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Clinical Outcomes

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Link To: Prostate Cancer – Mount Sinai St. Luke's Roosevelt

Prostate Cancer – Mount Sinai Beth Israel

Since 1998, more than 2,200 men with prostate cancer have been treated for cure in the Radiation Oncology Department at Mount Sinai Beth Israel in New York City. The 15-year follow up data presented in these curves represent a broad measure of successful patient outcomes after these treatments, or “failure free survival,” which includes a PSA rise of 2 ng/ml or more from the patient’s lowest level, any radiographic evidence of recurrence or spread, and any death caused by prostate cancer.

The reason the number of patients we report falls over time isn’t because they died or moved away but because we have treated more patients over time. The recently treated patients haven’t been followed as long. The variety of treatments administered is a reflection of the many factors we take into account in choosing the best treatment for each patient, the scarce evidence that any treatment is clearly superior to another, patient choices, and improved treatment technologies during that time.

The most common management strategies for localized (non-metastatic) prostate cancer include active surveillance; external beam radiation therapy, or EBRT, which now is usually given as intensity modulated radiation therapy, or IMRT, which currently includes image guided radiation therapy, or IGRT; brachytherapy (permanent or temporary radioactive “seeds”); or surgery to remove the prostate (open, laparoscopic, or robotic prostatectomy). Hormonal therapy, also known as androgen deprivation therapy, or ADT, is sometimes used with radiation treatments for more worrisome cancers to reduce the tumor size, minimize radiation side effects by shrinking the prostate and kill cancer cells that may have already left the prostate.

We have always embraced a shared treatment decision approach that involves patients, their loved ones, and their doctors, including primary care providers, urologists, medical oncologists, and radiation oncologists. Details that strongly influence treatment recommendations and choices include information about the cancers (PSA levels, rectal examination findings, prostate biopsy results, especially the Gleason score and radiographic findings), life expectancy (based on age and other medical conditions), and the patient’s priorities about treatment side effects (urinary, bowel, and sexual function) and treatment schedules.

We have categorized potentially curable prostate cancers into three groups based on their prognosis, which helps us make treatment recommendations. Those risk groupings include:

  1. Low risk: PSA no more than 10 ng/ml, a non-palpable (smooth prostate) or minimally palpable cancerous nodule in the rectal examination, and Gleason score of 6 or less.
  2. Intermediate risk: PSA 10.1 – 20 ng/ml, a palpable cancer nodule that doesn’t extend outside the prostate, or Gleason score of 7.
  3. High risk: PSA greater than 20 ng/ml, palpable spread outside of the prostate on rectal exam, CT or MRI, or Gleason score 8 or higher.

In general, more treatment is required for higher risk categories. Low risk cancers can be approached with either active surveillance or a single treatment, such as brachytherapy, EBRT or prostatectomy. Because intermediate risk cancers can bulge or infiltrate where radioactive seeds have more trouble reaching, we usually recommend either EBRT alone or adding EBRT to brachytherapy. Patients with high risk cancer are at risk for even greater cancer spread to seminal vesicles and lymph glands, so we most often recommend more comprehensive treatment that includes hormonal therapy (ADT) along with either EBRT alone or EBRT combined with brachytherapy.

FFS ALL

FFS BT

EBRT

FFS EBRT+BT

FFS BT+ADT

FFS EBRT+ADT

FFS EBRT+ADT+BT

Link To: Prostate Cancer – Mount Sinai Beth Israel

Prostate Cancer – Mount Sinai St. Luke's Roosevelt

Prostate cancer that has not spread, or metastasized, can be treated by surgery or radiation. The choice of treatment depends on the patient’s cancer, other health problems and their preferences after they consult with experts. The figures below show the likelihood of a patient being free of a cancer recurrence (based on the PSA blood test and all other methods) after various radiation treatments at one of our hospitals, St. Luke’s-Roosevelt. The results at our other are being prepared.

Low risk patients are those with:
Stage T1-T2a (normal feeling prostate or at most a small nodule)
and a blood PSA level of 10 or less and
a Gleason score on the biopsy of 6 or less
(A patient must have all 3 of these criteria to be low risk.)

High risk patients are those with:
Stage T3-4 (tumor can be felt growing beyond the normal boundaries of the prostate)
or a blood PSA level of higher than 20
or a Gleason score of the biopsy of 8 or higher
(A patient who has any 1 of these criteria is high risk.)

Intermediate risk patients are all the rest of the patients.

Patients were treated with brachytherapy alone, brachytherapy +IMRT, IMRT alone and IMRT+AD depending on their situation and their outcomes are shown in the figures below.

Abbreviations: IMRT - intensity modulated radiotherapy (a sophisticated form of external beam radiotherapy) AD - androgen deprivation (otherwise known as hormone therapy).

FFSallRX

FFSbyRxsep

FFSbyRisksep

FFHiIMRTADT

FFSIntbyRxsep

FFSLow


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