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 afterward, 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 discussed 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.