Radiation Oncology/Prostate/Prostate Overview

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Front Page: Radiation Oncology | RTOG Trials | Randomized Trials

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Prostate: Main Page | Prostate Overview | Screening and Prevention | Workup | Natural History | External Beam RT | IMRT | Androgen Suppression Therapy | Brachytherapy | Protons | Prostatectomy | Adjuvant RT after Prostatectomy | Salvage RT | Chemotherapy | Localized prostate cancer | Node Positive | Advanced disease | Recurrence after RT | Cryotherapy | RTOG Prostate Trials | Randomized Evidence

Contents

[edit] Diagnosis

Use of Percent-Free PSA:

  • Multicenter, 1998 - PMID 9605898 — "Use of the percentage of free prostate-specific antigen to enhance differentiation of prostate cancer from benign prostatic disease: a prospective multicenter clinical trial." Catalona WJ et al. JAMA. 1998 May 20;279(19):1542-7.
    • Prospective. 773 men with PSA 4-10, ages 50-75, no palpable disease, histologically proven prostate cancer or benign disease.
    • Lower free PSA associated with a higher risk of prostate cancer. Using 25% free PSA cutoff lead to 95% sensitivity and avoided 20% of unnecessary biopsies.


[edit] Anatomy


[edit] Workup

  • Use of bone scan and CT scan: Use of routine scans in early stage prostate cancer questioned. Bone scan + in <5% and CT scan + in <12% for those with PSA < 20, and <2% and 9% for those with PSA < 20 and Gleason 6 or less. For PSA > 50, positive in 10%; for Gleason 8-10 with PSA >20, positive in 20%. — (SEER data, Prostate Cancer Outcomes Study - Albertsen et al. PMID 10737483 J Urol. 2000 Apr;163(4):1138-43.)
  • PMID 15126770 reviews 48 articles and finds
    • Bone scan + in 2.3% if PSA < 10, in 5.3% with PSA 10-20 and 16.2% with PSA 20-50.
    • Bone scan + in 5.6% if Gleason 7 or less vs 29.9% if Gleason 8-10
    • Bone Scan + in 6.4% if stage T2 or less vs 49.5% if T3-4
    • CT + in 0% if PSA < 20 and 1.1% if PSA > 20
    • CT + in 1.2% Gleason 7 or less vs 12.5% Gleason 8-10
    • CT + in 0.7% T2 or less vs 25.8% of T3-4s


[edit] Pattern of spread to lymph nodes

Prostate lymphatic drainage is to hypogastric (primary), obturator (secondary), external iliac (tertiary), and presacral (quarternary). For radical prostatectomy, lymph node dissection includes only the obturator and external iliac LNs, and is recommended for PSA > 10 and Gleason > 6. Heidenreich et al (PMID 11912387) reported that with extended lymphadenectomy (including all four drainage regions), LN mets were detected in 26% vs 12%, and that 2/3 of patients had LN mets outside of the fields of standard lymphadectomy. Recommended extended lymphadenectomy of external and internal iliacs and obturator for pts with PSA > 10 and Gleason 7 or above (only 2% LN+). Do not recommend dissection of presacral region or common iliac.

