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Our meeting yesterday was extremely helpful but also totally challenged the thinking with which my wife and I came into the meeting.  We have pretty much ruled out implants, but we are now very interested in IMRT, whereas we had previously totally ruled out external radiation.

After the meeting, we had further thoughts which I’m happy to have answered by e-mail or to discuss in person or over the phone, but which I thought would be best first to put in writing.

1. We’re most concerned about the comparative cure rates and complication rates (especially for impotence and incontinence) for the different approaches (IMRT, implants, Da Vinci surgery) for my profile.  I was unable to find anything helpful through Google.  Can you  recommend any websites (or library sources that I would understand) that will have relatively recent (and preferably comparative), reliable statistics?
2. I looked at the Sloane-Kettering web site and came across an article (http://www.eurekalert.org/pub_releases/2006-09/mscc-lof092706.php), part of which reads:

“NEW YORK, September 27, 2006 -- Results from the largest study of men with prostate cancer treated with high-dose, intensity modulated radiation therapy (IMRT) show that the majority of patients remain alive with no evidence of disease after an average follow-up period of eight years. The 561 prostate cancer patients treated with IMRT at Memorial Sloan-Kettering Cancer Center were classified into prognostic risk groups. After an average of eight years, 89 percent of the men in the favorable risk group were disease-free and none of the men in any group developed secondary cancers as a result of the radiation therapy. This report, published in the October 2006 issue of The Journal of Urology, is the first description of long-term outcomes for prostate cancer patients using IMRT….

“Between April 1996 and January 2000, 561 patients with a median age of 68 (ranging from 46 to 86 years old) were treated with IMRT, an improved form of three-dimensional conformal radiation therapy (3D-CRT), also used in radiotherapy. IMRT uses enhanced planning treatment software that more precisely targets the prostate, allowing the beam of radiation to deliver a high dose (81 Gy) to the tumor target while sparing the adjacent bladder and rectum from exposure to the higher amounts of radiation. Perhaps because of this, the eight-year results show urinary continence was maintained for all patients, and only 1.6 percent of the five hundred sixty-one patients experienced rectal bleeding. The high-dose radiotherapy was curative for the majority of the patients in all three prognostic risk groups, with 89 percent of the favorable, 78 percent of the intermediate, and 67 percent of the unfavorable group alive after an average period of eight years. Of those men who were potent prior to IMRT, erectile dysfunction developed in 49 percent.”

Now this report does not seem to include statistics for the last 6 years, when I expect techniques and statistics have improved considerably, but I am concerned about how these numbers match up with my profile (which I assume is the “favorable risk group” referred to here), especially the 89% cure rate (vs. the 95% we discussed) and the 50-50 erectile dysfunction rate (vs. the 85-15 rate we discussed).

3. I want to make sure I understand a point we went over at length and that for some reason I found very hard to grasp—about what happens if the cancer recurs down the line.  Here is my understanding at this point:

a.        With either radiation treatment, if the cancer recurs the prostate will have to be removed, and the only method (with existing medical technology) is the old-fashioned radical prostatectomy that has a high risk for impotence and incontinence.  In addition, there is a high likelihood that the cancer will have spread elsewhere, especially the bones, and be much more serious and life-threatening.

b.       With Da Vinci, the prostate of course will already be out.  It is possible that the recurrent cancer will be in the immediate vicinity, but as with radiation, the likelihood is high that the cancer will now be present elsewhere and be very serious.

c.        Therefore, regardless of the cure I now choose, recurrence will likely kill me in short order, and life quality (sexual potency and continence) at that point will be of low concern.

4. By looking at web information, I understand that the goal of IMRT is to give small radiation doses over a long time that add up to a large enough dose (the 81 Gy cited in the above article) to kill any cancer present both within and at the edges of the prostate.  I assume among other things that this is how IMRT compensates for the uncertainty of whether the Gleason rating is accurate (that is, whether the biopsy missed cancer internal to the prostate).  But how do we know that the 81Gy is sufficient in all cases?  Or is that a compromise number that works in enough cases to give the same cure rate as the other methods?
5. As I recall, it takes about 6 weeks of preparation before actually starting IMRT, which would get me started around late November/early December (depending on when the preparation period could start).  I am wondering if I might then be hitting a 2-day Thanksgiving holiday and 2-day Christmas and New Year’s holidays plus multi-day blizzard stoppages, and if so whether cumulatively such interruptions would be too long.  I guess my general question is, given that you want to hit a regular 5-day/week schedule (minus occasional 1-day holidays), what are the provisions for such extra interruptions (and I guess I should include illness in that list—yours or mine)?  At what point do interruptions give the cancer cells time to regenerate?  Do  you just lengthen the treatment, or does the efficacy of the treatment get compromised?
6. I am eager to get on with one of these cures and get this cancer out of my body.  But given the slow rate of its growth and the apparent rapid development of treatment methods, is there any compelling reason to consider delaying treatment (say 6-12 months) for some improved treatment method that is in the pipeline?

I am not aware of any head to head comparative information for IMRT radiation vs. robotic surgery.  This information (or the lack of a randomized trial of the two) is the basis for all the controversy surrounding surgery and radiation over the last 50 years. The best data still comes from a 1996 NCI consensus conference when an expert panel was evaluating surgery and radiation for early stage disease. The conclusion of the conference was that they could not reach a conclusion as to which one was better and as far as non-randomized trials could determine. They actually said it deserved more study. The problem is that the study never has and never will be done because the randomization is too drastic. 

In any event I will contact you at home since I am a terrible typist and it would take me all night to type a coherent reply to your very excellent questions.