PIVOT trial vs Radiation Therapy for Patients with Prostate Cancer

[Tedebear]

Need a radiation oncologist's thoughts on this.

What do you guys think about radiation treatment vs surveillance for Stage I prostate cancer patient that is 63 with Gleason less than 6 and PSA of 7.

http://www.urologytoday.net/article/early-stage-prostate-cancer/

If you had one of these patients referred from Urology. What would you tell the patient?

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[Tedebear]

Does radiation treatment justify the side effects vs suveillance?

What about proton therapy vs surveillance?

http://www.nejm.org/doi/full/10.1056/NEJMoa1113162#t=article

Thank you for the rad-onc's perspective.

 

[Gfunk6]

If this pt had a life expectancy < 10 years, I would offer active surveillance only. I would try to dissuade patient from treatment based on the results of the Swedish data. Essentially, it would take ~14 years for a patient at this early stage to met out.

Protons would be obscene.

If >10 years life expectancy, again based on Swedish data, I would recommend either definitive treatment (I use hypofrac IMRT per the Cleveland Clinic) or active surveillance.

 

[Palex80]

This is a case by case decision with many factors playing a role.
In my experiece, the most important factor in these rather "young" low-risk prostate patients is sexual function. If the patient is sexually active and it's important for him to stay sexually active, then you have a good argument for AS, with the hope of having to treat him a couple or (even better) several years later, when sexual function may no longer be such an important issue for him.

I am currently monitoring 3 patients with AS in the age of 58-67. All 3 of them are sexually active and have for these reason declined surgery up front (urologists are very keen to talking younger patients into surgery in Europe, without even considering radiation therapy). All 3 patients have agree to undergo radiation therapy, if there are signs of progression. So far, I have been monitoring them with PSA every 3 months and yearly biopsies. They are all stable so far, the first one I saw is now 3 years into AS.

 

[medgator]

I am currently monitoring 3 patients with AS in the age of 58-67. All 3 of them are sexually active and have for these reason declined surgery up front (urologists are very keen to talking younger patients into surgery in Europe, without even considering radiation therapy).

similar to some urologists here,. The concern they have of course is the longevity of data with surgery and lack of second malignancy risk for younger patients. I have a similar bias myself in that population (outside of high risk disease). They should still hear the radiation options though

unfortunately, some urologists think cryo and hifu are equally reasonable (without the data to back it up - hifu is not even FDA approved here)

 

[Palex80]

similar to some urologists here,. The concern they have of course is the longevity of data with surgery and lack of second malignancy risk for younger patients. I have a similar bias myself in that population (outside of high risk disease). They should still hear the radiation options though

Seeds are an excellent option for low risk patients (and well doable in younger patients, which usually have smaller patients and less bladder issues). Seeds probably have quite a smaller risk for secondary malignancy in comparison to EBRT.

unfortunately, some urologists think cryo and hifu are equally reasonable (without the data to back it up - hifu is not even FDA approved here)

Cryo is exotic here, Hifu is practiced as salvage therapy after radiation therapy. Very few patients choose Hifu as a first line therapy and only very few urologists offer it in that setting.

 

[Tedebear]

Thank you everyone.

Also if one chooses brachy (HDR), standard fx IMRT, vs hypofx IMRT. What are the pros and cons of these 3 treatment choices for the above mentioned patient.