[edit] Predictors of pathologic stage

[edit] Partin tables

  • Online tool: Partin tables (Johns Hopkins)
  • Original; 1993: PMID 7685418 — "The use of prostate specific antigen, clinical stage and Gleason score to predict pathological stage in men with localized prostate cancer." Partin AW et al. J Urol. 1993 Jul;150(1):110-4.
  • Update; 1997: PMID 9145716 — "Combination of prostate-specific antigen, clinical stage, and Gleason score to predict pathological stage of localized prostate cancer. A multi-institutional update." Partin AW et al. JAMA. 1997 May 14;277(18):1445-51.
  • Update; 2001: PMID 11744442 — "Contemporary update of prostate cancer staging nomograms (Partin Tables) for the new millennium." Partin AW et al. Urology. 2001 Dec;58(6):843-8.
  • 2007 (2000-2005) PMID 17572194 -- "Updated nomogram to predict pathologic stage of prostate cancer given prostate-specific antigen level, clinical stage, and biopsy Gleason score (Partin tables) based on cases from 2000 to 2005." (Makarov DV, Urology. 2007 Jun;69(6):1095-101.)
    • Retrospective. 5730 men, prostatectomy, no neoadjuvant therapy. Variables used PSA (80% <10), clinical stage (77% T1c), biopsy Gleason (76% GS 5-6)
    • Outcome: Nomogram developed
    • Conclusion: Updated "Partin tables" reflect trends in presentation
  • Caution: The Partin tables assign the "worst-case" pathologic stage for each case; the categories are mutually exclusive. (E.g., those included as "capsular penetration" had to have no seminal vesicle involvement or lymph node involvement, and those included as "positive seminal vesicle" had to have no lymph node involvement. The categories sum to 100%.) This method gives an underestimation of the true rate of extracapsular extension and seminal vesicle involvement.

[edit] Roach equations

  • Seminal vesicle involvement - PSA +([Gleason -6] x 10) — PMID 7523343
    • Cutoff is 13%. If <13%, risk 7%; if >=13%, risk 37%.
  • Lymph node involvement - 2/3*PSA + ([Gleason-6] x 10) — PMID 7505775
    • Cutoff is 15%. If calculated risk is <15%, actual risk 6%; if >=15%, actual risk 40%.
  • Extracapsular extension - 1.5*PSA + ([Gleason-3) x 10) — PMID 10875450
    • Approximates actual risk.


  • Harvard; 2009 (2004) PMID 19286330 -- "Predicting the risk of pelvic node involvement among men with prostate cancer in the contemporary era." (Nguyen PL, Int J Radiat Oncol Biol Phys. 2009 May 1;74(1):104-9. Epub 2009 Mar 13.)
    • SEER analysis. 9,387 men with cT1c-T4 PCA, surgical LN evaluation, GS and PSA. 98% were cT1c/T2
    • Outcome: LN+ in 3.3%. Roach scores overestimated actual rates by 16x if score <10%, by 7x if score 10-20%, and by 2.5x if score >20%
    • Conclusion: Roach formula appears to overestimate contemporary patients with mainly T1c/T2 disease

[edit] Kattan nomogram

  • Preoperative nomogram - PMID 9605647, 1998 — "A preoperative nomogram for disease recurrence following radical prostatectomy for prostate cancer." Kattan MW et al. J Natl Cancer Inst. 1998 May 20;90(10):766-71.

[edit] SV invasion

Seminal vesicle invasion:

  • Mayo (1988-93) - PMID 8948342, 1996 — "Correlation of pretherapy prostate cancer characteristics with seminal vesicle invasion in radical prostatectomy specimens." Pisansky TM et al. Int J Radiat Oncol Biol Phys. 1996 Oct 1;36(3):585-91.
    • T-stage (T2a or less vs. T2b-c vs. T3a-b), primary Gleason grade (1-2, vs. 3, vs 4+), and PSA predict for SVI on multivariate analysis.

[edit] PSA Measurement

PSA level may be affected by a number of processes:

  • Minimal impact - DRE, TRUS, cystoscopy
  • Impact unclear - ejaculation (some studies show no impact, others show elevation at 24 or even 48 hours)
  • Significant impact - prostatic massage, needle biopsy, TURP, prostatitis

Literature:

