1. PROSTATE CANCER: RADIATION THERAPY APPROACHES ANDREW L. SALNER, MD FACR DIRECTOR HELEN & HARRY GRAY CANCER CENTER HARTFORD HOSPITAL, CT

2. ARS ? ?

3. Conventional external beam Conformal external beam High-dose conformal Brachytherapy Brachytherapy/external beam Any of the above with androgen deprivation or chemotherapy 3-D IMRT Proton Ultra-high-dose High dose rate Low dose rate CHOICES!!!

4. Prostate Conformal therapy Conventional therapy Constraints: Volume rectum Volume of bladder Hips Conformal radiation therapy

5. Why IMRT? Treated Volume Tumor Target Volume Intensity Modulation Treated Volume Critical structure Target Volume Collimator "Classical" Conformation Critical structure Answer: great for treating donuts and bananas

6. IMRT

7. Fontenot, MDACC, IJROBP 2009

8. Percent of Rectal wall receiving high doses of radiation Plans run on 23 patients with prostate cancer Tufts, NEMC

9. Tomotherapy

10. Contemporary prostate brachytherapy: Trans-perineal approach

11. HIGH DOSE RATE “TEMPORARY” BRACHYTHERAPY

12. Quality of life after treatment for early-stage prostate cancer Talcott et al 2003 Prospective study Brachytherapy n = 80 Median age 64 years Max score 100 Min score 0

13. Quality of life after treatment for early-stage prostate cancer Talcott et al 2003 Prospective study External beam radiation N = 182 Median age 69 years Max score 100 Min score 0

15. Radiation Therapy Approaches  Many options  Must be tailored to meet patient needs  Highly conformal resulting in: Better tumor control Better tumor control Fewer side effects Fewer side effects  Comparable to other therapies over 10-15 years

16. THANK YOU

17. Prostate Cancer Treatment: What’s Best for You Daniel P. Petrylak Professor of Medicine Columbia University Medical Center/NY Presbyterian Hospital

18. When does a patient see a medical oncologist Local disease: As “unbiased” opinion for local therapy High Risk Disease: Add hormone or chemotherapy to decrease risk of relapse Metastatic disease: Initiation of second line hormones, chemotherapy, radiation therapy

19. High-Risk CAP: The Options Surgery – Standard RP, wide/extended resection RP – Hormone therapy: NHT, AHT – ART – Chemotherapy: Neoadjuvant, adjuvant RT – EBRT with NHT and/or AHT – Dose escalation – EBRT with chemohormonal therapy – Other RT techniques HT alone New therapies NHT = neoadjuvant hormone therapy; AHT = adjuvant hormone therapy; ART = adjuvant radiotherapy. Payne, 2009.

20. Challenges for the Implementation of Multimodality Therapy High risk local therapy –Role of chemotherapy not defined –Investigational studies require long follow- up due to the natural history of disease –By selecting the highest risk patients, reduce the available patient pool Clinical trial accrual has been poor.