Brachytherapy 12 year follow up data

Compelling findings and hopefully patients will realize more about their choices and weigh all factors, especially side effects and quality of life, when making their own personal decisions for treatment type(s). Brachy with IMRT is also another choice and worth looking into, sources like Dattoli and RCOG and well known about on a national level.

Tony,
I hear you, but considering the other options Brachy even with 3-6 mos of HT has pretty minor side affects. If you only take Casodex the side affects are pretty minor, you have some hot flashes that are very tolorable, have a loss of libido, but can still get an errection and all side affects disappear in 2-3 months. Taking Lupron to shrink the prostate like most doctors recommend is unnessary. The risk of permanent complications such as ED and incontinance are rare. Compare this to the recovery time for a surgery and the time it takes to be continent or get an errection.
Most Brach doesn't require HT only those with large prostates or high risk stats.
I just don't buy long tem results as that important. In just about every study done with every treatment option the rate of reoccurrance the curve levels out at 5 years and flatlines at 10 years. Your chance of a reoccurrance after 10 years with any treatment is very rare, but it does happen with surgery as well as with radiation. I don't think it has anything to do with the treatment, but much more with the biology of the cancer. The Seattle Prostate Institute as well as Dattolli has very good 15 year data that is similar to the above study. When Brachy get 20 years of data you will be asking for 30 years.
As long as the prostate is completely ablated with radiation it is extremely unlikely that something will grow in the future.
The study and posts concerning Brachy and HT were about another study posted at the same time. I read that and your and Mike's posts. That study also showed superior result for Brachy as compared to surgery. The differences were statictically signifacnt.
JT

John,
The studies showed COMBINED therapy is better than surgery as a mono-therapy in a biased study by a group that has never done surgery on a patient. That's it. There is little doubt in my mind that adding a stint of ADT to the surgery side would reap the same results if not better. I have never mentioned a 30 year study result so please leave it where I stated it. My point is valid that in the PSA testing era, except in extreme cases, almost no one dies in ten years regardless of treatment modality. But we are absolutely seeing a shift in data after ten years. This was just noted in the 9 year European study that was included in the New England Journal of Medicine just three years ago that had guys here saying that screening only saved one life in 48 men diagnosed through screening. Data in just three years later changed dramatically in that same study, which now says 1 in 15 men diagnosed are saved by screening. That was a 300% change in just three years, and the group stated that they needed to follow the data for 20 years to get a more accurate accrual of data.

We need independent studies to make these comparisons on treatment modalities. If you go to MSK and use the nomograms, combined brachytherapy NEVER outperforms surgical intervention with adjuvant or salvage therapy using a database of over 20,000 cases. MSK is a multi-faceted center that does both treatment modalities and the radiation oncology center is run by world renowned RO Michael Zelefsky, one of the first to do todays methods of brachytherapy and the editor in cheif of Brachytherapy magazine. I find it less than amazing that independent radiology centers combine therapies and compare to mono-therapies and they use the data to prove what they do is better yet the MSK nomograms don't align with their data. Here try it:

www.mskcc.org/applications/nomograms/prostate/PreTreatment.aspx

Key in intermediate or high risk cases for both surgery and brachytherapy and compare for yourself.

I think for a median aged man at 63 with low risk disease, brachytherapy is a good option. I also think that data beyond ten years is ultra important to any man under that age group... I don't understand with compelling data that things change dramatically in year ten and beyond, you don't agree with that...

Tony

Also note ~ The median follow up is 7 years in this study not 12. You can have a median of 7 years by combining a 12 year patient with a 2 year patient. The term of this study is over a 12 year period with the patients averaging 7 years after treatment.

Your statement that prostate cancer recurs mostly in the first 5 years is true. But the statement that prostate cancer recurs less with each year is not true for all patients. In fact, relapse increases with higher risk and time just as the mortality rate does. In breast cancer, they say get past 5 years and you're odds improve dramatically. This is completely untrue in prostate cancer. Which is why in the 5 and 10 year data tables shows significantly differing results.