  • PMID 9569113 -- The effects of ejaculation on serum prostate-specific antigen (PSA). (Yavascaoglu I, Int Urol Nephrol. 1998).
    • Conclusion: "No relation was found between seminal plasma levels or total amounts expelled of this marker and the difference in serum levels due to ejaculation."
  • PMID 9510352 -- The effect of ejaculation on prostate-specific antigen in a prostate cancer-screening population. (Stenner J, Urology. 1998)
    • Conclusion: "For the total screened population, ejaculation has no clinically significant effect. Men should not be asked to abstain from sexual activities before a PSA-screening test"
  • PMID 9255295 -- Effect of ejaculation on serum total and free prostate-specific antigen concentrations. (Herschman JD, Urology. 1997)
    • Conclusion: "Both total and free PSA increase immediately after ejaculation, with differing rates of return to baseline levels. PSA testing within 24 hours after ejaculation may lead to an erroneous interpretation of the results of both total and percent free PSA measurements in a small proportion of men."
  • PMID 9126226 -- The effects of prostatic manipulation on prostate-specific antigen levels. (Klein LT, Urol Clin North Am. 1997)
    • Minimal effect on PSA level - DRE, TRUS, cystoscopy, and ejaculation
    • Significant effect on PSA level - Prostatic massage, needle biopsy, TURP, and prostatitis
  • PMID 9266232 -- Postejaculation serum prostate-specific antigen level. (Zisman A, Eur Urol. 1997)
    • Conclusion: A significant postejaculation serum PSA elevation does occur, it is thus recommended that men abstain from ejaculation for 24 h prior to PSA sampling.
  • PMID 8976253 -- The influence of ejaculation on serum levels of prostate specific antigen. (Heidenreich A, J Urol. 1997)
    • Conclusion: "Ejaculation does not affect serum PSA concentration in young men, and there seems to be no physiological relationship between ejaculation and PSA level."
  • PMID 8638359 -- Ejaculation increases the serum prostate-specific antigen concentration. (Tchetgen MB, Urology. 1996)
    • Conclusion: "Ejaculation causes a significant increase in the serum PSA concentration in men between 49 and 79 years of age that may persist for up to 48 hours. This change appears to correlate with age and baseline PSA. It is recommended that men abstain from ejaculation for 48 hours prior to having a serum PSA determination."
  • PMID 7544734 -- Effect of ejaculation on prostate-specific antigen levels in normal men. (Kirkali Z, Eur Urol. 1995)
    • Conclusion: "Ejaculation does not seem to affect the serum PSA concentration at 5 consecutive days after ejaculation."
  • PMID 7684542 -- Effect of digital rectal examination (and ejaculation) on serum prostate-specific antigen after twenty-four hours. A randomized, prospective study. (McAleer JK, Urology. 1993)
    • Conclusion: "DRE had no clinically important effect on PSA values twenty-four hours later. Ejaculation had no meaningful effect on the serum PSA values."
  • PMID 1384015 -- Prostate-specific antigen: establishment of the reference range for the clinically normal prostate gland and the effect of digital rectal examination, ejaculation, and time on serum concentrations. (Glenski WJ, Prostate. 1992)
    • Conclusion: "Digital rectal examination and ejaculation have no significant effect on the serum concentration."


[edit] PSA Failure

[edit] PSA Nadir (PSAn) Post Radiotherapy

In postradiotherapy patients PSA may never reach completely undetectable levels and rather will reach a very low nadir, typically below 1.0 ng/mL within 2 years after therapy. (0.2 ng/mL within 5 years in patients treated with simultaneous irradiation with a transperineal prostate iodine implant, followed by external beam irradiation) Of particular interest is the correlation of PSA nadir levels to outcomes among RT patients.

