My personal experience with prostate cancer and opinion of treatment options for localized prostate cancer.

Diagnosed with prostate cancer is a frightening experience, followed by many confusing choices for treatment. The goal of this web site is to help men make an informed choice by providing information for men to educate themselves about prostate cancer and treatment options.

After meticulously researching all treatment options and their survival rates as well as risk factors for each treatment, my choice for treatment of localized (Gleason Score of 6, PSA ~5, 2/12 cores positive) prostate cancer was stereotactic body radiotherapy (SBRT) /CyberKnife. My treatment consisted of five outpatient sessions, completed May 7, 2008. The choice of the CyberKnife was made because it was the best chance for cure with the lowest risk to my quality of life.

Men need to be well informed and have consultations with specialist from all treatment options prior to making this treatment decision, which can have serious consequences.
Each specialty has a preference, for the treatment they themselves provide. http://link%20http//jama.ama-assn.org/cgi/content/abstract/302/14/1557

My assessment of the options follow:

CyberKnife - Rating 10 (10 being the best)
• Cure - High Rate of cure, 98% + projected. Dose similar to HDR brachytherapy with external delivery. While cure rate is extremely encouraging, it has not been tested long term.
• Side effects:
o ED very low, ranges from 10 to 25%
o Incontinence, less than 1%
o Rectal complications rates are low, less than 1% typical
• No Recovery
• Non invasive
• No blood loss
• No blood clots
• No anesthesia
• Radiation safety is optimized (best dose delivery and control)
• Accelerated course of treatment Hypo fractionation confers a biological treatment advantage.
• Patient-friendly procedure (4-5 sessions)

High Dose Brachytherapy (temporary seeds) - Rating 8.5 to 2 (high dependence of doctor skill)
• Cure - High Rate possible, but results will vary considerably, based on the skill of the practitioner and patient biology.
• Side effects:
o ED very low, 50% typical
o Incontinence, less than 10% typical
o Rectal complications rates are low, less than 2% typical
• Accelerated course of treatment Hypo fractionation confers a biological treatment advantage.
• Invasive procedure
o Requires Hospitalization
o Anesthesia complications possible
o Infection possibility
o Pain from Catheter inserts. (short term in most cases)
o Recovery (weeks) from procedure required

Brachytherapy (permanent seeds low dose) - Rating 7 to 1
• Cure - High Rate possible, but results will vary considerably, based on the skill of the practitioner and patient biology.
• Side effects:
o ED very low, 50% typical
o Incontinence, less than 10% typical
o Rectal complications rates are low, less than 2% typical
• Seed migration potentially contributes to suboptimal dosimetry.
• Dose can vary during the time it takes a permanent seed implant to emit the dose.
• Radiation exposure for infants, children or pregnant women present some risk with serious consequences until radioactivity has decayed to safe levels (months).
• Permanent seed implants require time and distance restrictions
• Travel (major Airports) where radiation sensors are used for security from terrorist will be triggered until the radioactivity of the seeds have decayed.

3D RT/IMRT - Rating 7.5 to 5
• Cure – High Rate possible, 92-96%, but results will vary considerably; based on variables such has prostate movement during treatment, the skill of the practitioner and patient biology. The long course of the treatment (7-8 weeks) results in anatomic changes to the prostate and surrounding critical structures. All these variables contribute to treatment dose plans with increased prescribed dose margins to compensate for movement of the prostate during treatment. Delayed relapse rate may be higher.
• Side effects:
o ED very low, 50% typical
o Incontinence, less than 15-50% typical
o Rectal complications rates are low, less than 2% typical
• Non-invasive
• Large dose margin required to compensate for prostate movement, resulting in a suboptimal dose plan.
• Low dose course of treatment confers a biological treatment disadvantage.

• Patient-un-friendly procedure (39-43 sessions) 7-8 weeks

Proton Therapy - Rating 7 to 5
• Cure No better than 3D RT/IMRT
• Side Effects no lower than 3D-RT/IMRT
• Patient-un-friendly procedure (36-43 sessions) 7-8 weeks
• Most expensive of all therapies

Surgery (prostatectomy) – Rating 6 to 1
• Cure - High Rate possible, but results will vary considerably, based on the skill of the practitioner and patient biology.
• Side effects
o ED, 20 % to 80% risk typical
o Incontinence, 20 to 70% risk typical
• Invasive procedure
o Requires Hospitalization
o Anesthesia complications possible
o Infection possibility
o Blood loss
o Blood clots (my father had a clot in his lung after surgery)
o Recovery (weeks) from procedure required

CRYOSURGERY - Rating 4
• High Cure Rate 92-98%
• High ED 80-100% Typical

HIFU – Not Rated
• Cure - Preliminary results seem encouraging but the cure rate is unknown.
• Not FDA approved

The good news, localized prostate cancer is very curable. The bad news is the risk of nasty side effects is not fully disclosed and in many cases can be worse than the disease.

