Radiation Treatment For Prostate Cancer Webcast May 6, 2010 Debbie Kuban, M.D., F.A.C.R. Doug Messer Please remember the opinions expressed on Patient Power are not necessarily the views of M. D. Anderson Cancer Center, its medical staff or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. That s how you ll get care that s most appropriate for you. Doug s Story Radiation is one of the primary treatments for prostate cancer. In this Patient Power program M. D. Anderson radiation oncologist Dr. Deborah Kuban will discuss the various types of radiation and how they work. It's all next on Patient Power. Hello and welcome to Patient Power sponsored by M. D. Anderson Cancer Center. I'm Andrew Schorr. Well, we're especially focusing right now on prostate cancer, and we've produced another discussion I hope you'll listen to with Dr. John Davis who is a urologist and specialist in the surgical options for men who are seeking treatment for prostate cancer. But there's another way to go too and should be discussed among your treatment options, and that's radiation. In a minute we'll hear all about the various options when it comes to radiation for prostate cancer from a world renowned leader in the field, but first I want you to meet someone who has benefitted from radiation treatment for prostate cancer at M. D. Anderson, that is Doug Messer. Doug is in Austin, Texas. He's been with the university department of athletics for, what, 25 years or so, Doug? 27. 27 years. So he joins us from Austin. He's 68 years old, married, a child, a grandchild, looking forward to, what, in a couple years or maybe even next year, a very happy retirement, right, Doug? That's right, about a year. Okay. But going back five years ago you were told that you needed some heart valve replacement surgery, really maybe not such a surprise having had a childhood rheumatic condition. So you get worked up for that, and when they kind of check you from stem to stern what did they find with your prostate?
Well, it was identified at that time that I needed to also consider some treatment for my prostate, that I was looking very much like I was in a small amount of prostate cancer situation. Wow. That's a shocker. You go in for one procedure and you find out you have another serious health condition. It was, yes. Well, that heart institute you were at was across the street from the number one cancer center in the world, happens to be in Texas, M. D. Anderson, so that's where you went for a consultation. That's correct. So you were thinking radiation from the beginning. Why was that? Well, my cardiologist was one of the best in the world, too, and I was very, very blessed to be in a situation where Dr. James Willerson, who was my cardiologist, was very familiar with what they do at M. D. Anderson, and he was able to connect me with Dr. Kuban, and I was blessed to have the opportunity to work with one of the best cardiologists in the world and one of the best radiation oncologists in the world with Dr. Kuban. Right. So because with the heart valves and you'd be taking Coumadin, which is the blood thinner that's been around for 40 years or so, the idea was that radiation might be the better way to go than have a prostate removal surgery. That was correct. That was our view of it, and that was certainly Dr. Willerson's view of it. How has it worked out? So we're five years out. We said you're looking forward to retirement, and you live on a golf course, I know, and you like to play golf. How are you doing because men worry about any kind of treatment, prostate cancer, we all worry about it and worry about side effects. How are you doing? 2
Well, I've been blessed. I'm doing very well. I'm doing very well, I think, in both situations. My cardiologist is pleased with the results that I have had from the heart surgery, and I've been an active person all of my life and I continue to be active and find it successful to be able to be active and physical, and besides playing golf I enjoy routine workouts weekly. How many sit-ups do you do at a time, there, Doug? I'll do about a hundred at a time. Oh, my goodness. And how many push-ups? Oh, I don't do as many push-ups, but 50 or so. Well, that's got most of us beat, believe me. So how would you say your quality of life is now? It's very good. I think I have been blessed again in many ways, but my quality of life has been good. There are very, very few, hardly, if any, limitations on what I can do physically. I don't run and jog and sprint and do that kind of exercise anymore, but I do enjoy exercise as I was saying a moment ago. And you go to M. D. Anderson for a checkup how often now? Now I'm on a yearly schedule with Dr. Kuban. Okay. Well, let's meet her. So you've referred to really a world-renowned expert when it comes to radiation for prostate cancer and an expert in prostate cancer. She's the medical director of the multidisciplinary clinic for prostate cancer at M. D. Anderson. She's a professor of radiation oncology, so she's a radiation oncologist, and that is Dr. Deborah or Debbie Kuban. Welcome back to Patient Power. It must make you feel great to hear a happy story about Doug Messer and men like him. Yes, absolutely, Andrew, and it's great to be back on Patient Power. Mr. Messer, as he told you, he's doing fabulously, but that's pretty typical of most of our patients, I 3
have to tell you. I hate to pat ourselves on the back too much, but mostly our patients do well. After their prostate cancer radiation their cancer is no longer evident, and they go back to their normal life. And they just get to see you every once in a while. Absolutely. So shortly after their treatment we see them more frequently, but then as we get further and further out and if they're doing well then we can see them less and less frequently. Factors in Treatment Decisions Well, let's back up. So we mentioned in Doug's case that he would be taking a medicine to thin his blood because of the heart valves, and some people have preexisting conditions. Is that one of the things you evaluate when you all decide as a group your recommends whether, a, a man should have treatment and, b, would you recommend surgery or some form of radiation? Yes, absolutely. The existing medical conditions are something that we surely do need to take into account because obviously