  • PMID 12946753 - DWitt KD et al. "What does postradiotherapy PSA nadir tell us about freedom from PSA failure and progression-free survival in patients with low and intermediate-risk localized prostate cancer?" Urology. 2003 Sep;62(3):492-6.
    • Patients were categorized by nPSA quartile groups with cutpoints of less than 0.3, 0.3 to less than 0.6, 0.6 to less than 1.2, and 1.2 ng/mL or greater.Freedom from PSA failure was strongly associated with nadir quartile groups (P <0.0001). PFS was also significantly different statistically among nadir quartile groups (P = 0.02). No statistically significant difference was found in overall survival associated with nPSA at this point. CONCLUSIONS: nPSA is a strong independent predictor of freedom from PSA failure and PFS in patients with low and intermediate-risk localized prostate cancer treated with RT alone. Longer follow-up and larger patient numbers are required to confirm these observations.
  • PMID 12441934 - "Time to achieve a prostate specific antigen nadir of 0.2 ng./ml. after simultaneous irradiation for prostate cancer." Critz FA J Urol. 2002 Dec;168(6):2434-8.
    • With rare exceptions to be potentially cured of prostate cancer by simultaneous irradiation men must achieve a PSA nadir of 0.2 ng./ml. within 5 years of implantation. Failure to reach this goal by 60 months of followup almost always indicates persistent disease."

Critz and colleagues found that a PSA nadir < 0.2 ng/mL defines disease freedom following brachytherapy plus EBRT, and that a PSA nadir > 1.0 ng/mL predicts for disease recurrence at a median of 5 years of follow-up. In addition, data from DeWitt and colleagues demonstrate that a PSA nadir > 1.2 predicts worse outcomes in measures of freedom from PSA failure and progression-free survival in patients undergoing EBRT at the same time point.

[edit] Definition of PSA Failure Post-Radiation therapy

  • PMID 13130113 Full text - "Surrogate End Point for Prostate Cancer–Specific Mortality After Radical Prostatectomy or Radiation Therapy." D'Amico et al Journal of the National Cancer Institute, Vol. 95, No. 18, 1376-1383, September 17, 2003
    • A post-treatment PSA-DT of less than 3 months and the specific value of the post-treatment PSA-DT when it is 3 months or more appear to be surrogate end points for prostate cancer-specific mortality after surgery or radiation therapy.
  • ASTRO Consensus Statement
    • Original (1997) - Three consecutive rises in PSA. Date of failure is midpoint between postirradiation nadir PSA and first rise in PSA.
      • PMID 9169810 (No abstract). "Consensus statement: Guidelines for PSA following radiation therapy" Int J Radiat Oncol Biol Phys. 1997 Mar 15;37(5):1035-41.
      • 1. Biochemical failure is not justification per se to initiate additional treatment. It is not equivalent to clinical failure. It is, however, an appropriate early end point for clinical trials
      • 2. Three consecutive increases in PSA is a reasonable definition of biochemical failure after radiotherapy. For clinical trials, the date of failure should be the midpoint between the postirradiation nadir PSA and the first of the three consecutive rises
      • 3. No definition of PSA failure has, as yet, been shown to be a surrogate for clinical progression or survival
      • 4. Nadir PSA is a strong prognostic factor, but no absolute level is a valid cutpoint for separating successful and unsuccessful treatments. The nadir PSA is similar in prognostic value to pretreatment prognostic variables
    • Revised "Phoenix Definition" (2006)
      • PMID 16798415, 2006 — "Defining biochemical failure following radiotherapy with or without hormonal therapy in men with clinically localized prostate cancer: Recommendations of the RTOG-ASTRO Phoenix Consensus Conference." Roach M 3rd et al. Int J Radiat Oncol Biol Phys. 2006 Jul 15;65(4):965-74.
      • 1. Biochemical failure is defined as a rise of 2 ng/mL or more above the nadir after EBRT w/ or w/o hormonal therapy.
      • 2. The date of failure should be "at call" (not backdated).


