BY ANKIT AGARWAL, MD

Finding out you or a loved one has been diagnosed with prostate cancer can be a scary thing to hear. The first thing many men ask is, what does this mean, and is my prostate cancer curable. Before I delve into treatment options with men, I like to discuss the specific risk group they belong to.

While many cancers are described as stage 1, 2, 3, or 4 cancers, localized prostate cancers are more typically described as low risk, intermediate risk, or high risk. Furthermore, many physicians group patients into sub-groups within each of these categories. These risk category groups are used to determine both how aggressive your prostate cancer is and what the best treatment may entail. Your specific risk group of prostate cancer is determined by a combination of factors, including, but not limited to, the PSA blood test value and the Gleason score determined by the prostate biopsy. This article will further discuss treatments for intermediate risk prostate cancer, specifically.

The Prostate Cancer Foundation has a nice, simple guide and video describing the prostate cancer risk groups here.

A large proportion of men diagnosed with prostate cancer are sorted into the intermediate risk prostate cancer category. Men in the intermediate risk category have many treatment choices, including surgery, external beam radiation therapy, and definitive brachytherapy. All of these treatment options are potentially curable treatment options, so choosing the best option entails choosing one that promises a very high chance of cure while minimizing long term side effects. 

For men with favorable intermediate risk prostate cancer, definitive brachytherapy can be an excellent treatment option. Brachytherapy involves the placement of radioactive seeds in your prostate to eradicate any cancer in your prostate. The treatment, when done by experienced brachytherapists, is a highly targeted, adaptively planned treatment that can provide a very high chance of cure while minimizing any long term side effects.

One of the best large studies to show the results of prostate brachytherapy in this population of men is NRG/RTOG 0232, a large randomized trial that included 588 men. In this trial, men with intermediate risk prostate cancer were randomized to 2 different treatments

  • Treatment A: A combination of external beam radiation therapy and brachytherapy
  • Treatment B: Brachytherarpy alone to the prostate 

The theory was that the combination therapy may increase the overall “cure rate”

A total of 588 men were treated with approximately half getting treatment A and half getting treatment B. Overall, the long term results between the 2 groups were the same. Approximately 85% of patients in both groups had long term control of their prostate cancer. Unfortunately, however, patients who received Treatment A (the combination of brachytherapy and external beam radiation) had worse long term gastrointestinal and urinary side effects. Based on this study, the authors recommended brachytherapy alone as an appropriate treatment modality.

Brachytherapists with more experience, and who use intraoperatively, adaptively planned brachytherapy techniques can often achieve better results than radiation oncologists who are exclusively using older techniques to perform brachytherapy. Brachytherapy, by targeting radiation directly to the prostate, can often dose escalate the radiation dose to the prostate, thus maximizing the chance of cure, while minimizing the risk of long term side effects by preventing the radiation from affecting adjacent normal tissues. For example, Dr. Jorg Zimmerman, an expert brachytherapist in Germany, recently published his results of treating 1,187 patients with brachytherapy in Germany. Among his patients, over 90% of men in the intermediate risk category treated with brachytherapy remained cancer-free long term, which is significantly better than would be predicted with most other treatments for intermediate risk prostate cancer. 

Finally, some men with what is categorized as unfavorable intermediate risk prostate cancer, may benefit from a combination of external beam radiation and brachytherapy. The ASCENDE-RT trial showed that men with unfavorable intermediate risk prostate cancer could achieve a breathtaking 94% long term cure rate (profession-free survival with a 6.5 year median follow-up).

Other reasonable treatment options include intensity modulated radiation therapy or stereotactic body radiation therapy (often referred to as SBRT or CyberKnife radiation therapy) 

Ultimately, choosing a treatment option for prostate cancer is a very personalized decision. I recommend all men with prostate cancer to meet with a urologist, an experienced radiation oncologist, and an experienced radiation oncologist/brachytherapist to discuss all of their treatment options. 

If you’re in California and would like to consult with one Western Radiation Oncology’s physicians, please contact us here.