When journalists define the “gold standard” for prostate cancer treatment
Posted Apr 26 2010 12:00am
Reports occur in the media on a regular basis in which journalists talk about their personal experiences in diagnosis and treatment of prostate cancer. These reports can be misleading because, like most prostate cancer patients, these journalists have limited experience (if any) as medical reporters, and they don’t always know or appreciate all of the facts.
The latest example of this can be seen in two articles just published by Tom Halsted in The Huffington Post. In the first article , Mr. Halsted has provided a compelling saga of his diagnosis, his research on his treatment options, and his decision to have proton beam radiation therapy (PBRT) at Loma Linda. In the second article , regrettably, Mr. Halstead has then provided what can only be described as an enthusiastic panegyric for proton beam radiation that will undoubtedly be received with delight by every currently open and development-stage proton beam radiation center in America.
The Huffington Post has a large circulation. A lot of prostate cancer patients are going to see Mr. Halsted’s articles and read his message that proton beam radiation therapy “will soon replace surgery as the ‘gold standard’ for treating prostate cancer.” The truth is more complicated.
For starters, the only people arguing that a radical prostatectomy (RP) is still the “gold standard” for the treatment of prostate cancer are urologists. RP is one of several highly appropriate options for carefully selected patients. It is also the only form of treatment that allows you to get a good idea of exactly what was in your prostate after first-line treatment. In today’s world, other forms of therapy on which we have good 10-year follow-up data are also highly appropriate options for carefully selected patients most particularly including brachytherapy. Several forms of external beam radiation therapy (IMRT, IGRT) have been evolving so fast that we really do not have good long-term data on their most current evolutions, but older data suggest that the highly targetable forms of high-dose radiation now available can and will demonstrate outcomes similar to those of brachytherapy and they may well be able to do this using stereotactic body techniques (such as those used by the CyberKnife and RapidArc systems). This will mean that external beam radiation can customarily be carried out in just 5 days.
Will it soon be possible to carry out stereotactic proton beam radiation therapy? We suspect that it will. And that may well offer the very best of all external beam radiation therapy options but it isn’t available yet.
We believe proton beam radiation therapy is an effective and relatively safe form of treatment for prostate cancer and most particularly for early stage, low-risk prostate cancer. However, we also think it is expensive; we think that a lot of the men who have received this form of treatment may never have needed treatment at all (which is not exclusive to PBRT); and we think that when you compare the very limited, published, clinical data on the effectiveness and safety of PBRT (three articles in the late 1990s) to the data for high-dose IMRT and IGRT and the most recent data for CyberKnife therapy, it would be hard to make a compelling argument that any one of them is demonstrably “better” than any other for the treatment of low-risk disease.
If you think we are in some way biased against PBRT, we wish to be clear that we are not. What we are biased about is the marketing of prostate cancer treatments on the basis of limited data. The da Vinci robot is a classic case in point. The use of this robotic system to carry out prostate cancer surgery has, over the past decade, been used by hospitals across America as a marketing tool. The insinuation was that if you weren’t having robotic surgery, you weren’t getting “state of the art” treatment. The truth is that good surgeons don’t need a da Vinci system to carry out a high quality, “state of the art” radical prostatectomy. There is nothing wrong with experienced urologic surgeons using the da Vinci robot if they want to but its use has minimal impact on patient outcomes by comparison with the skill of the surgeon to whom you have entrusted your prostate.
In the next few years we are going to see a prostate cancer radiation therapy marketing war, in which the proton beam centers will be pitted against the CyberKnife and other stereotactic body radiation centers and the brachytherapy centers, and “no holds will be barred.” This despite that fact that there are no current plans (that we are aware of) for sound comparative trials of these evolving options. The war will be conducted on billboards on the freeways and in articles like that of Mr. Halstead.
We should state that we are delighted that Mr. Halsted appears to have had an excellent response to his treatment. He received PBRT 3 years ago, and apparently his outcomes have been everything he could of wished for. That is excellent news. What we do not know is whether Mr. Halsted would have done just as well on active surveillance. He was 74 years of age at diagnosis and appears to have had early stage, low-risk disease. It seems highly likely that he could have been carefully monitored for some considerable period of time before any decision about treatment was necessary. He does not mention that option in his first article, so we are uncertain that it was ever discussed with him in a clear and concise manner.
What is the “gold standard” for the treatment of early stage, low-risk prostate cancer today? Well, The “New” Prostate Cancer InfoLink doesn’t think we have one, and that’s 95 percent of the problem. What we need are the data to reset the baseline. Those data would need to be able to compare any form of invasive therapy to active surveillance for patients with a life expectancy of 10-15 years at diagnosis. And for patients with higher-risk but early stage disease, things become more complicated rapidly!