Proton beam radiation therapy in prostate cancer

Three new articles in the June 15 issue of Oncology review the current data and the potential of proton beam radiation therapy (PBRT) as a first-line treatment for localized prostate cancer. The full texts of all three articles are available on line.

In the primary review article, Hoppe et al. offer a thorough if relatively standard overview of the supposed benefits of PBRT compared to other forms of radiation, whether a randomized trial is necessary to compare the results of PBRT to other forms and radiation therapy, and the (relatively few) long-term data available on outcomes of patients treated with PBRT. It is worth noting that Hoppe et al. admit the significantly higher cost of PBRT today compared to other forms of radiation therapy (even including IMRT). They estimate the current cost of PBRT for one course of treatment for one patient at $65,000.

In the first of two commentaries on the paper by Hoppe et al., Beyer focuses on the need for appropriate comparative effectiveness data that can be used to help us understand whether the supposed benefits of PBRT are really sufficient to justify the additional cost. He argues that it may be difficult to demonstrate such a benefit for the treatment of men with prostate cancer.

In the second commentary, Kavanagh and Raban poke a little fun at the various “interest groups” in the world of radiation therapy while trying to predict what we may have actually been able to learn about the clinical application of PBRT some 15 years from now (in 2026).

There is no question about the clinical effectiveness and relative safety of PBRT compared to older forms of radiation therapy for localized prostate cancer (e.g., “wide field” and even three-dimensional conformal beam radiation). However, whether PBRT is capable of results that are clinically superior to IGRT/IMRT and stereotactic body radiation therapy is much less certain, and whether we can afford (as a society) to cover the costs of PBRT as a standard treatment for localized prostate cancer is coming increasingly into question — along with many other cost issues in the management of cancer today.

7 Responses

  1. Admittedly as a layman I certainly have no particular expertise, but after reading dozens of research reports, several books, and many articles, PBRT would be my treatment of choice even if I had to pay for the treatment. From my perspective, Dr. Zietman seems to have less than fully objective views and a strong bias against PBRT. Many CERs also look at only the initial costs of treatment and do not consider lifetime costs. Proton therapy clearly has many inherent advantages over photon/gamma ray therapy.

  2. I’m glad the proton folks finally, at long last, came up with some solid, relatively long-term data that showed it to be among the best of the external beam approaches.

    However, when thinking of radiation, even that favorable report shows results for low-risk men treated with protons that are well below the nearly perfect results being achieved with brachytherapy at centers of excellence, with long-term average follow-up (much longer than for proton therapy) and flat-line success continuance. Those results for brachytherapy, coupled with impressively low rates for side effects, make it hard to argue a case for proton beam when cost is considered or even without cost in the picture.

  3. I posted this on the site of the Hoppe paper:

    Fig. 2 shows a very favorable dose-volume comparison between protons and photons with regard to the structures around the prostate, much more so than the analogous analysis by Trofimov et al. (see Fig. 7 in ref. 14). I would be interested in an explanation for the difference.

  4. I added this to the Hoppe paper site too:

    The reference about the lack of hip fracture risk from PT seems somewhat rudimentary, but I think that statistical significance would be hard to achieve. Perhaps a prospective before-and-after study of hip bone densitometry measurements would be practical and informative, especially if one could narrow down on demarcated regional changes conforming with the radiation field.

  5. I recently completed proton therapy for prostate cancer at the Procure facility in Warrenville, Illinois (outside Chicago). I was able to continue working throughout the 44-treatment regimen and have not missed a day of work since my diagnosis in February. I am not suffering from incontinence and impotence and have been able to continue my lifestyle virtually unaffected by my therapy. Proton therapy has been around for 20 years and the studies are indicating that it is at least as effective as the other options with fewer compromises to one’s post-treatment quality of life. I will continue getting PSA tests and am hopeful that my cancer is on the wane. But, from the perspective of having completed my treatment 2 months ago, I can tell you I am seeing significant improvement in my symptoms and am optimistic about the future.

  6. I’ve just been diagnosed. 2 out of 12 tissue samples positive.T1c. One sample Gleason 7 (3+4); other sample Gleason 6 (3+3). Does anyone have any comments/thoughts re proton therapy vis-a-vis Calypso 4D localization radiation?

  7. Dear William:

    Please log on to our social network, where we will be able to address issues related to your personal risk profile and appropriate treatment options, and you can get direct input from others who have been through various types of radiation therapy.

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