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Aggressive prostate cancer: Surgery compared to two types of radiation


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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:


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.



The optimal treatment for Gleason score 9-10 prostate cancer is unknown.


To compare clinical outcomes of patients with Gleason score 9-10 prostate cancer after definitive treatment.


Retrospective cohort study in 12 tertiary centers (11 in the United States, 1 in Norway), with 1809 patients treated between 2000 and 2013.


Radical prostatectomy (RP), external beam radiotherapy (EBRT) with androgen deprivation therapy, or EBRT plus brachytherapy boost (EBRT+BT) with androgen deprivation therapy.


The primary outcome was prostate cancer-specific mortality; distant metastasis-free survival and overall survival were secondary outcomes.


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]).


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.

PMID: 29509865
PMCID PMC5885899
DOI: 10.1001/jama.2018.0587
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Radiation Oncologist Michael Dattoli, Physician-in-Chief, Dattoli Cancer Center & Brachytherapy Research Institute www.dattoli.com in Sarasota Florida  USA has been providing this service for over ten years and likely then some.  I first heard his presentation back then that he uses brachytherapy first to "draw in tentacles" that have spread out from tumors, then follows with EBRT.  He has the top equipment to perform most any form of radiation.  Over the years he has become both a friend and mentor to me when it comes to questions I might have regarding any form of radiation.  This is not "new" revelations, but rather others finally catching on to what physicians like Dattoli have been doing for years.  One would hope Radiation Oncologists and Urologists in your country would also "catch up," but egos are so difficult to work your way through to get them to read the literature and realize they are running behind.  It IS difficult to find both Radiation Oncologist and Urologists in a same location who can provide these procedures.  



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The vast majority of our members are Australians.

Because we have no guarantee of freedom of speech, we risk legal actions if we criticize medical practitioners.

So we make it a practice not to identify Australian doctors by name at all.

At the last PCRI prostate cancer conference in September 2018, Mark Moyad named Mack Roach (San Francisco) as the leading proponent of this treatment in the USA.

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To answer a question that arose offline:

The protocol used only prescribed the initial treatment.

Further treatment was up to a man's doctors.

So, as is normal:

  • 34% of men who had surgery were also given salvage radiation; and
  • most men having radiation also had ADT (hormone therapy).

Details are given in the full paper. 

The full paper is available for free by searching pubmed.com for PMID: 29509865.

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I cannot see in my response that I provided nothing more than the name and website of Rad Onc Michael Dattoli of whom I would arguably consider more experienced and qualified than Mack Roach as regards specialization in brachytherapy, though I am aware that RadOnc Roach is also among the best in general radiation for prostate cancer issues.  Note that in my earlier response I did not "criticize" any physician by name.  Yet I do recommend physicians by name of whom I have come to learn in my daily research and study (and those we learn of at PCRI conferences).  I cannot recall where I have ever criticized any physician by name.  Note, also, that I did not criticize any of your Australian physicians by name; I merely made note that it is well recognized that in our prostate cancer medical community in many countries, there are so many physicians who fail to go beyond their daily practice to keep up with new medications and treatment protocols.  Have I addressed your concern?

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Your comment was quite proper and valued.

The fault lies with me. Sorry.

I did not have any concern, really, about your comment.

Though I addressed my remarks to you, my message was to our Australian members. I wanted to tell the newer Australian members, and to remind the older Australian members, of our policy and the need for it.

Our USA members are welcome to exercise their wonderful First Amendment rights to free speech on our site, and to say anything they wish about any American doctor.

I am very aware of the great reputation that Dr Dattoli has, particularly because Dr Charles "Snuffy" Myers has continually recommended him for many years.

Sorry again for causing you any concern



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Dear Friend Jiim, I took absolutely no offense.  My explanation was more to be certain that I had not, unknowingly, posted anything that might be considered not in keeping with the forum rules.  I admire you and the several others who post here for being involved in research, study, understanding, and assistance to others who post seeking answers to concerns to their prostate cancer issues.  It's what we are all about - brothers in the battle.


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