  • Horwitz, William Beaumont (1996) - Determined difference in therapeutic outcome was observed if different definitions of PSA failure are used.
    • PMID 8948340 — "Assessing the variability of outcome for patients treated with localized prostate irradiation using different definitions of biochemical control." Horwitz et al. Int J Radiat Oncol Biol Phys. 1996 Oct 1;36(3):565-71.
  • Fox Chase (1995) - 2 consecutive rises to a level > 1.5
    • PMID 7531222 (1995)
    • PMID 10701734 — "Scrutiny of the ASTRO consensus definition of biochemical failure in irradiated prostate cancer patients demonstrates its usefulness and robustness. American Society for Therapeutic Radiology and Oncology." Hanlon et al. Int J Radiat Oncol Biol Phys. 2000 Feb 1;46(3):559-66.
  • Vancouver rules (1999) - 1) True nadir is the lowest post-therapy PSA value. The reference nadir is the lowest reading which is not followed by a subsequent fall. 2) Must be 2 consecutive rises above the reference nadir, at least 1 month apart. 3) PSA > 1.5 is required at any time after the reference nadir before PSA relapse can be scored. 4) Date of failure is midpoint between reference nadir and first post-true-nadir reading. 5) If true nadir is >=4, relapse is scored at that time and no further rises are needed. 6) Salvage therapy is considered a relapse.
    • (Letter) "PSA relapse definitions--the Vancouver Rules show superior predictive power." Pickles et al. Int J Radiat Oncol Biol Phys. 1999 Feb 1;43(3):699-700.
  • Mass General - "Strict definition": after a nadir of <1 which occurs in 1 year, failure occurs if there are 2 consecutive rises. Failure is scored at the first increase. "Liberal definition": same as strict, but nadir only needs to be <4.
  • Memorial - After a nadir of <4, failure occurs if PSA rises above 4.
  • Stanford - Def#1: Def#2: 2 consecutive increases where 2nd was higher than normal and at least 20% above the nadir.
  • Houston criteria - absolute increase of 2 above the nadir
    • ASTRO 2002 - criteria proposed
    • PMID 12909209 — "Evaluation of the Houston biochemical relapse definition in men treated with prolonged neoadjuvant and adjuvant androgen ablation and assessment of follow-up lead-time bias." Pickles. Int J Radiat Oncol Biol Phys. 2003 Sep 1;57(1):11-8.
    • Houston definition has improved predictive ability compared to ASTRO and Vancouver defs. Moreover, it does not violate the Cox propoprtional hazards test for patients treated both with and without androgen suppression.

[edit] Comparison of PSA failure definitions

  • PMID 15711272 -- Definitions of biochemical failure that best predict clinical failure in patients with prostate cancer treated with external beam radiation alone: a multi-institutional pooled analysis. (Horwitz EM, J Urol. 2005)
    • Pooled data on 4,839 patients with T1-2 prostate cancer treated with EBRT alone at 9 institutions
    • Conclusion: "Defining BF as PSA greater than absolute nadir plus 2 ng/ml, dated at the call, PSA greater than current nadir plus 3 ng/ml, dated at the call, or 2 consecutive increases of at least 0.5 ng/ml, back dated, had higher sensitivity and specificity for DF alone or CF compared with the ASTRO definition."
  • Taylor (Michigan) - Abstract — "Definitions of biochemical failure in prostate cancer following radiation therapy." Taylor JMG et al. Int J Radiat Oncol Biol Phys. 2001 Aug 1;50(5):1212-9.
    • Single institution, 688 pts, 1987-96, all T stages, N0. Evaluated 10 definitions of biochemical failure.
    • Favor Fox Chase Cancer Center method over ASTRO definition.
  • Thames et al - Abstract — "Comparison of alternative biochemical failure definitions based on clinical outcome in 4839 prostate cancer patients treated by external beam radiotherapy between 1986 and 1995." Thames H et al. Int J Radiat Oncol Biol Phys. 2003 Nov 15;57(4):929-43.
    • Used same pooled data set as Kuban et al, 2003 with 4839 pts and median f/u 6 years. Assessed 102 definitions of biochemical failure.
    • Favors ASTRO definition but recognizes its bias from the backdating of PSA failures.

[edit] PSA failure after RT + hormonal therapy

These methods account for the expected rise in PSA after coming off hormonal therapy.