everyone has various issues. And Mr. Messer is a good example where he had a medical condition that was going to make surgery more risky and more difficult, and it was also going to put him at risk for things that could happen because of his heart condition. So in his case radiation was a pretty obvious option to be able to avoid all that, but some men without that particular condition or other conditions that may impact their cancer treatment, those men choose radiation anyway just because it is a good option for most men. Let's discuss that. So if I were diagnosed with prostate cancer just like any illness I'd often want to go to the doctor and say, okay, Doc, based on your years of experience tell me what to do. Unfortunately, when it comes to prostate cancer there hasn't always been a clear winner all the time. I'm sure in some cases there are, but for many of us you say, well, gee, should I have surgery, should I have radiation. So it sounds like at your multidisciplinary clinic you have a lot of smart people who put their heads together, who have nothing to gain whether you do this or that and everybody tries to make a sound recommendation, but in the end it's the patient's decision. Did I have that right? Yes, you're right on track there, Andrew. You know, prostate cancer is a bit unique in the malignancy realm because it is a cancer that does have multiple treatment options, and typically for the early-stage cancer patients they're not combined. So for instance for breast cancer you might do surgery and radiation and maybe a 4
drug. With prostate cancer in the early stages it's either/or, and there are many ors now. So there are several ways to do radiation. There are several ways now to do surgery. There are some other treatments coming online, and there really is a pretty large menu of options for men. And it's been pretty well reported that depending on your specialty there can be quite a lot of specialty bias. So, for instance, if you go to a urologist, who is a surgeon, he, probably rightly so, is pretty passionate about what he does, and so the surgeon may tell the patients, that's the thing for you. And similarly we're radiation oncologists and we believe in what we do so we would have a tendency, I think, to tell patients, yes, this is a good treatment for you. So several years ago we saw the need to try to take that bias out of the decisionmaking as much as possible so that men could be offered all the good treatment options, and we've also gone a step further and we've tried to take into account all the other factors other than the cancer and to try to direct men a bit more. So Mr. Messer actually came directly to me because his cardiologist happened to know M. D. Anderson very well and the people here, and so he was directly referred to me because he had already gone through that decision-making process. But we now have a clinic specifically for patients who haven't been through that process, and they would come in to what we call the multidisciplinary clinic, and in this clinic they would see both a urologist and a radiation oncologist, and if their cancer is more advanced then they would also need to see a medical oncologist. And all of us would see a patient at the same time in the same place. They would get all of our opinions. We could confer, and we would try to also give them a joint opinion to say, well, here are the things you could do and here are the things you probably should put at the top of your list. And sometimes there's a one best option, but in most cases that isn't true. And one of the things, and we discussed this on the program with Dr. Davis, is in some cases with I guess what you call low-risk prostate cancer because we've often heard many of us will die with it rather than from it, is that sometimes there's that approach of active surveillance. So first question would be do we need to treat now, do we recommend that. And then kind of a joint conference related to would surgery be an approach we'd recommend or radiation. And of course the patient is very much involved in that decision. Absolutely. I'm glad you made that point because when I typically say there are several treatment options included in that of course is the no treatment option. And we really do consider that very seriously for our patients. We have a protocol that has guidelines about who we think we can offer that no treatment option to, and that of course varies a bit depending on the patient's age and medical 5
conditions, etc., but that is something that we take into account. And I think we're going to see that no treatment option or surveillance option emphasized more and more as we go forward. Radiation Treatment Let's start our discussion of radiation approaches. So just an overview. What are the radiation approaches you have now? I know they're both external and internal. Just give us the overview and then we'll take a quick break and then we'll come back and get to it in more detail. Sure. So, as you say, the two main ones would be the external type and then the internal or the implant. For the external type we have x-ray treatment, and we also have now proton therapy, which many centers don't have, but of course we're very fortunate in our resources here. And then the implant can be done with several different isotopes or, the implanted material. All right. Well, we're going to learn all about these radiation options, and before we're over we're going to hear what Doug Messer says to men who are weighing these decisions, any guidance he has. We'll be back with more about radiation approaches for prostate cancer as we continue Patient Power right after this. Welcome back to Patient Power as we're discussing radiation treatments for prostate cancer, and I'm delighted that we have back on our program Dr. Debbie Kuban, who is the medical director for the multidisciplinary clinic for prostate cancer at M. D. Anderson, and she's professor of radiation oncology. Dr. Kuban, so as we learn about this we talked very briefly about, as you said, the external approach, and there were two. So there's the external beam radiation you used to call it and now it's sort of image-guided radiation, and then you also have proton. And then we'll talk about the internal or what I think is sometimes called brachytherapy. But first let's start on the outside. So where are we now with putting radiation where it needs to be and sparing healthy tissue? So we have very sophisticated techniques now. These are image-guided, as you said, because we use imaging to know exactly where the prostate is every day, and the radiation technique for the x-ray therapy is called intensity modulated radiation therapy. And the reason for that name is because we apply the intensity of the radiation so that there's more in the prostate and less in the surrounding tissues, and that's the whole goal, to get the radiation to the cancer and avoid the normal tissue so that we don't cause side effects and complications. We've gotten quite good at that actually, both for x-ray, which is IMRT, and also for proton therapy. 6
