prostatecancerfree.org

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2 The PROSTATE CANCER FREE FOUNDATION was established in 2010 to help those interested in, and affected by prostate cancer through education and research. The Foundation is supported by YOU and the members of the Prostate Cancer Results Study Group, an international team of experts in the field of prostate cancer. Visit for more information.

3 PROBLEM Patients, physicians and providers need simple, unbiased data by which to compare the effectiveness of modern prostate cancer treatment methods. The most effective treatments are those in which the patient remains Prostate Cancer Free for their lifetime.

4 SOLUTION The Prostate Cancer Treatment Study Group has evaluated over 51,000 prostate articles published between 2000 and 2017 to compare treatment results and offer that comparison to doctors and patients so they may make better treatment decisions. +51,800 prostate articles were published between 2000 and Dec ,604 of those articles featured TREATMENT RESULTS 243 articles have met PCRSG criteria to be included in this review study Some treatment methods are under-represented due to failure to meet criteria.

5 The Study Group The purpose of this work is to review all of the current literature on prostate cancer treatment and provide results to patients and their physicians. Peter Grimm, DO Prostate Cancer Center of Seattle, Seattle, WA (Founder, deceased Feb. 20, 2016)

6 Ignace Billiet, MD F.E.B.U.-Urologist, AZ Groeninge Teaching Hospital, Kortrijk, Belgium David Bostwick, MD Bostwick Laboratories, Orlando, FL Luis Campos-Pinheiro, MD Univ. of Lisbon, Lisbon, Portugal Brian Davis, MD Mayo Clinic, Rochester, MN D. Jeffrey Demanes, MD UCLA Medical Center, Santa Monica, CA Adam Dicker, MD Thomas Jefferson U., Philadelphia, PA Steven Frank, MD MD Andersen, Houston, TX Gustavo Guimaraes, MD AC Camargo Cancer Center, São Paulo, Brazil R. Alex Hsi, MD Peninsula Cancer Center, Poulsbo, WA Jos Immerzeel, MD De Prostaat Kliniek, Netherlands Mira Keyes, MD BC Cancer Agency, Vancouver BC, Canada Patrick Kupelian, MD UCLA Med Center, Los Angeles, CA Steven Kurtzman, MD Western Radiation Oncology, San Francisco, CA Stephen Langley, MD St Luke's Cancer Centre, Guildford, England W. Robert Lee, MD Duke University Medical Center, Durham, NC Stefan Machtens, MD Marien-Krankenhaus Hospital, Bergisch-Gladbach, Germany Alvaro Martinez, MD William Beaumont, Royal Oak, MI

7 Gregory Merrick, MD Schiffler Cancer Center, Wheeling, WV Jeremy Millar, MD Alfred Health Medical Center & Monash University, Melbourne, Australia Brian Moran, MD Chicago Prostate Institute, Chicago, IL Peter F. Orio, DO Dana-Farber/Brigham & Women s Cancer Centers, Boston, MA Antonio Cassio Pellizzon, MD Camargo Cancer Center, São Paulo, Brazil Bradley R. Prestidge, MD, MS Bon Secours Cancer Institute, Norfolk, VA Thomas Pugh, MD University of Colorado School of Medicine, Denver, CO Mack Roach, MD UC San Francisco, San Francisco, CA Mark Scholz, MD Prostate Cancer Research Institute, Marina del Ray, CA Katsuto Shinohara, MD UC San Francisco, San Francisco, CA Janusz Skowronek, MD Greater Poland Cancer Center, Poznań, Poland Richard Stock, MD Mt. Sinai, New York, NY Frank Sullivan, MD College of Medicine, Nursing and Health Sciences, NUI, Galway, Ireland Jehan Titus, MD Calvary Hospital, St Josephs Collage, Adelaide, Australia Robyn Vera, DO Radiant Oncology, Lacey, WA Edward Weber, MD Prostate Cancer Center of Seattle, Seattle, WA Michael Zelefsky, MD Memorial Sloan Kettering, New York, NY Anthony Zietman, MD Harvard Joint Center, Boston, MA

8 About This Review Study The indicator of being Prostate Cancer Free is a low PSA level which does not rise. SUCCESS: Five to ten years after treatment, a low PSA level indicates cancer is controlled and there is a high likelihood the cancer will not return. FAILURE A consistent rise in PSA after treatment is generally considered a failure, requiring additional treatment or action.

