5-year brachytherapy outcomes vs. predicted surgical outcomes

As an adjunct to the 12-year outcome data provided in the immediately preceding report come data from Canada that compare actual 5-year brachytherapy outcome data to predicted 5-year surgical outcome data for the same patients.

Pickles et al. have published this report based on data collected prospectively from their series of 1,254 consecutive patients diagnosed with low- and intermediate-risk prostate cancer and treated with brachytherapy (with or without neoadjuvant hormone therapy) between 1998 and 2005. Patients were deemed to have progressed after brachytherapy if their PSA rose to >0.4 ng/ml or any secondary treatment intervention was provided, so these data are based on a relatively strict definition of disease progression. The Kattan pre-treatment nomogram was then used to calulate predicted outcomes at 5 years for the entire series of patients if they had been treated with surgery as opposed to brachytherapy.

The results of this analysis show the following:

  • Median follow-up of the patients after brachytherapy is 56 months.
  • 46 percent of the patients were diagnosed with clinical stage T1, and 54 percent with clinical stage T2 cancers.
  • 25 percent of the patients were diagnosed with a Gleason score of 7.
  • The median PSA of the patients at diagnosis was 6.3 ng/ml (range, 0.3 to 19.6 ng/ml).
  • 58 percent of the patients had low-risk disease at diagnosis, and 41 percent had intermediate-risk disease.
  • Neoadjuvant androgen deprivation therapy was used for 6 months in 92 percent of patients with intermediate-risk disease and in 46 percent of patients with low-risk disease.
  • The median PSA of all patients at last follow-up is 0.06 ng/ml.
  • At 5 years post-brachytherapy, 90.6 percent of patients had no biochemical evidence of progressive disease.
  • The predicted outcome of surgery in the same set of patients is that 86.8 percent of patients would have had no evidence of progressive disease.
  • The difference between the actual brachytherapy outcome and the predicted surgical outcome is statistically significant.

Once again, these data help to support the case that — for patients with low and intermediate risk disease — brachytherapy (when, to a large extent, combined with 6 months of androgen deprivation therapy) may well be a better treatment option than surgery. However, it is also worth asking how many of these patients would have met criteria for active surveillance and may never have needed treatment at all.

3 Responses

  1. I’m not as easily ready to give it all to brachtherapy, Mike …

    Using ADT in neo-adjuvant fashion is likely to skew statistics heavily for whatever treatment modality it is combined with. I have long argued that combination therapies are better than any stand-alone therapy and this data ONLY supports that claim. Combination BT/ADT will outperform surgery alone. That’s not surprising … And it comes with a total shut-down of sexual function while on ADT, as surgery might do as well. But it also comes with the other inherent side effects that I experienced with ADT.

    What’s also an interesting question, is why would 46% of low-risk patients want ADT at all? Forget that many would have more likely qualified for active surveillance than active therapy.

    It would seem sensible that the use of one therapy with ADT should only be compared with the use of another therapy with ADT…. And ADT should not be a “just in case” (neo-) adjuvant therapy unless absolutely needed such as in high-risk cases….

  2. Tony:

    The reason that so many patients get neoadjuvant ADT in combination with brachytherapy is actually to shrink the prostate in order to optimize the effectiveness of the radiation seed implants. However, I don’t disagree with you about some of the other points you are making…. Sometimes I’m just the messenger.

  3. Tony and Mike,

    You both make excellent points.

    I would just like to take issue with one of your sub-points Tony. You wrote, regarding use of 6 months of adjuvant ADT: “… And it comes with a total shut-down of sexual function while on ADT, as surgery might do as well …”

    Triple intermittent ADT has been my only therapy for a challenging case, and I have now gone through three phases of full therapy (Lupron, Casodex, finasteride with a bisphosphonate in support) since December 1999 (now off therapy since April; current PSA 0.02). What I learned from my own experience was that it takes a number of months before sexual function shuts down to the point of making romance difficult and burdensome. On my first cycle, started at age 56 in December 1999, I was still active in the summer of 2000, though clearly on a downward slope. Also, provided we are young enough and not on ADT overly long (especially 2 years or longer at age 70 or older), we will recover sexual functioning within a number of months of stopping blockade, including ejaculation, though with less volume if we are maintaining with Avodart or finasteride (which shrink the prostate).

    I’m thinking that just 6 months of hormonal blockade is not going to have a really burdensome impact on most of us. That’s because the onset is far from immediate, and recovery is only a matter of several months. (Also, unlike impotence due to surgery, ADT tends to diminish desire so that sex is not missed much.)

    Countermeasures can also help a lot. While sex becomes a matter of work rather than desire and drive, Dr. Mark Scholz and others have encouraged us that we can help ourselves remain active. It is fully credible to me that at least some of us on ADT can maintain the ability to have erections throughout our intermittent ADT cycles, even at the 10-year point since beginning therapy.

    Mike — you are a great messenger!

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