Family doctors refer patients to their local network (as my doctor did) of specialist that treat prostate cancer. Each specialty advises that we are good candidates for cure, promoting their expertise, which is logical.

Take time to do due diligence to make an informed decision for the treatment option and doctor that is best for you. There are many options with 90% or higher chance for cure, however the risk for nasty side effects and quality of life varies by modality and by doctor. The outcome by modality (treatment) will also vary with physical skill, experience, intellectual capability and doctors performance during your treatment. Some modalities depend more on intellectual capability, training and experience. Take the time necessary to make an informed choice for the modality and doctor that is best for your specific circumstance and diagnosis.

Surgery is typically the first option offered by the urologist who usually are the first to discuss the biopsy results. Many patients accept the first option, surgery (radical prostatectomy) for treatment. Some men facing prostate cancer like the idea of having the cancer removed from their body. Many surgeons say the only way to remove prostate cancer is with surgery, which is a partial and misleading truth. State of the art surgical robotics also called minimally invasive radical Prostatectomy (MIRP) are being promoted as surgical advancements with smaller incisions, less blood loss and faster recovery. But, there also are higher risks for very unpleasant complications. All men considering surgery need to be aware of the considerable risk, especially since these high-tech procedures are being aggressively marketed by hospitals and doctors keen to treat patients without full disclosure of the risk. The following link points out the good and bad outcome for open and robotic surgery. Neither are optimal options in my opinion.
Comparative Effectiveness of Minimally Invasive vs Open Radical Prostatectomy
http://jama.ama-assn.org/cgi/content/abstract/302/14/1557

MIRP Open Surgery
Hospital Stay (average) 2 days 3 days
Erectile Dysfunction 26.8% 19.2%
Incontinence 15.9% 12.2%
Blood transfusion 2.7% 20.8%
Strictures or scar tissue 5.8% 14.0%
Infection(genitourinary) 4.7% 2.1%
Respiratory complications 4.3% 6.6%
Other Surgical complications 4.3 5.6
Recurrence 30 day-18mo 8.2% 6.9%
Anesthesia complications

One of my friends had MIRP which required a few extra days of hospitalization because he went into atrial fibrillation directly related to the surgery. I guess that would fall into the “other surgical complications.”

Add complications from anesthesia and recovery time to the risk above.

Radical Prostatectomy was once considered the standard of care for prostate cancer against which all other treatments were compared.

The following link is a study-comparing outcome with the doctors’ skill and experience. http://www.sciencedaily.com/releases/2007/07/070724161655.htm

Radiation, Cryosurgery and HIFU are other typical options. HIFU is new in the U.S., not approved by the FDA and with outcome results, no better than any other option. Cyro has a high cure rate with high rate of side effects ED approaching 100%, not a very attractive option for most men. The Cyro rate for cure is no better than any other option.

Radiation (radioactive material was inserted in the prostate) was first used to treat prostate cancer in 1909. It was successful at cure but the side effects from radiation toxicity (patients, doctors, nurses and assistants) were unacceptable.

Radio Therapy has made the most significant improvements over the last 20 years. Advancements in technology (Computers, Linacs, Robotics) have improved imaging, treatment planning and radiation dose control, beam delivery, and target identification or tracking have improved radiation treatment outcomes.

Radiotherapy uses ionizing radiation to disrupt the DNA of cancer cells causing then to die. Radiotherapy uses two types of particles, photons and protons, for treating prostate cancer. Photons (also known as X-rays) are the same particles produced by, 2D-RT, 3D-RT, IMRT, Brachytherapy and the CyberKnife/SBRT to treat cancer.

Photons have a long history in medicine, treating cancer for over 100 years. Proton Radiotherapy is relatively new, approximately 20 years.

The radiation energy delivered to the prostate per session is either Low Dose Radiation (LDR) or High Dose Radiation (HDR). HDR is also referred to as hypo fractionation. The radio biology of prostate cancer indicates that it will respond better with a higher dose-per-fraction (ie. hypo-fractionation) than compared with lower dose-per-fraction.

The radiotherapy can be delivered to the prostate internally (Brachytherapy) or externally (External Beam, EB)

There are two types of Brachytherapy one with permanent seeds (LDR) and one with temporary seeds (HDR). Temporary seeds have demonstrated a high rate of cure.

Permanent seeds deliver radiotherapy over many months to the prostate and surrounding tissue. Men with permanent seeds are radioactive and present a danger to people in close contact with them for several months. This therapy is not suggested for men in close contact with children. Traveling through major airports may set off radiations sensors.

HDR Brachy therapy is a surgical procedure requiring a hospital stay. The risk (anesthesia, infection, etc ) from surgery apply. Radioactive seeds are inserted in delivery tubes that are inserted into the prostate. The seeds are inserted, removed, inserted, removed etc until the prescribed dose is delivered. Unlike permanent seeds the patient is not radioactive. HDR Brachy therapy delivers a high dose per session which is called hypo fractionation.