9 About This Review Study PSA expectations, post treatment, result in dissimilar ways to review a man s PSA history to judge success. Therefore, results greater than five years are necessary to be able to compare treatment results. SURGERY PSA numbers usually fall after surgery rapidly to very low numbers and stay low. RADIATION PSA numbers usually come down after radiation slower than surgery, and may increase briefly, then subsequently fall (this is called a PSA Bump. )

10 Abbreviations A range of treatment options are available to treat prostate cancer. They are abbreviated as the following. BRACHY Seed Implantation (Brachytherapy, either permanent or temporary seeds) HIFU High Intensity Focused Ultrasound EBRT External Beam Radiation Therapy (includes IMRT = Intensity Modulated Radiation Therapy) RP SURGERY Standard Open Radical Prostatectomy CRYO Cryotherapy PROTONS form of External Radiation using Protons ADT Hormone Therapy ROBOTIC SURGERY Robotic Radical Prostatectomy

11 Article Review Process Every Prostate Cancer article written since 2000 is reviewed and determined for inclusion within the study on a biannual basis. First to decide if it is a treatment article and secondly if it meets the expert panel's study criteria. The results of the accepted treatment articles are plotted together according to each risk group s Prostate Cancer Free status (in the professional literature this is known as PSA Progression Free status, meaning no evidence of a rising PSA.) +51,800 prostate articles were published between 2000 and June Articles have met PCRSG criteria to be included in this review study. +114,000 Participants are represented in all study accepted articles.

12 Criteria for Inclusion of Article* Articles must be published in a Major Medical Journal. Patients should be separated into Low-, Intermediate-, and High-Risk Groups Success must be determined by PSA analysis All major treatment types considered: Seeds (Brachy), Surgery (Standard or Robotic), EBRT (including IMRT), HIFU (High Intensity Frequency Ultrasound), CRYO (Cryotherapy), Protons, HDR (High dose Rate Brachytherapy) Low-Risk articles a minimum of 100 patients Intermediate-Risk articles a minimum of 100 patients High-Risk articles, because of fewer patients, a minimum of 50 patients Patients need to be followed for a median of 5 years For additional criteria information contact: l.grimm@pctrf.org * Expert panel consensus

13 % Articles Meeting Criteria by Treatment RP Surgery EBRT/IMRT Cryo Brachy/HDR Robotic +48,700 prostate articles were published between 2000 and June Surgery Proton HIFU 1,502 of those articles featured treatment results. 9.7% 16% 6% 25.5% 4.7% 24% 11% 223 articles have met PCRSG criteria to be included in this review study. 43/443 73/458 3/49 108/423 5/106 5/21 6/54 Some treatment methods are under-represented due to failure to meet criteria. Total of 1,604* Treatment Articles. Some articles addressed several treatments and were counted as separate articles for each treatment. *Some articles evaluated other/minor treatments that are not listed here and are therefore not included in these calculations.

14 COMPARE TREATMENTS

15 How to Use the Results The Risk groups are defined by a combination of factors provided by the diagnosing physician and include the stage of the cancer, the Gleason Score, and PSA level. LOW RISK INTERMEDIATE RISK HIGH RISK Stage: T1 or T2a,b Stage: T1-2 Stage: T1 or T1-2 Stage: T2c or T3 Gleason Score: < 6 Gleason Score: 6 OR Gleason Score: 7 Gleason Score: > 8 PSA: < 10 ng/ml PSA: PSA: > 10 PSA: > 20 ng/ml Review the treatment outcomes and then ask a doctor in each discipline (Seeds, External Radiation, Surgery, etc.) to tell you where his/her own peer reviewed published Treatment Success % would fit on this plot.

16 Abbreviations Here is a list of all the major primary treatment options available for prostate cancer. BRACHY Seed Implantation (Brachytherapy, either permanent or temporary seeds) HIFU High Intensity Focused Ultrasound EBRT External Beam Radiation Therapy (includes IMRT = Intensity Modulated Radiation Therapy) RP SURGERY Standard Open Radical Prostatectomy CRYO Cryotherapy PROTONS form of External Radiation using Protons ADT Hormone Therapy ROBOTIC SURGERY Robotic Radical Prostatectomy

17 LOW RISK Stage: T1 or T2a,b l Gleason Score: < 6 l PSA: < 10 ng/ml More than 80% of all Low Risk patients will do well with any treatment without fear of recurrence or their cancer returning. However, when selecting a course of action, consultations are recommended with a urologist or surgeon, radiation oncologist and medical oncologist. Different treatments have different results and side effects. It is important to understand the potential impact each treatment can have on your quality of life after treatment.

