Admin Posted March 30, 2019 Share Posted March 30, 2019 Jim Marshall (not a doctor) said ... When I was diagnosed 9 years ago I could find little evidence available to guide my choice of initial treatment. I had to guess by looking at studies that included people with Gleason score 9 like me. But for a newly diagnosed man with aggressive prostate cancer (Gleason score of 9 or 10), this paper compares surgery, ordinary radiation (external beam radiation), and a combination of ordinary radiation and high-dose-rate brachytherapy. HDR brachytherapy uses temporary seeds that spend seconds in the prostate instead of the lifetime that low-dose-rate permanent seeds spend there. HDR brachytherapy given in combination with ordinary radiation is called 'brachytherapy boost'. Gleason score (out of 10) tells how aggressive a cancer is. Gleason score 9 and Gleason score 10 are the same as Epstein Grade 5. Their conclusion: 'Among patients with Gleason score 9-10 prostate cancer, treatment with EBRT+BT with androgen deprivation therapy was associated with significantly better prostate cancer-specific mortality and longer time to distant metastasis compared with EBRT with androgen deprivation therapy or with RP.' In simpler terms: compared to ordinary radiation or surgery, ordinary radiation with added high-dose-rate brachytherapy gave these men: less chance of dying of prostate cancer; and less chance of their prostate cancer spreading to other parts of their body (metastasis). In the graphs from the study (below) the higher a line the better. If you know how to read graphs, you can see that for any year you choose, surgery (prostatectomy) and ordinary radiation (EBRT) pretty well match each other. Ordinary radiation with brachytherapy boost (EBRT + brachytherapy) on the other hand is much better for both prostate cancer-specific survival (not having prostate cancer as the cause of death) and distant metastasis-free survival (not having the cancer spread to other parts of the body.) Overall survival (how long you live after diagnosis) appears to be not much different. If you don't know how to read this kind of graph and would like to find out, I cover that in one of my videos on Epstein score: https://www.youtube.com/watch?v=mFxhIEfqLNQ For those more technical, the abstract is included below. The full paper is available for free by searching pubmed.com for PMID: 29509865 The full paper sets out the limitations of the study. A big limitation for many members will be that HDR brachy needs both a surgical oncologist (urologist) and a radiation oncologist, both with HDR brachy experience and is only usually offered at big centres. Some clinical trials are underway to see if a stronger more focused radiation might be as good as HDR brachy, but this is still experimental. ... end Jim JAMA. 2018 Mar 6;319(9):896-905. doi: 10.1001/jama.2018.0587. Radical Prostatectomy, External Beam Radiotherapy, or External Beam Radiotherapy With Brachytherapy Boost and Disease Progression and Mortality in Patients With Gleason Score 9-10 Prostate Cancer. Kishan AU1, Cook RR2, Ciezki JP3, Ross AE4, Pomerantz MM5, Nguyen PL6, Shaikh T7, Tran PT8, Sandler KA1, Stock RG9, Merrick GS10, Demanes DJ1, Spratt DE11, Abu-Isa EI11, Wedde TB12, Lilleby W12, Krauss DJ13, Shaw GK5, Alam R4, Reddy CA3, Stephenson AJ14, Klein EA14, Song DY8, Tosoian JJ4, Hegde JV1, Yoo SM1, Fiano R10, D'Amico AV6, Nickols NG1,15, Aronson WJ16, Sadeghi A15, Greco S8, Deville C8, McNutt T8, DeWeese TL8, Reiter RE16, Said JW17, Steinberg ML1, Horwitz EM7, Kupelian PA1,18, King CR1. Author information In Library Abstract IMPORTANCE: The optimal treatment for Gleason score 9-10 prostate cancer is unknown. OBJECTIVE: To compare clinical outcomes of patients with Gleason score 9-10 prostate cancer after definitive treatment. DESIGN, SETTING, AND PARTICIPANTS: Retrospective cohort study in 12 tertiary centers (11 in the United States, 1 in Norway), with 1809 patients treated between 2000 and 2013. EXPOSURES: Radical prostatectomy (RP), external beam radiotherapy (EBRT) with androgen deprivation therapy, or EBRT plus brachytherapy boost (EBRT+BT) with androgen deprivation therapy. MAIN OUTCOMES AND MEASURES: The primary outcome was prostate cancer-specific mortality; distant metastasis-free survival and overall survival were secondary outcomes. RESULTS: Of 1809 men, 639 underwent RP, 734 EBRT, and 436 EBRT+BT. Median ages were 61, 67.7, and 67.5 years; median follow-up was 4.2, 5.1, and 6.3 years, respectively. By 10 years, 91 RP, 186 EBRT, and 90 EBRT+BT patients had died. Adjusted 5-year prostate cancer-specific mortality rates were RP, 12% (95% CI, 8%-17%); EBRT, 13% (95% CI, 8%-19%); and EBRT+BT, 3% (95% CI, 1%-5%). EBRT+BT was associated with significantly lower prostate cancer-specific mortality than either RP or EBRT (cause-specific HRs of 0.38 [95% CI, 0.21-0.68] and 0.41 [95% CI, 0.24-0.71]). Adjusted 5-year incidence rates of distant metastasis were RP, 24% (95% CI, 19%-30%); EBRT, 24% (95% CI, 20%-28%); and EBRT+BT, 8% (95% CI, 5%-11%). EBRT+BT was associated with a significantly lower rate of distant metastasis (propensity-score-adjusted cause-specific HRs of 0.27 [95% CI, 0.17-0.43] for RP and 0.30 [95% CI, 0.19-0.47] for EBRT). Adjusted 7.5-year all-cause mortality rates were RP, 17% (95% CI, 11%-23%); EBRT, 18% (95% CI, 14%-24%); and EBRT+BT, 10% (95% CI, 7%-13%). Within the first 7.5 years of follow-up, EBRT+BT was associated with significantly lower all-cause mortality (cause-specific HRs of 0.66 [95% CI, 0.46-0.96] for RP and 0.61 [95% CI, 0.45-0.84] for EBRT). After the first 7.5 years, the corresponding HRs were 1.16 (95% CI, 0.70-1.92) and 0.87 (95% CI, 0.57-1.32). No significant differences in prostate cancer-specific mortality, distant metastasis, or all-cause mortality (≤7.5 and >7.5 years) were found between men treated with EBRT or RP (cause-specific HRs of 0.92 [95% CI, 0.67-1.26], 0.90 [95% CI, 0.70-1.14], 1.07 [95% CI, 0.80-1.44], and 1.34 [95% CI, 0.85-2.11]). CONCLUSIONS AND RELEVANCE: Among patients with Gleason score 9-10 prostate cancer, treatment with EBRT+BT with androgen deprivation therapy was associated with significantly better prostate cancer-specific mortality and longer time to distant metastasis compared with EBRT with androgen deprivation therapy or with RP. Comment in Optimal Treatment for High-Risk Prostate Cancer. [JAMA. 2018] Re: Radical Prostatectomy, External Beam Radiotherapy, or External Beam Radiotherapy with Brachytherapy Boost and Disease Progression and Mortality in Patients with Gleason Score 9-10 Prostate Cancer. [Eur Urol. 2018] PMID: 29509865 PMCID PMC5885899 DOI: 10.1001/jama.2018.0587 Link to comment Share on other sites More sharing options...
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