15-year outcomes after brachytherapy for localized prostate cancer

A new paper from the Seattle group, already available on line, has offered 15-year follow-up data on the outcomes after treatment with brachytherapy alone in their long series of patients.

Sylvester et al. report data on 15-year biochemical relapse-free survival (bRFS), prostate cancer-specific survival (PCSS), and overall survival (OS) of patients with localized prostate cancer treated with using 125I brachytherapy alone. All patients were prospectively followed as a tight cohort. bRFS was assessed based on use of the Phoenix (nadir + 2 ng/ml) definition.

The results of this long-term follow-up study, inclusive of data from the early days of modern brachytherapy experience, are as follows:

  • The study cohort includes 215 consecutive patients treated between 1988 and 1992.
  • Average (mean) age of patients at time of treatment was 70 years.
  • Median follow-up was 15.4 years for patients who were biochemically free of disease.
  • Median overall follow-up was 11.7 years (range, 3.6 to 18.4 years).
  • The 15-year bRFS for the entire cohort is 80.4 percent.
  • The 15-year bRFS when broken down by D’Amico risk group classification cohort analysis is
    • 85.9 percent for low-risk patients
    • 79.9 percent for intermediate-risk patients
    • 62.2 percent for high-risk patients. 
    • There was no significant difference in bRFS between low- and intermediate-risk groups.
  • Median time to biochemical failure (in those who failed) was 5.1 years.
  • PCSS was 84 percent.
  • OS was 37.1 percent.  

A media release related to this study places considerable emphasis on these outcomes as compared to the predictions for outcomes after brachytherapy given in the Kattan nomograms (which are based on much earlier data).

There is little doubt that the long-term outcomes of patients with localized prostate cancer treated with brachytherapy alone in the modern era are closely comparable (and arguably superior) to the long-term outcomes of similar patients treated with radical prostatectomy. However, in the absence of a carefully controlled trial designed specifically to compare these outcomes, the newly diagnosed patient needs to come to his own decisions about therapy preference — preferably without being subjected to an overdue emphasis on the personal views of advocates for one or the other form of therapy.

It is the case that in the only prospective trial designed to assess quality of life and satisfaction with outcome after treatment, patients treated with brachytherapy certainly expressed higher satisfaction levels than patients treated surgically in some areas.

3 Responses

  1. This is exactly what I have feared all along. This study uses only patients treated a long time ago. The study is not polluted with more recently treated people. Only this way can you see the true outcomes for specific risk groups in the long run. Low-risk bRFS was only 85% after 15 years. I don’t understand the higher numbers I see quoted by people at Johns Hopkins and Memorial Sloan-Kettering. I was told my cure rate was 99.6% by Epstein at Johns Hopkins. I don’t understand where he is getting that or why they would say something like that when their studies are “polluted” with more recent cases. I have always suspect that brachytherapy is superior to surgery. The urologist that diagnosed me is closely affiliated with the Seattle Institute. He said that I should have RPP at Johns Hopkins. I think one of the things you try to do as a patient is find some predictability in what you have so you know what to expect. Fact is biology is not an exact science.

  2. Chris:

    (a) Without a well-structured, head-to-head study we are never going to know whether brachytherapy is “better” than surgery or vice versa. Frankly, I doubt if there is any truly clinically significant difference in the oncological outcomes if both techniques are carried out on comparable patients by highly skilled practitioners. And when they aren’t, the results of brachytherapy can be just as bad as the results of bad surgery. Look what happened at the Philadelphia VA Medical Center.

    (b) Epstein did not lie to you. The long-term data from Walsh’s series of 2,550 low-risk patients at Johns Hopkins (based on patients treated between 1983 and 2005), which goes back 27 years now, show 5-, 10-, and 15-year actuarial probabilities of biochemical recurrence of 0.3%, 0.9%, and 1.3%, respectively. Those data are based on a definition of biochemical failure being a PSA of 0.2 ng/ml or higher (as compared to the biochemical failure defined by the Phoenix criteria, which is inevitably a minimum of 2.0 ng/ml). I don’t understand what you mean by saying that the Hopkins data are ‘ “polluted” with more recent cases.’ That just depends where you draw the line on which patients are actually included in the follow-up data. Biochemical recurrence 5 or more years after surgery in low-risk patients is relatively rare, so the actuarial data are — in fact — really quite accurate.

    (c) The results of this study include patients treated in the earliest days of “good” brachytherapy (in the late 1980s). My bet is that if you did the same actuarial analysis on the Seattle low-risk brachytherapy patients treated from 1988 to 2005, using the Phoenix criteria for biochemical recurrence, you would get biochemical recurrence rates of 97% or higher at 5, 10, and 15 years, just like the Hopkins series.

    (d) The basic problem is that we aren’t able to compare apples to apples, so all of these data are inevitably open to question depending on points of view. The great unanswered question is whether a biochemical recurrence in a brachytherapy patient as defined by the Phoenix criteria is in fact equivalent (or even comparable) to a biochemical recurrence defined by a PSA of 0.2 ng/ml or higher in a surgery patient. Arguably, we don’t really have a clue.

  3. Where are the “side effect” comparables? That’s the point of choosing a less invasive technique over another, right?

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