So radiation now is very well directed, and that means we can increase the dose and positively affect the cure rates and also cut down on the side effects and the complications. Now, if a man has surgery he goes into the hospital, has the surgery, the prostate is out and then there's recovery, of course. Radiation goes on over time. Tell us what would a typical schedule be? So for the external beam now we're doing it over about seven and a half weeks. So it would be a daily treatment, once a day, five days a week for about seven and a half weeks. It's all done as an outpatient, so there really isn't down time. The man would have to allow about an hour a day or so to come in, get the treatment, and then his day can be pretty much as usual. Occasionally there can be a little tiredness or some fairly minor urinary-type symptoms, but it's not one major event. So men during this can have a pretty normal lifestyle. Now, with proton therapy is the schedule the same? Yes, it is. We have kept that schedule exactly the same, so with proton therapy it's also a seven and a half week course, and again all outpatient and a pretty normal life during the treatment. Help us understand the difference. So if you all walk back into the room and you say to a patient, our recommendation in our multidisciplinary clinic is radiation would be something we might offer you. Then they say, okay, well, which way? How do you decide? Usually the main decision, Andrew, is between the external and the implant because those are the two that are going to be very different. So the implant is putting the little radioactive seeds in the prostate. It is a one-time procedure, and it is a more minor surgical procedure because we actually put the needles through tissue and there's no incision. But it does require a trip to the operating room and some anesthesia but typically no major recovery time. Most men walk out of here and go back to fairly normal activities after a few days or surely within the week unless they have very strenuous activity, and then we limit that for a short period of time. But those are the two treatments that are mainly different just because one is a series of several weeks, one is a one-time procedure. But for the x-ray treatment and the proton treatment, those are quite similar. The x-rays, though, are exactly that. It's x-ray, and protons are positively charged particles, and each one deposits energy differently, but the outcomes are quite 7
similar. The way the radiation is delivered is different. The x-rays have to be delivered from multiple directions in usually eight beams or so, and with the protons because the radiation is deposited differently we do it from just two directions. So there are pros and cons of the way that it's given, but in general the outcome is very similar. So you talked about the external approaches and the brachytherapy. Is the evidence just among these different radiation approaches that they're both equally effective? Where are we with that? Yes, the implant and the external beam are equally effective with the caveat that the implants typically are given to patients with early-stage cancer, whereas external radiation can be given to patients with more advanced cancer. But if you compare like cancers, then, yes, the outcomes are very similar among the radiation options and also as compared to surgery. And that's what creates this huge dilemma for men, I might add. A typical man with an early-stage cancer will have several treatments to choose from, and the outcome in terms of cancer cure for all of those options is similar, but how it's done, one major treatment versus several daily treatments, that can be different. And the side effect and complication profile of course can also be different, surgery versus radiation. How about this, though, Doctor, so, god forbid, prostate cancer rears its head again and people have checkups and if something showed up would having had surgery or having had radiation, either one, burn any bridge as far as treatment options should you need treatment again? Well, depending on which treatment you have to start with, that will dictate the treatment that you can have or the treatments that might be best if the cancer does come back. Now, the good news is that with early prostate cancer the chances of the cancer coming back are quite small if the first treatment is done well, and that's why we try to encourage patients to go to a center where they're going to get a good outcome because it's so important that you get good treatment the first time. You know, that's the best chance to get rid of this. But in the case that the cancer does come back then the secondary options would depend on what you had to start with. So of course if you had surgery to start with obviously you wouldn't have another surgical procedure. Then you could look at radiation if we thought that the tumor came back in the local area. If, on the other hand, you had radiation, either the external or the implant, surgery after that then 8