Researching published literature, will show that higher radiation dose per session increases the cure rate.

External beam (EB) radiation, is a general category for radiotherapy which includes IMRT/3D-RT, Proton Therapy and the CyberKnife/SBRT.

Proton therapy has proven to be no better than IMRT/3D-RT but better than the treatment radiation options of the early 80's and before. Beam control and imagining have improved to allow better dose volume control to the target volume. These treatments require 36-45 sessions over 7-8 weeks. The total dose has increased from 50-60 Gy fifteen years ago to 78-86.4 Gy today. Increasing the radiation dose has improved the chance for cure. Improved imaging, radiation hardware, and software have allowed increased dose with tolerable toxicity to critical structures and healthy cells.

The CyberKnife (not a knife, no cutting) uses hypo fractionation (high dose per session similar to HDR Brachytherapy); its radiation source is on a robot that can deliver the radiation beams from a hundreds of angles. There are two protocols four (4) treatment sessions of 9.5 Gy each with a total dose of 38 Gy or five (5) treatment sessions of 7.25 Gy, with a total dose of 36.5 Gy. The CyberKnife total dose is 50% or less than the total dose from IMRT. Prostate cancer cure improves with increases dose per session/fraction.

The CyberKnife has real time target (prostate) tracking, keeps the beam on target between doses, which no other treatment can provide.

The CyberKnife dose volume control, delivery and target tracking allow the prescribed dose volume (radiation) margin to be much smaller than IMRT/3D-RT. IMRT/3D-RT has to increase the prescribed dose volume margin to compensate for prostate movement during treatment. The CyberKnife reduced margin lowers the dose to the surrounding critical structures such as the rectum.

Hypo fractionation, delivered by the CyberKnife, increases the chance for cure, reduces the prescribed dose volume to surrounding critical structures, which reduces the risk for side effects. Treatment is accomplishes in 4/5 days depending on the treatment protocol. Stanford (where I was treated) used the five day protocol.

There are doctors (usually offering only IMRT) who will argue that the CyberKnife data is not mature because the first patient ( http://www.emaxhealth.com/33/2137.html ) for prostate cancer was treated in Dec. 2003. This may be valid but the data to date is very good for cure 3-5/3000 total failures and only 1-3/3000 for localized PCa. Side effects are minimal and in my case at three months were ZERO. Dr. Christopher King treated me at Stanford in his clinical (NCT00855647) trial which is the longest study started Dec. 2003.

I have debated the CyberKnife with doctors offering only IMRT. When they say, it takes 10-20 years to prove CyberKnife safety and cure. They cannot answer one simple question. The IMRT dose plan of 10-15 years ago was 68-70 Gy today it is 80-84.6 Gy. I ask for the 10-20 year IMRT data for the present dose 80-84.6 Gy. They have none.
IMRT is not a specific treatment process it is a payment code. IMRT equipment varies in shape and size, number of beams, range from three to seven that intersect to create the prescribed dose volume. Increasing the number of beams improves the ability to shape the prescribed dose volume to match the target volume. The ability to have many beam angles increases the probability to produce a treatment plan that minimizes the radiation dose to critical structures.

Increasing the dose improves the cure rate. As imaging improves, the ability to match the prescribed dose volume to the target volume also improves. However, movement of the beam to compensate for prostate during treatment cannot be auto adjusted with IMRT or Proton therapy. Only the CyberKnife can automatically track prostate movement and automatically adjust the radiation beam to keep the prescribed dose volume on the target volume.

My suggestion to all patients is to research all the options and discuss them with the various experts then select the one you are most comfortable. I would suggest meeting with the best in the field for treating prostate cancer with the CyberKnife, IMRT Brachytherapy and surgery.

As a technology entrepreneur, I understand and appreciate the CyberKnife technology that treated me non-invasively, offers me the best chance for cure. The short-term (two weeks) side effects were minimal (frequency and urgency of bowel and urination). Some patients have reported no short or long-term side effects. My longer-term (22 months) side effects are ZERO. I am a founding member of ZERO http://www.zerocancer.org/index.html?cvridirect=true and advocate for prostate cancer patients. I have testified at a Medicare LCD meeting, met with CMS Directors, met with many politicians and patients: including the first patient treated with the CyberKnife. He is a neurosurgeon, has no long-term (over 6 yrs after treatment) side effects, and remains cancer free.
If you would like to have more information or ask Doctors a question visit the CyberKnife patient forum http://www.cyberknife.com/Forum.aspx . Join my patient forum to ask CyberKnife patients questions.
Trust no one, do your own research.

You have to live with the treatment side effects and outcome.

Revised Apirl 2,, 2010