  • Fox Chase modification of ASTRO definition (2005) - Uses the original ASTRO definition, with the following modifications: 1) If after an initial rise there is a decline in PSA, 2 further consecutive rises in PSA >0.1 are required for a failure. 2) If the PSA after 3 consecutive rises was unchanged but then declined, 2 further consecutive rises were also required.
    • PMID 15817330 - "Biochemical failure and the temporal kinetics of prostate-specific antigen after radiation therapy with androgen deprivation." Buyyounouski MK et al. Int J Radiat Oncol Biol Phys. 2005 Apr 1;61(5):1291-8.
  • EORTC (Bolla) - used PSA > 1.5 and 2 consecutive rises separated by >= 3 months (from PMID 12126818, 2002)

Comparisons:

  • Fox Chase, 2005 (1991-98) - PMID 16169682 - "Defining biochemical failure after radiotherapy with and without androgen deprivation for prostate cancer." Buyyounouski MK et al. Int J Radiat Oncol Biol Phys. 2005 Dec 1;63(5):1455-62.
    • Purpose: Compare 3 definitions of biochemical failure in pts treated with or without AD: ASTRO, modified ASTRO, and nadir plus 2 (Houston definition).
    • Used same patient set as the other 2005 Fox Chase paper (see below).
    • Conclusion: Nadir + 2 (Houston definition) is superior to the ASTRO and modified ASTRO definitions in predicting true failures.

[edit] Definition of PSA Failure Post-Radical Prostatectomy

Therapeutic goal of Radical prostatectomy is removal of prostatic and neoplastic tissue, so post-RP PSA level is undetectable, that is under 0.2 ng/ml (evaluated 30-45 days after surgery). Standard practice is to define post-RP biochemical failure as a PSA level exceeding 0.2 ng/mL on at least two successive evaluations or exceeding 0.4 ng/mL on a single evaluation. By contrast, patients who never achieve undetectable levels and/or whose PSA rises very rapidly following surgery likely have metastatic disease.

  • PMID 10799151 - "Prostate specific antigen only progression of prostate cancer." J Urol 2000 Jun;163(6):1632-42 Moul JW

The use of very low PSA thresholds risks overtreating patients whose PSA level is detectable due to residual benign prostatic tissue. For example, one recent report demonstrated that a single PSA elevation of less than 0.4 ng/mL after radical prostatectomy is associated with subsequent stable, nonprogressing disease in up to 50% of patients.

  • PMID 11257657 - "Defining prostate specific antigen progression after radical prostatectomy: what is the most appropriate cut point?" Amling et al. J Urol. 2001 Apr;165(4):1146-51.

[edit] PSA kinetics

[edit] Post-treatment PSA Bounce

  • PMID 15936550 -- PSA bounces after neoadjuvant androgen deprivation and external beam radiation: Impact on definitions of failure. (Zietman AL, Int J Radiat Oncol Biol Phys. 2005)
    • Conclusion: "A substantial proportion of patients treated by EBRT with neoadjuvant deprivation experienced a PSA bounce. A large percentage of these bounces scored as biochemical failure according to the ASTRO definition. The Nadir-plus-three definition is less vulnerable to this bias."
  • PMID 12377320 -- Using the magnitude of PSA bounce after MRI-guided prostate brachytherapy to distinguish recurrence, benign precipitating factors, and idiopathic bounce. (Das P, Int J Radiat Oncol Biol Phys. 2002)
    • Results: +0.6ng/ml idiopathic bounce vs. +1.2ng/ml for ejaculation (p=0.003), instrumentation (p=0.007), proctitis (p<0.0001) and biopsy-proven local recurrence (p=0.006)
    • Conclusion:"In patients treated with MRI-guided prostate brachytherapy, recent ejaculation, instrumentation, or ongoing radiation proctitis can cause a transient increase in PSA, the magnitude of which is significantly higher than that for idiopathic PSA bounce, but is similar to that in patients with recurrent disease."

