Radiation therapy for Early Stage Prostate Cancer
John A. Kalapurakal MDProfessor, Radiation Oncology
Northwestern University Medical School
Chicago, IL
ARS
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RACE/ETHNICITY INCIDENCE MORTALITY
All Races 156.9 per 100,000 men
24.7 per 100,000 men
White 150.4 per 100,000 men
22.8 per 100,000 men
Black 234.6 per 100,000 men
54.2 per 100,000 men
Asian/Pacific Islander
90.0 per 100,000 men
10.6 per 100,000 men
American Indian/Alaska Native
77.7 per 100,000 men
20.0 per 100,000 men
Hispanic 125.8 per 100,000 men
18.8 per 100,000 men
It is estimated that 217,730 men will be diagnosed with and 32,050 men will die of cancer of the prostate in 2010 (SEER DATA)
Anatomy
Risk stratification of Prostate Cancer
• Low riskT1c-T2a and PSA<10 and Gleason score <6
• Intermediate risk
T2b-T2c or PSA 10-20 or Gleason score 7
• High risk
T3-T4 or PSA >20 or Gleason score 8-10
Low-risk Prostate Cancer
• External beam RT: (x-rays, protons)– 70.2Gy-79.2Gy in 39-45 sessions (5 treatments/week, 8-9 weeks)– 3D Conformal, Intensity Modulated RT, Protons
• Brachytherapy: I-125 (Iodine), Pd-103 (Palladium)– 144Gy in single session
Intermediate-risk Prostate Cancer
• External beam RT: (x-rays, protons)– 75.6-79.2Gy in 42 sessions (5 treatments/week, 8-9 weeks)– 3D Conformal, Intensity Modulated RT (IMRT), Protons
• External beam RT + Short term Hormone therapy (6-8 months)
• External beam RT + Brachytherapy: I-125 (Iodine), Pd-103 (Palladium)– 45 Gy in 25 sessions (5 weeks) + brachytherapy (seeds, HDR)
Image Guided RT (IGRT)
• ALL MODERN RT DELIVERY SHOULD BE IGRT• Improve accuracy of treatment • Track daily position of the prostate before delivering RT• Fiducial markers (x-rays), ultrasound scans,
electromagnetic tracking, CT scans (cone beam CT, fiducials), endorectal balloon (x-rays, CT scan)
3D conformal versus IMRT versus Protons
Prostate Seed Implantation: Indications, Techniques and
Outcomes
Post Implant CT scan dosimetry
Long-term results: Brachytherapy alone (Low-risk) and RT+Brachytherapy in intermediate-risk Prostate Cancer
IJROBP 2010
IJROBP 2007
Higher RT dose (79.2Gy) resulted in higher PSA control in low and intermediate-risk prostate cancer without any increase
in toxicity
JCO 2010
Low risk Intermediate-risk
Harvard Study: Adding 6 months of hormones to RT improved survival in intermediate-risk and high-risk disease
Intermediate-risk High-risk
IJROBP 2010
MD Anderson Study: Higher RT dose (78 Gy) for intermediate-risk patients resulted in better PSA control and
cancer–specific survival
IJROBP 2010
Low-intermediate risk Prostate Cancer: RTOG 94-08 Study
• T1b-T2b, PSA <20• RT: 66.6Gy + 4 months of hormone therapy• 1979 patients randomized• Overall survival significantly better RT+ hormones (51% vs.
4%)• PSA control significantly higher with RT+ hormones in low
and intermediate risk patients• Subset analysis: survival benefit mainly for higher GS and
PSA• Final results awaited• IJROBP 2009
Radiation-related Side Effects
• Likely– Increased urinary frequency, burning and urgency– Increased bowel frequency, burning and urgency– Fatigue
• Less likely– Rectal bleeding, urinary bleeding– Chronic bowel/bladder symptoms– Temporary blockage of urination requiring a catheter
• Rare but serious– Permanent Rectal and Bladder injury requiring surgery
Hormone-related Side Effects
Conclusions – RT for Early Prostate Cancer
• Best Results: Higher tumor RT doses with improved technology treatments (Brachytherapy, IMRT, Proton therapy)
• Role of hormone therapy with RT in low and intermediate-risk patients remains to be defined
• Stereotactic Body Radiotherapy (SBRT): Cyberknife, Linear Accelerator, Tomotherapy
• Role of hypofractionated RT (70 Gy in 28 fractions, 50Gy in 5 fractions) ?
• Role of protons• PATIENT’S CHOICE: Surveillance vs. Surgery vs.
Radiation* vs. Seeds
Radiation therapy for Early Stage Prostate Cancer
John A. Kalapurakal MDProfessor, Radiation Oncology
Northwestern University Medical School
Chicago, IL