Also, relapse is not the only measuring stick and is less significant tool than prostate cancer specific mortality...Which is why we need longer term studies...

Tony

This debate -- and the article that began it -- is very interesting. To me, it shows (at least) two things. The first, is the value of the multi-disciplinary panels that exist at some hospitals -- particularly large teaching hospitals -- where docs from different specialties get together and make a combined recommendation to a patient. The second is the value for a newly diagnosed patient, who is unsure what treatment he wants, of consulting with a medical oncologist, who may have less bias becuase he does not do surgery or radiation. Becuase the choice is not really surgery versus radiation. It is brachy versus brachy plus IMRT/IGRT, versus either or both with ADT (and then which form of ADT), versus surgery (which one?), versus surgery plus ADT, versus surgery plus ART (versus cryo, cyberknife, proton, etc.). So, good, unbiased advice is key.

Guys until I see a major multifaceted facility, like Mayo, MD Anderson, MSK, Harvard, Stanford, etc. until I see facilities like them switch their m.o. of recommending brachytherapy first, then you are correct, you won't win me with a study abstract like this one...

I asked earlier why the MSK nomograms, with data provided by both the urologic and radiation oncology groups at MSK, absolutely contradicts both this study and John's claim that brachytherapy is better against all prostate cancer risk groups ~ but no one answered that. Anybody care to take a swing at it, I'd appreciate it. I think I'll try to contact Zelefsky and get his response (while of course inviting him to speak at our UsTOO group ;-))

If my father decides on treating prostate cancer, I would tell him to go the seed rout. I'm not as closed minded as you both just said. He is almost 76 and he is on active surveillance, which I am also fine with. Treatment for him can be quite less aggressive because of his age and life expectancy.

My guest speaker for September is a radiation oncologist who told me point blank that they would encourage a 44 year old high risk case like mine to look at surgery first. When I went to their facility at their invitation to look at the Calypso and brachytherapy program, I was impressed by the technology. But I was most impressed when they said that to me. They also acknowledged that more time is needed with studies to determine the efficacy of the latest RO technologies on mortality.

So yes. I am likely to offer counterpoint to statements that say that brachytherapy is absolutely more effective than surgery (one should note that this study does not make that claim)

Tony

Hero, medved,
I am a very serious fan of everybody at this site. If I had it my way, everybody will do very well here, with minimal side effects ~ regardless of treatment modality, or that we would stamp out prostate cancer all together. Until then, I hope that John keeps posting studies. And everybody who was treated in other ways keep posting them. I'll keep commenting on what I see in the study.

It's important to note that 85% of released abstracts in PubMed are not accepted by any general medical organizations. They are just pieces of information that can be used or discarded when comparing cases. How they are compiled can be through a single doctor, an institution that specializes certain illnesses - sometimes in certain ways, or by multi-center corroboration. Personally I weight the multi-center ones the highest, but not always.

If I had it to do over again with the numbers I had, and I could not go with surgery for some reason, I can say I likely would go with brachytherapy with adjuvant EBRT and HT for two years. But in the back of my mind I would be questioning every study I see on it. I would be happy to see studies like this one, but I would keep asking questions about it. Zufus' best advice here is question everything.

What I would really like to see is a controlled trial with random inclusion from many centers comparing treatment modalities. Probably won't ever happen. There's way too much money at stake with the arguments being as they are...

Tony

I actually think it is fabulous that these discussions happen.
This is why this site is so powerful, knowledgeable people like Tony, John and Jim can have this discussion and we can watch them have it. I love the fact that John put up this study and I also love the fact that Tony challenge’s the study’s assumptions.

This disease is confusing, there are many right answers and the right answer for one individual may be the wrong answer for another. Specialists in the field do not agree on a universal approach so there is little chance that people in this forum will. However if there is a new input into the discussion (e.g. 12 year Brachy studies) then it is certainly a good opportunity to revisit the discussion again – it is possible that after reading all this the pendulum would shift a little towards Brachy and someone may make the decision that Brachy makes more sense to them than surgery.

This is what makes this site great.