Prostate Cancer Matters

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Radiation oncologists are quite familiar with prostate cancer, with the statistics of it (the most common male cancer and the second most common cause of US cancer deaths), and with the faces of prostate cancer patients because they are commonly seen in most radiotherapy facilities, looking to us for guidance. We are also aware of the 3 types of prostate cancer: those that are so slow growing that local therapy is irrelevant, those so aggressive that local therapy is futile, and those that are moderately aggressive and amenable to the lifesaving benefit of effective prostatic treatment. Stated in another way, because of these various phenotypes, we often overtreat or undertreat prostate cancer. We continually attempt to develop tools to discern who needs or does not need intensive local treatment so that we only subject men who will benefit from local therapy to the morbidity that is bound to accompany prostatic treatment. For now and for the foreseeable future, we will remain familiar with that typical soon-to-be confused patient (65 years old, T1c, Gleason 6, PSA 8) to whom we say, “Yes, you can have your prostate surgically removed, or treated with intensity modulated radiotherapy (IMRT), or treated with seeds, or with high dose rate (HDR), or with cryotherapy, or you don’t need to have it treated at all, we can just watch you carefully. Unfortunately, I can’t tell you which treatment is best for you because we really don’t know.”

This issue of Seminars of Radiation Oncology paints the practice of prostate radiation oncology with a broad brush and highlights a number of ongoing concerns.

Laurence Klotz addresses whether or not there is a role for active surveillance in the current management of prostate cancer. As the principal investigator of the international START trial prospectively testing active surveillance compared with immediate therapy, he is an ideal spokesperson for the potential benefits of carefully delaying the onset of definitive therapy.

Abramowitz and Pollack summarize the available data, including recently published randomized trials, regarding which patients benefit from postoperative radiotherapy, whether RT should be delivered adjuvantly, or if patients should wait until the earliest signs of biochemical failure. Despite these data, the role of adjuvant radiotherapy remains widely unaccepted by the urologic community.¹

Lee and I review the data that are available on intermediate-risk patients who are treated with external-beam radiotherapy and whether they benefit from neoadjuvant and concurrent androgen suppression. After all, even short-term androgen suppression has long-term effects on quality of life² so we should be secure in the benefit before widely using this modality in combination with radiotherapy.

We need to determine our confidence level in the reported low alpha-beta ratio for prostate cancer. If we are confident, then there are novel hypofractionation regimens that may increase the cure rate, decrease the morbidity, and minimize the inconvenience associated with a course of radiotherapy. However, if it turns out that we have underestimated the alpha-beta, these novel regimens may be ineffective or toxic. Clearly, more prospective trials are needed. Miles and Lee (who is the principal investigator of the RTOG hypofractionation trial RTOG 0415) summarize what is known about hypofractionation and prostate cancer.

One of the oldest questions in prostate cancer radiotherapy, whether the pelvic lymph nodes need to be treated, is explored by Wang and Lawton who summarize the recent trials.

We need to know if technological innovations are improving prostate cancer treatment and whether their use and expense can be justified. Although there are no randomized trials testing the benefit of intensity-modulated radiation therapy, it has become widely used in the United States and it is hard to imagine treating prostate cancer without it. Cahon and coworkers update the use of IMRT, and Kupelian and coworkers describe the role of image-guided radiotherapy (IGRT), which is a necessary adjunct to high-dose, tight-margin IMRT.

Another matter yet to be decided is when external beam is needed at the same time that permanent prostate seed implants are used for treatment. Soto and McLaughlin describe the past use and possible future use of postimplant IMRT to optimize implant therapy.

I believe this issue provides a thorough overview of these important issues and will help us minimize the potential for confusion in the next patient with prostate cancer who walks into our clinic.

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References 

1. Montie JE, Hussain M. Outcomes for radiation therapy after radical prostatectomy for prostate cancer: What really matters?. BJU Int. 2007;100:485–486
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2. Miller DC, Sanda MG, Dunn RL, et al. Long-term outcomes among localized prostate cancer survivors: Health-related quality-of-life changes after radical prostatectomy, external radiation, and brachytherapy. J Clin Oncol. 2005;23:2772–2780
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