of organ-confined disease = 27%
– Probability of extracapsular extension = 66%
– Probability of seminal vesicle invasion = 42%
– Probability of positive lymph nodes = 13%
In other words, the probability is very high that such a man has cancer that has already escaped from his prostate into the surrounding tissues. The ability of any form of localized treatment to cure such a patient on its own is limited. He is highly likely to need some form of adjuvant or follow-up therapy if he is to be cured, and his risk for side effects of treatment are significant over time. In such a man, the longer his real lif expectancy and the greater his desire to live to the full extent of his life expectancy, the more reasonable it becomes to consider aggressive, early treatment — but there will be some associated cost in terms of quality of life in the majority of such patients.
Has Kaiser approved CyberKnife for treatment of prostate cancer? I have their Senior Advantage Medicare coverage.
Thank you.
Dear Bob:
I’m sorry. I have no idea. That’s a question you need to ask Kaiser (or a California-based provider of CyberKnife radiation therapy).
I am presently considering the CyberKnife for prostate surgery. Is it encouraged to have hormone treatment after the CyberKnife treatment?
Dear John:
First, let me be very clear that CyberKnife therapy is not surgery. It is radiation therapy. The idea that is is “surgical” in any way is pure marketing hype.
Second, if one was to have hormone therapy in association with CyberKnife radiation therapy, it would be normal to initiate this at least a few months prior to the actual radiation. This is called “neoadjuvant” hormone therapy.
Third, there are several possible reasons why neoadjuvant hormone therapy might be used in conjunction with CyberKnife therapy. They include reduction in the size of the prostate prior to the actual radiation therapy and reduction of any possible risk from cancer that may have escaped from the prostate itself. If your doctor is recommending this for you, you need to talk to him or her about exactly why this is being recommended for you.
The CyberKnife is a form of external beam radiation therapy (using photons) which may be called extreme hypofractionation. In lay terms — very high radiation dose per visit. Prostate cancer is treated in four or five visits. The cure rate (biological disease-free control at 5 years 95% to 98%, depending on the study) is very high for localized prostate cancer. The risk of side effects very low relative to all other options.
Age is not a consideration for the Cyberknife because of low risk from treatment and side effects. Life expectancy is a consideration for any treatment. Hormone therapy is not common with Cyberknife treatment for prostate cancer.
There is a lot of false information about every treatment option. Every man with prostate cancer will benefit if they take time to understand each option.
The use of hormone therapy in combination with CyberKnife therapy is rare.
I was treated with the CyberKnife in 2008. I have had zero side effects and am biologically disease free.
Dear Viperfred,
Thank you very much for your comments. I am 69 years old and am presently undergoing the CyberKnife. My urologist is encouraging the hormone treatments after the five fraction procedures. What I have read about the effects of Hormone treatment on one’s quality of life is something that I do not want to have invade what life I have left.
My doctor has said that hormone therapy increases the success of the CyrerKnife treatment. A 95% success rate without hormones from the limited studies that are available is good enough for me.
Please comment
Dear John:
The 95% success rate for CyberKnife therapy (at 5 years of follow-up) is only applicable to men who are diagnosed with low- and very low-risk disease. Thus, if you have a higher risk level (e.g., localized disease but a Gleason score of 7 and/or a PSA level > 10 ng/ml), some form of hormone therapy for a period of time may be sensible (maybe a year or so). However, what I find puzzling about your comment is that it would be much more common to start such hormone therapy before the radiation therapy in order to optimize the long-term outcome. Clearly this was not done in your case.
John:
Please read the clinical studies related to prostate cancer and the use of CyberKnife. High-risk patients are treated with a combination of IMRT and three Cyberknife sessions as a boost (without hormone therapy).
The first study (by Dr King) has 5-year biological control rate of 95% without the use of hormones. The study by Alan Katz has a 5-year biological control rate of 98%.
Hormones after Cyberknife make no sense. As someone posted earlier, some have used hormones before IMRT, but from my reading this is after the prostate cancer has left the barn following surgery.
There are no studies that I have read in which hormone therapy has been used in conjunction with CyberKnife. Talk to your doctor and ask him for the published data showing use of hormones after CyberKnife. May be a good time for another urologist.
I am a patient, not a doctor; however I am well informed when comes to prostate cancer treatment with SBRT/CyberKnife.
Good Luck!
I have three of three cores that are Gleason 3 + 4 = 7 (60%), one of two cores that are Gleason 3 + 3 = 6 (9%), one of five cores that are Gleason 3 + 3 = 6 (5%), one of two cores that are Gleason 3 + 3 = 6 (18%) and a PSA of 7.02. My prostate volume is 43 cc.
I am borderline intermediate. Would you suggest hormones?
John:
The immediate use of adjuvant hormone therapy in a case like yours would seem very odd to me. However, I am not a doctor, just a well-informed layman. If your CyberKnife therapy has worked well, then there is a good chance that this therapy is curative. If it has not been curative, there are other forms of second-line therapy that might be considered prior to initiation of hormone therapy. You are correct when you state that you are “borderline intermediate” risk.
I would suggest two things: (1) Waiting until you have got a clear indication of how low your PSA goes before you accept further treatment AND (2) getting a second opinion from another prostate cancer specialist to be sure that this is a good decision. Having said that, if your current physician can give you some really good reason why he believes that adjuvant hormone therapy is a good idea for you, then you should be listening to him. All I can really tell you at this point in time is that I am not hearing any really good reason for such a management strategy … but your doctor has examined and treated you. Only he can possibly explain to you at this point in time why he considers that adjuvant hormone therapy is a good idea.
John,
(1) Hormone therapy is not indicated.
(2) SBRT is extreme hypofractionation — like HDR brachytherapy except with advanced dose control and outpatient external beam delivery.
There is nothing proven to be better for low-risk cure and ease of therapy for the patient.
Many naysayers … all with conflicts of interest!