Video: Choosing a Treatment for Intermediate Risk Prostate Cancer

THE STAGING GUIDE VIDEO SERIES | TRANSCRIPTION:

Hi, I’m Dr. Scholz.  Let’s talk about prostate cancer.

We’ve been going through a series of short videos about the management of Teal otherwise known as intermediate risk prostate cancer.  In this video we’re going to cover the comparison of all the different treatment options for Teal, and try to give you a little hierarchy—give you a kind of number 1, 2, 3 in terms of options that I would be thinking of if I was in this situation.  

First, when you’re talking about Teal you have to realize there are three subtypes, the Teal subtype we divide at PCRI into Low, Basic, and High.  So when we talk about many options for treating teal, we’re really talking about Basic-Teal.  Why is that? Well, Low-Teal those men are candidates for active surveillance.  High-Teal are going to get better cure rates with combination therapy—that is a seed implant plus IMRT and a short course of hormone blockade (we call it TIP or testosterone activating pharmaceuticals).  For Basic-Teal we’re really talking about having a broad selection of therapy amongst surgery, radiation therapy which could be IMRT, proton therapy, SBRT stereotactic body radiation [also known as] CyberKnife, two different types of seed implants, and even primary hormone blockade (TIP), or just TIP alone which was very popular before radiation technology got a lot better.  So the remainder of the video is really going to be talking about options or Basic-Teal, comparing the pros and cons of all these different treatments.  

When you’re looking at a comparison of treatments, I think you’re looking basically at three things.  Number one, cure rates—which treatment has the best cure rates? That’s easy, well we’ll go through that.  Number two, convenience and discomfort. If the cure rates are the same, you’re going to want to go for the more convenient and less uncomfortable procedure.  Number three, if cure rates are equal you’re going to want to go for the type of treatment that has the lowest incidence of long-term side-effects. When we talk about long-term side-effects that never go away, irreversible side-effects.  Let’s cover each of these three categories very briefly.

When we look at cure rates the outcomes fall into three major categories.  The best cure rates clearly come with radioactive seed implants. There are two types of radioactive seeds: temporary seeds and permanent seeds (outcomes as far as we know are the same between those two). So when you’re looking at cure rates, seed implants beat out all the other types of radiation and they certainly beat out TIP which doesn’t really cure the disease, it just puts it in remission.  Now if seed implant cure rates are superior to everything else why would we even talk about just doing IMRT or SBRT if we want to get optimal cure rates? The reason is that Basic-Teal is pretty darn easy to cure.  So even with treatments that may not have cure rates quite as high, the differences are very small.  So the door is open then to consider other factors like side-effects, convenience, and discomfort of therapy.  

So let’s move on and talk about that, let’s talk about discomfort and inconvenience.  

Again, I think seed implants come out near the top.  Another type of beam radiation called SBRT (another name for it is CyberKnife) these treatments, the seeds, the CyberKnife (SBRT) are attractive because the duration of therapy is relatively short.  Seed implants can be done in a day. SBRT (or CyberKnife), again, in a very short time period.  Other treatments such as IMRT and IMPT may require from 5-9 weeks.  So again, convenience and side-effects put seed implants at the top of the list.  

Let’s talk about long-term side-effects.  Since we’re talking about very high cure rates with practically every therapy except for hormone therapy, then long-term side-effects may be the defining issue in terms what’s the best treatment for you.  In this department, I believe probably hormone blockade (TIP) is the least in terms of long-term side-effects. In fact there are relatively few long-term side-effects with hormone blockade. Some men say that maybe their sex drive isn’t as strong afterwards, but that’s never really been well quantified, but pretty much everything in terms of side-effects reverses when the hormone blockade is stopped.  So hormone blockade comes out at the top of the list in terms of long-term side-effects, and that’s probably the only reason that hormone blockade is even on the list since it doesn’t cure the disease—it merely puts it in remission and men have to be monitored afterwards sort of along the style of active surveillance. Next down the list after hormone blockade is basically all the radiation treatment options.  If you look at seed implants, SBRT, IMPT the incidence of long-term side-effects is going to be very similar, perhaps indistinguishable. Of course it’s important that you go to a quality center, but I’m assuming in these sorts of analyses that we’re talking about comparing a quality center with a quality center if you’re going with different treatments. So the radiation options are really pretty identical. There is some discussion about maybe seed implants causing a slight incidence of increased urinary problems compared to the other radiation options, but that data is not really that clear.  Coming up at the bottom of the list once again is surgery. With higher incidence of impotence and significant risk of incontinence which is not really associated with the other radiation options.

So to summarize, all of the treatments that we’ve discuss should be considered for people who have Basic-Teal.  In general, if you’re looking at convenience and cure rates, seed implants seem to be ahead of the rest of the pack.  If you’re really serious about avoiding side-effects at all costs perhaps you might want to consider some hormone blockade, kick the ball down the field, push the day of decision a few years into advance, and just temporize with hormone therapy.  What I generally recommend for patients that are in this situation is that they make a list of the different treatments and start drawing out the ones they clearly know they don’t want to do. Now you may be left with either one [option] or a short list when you’re done with that process, but it’s really avoiding bad things since outcomes are generally quite good; it’s avoiding bad things that’s your main goal when you’re considering treatment for Basic-Teal.

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