Mills-Peninsula Cancer Care Symposium - Ori Melamud, M.D. and Al Taira, M.D.

1. Ori Melamud, M.D.
Al Taira, M.D.
Surgery, Radiation therapy or neither:
Evolving approaches to prostate cancer
management
October 24, 2015

2. Objectives
• Review prostate cancer demographics
• Understand how our multidisciplinary approach to
prostate cancer management is evolving
• Review staging and treatment guidelines

3. Key facts
* Source: American Cancer Society Cancer Facts and Figures
• 1 in 7 men will be diagnosed with prostate cancer in his lifetime
• Prostate cancer is the second leading cause of cancer death in American men
• 1 in 38 men will die of prostate cancer
When diagnosed early, prostate cancer has a >95% 5 year survival. When
diagnosed late, 5 year survival drops to 28%.

4. Should we stop screening for prostate cancer?
• US Preventative Services Task Force controversy
• Is the main issue really too much screening?

5. Staging / risk categorization
Low risk: Gleason ≤ 6 AND PSA <10 AND T1 - T2a
Intermediate risk: Gleason 7 or PSA 10 – 20 or T2b – T2c
High risk: Gleason 8 – 10 or PSA >20 or T3a+

6. Active surveillance
Surgery
Brachytherapy
External radiation
(IMRT)
Pros Cons
Prostate cancer management options

7. Radical Prostatectomy
Surgical Removal of the Prostate allows for complete removal of
any cancer in the prostate gland and, if needed, removal of lymph
nodes as well.

8. Radical Prostatectomy
• Generally done robotically
• When compared to open surgery:
•Less blood loss
•Faster recovery
•Possibly better recovery of urinary control
and erectile function
• Allows for subsequent radiation if disease more
advance on final pathology than expected, or if it
returns in the future

9. Radical Prostatectomy
Nepple, et al. Mortality After Prostate Cancer Treatment with Radical Prostatectomy, External-Beam
Radiation Therapy, or Brachytherapy in Men Without Comorbidity. European Urology, Volume 64 Issue 3,
September 2013, Pages 372-378
Surgery for prostate
cancer has high cure
rates, but at the
expense of longer
recovery and different
side-effects when
compared to radiation
treatments.

10. Advanced beam shaping technology and integrated computer modeling
allowed for delivery of almost any shape dose cloud to target, while limiting
dose to adjacent critical normal tissues.
IMRT

11. Brachytherapy allows delivery of high radiation dose directly to the prostate,
with very limited dose to surrounding tissue. (Also eliminates the issue of
prostate motion.)
Brachytherapy

12. Quality of Life
LDR brachytherapy offers
little potential for urinary
leakage, relatively high
level of preserved patient
sexual satisfaction,
moderate acute urinary
and rectal irritative
symptoms, with high
patient convenience.
*Sanda et al, Quality of Life and Satisfaction with
Outcome among Prostate-Cancer Survivors. NEJM
2008.358:1250-61.

13. Low risk disease
Active surveillance
Surgery
Brachytherapy
External radiation
(IMRT)
Pros Cons
-avoid/delay inconvenience and side
effects of active treatment
-very low likelihood of dying from
prostate cancer, even if tx ultimately
required (depending on stage)
~30-35% chance that disease grade is
more advanced than biopsy suggests
(but still unlikely to die from disease)
-30-50% likelihood will ultimately
receive treatment
-psychologic
-gets rid of bad plumbing
-know final pathology
-less rectal side effects
-increased risk urine leakage
-increased risk lose erections
-most invasive
-time off work /catheter for several
weeks
-most convenient (1 day)
-most favorable for erections
-less risk urine leakage
-less overall radiation than IMRT
-most near-term urinary obstructive
symptoms
-radiation precautions
-potential rectal side effects
-extremely low risk/no risk long term
secondary malignancy
-most “gentle” re: acute side effects
-best extraprostatic coverage
-less risk urine leakage
-less risk lose erections
-large number of treatment visits
-moderte acute rectal side effects
-moderate urinary obstructive symptoms
-extremely low risk long term secondary
malignancy
-psychologic
-gets rid of bad plumbing
-know final pathology
-less rectal side effects
-increased risk urine leakage
-increased risk lose erections
-most invasive
-time off work /catheter for several
weeks
Low risk prostate cancer management options

14. Patient example #1
• 73 yo gentleman with moderate
comorbidities.
• PSA 5, small nodule at right mid prostate.
Prostate biopsy revealed 1/12 cores with
Gleason 3+3 adenocarcinoma

15. Patient example #2
• 63 yo gentleman, general good health, but
significant urinary obstructive symptoms.
• PSA 9, small nodule at left prostate apex.
Prostate biopsy revealed 5/12 cores with
Gleason 3+3 adenocarcinoma.
• History of ulcerative colitis

16. Patient example #3
• 53 yo gentleman, good health, no urinary or
bowel symptoms.
• First PSA test of 12, induration along entire
right prostate. Prostate biopsy revealed 7/12
cores with Gleason 4+4 adenocarcinoma.
• Staging exams negative for metastatic dz