This document discusses treatment options for prostate cancer including surgery, radiation, and watchful waiting. It compares factors like cure rates, risks of recurrence, and quality of life outcomes between treatments. Key points covered include that cure rates for early stage cancer are similar with radiation or surgery, and that treatment should be chosen based on cancer risk level and patient life expectancy. The experience of the treating physician is also an important factor for surgical outcomes. Options are evaluated based on Gleason score, PSA level, and tumor stage to determine low, intermediate, or high risk categories to guide treatment decisions.

1. Making Treatment Decisions for
Prostate Cancer
Robert Miller MD
www.aboutcancer.com

2. Treating prostate cancer
Surgery?
Radiation?
Or Watchful Waiting?

3. Choices with Prostate Cancer
1. Depending on the man’s life expectancy
and the nature of the specific cancer
(Gleason score) is treatment necessary?
2. If treatment is appropriate how to
choose between surgery or radiation?

4. Watchful Waiting or Active Surveillance
NCCN appropriate for:
1. Very low risk cancers
and life expectancy < 20 y
2. Low Risk and life
expectancy < 10 y

5. Very Low Recurrence Risk
1. Stage T1c
2. Gleason 6 or lower
3. Less than 3 cores positive and
none over 50%
4. PSA density < 0.15 (so PSA was
5 and volume 35g then density
would be 0.14 or 5/35)

6. Low Recurrence Risk
1. Stage T1 – T2a
2. Gleason 6 or lower
3. PSA < 10

7. Median Life Expectancy in Men by Health
(poor, average or excellent)

8. Life Tables for Men in the US (2007 data)
Age Expectancy
50 29
55 25
60 21
65 17
70 14
75 11
80 7.9
85 5.7

9. Watchful Waiting?
Mortality if Untreated
Gleason Score Death by 15 Years
2–4 4 – 7%
5 6 – 11%
6 18 – 30%
7 42 – 70%
8 – 10 60 – 87%

10. Watchful Waiting, the odds that untreated prostate cancer
would cause death related to the age and the Gleason Score

11. Laparoscopic Prostate Surgery

13. Laparoscopic Prostate Surgery
The surgeon
tries to dissect
the prostate
away from the
rectum,
bladder, the
neurovascular
bundle (nerves)
and penile
urethra

14. Radiation Fields with Prostate Cancer
A Low Dose Large Area (Phase 1)
With radiation it is
possible to include
a wider area
around the
prostate to cover
any cells that may
have escaped
After the highest
safe dose is
reached, the
radiation target
will be made
smaller

15. Radiation Fields with Prostate Cancer
A High Dose Large Area (Phase 2)
The final, high
dose radiation
target will be
focused very
precisely only
on the prostate
gland

16. NCCN.org

18. Prostate Cancer Risk Groups
combine all 3 things, the stage, the
PSA level and the Gleason score
•Low risk: (T1c, T2a Gleason 6, PSA <10)
•Intermediate risk: (T2b, T2c, Gleason 7, PSA 10-20)
•High risk: (T3, Gleason 8-10 or PSA > 20)

23. Cure Rates with Radiation versus Surgery
for Early Stage Prostate Cancer are the same
from the Cleveland Clinic.
Kupelian. JCO Aug 15 2002: 3376-3385

24. 10 Year Cure Rates for Patients with High
Risk Prostate Cancer
(PSA >20 or Gleason 8-10 or T3)
Treatment Number Cure Rate
Radical 1,238 92%
Prostatectomy
Radiation plus 344 92%
Hormones
Radiation 265 88%
Mayo Clinic Study (Cancer Jan 10, 2011)

25. Prostate Cures Rates by Treatment
External beam > 72Gy
Surgery or Seeds
External beam < 72Gy
IJROBP 2004; 58:25
Months

26. Prostate Cancer Relapse Rate by
Radiation Dose
< 72Gy
72 - 82Gy
82Gy
Years
Kupelian. IJROBP 2008:71:16

27. Cure Rates for High Risk Prostate Cancer
Hormones + External + Seeds
Surgery
Seeds alone
IJROBP 2006;66:1092
Months

28. Quality of Life / Medicare Survey
Prostate Cancer Patients
Symptom Surgery Radiation
Wear Pads 30% 7%
Potent (< 70y) 11% 33%
Potent (>70y) 12% 27%
More frequent bowel 3% 10%
movements
J Clin Oncol 14 (8): 2258-65, 1996

29. Potency Rates after Prostate Cancer Treatment
Treatment Probability Range
Seeds 80% 64 – 96%
Seeds + External 69% 51 – 86%
External 68% 51 – 95%
Radical Prostatectomy
Nerve Sparing 22% 0 – 53%
Standard 16% 0 – 37%
Cryotherapy 11% 0 - 53%
IJROBP

30. Potency Rates after Surgery
can range from 2% to 70%)
 Did they have a ‘nerve sparing’
prostatectomy?
 Hold old is the man?
 How high was the PSA?
 How good was their sexual function
before?
JAMA. 2011;306(11):1205-1214

31. Potency Results after surgery from 2% to 70%)

32. Potency Results after External Radiation
can range from 16% to 92%
 Did they get hormone therapy along
with the radiation?
 How high was the PSA prior to
radiation?
 How good was their sexual function
before?

33. Potency Results after External Radiation
can range from 16% to 92%

34. Potency Results after Seeds
can range from 6% to 98%
 Patient Age?
 Race?
 Obese or thin?
 How good was their sexual function
before?

35. Potency Results after Seeds range from 6% to 98%

36. Responded to Viagra
Surgery: 60%
External Radiation: 63%
Seeds: 85%
JAMA 2011:306:1205

37. Responded to Viagra
Surgery: 43%
Radiation: 70 –
91%
General Population: 80%
from other studies in the literature

38. Choosing Treatment Prostate Cancer
Urologist with
experience and a good
outcome experience
with the procedure
Experienced Radiation
Oncologist with Modern
Technology (IGIMRT) and
good outcome data

39. The experience of the surgeon is a critical
factor associated with a successful outcome
Open prostatectomy the learning curve did
not plateau until a surgeon had performed at
least 250 retropubic radical prostatectomies
The probability of biochemical recurrence at
five years was significantly lower (10.7 versus
17.9 percent)

40. Minimally invasive prostatectomy – In a series
of 4,702 men who were managed with
laparoscopic prostatectomy by one of 29
surgeons at seven centers,
the five-year risk of recurrence progressively
decreased with increasing experience (17, 16,
and 9 percent with 10, 250, and 750 prior
laparoscopic procedures)

41. Understanding Prostate Cancer
Robert Miller MD
www.aboutcancer.com