18 Low Risk Results Each Symbol is a different article for that treatment assemble at ProstateCancerFree.org. Example A: A green square positioned at 5 years along the 97% line indicates that, 97% of the patients, treated with EBRT alone in low-risk patients at 5 years were free of disease progression and were Prostate Cancer Free. A B Example B: A blue circle positioned at 5 years along the 84% line indicates that, 84% of the patients, treated with brachytherapy seeds alone in low-risk patients at 5 years were free of disease progression and were Prostate Cancer Free.

19 Low Risk Results The colored ellipses outline the results of multiple articles in the same treatment. These ellipses demonstrate 2 things: 1. Dividing the ellipses in half will give you the average result of the treatment. 2. The direction of the ellipse will give you an idea of the long term success. A downward direction of the ellipse indicates that some patients are failing over time. Ideally, if a treatment reaches a point where no or few patients fail, the ellipse pattern will look like this. *Ellipses can only be drawn if there are 4 or more accepted studies within that treatment.

20 INTERMEDIATE RISK Stage: T1-2 l Gleason Score: 6 l PSA: OR Stage: T1 or T1-2 l Gleason Score: 7 l PSA: > 10 Intermediate Risk patients experience a wider range of results and approaches due to the risk of disease beyond the prostate. When selecting a course of action, consultations are recommended with a urologist or surgeon, radiation oncologist and medical oncologist. Different treatments have different results and side effects. It is important to understand the potential impact each treatment can have on your quality of life after treatment.

21 Intermediate Risk Results Each Symbol is a different article for that treatment assemble at ProstateCancerFree.org. A Example A: A blue circle positioned at 5 years along the 97% line indicates that, 97% of the patients, treated with brachytherapy seeds alone in intermediate-risk patients at 5 years were free of disease progression and were Prostate Cancer Free. Example B: A red triangle positioned at 5 years along the 59% line indicates that, 59% of the patients, treated with RP Surgery in intermediaterisk patients at 5 years were free of disease progression and were Prostate Cancer Free. B

22 Intermediate Risk Results The colored ellipses outline the results of multiple articles in the same treatment. These ellipses demonstrate 2 things: 1. Dividing the ellipses in half will give you the average result of the treatment. 2. The direction of the ellipse will give you an idea of the long term success. A downward direction of the ellipse indicates that some patients are failing over time. Ideally, if a treatment reaches a point where no or few patients fail, the ellipse pattern will look like this. *Ellipses can only be drawn if there are 4 or more accepted studies within that treatment.

23 HIGH RISK Stage: T2c or T3 l Gleason Score: > 8 l PSA: > 20 ng/ml High Risk prostate cancer patients experience the highest range of results and approaches as they are likely to have prostate cancer outside of the prostate. When selecting a course of action, consultations are recommended with a urologist or surgeon, radiation oncologist and medical oncologist. Different treatments have different results and side effects. It is important to understand the potential impact each treatment can have on your quality of life after treatment.

24 High Risk Results Each Symbol is a different article for that treatment assemble at ProstateCancerFree.org. A Example A: A green diamond positioned at 5 years along the 98% line indicates that, 98% of the patients, treated with EBRTand ADT in highrisk patients at 5 years were free of disease progression and were Prostate Cancer Free. Example B: A red triangle positioned at 5 years along the 38% line indicates that, 38% of the patients, treated with RP Surgery in high-risk patients at 5 years were free of disease progression and were Prostate Cancer Free. B

25 High Risk Results The colored ellipses outline the results of multiple articles in the same treatment. These ellipses demonstrate 2 things: 1. Dividing the ellipses in half will give you the average result of the treatment. 2. The direction of the ellipse will give you an idea of the long term success. A downward direction of the ellipse indicates that some patients are failing over time. Ideally, if a treatment reaches a point where no or few patients fail, the ellipse pattern will look like this. *Ellipses can only be drawn if there are 4 or more accepted studies within that treatment.

26 Study Observations

27 Observations For most low-risk patients, most therapies will be successful*. Treatments at the top of the results comparison graphs for the long periods of years, indicate that patients treated with these methods did not experience an increase in PSA after treatment. These patients are more likely to remain Prostate Cancer Free. Patients are encouraged to look at graphs and determine for themselves. Serious side-effect rates must be considered for any treatment. For additional criteria information contact: * Expert panel consensus

28 Talk to your doctor about your treatment options.

29 Record your treatment journey with the help of the Patient Worksheet.

30 Find the latest updates to this study at ProstateCancerFree.org.