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Old 02-13-2009, 10:05 AM   #31
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Re: The Cyberknife? Has anyone used this form of treatment?

Quote:
Originally Posted by viperfred View Post
... The CyberKnife is very quickly becoming the standard of care across the US. IMRT.... was on a big growth curve driven by prostate cancer. That is now slowing and those newly invested in IMRT are saying there is not enough data or time. ....
Fred,

I can only give you my impressions from the viewpoint of what I am hearing in support group, education and advocacy circles and in research circles, as I understand it. Based on that, it looks like something different is occuring.

First, I know you are eager to declare CyberKnife with Stereotactic Body Radiotherapy dosing (CK SBRT) a standard of care, but my impression is that virtually all doctors would be unwilling to do that at this time, and I'm confident that neither Dr. King nor Dr. Fuller would want to do it either. Just be patient - I think it will get there. And, it does not have to be considered a standard of care to be widely used and reimbursed, though obviously reimbursement via insurance will be easier for many of us if it is so recognized.

Also, though it is wonderful to learn that a growing number of patients are now feeling comfortable in choosing CK SBRT, if only a couple of thousand have done so in recent years, then the percentage choosing that therapy is really tiny considering that more than 200,000 men in the United States are diagnosed with prostate cancer each year; obviously, they are choosing other approaches. I'm confident that percentage will grow with the good work you and others are doing in bringing this option to the forefront.

Second, regarding IMRT, my impression is that regular dose brachytherapy was the approach on the bigger growth curve rather than IMRT, but also that data for both IMRT and brachy are now considered fairly long and adequate, though we would always like to see more data.

For instance, knowing that Dr. Michael Dattoli, MD, is a leader in brachytherapy and IMRT who has recently published long term results, I went to [url]www.pubmed.gov[/url] with this search string: " dattoli m [au] AND prostate cancer " and got ten hits. Here's one key paper:
"Long-term outcomes after treatment with brachytherapy and supplemental conformal radiation for prostate cancer patients having intermediate and high risk features." Dattoli M, Wallner K, True L, Cash J, Sorace R. Cancer. 2007 Aug 1;110(3):551-5.

The non-failing followup period averaged ("median") 9.5 years, giving capability to project to 14 years, and here are key sentences from the results section: "... Overall actuarial freedom from biochemical progression at 14 years was 81%, including 87% and 72% having intermediate and high-risk disease, respectively. Absolute risk of failure decreased progressively, falling to 1% beyond 6 years after treatment. ..." I've seen some of Dr. Dattoli's recurrence free survival tables for such patients, and it is striking how the recurrence line flattens out - meaning virtually no more recurrences if you have success for the first few years. These are truly stunning statistics for the risk groups he was treating. (By the way, for anyone who wants more detail, PubMed links you to the full paper for free in this case.) (As we would expect, Dr. Dattoli's results for low risk patients, which are not the subject of this paper, are extremely good!)

Finally, I have a strong impression that robotic surgery is replacing conventional radical prostatectomy, and I have a hunch that this is partly rebuilding the percentage of patients choosing surgery as an option. Until the advent of widely available laparoscopic and robotic surgery, in recent years it appeared that many men were concluding the value of dealing with a small risk of uncontrollable prostate cancer with surgery was not worth the likelihood of a substantial side effect and complication burden; now that burden is being lightened.

I wasn't able to find a PubMed search string that gave hard data on any recent statistics for the percentages of patients choosing various therapies. Perhaps others will have better luck.

Fred, if you have hard figures for recent years for the numbers and percentages of men choosing various prostate cancer treatments by year, I would like to learn about them.

Here's a last thought. I'm impressed with the case you are making for CK SBRT on its own merits, and I'm thinking your energy will probably have a bigger payoff there than in the difficult and likely self-defeating task of attacking other therapies, most of which are established or are emerging as pretty decent options.

Jim