becomes a bit tricky. We do it here, but quite honestly men don't choose to have surgery after radiation too often just because if you do have surgery after radiation then the incontinence rate can actually be quite high. Side Effects Let's talk about side effects. So typically first time around man has radiation, one of the forms. What are the side effects that could occur and that may be initial but might subside? Well, during radiation most men do get some urinary irritation where they have to urinate a little more frequently, maybe get up at night more. Sometimes there can be a little burning or a stronger urge to urinate, but usually these things are mild or moderate at most, and we have some medications that will help. So most men go through treatment without too many problems, and then afterwards most men will go back to normal. After radiation if there are residual effects in the ensuing years, again those are usually pretty mild that usually a medication can treat. Occasionally some more worrisome things happen, and maybe the urinary stream isn't as good or occasionally there can be a little bit of bleeding, sometimes from the rectum, sometimes from the bladder, but again usually nothing too severe. And the severe complications where maybe the urine tube narrows a lot or there's more bleeding from the rectum, those things tend to happen infrequently, in only a few percent of patients, and usually it's in patients who have had some other complicating issues or some other conditions that would impact this. So in the usual normal healthy guy without too many problems, typically the scenario is that he goes back to normal or very nearly normal after the treatment. What about age? Does a man's age make a difference whether he can have radiation or which type? Usually it doesn't make a big difference in terms of the complications. We worry more about any preexisting conditions, for instance, if a man has some bowel problems to begin with or some urinary problems or some other conditions that may be associated with complications. It's not just age per se. I just finished treating an 85-year-old who needed treatment. But the other thing we consider is does the man really need treatment because obviously if they're late 70s or 80 years old or sometimes even younger if they have a very early cancer they may never need treatment in their lifetime because the cancer may progress very slowly. 9
But if they do have a more advanced cancer and it's aggressive and they do need treatment, a certain age does not necessarily prevent it. Treatments for older men is safe, it's just determining whether it's necessary. The Future of Treatment Dr. Kuban, you're in a very high-tech field, radiation oncology, and you have physicists and all kinds of sophisticated imaging. How do you feel about that as far as getting ever more sophisticated to put the cancer-killing radiation where it needs to be and let men go on with a high quality of life and hopefully a cancer cure? So currently we have better and better techniques to get the radiation where it needs to go, and that's to the cancer and not to the surrounding tissues. I know we've emphasized that already, but that's what radiation is all about. And so now what we would do is image, either through an ultrasound technique or maybe through some markers in the prostate. We would image each and every day before we deliver the radiation to make sure that we're on target, and that's so important. The point that's so important to get across to patients is that it's not just the technology, it's who is using the technology and that they must go to a center where the physicians and, as you say, the physicists, the dosimetrists and the therapists who treat the patient each day are very well versed and very experienced in this treatment as well. I couldn't agree with you more. I'm just going to put in my little Patient Power commercial here, and that is, right, I think Dr. Kuban said it. We talked about multidisciplinary clinic, so here are really consultants for you, urologists, radiation oncologists, maybe a medical oncologist, helping, putting their heads together, bringing their wisdom to you, make recommendations. In the end it's your decision. Standing behind them, and certainly as we talk about in radiation oncology is a whole at M. D. Anderson certainly an array of technology but a tremendous amount of experience among people who are very specialized. So you want that on your team. I do anyway. But I want to see what Doug says. Doug, you chose M. D. Anderson. When you look back on that experience, good choice? Absolutely. I was always a treated with the utmost respect. I was always welcomed. I was absolutely amazed at the level of professionalism that the people had and likewise amazed at how friendly they were. I was amazed that after a few treatments and a few days of going in for my treatments that it wasn't long before everyone called me by my name when I walked in. I was just absolutely pleased with that as well as amazed at that. 10
Yeah, I had the same experience as a leukemia patient there coming from very far away. Doug Messer, I want to wish you well. First of all, I hope that the Longhorns do great, although I know we may have listeners who have other teams, but you've had a lot of dedication to the university athletic program there, and I know they're very grateful and glad that you're healthy. And, man, hundred sit-ups each time. I don't think I could do that. I hope you get to do that for many, many years, Doug. You bet. Well, we're planning on it. Okay. Thanks. And, Dr. Debbie Kuban, thank you for being with us, and I really appreciate that M. D. Anderson is dedicated, just helping people make sound decisions. Do they need prostate cancer treatment now if it's been discovered and then help sort of give all their options out before them in an unbiased way. I think that's really important. You bet. That's what we do. And they are very, very good at what they do. Yes, they are. Again, I want to thank both of you for being with us. I want to mention to our listeners, also listen to the program with Dr. John Davis, urologist. You'll hear about surgical options there and more about this term "active surveillance," and he's describe exactly what that is. And again remind you that most of us, we have a chance of being diagnosed with prostate cancer, and our listeners, maybe you have, but there are a lot of options and there's a lot of expertise to help you. So once again, I like to say remember, knowledge can be the best medicine of all. I'm Andrew Schorr. Thanks for joining us. Please remember the opinions expressed on Patient Power are not necessarily the views of M. D. Anderson Cancer Center, its medical staff or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. That s how you ll get care that s most appropriate for you. 11