[edit] After hormonal therapy + RT

  • Fox Chase, 2005 (1991-98) - PMID 15817330 - "Biochemical failure and the temporal kinetics of prostate-specific antigen after radiation therapy with androgen deprivation." Buyyounouski MK et al. Int J Radiat Oncol Biol Phys. 2005 Apr 1;61(5):1291-8.
    • Purpose: 1) describe the PSA kinetics after RT alone, RT + short term androgen deprivation (STAD, 3-12 months), and RT + long-term AD (LTAD, 1-3 yrs). 2) show the potential rise of PSA after withdrawal of AD. 3) Test the ASTRO definition in this setting. This paper provides a graphic representation of PSA kinetics.
    • Retrospecitive. 688 men with localized prostate cancer treated with 3D-CRT, without AD or with STAD (82) or LTAD (20). Minimum of 4 yrs f/u. Mean dose 74 Gy (ICRU dose). Biochemical failure used ASTRO definion as well as modified ASTRO definition (see section above). PSA obtained q6months.
    • Median f/u 5-6 years. For those without biochemical failure, the PSA after STAD remains relatively constant, and after LTAD, PSA rises steadily towards 1. Between 22% and 29% of pts who had a failure by the ASTRO criteria subsequently had a fall in the PSA and were not classified as BF by the revised definition.

[edit] Surrogate Endpoints

  • Post-treatment PSA-DT
    • ASCO Abstract. Surrogate Endpoint for Prostate Cancer-specific Survival: Validation from an Analysis of Radiation Therapy Oncology Group Protocol 92-02. Valicenti et al.
      • Conclusion:Post-treatment PSA-DT <12 months met all of Prentice’s criteria for surrogacy. For the first time, this was accomplished for a prospectively studied patient population, and justifies strong consideration for PSA-DT< 12 months as a surrogate endpoint for prostate cancer mortality.

[edit] Reviews


[edit] Utilization


  • Center for Disease Control (CDC), Atlanta; 2007 PMID 17469027 -- "Use of additional treatment for prostate cancer after radical prostatectomy, radiation therapy, androgen deprivation, or watchful waiting." (Berge V, Scand J Urol Nephrol. 2007;41(3):198-203.)
    • SEER + Medicare claims data. 12,711 patients. Initial RP 31%, initial RT 31%, initial ADT 9%, initial WW 28%
    • Outcome: Initial RP: 8% additional RT, 12% additional ADT. Initial RT: 23% additional ADT. Initial WW: 22% additional ADT
    • Conclusion: If initially treated with RT or observation, more likely to receive ADT as follow-up treatment than if initially treated with RP
  • American College of Radiology; 2002 (1992-1993) PMID 12065564 -- "Comparing the costs of radiation therapy and radical prostatectomy for the initial treatment of early-stage prostate cancer." (Burkhardt JH, J Clin Oncol. 2002 Jun 15;20(12):2869-75.)
    • Linked SEER-Medicare analysis.
    • Outcome: Costs RT $14,048 vs. RP $17,226 (SS)
    • Conclusion: For early-stage PCA, average costs were at least 23% greater for RP
  • UCLA; 2000 (1993-1996) PMID 11042575 -- "A nationwide charge comparison of the principal treatments for early stage prostate carcinoma." (Brandeis J, Cancer. 2000 Oct 15;89(8):1792-9.)
    • HCFA claims data for inpatient, outpatient and Part B claims. 10,107 men with initial diagnosis of prostate cancer, treatment, +6 months of follow-up. RT 58%, brachy 7%, RP 35%. During the 4 years, RT decreased by 20%, brachy increased by 21%
    • Cost: RP + adjuvant RT $31,329 vs. RT + brachy boost $24,407 vs. RP $19,019 vs RT $15,937 vs brachy $15,301 (SS). Utilization varied with age, race, and geographic region
    • Outcome: Without clear survival advantage, costs, QoL and patient preference take on paramount importance
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