2015 myresearch Science Internship Program: Applied Medicine. Civic Education Office of Government and Community Relations

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1 2015 myresearch Science Internship Program: Applied Medicine Civic Education Office of Government and Community Relations

2 Harguneet Singh Science Internship Program: Applied Medicine

3 Comparisons of Outcomes among Patients Treated with Brachytherapy, External Beam Radiation or Radical Prostatectomy for High Risk Prostate Cancer Harguneet Singh Jay Ciezki, MD Chandana Reddy, MS

4 Abstract Study was focused on patients with high risk prostate cancer. Patients were treated with brachytherapy, external beam radiation or radical prostatectomy. Outcomes of treatments were compared. Most outcomes were similar among the modalities.

5 Introduction Prostate - A gland within the male reproductive system that is located just below the bladder, whose main function is to secrete a fluid that nourishes and protects the sperm. Prostate Cancer - a malignant growth of the glandular cells within the prostate. 2 nd leading cause of cancer death in American men

6 Background Prostate-Specific Antigen (PSA) Biopsy Gleason Score Clinical Staging To be considered at high risk: One high risk factor: Clinical stage T3 Biopsy Gleason score 8-10 PSA > 20 ng/ml Or two intermediate risk factors: Clinical stage T2b or T2c PSA >10 ng/ml Biopsy Gleason score 7

7 Background (cont.) Treatment options: Brachytherapy (BT) internal radiation with seeds External Beam Radiation (EBRT) machine directs x-ray beams at tumor Radical Prostatectomy (RP) surgical removal of prostate

8 Hypothesis High-risk patients who were treated with brachytherapy, external beam radiation or radical prostatectomy will have comparable rates of biochemical control, clinical control, and cause-specific survival.

9 Methodology Inception Cohort Study Study population: 2736 high risk prostate cancer patients Treated at the Cleveland Clinic from 1996 to 2012 Data was extracted from patients electronic medical records and entered into an IRB approved database. Some additional factors that were examined: Use of neoadjuvant therapy (hormonal treatment given before primary treatment) Frequency of post treatment PSA testing

10 Methodology (cont.) Biochemical failure Radical Prostatectomy post treatment PSA 0.4 ng/ml Radiation therapy post treatment PSA value 2 ng/ml above PSA nadir (lowest) value Clinical failures Local failure recurrence of cancer within prostate or prostate bed Distant failure cancer metastasizes to another site within the body (ex. bone or lymph nodes) Cause Specific Survival Death from prostate cancer

11 Data: Patient Disease and Treatment Characteristics All Patients External Beam Radiation Brachytherapy Radical Prostatectomy Number of Patients Risk Two Intermediate Factors n % n % n % n % High T1T2A Clinical Stage T2BC T < < Initial PSA (ng/ml) 10-< Unknown Biopsy Gleason Score

12 Data: Patient Disease and Treatment Characteristics All Patients External Beam Radiation Brachytherapy Radical Prostatectomy Neoadjuvant Therapy n % n % n % n % N Y UNK Duration of Androgen Deprivation (months) 2 Post Treatment PSAs Biochemical Failure Clinical Failure Local Failure Distant Failure > UNK N Y N Y N Y N Y N Y

13 Data: Patient Disease and Treatment Characteristics All Patients External Beam Radiation Brachytherapy Radical Prostatectomy n % n % n % n % Alive Status Died from Prostate Cancer Age (years) Initial PSA (ng/ml) # of Post Treatment PSAs PSA Follow Up (months) # of PSAs per Year Follow Up Time (months) Died from Other Diseases Median Range Median Range Median Range Median Range Median Range Median Range

14 Results: Biochemical Relapse Free Survival Multivariable Analysis for Biochemical Failure EBRT External Beam Radiation BT Brachytherapy RP Radical Prostatectomy Treatment Clinical Stage Variable P-Value Hazard Ratio 95%CI L 95%CI U BT vs RP BT vs EBRT RP vs EBRT T2BC vs T1T2A T3 vs T1T2A T3 vs T2BC Biopsy 7 vs Gleason 8-10 vs Score 8-10 vs 7 < Initial PSA < Duration of NeoAdj Tx (m) PSA Frequency < PSA Frequency*Time < Kaplan Meier Curve

15 Results: Clinical Relapse Free Survival Multivariable Analysis for Clinical Failure Treatment Clinical Stage Biopsy Gleason Score Variable P-Value Hazard Ratio 95%CI L 95%CI U BT vs RP BT vs EBRT RP vs EBRT T2BC vs T1T2A T3 vs T1T2A < T3 vs T2BC vs vs 6 < vs 7 < Initial PSA Duration of NeoAdj Tx (m) PSA Frequency < PSA Frequency*Time <

16 Results: Cause Specific Mortality Multivariable Analysis for Cause Specific Mortality Treatme nt Clinical Stage Biopsy Gleason Score Variable P-Value Hazard Ratio 95%CI L 95%CI U BT vs RP BT vs EBRT RP vs EBRT T2BC vs T1T2A T3 vs T1T2A T3 vs T2BC vs vs 6 < vs 7 < Initial PSA Duration of NeoAdj Tx (m) Age <

17 Conclusions Radical prostatectomy Worse biochemical control Best clinical control and better cause specific survival Better salvage therapy options External beam radiation Worse clinical control and cause specific survival Were higher risk and had longer follow up Brachytherapy: Had biochemical and clinical control comparable to EBRT Better cause specific survival Smallest sample size

18 Recommendations Limitations: Limited follow-up information on some patients Patients were not randomized to treatment option. Recommendations: Consider patient s health Consider side effects Patient s preference

19 References "Adjuvant and Neoadjuvant Therapy for Breast Cancer." National Cancer Institute. N.p., n.d. Web. 24 July Marks, Sheldon. Prostate & Cancer: A Family Guide to Diagnosis, Treatment & Survival. Tucson, AZ: Fisher, Print. "NCCN Guidelines for Patients Prostate Cancer." NCCN Guidelines for Patients. N.p., n.d. Web. 24 July "Prostate." MedicineNet. N.p., n.d. Web. 24 July "What Are the Key Statistics about Prostate Cancer?" What Are the Key Statistics about Prostate Cancer? N.p., n.d. Web. 24 July "What Is Brachytherapy?" Cancer Treatment Centers of America: Brachytherapy.com. N.p., n.d. Web. 24 July 2015.

20 Special Thanks Jay Ciezki, MD Chandana Reddy, MS Department of Radiation Oncology Glickman Urological and Kidney Institute Bryan Pflaum, MFA Nedra Starling, MA, MPH, ABD/DrPH Office of Government and Community Relations Civic Education Department

21 Copyright 2015 Cleveland Clinic Foundation