In September 2006, the Memorial Sloan Cancer Center published a peer-reviewed paper on IMRT outcomes. Along with that publication, the public relations office at MSKCC marketed their results with terms such as 'treatment of choice' and 'curative for the majority of patients'. These results in fact, demonstrate the best data-to-date on external beam radiation (using IMRT) for prostate cancer.

Yet, this data is being used by physicians as proof of principle that IMRT is the 'best' approach for treating prostate cancer. The establishment of 'urology' owned radiation facilities coupled with a high reimbursement for IMRT has encouraged urologists to suggest IMRT for most, if not all their patients. This is both a local and national trend.

After reviewing the MSK article, and not the press release, I was impressed that the biochemical outcomes from one of the best cancer facilities were less than our 12-year experience using brachytherapy (seeds). When I went back to the database and looked at the 8-year outcomes (to match the MSK publication), there was in fact a 6% improvement in outcome for both the low and intermediate risk patients. Plus, when I went back to our potency paper, the ability to maintain potency for men undergoing a seed implant was considerably better than the 49% reported for IMRT.

Another competitive trend in prostate management is the use of stereotatic radiation treatments. The concept is to use highly focused radiation beams in 5 fractions, instead of 45 treatments. While the 'concept' of such treatment is based on radiobiologic principles, the technology is new and there is only preliminary data. Yet, this procedure is advertised as 'the next generation', 'less risk', 'surpasses conventional and IMRT radiation' Well then, show me the data.

So, finally, there is some data. The Virginia Mason Hospital in Seattle published 4-year outcomes in only 40 men using stereotatic radiation (The MSKCC IMRT paper had 561 patients and out 12-year seed paper had >1200 patients). The purpose of their study was to look at toxicity, which is not any better than IMRT or seed therapy. But this study is the first study presenting any outcomes using this technique and I was surprised that the 4-year outcome using the accepted ASTRO definition was only 70%. Without going into detail, the shorter the follow-up compared with 8 years with the MSK paper and 12-years with the seed paper is generally associated with inflated outcomes. Yet these results are quite poor (22% less than seeds and 16% less than IMRT). So, the authors of that study conclude that they must perform 'dose escalation' in the future. What does that mean? That means they need to go to higher radiation doses just to match the outcomes of other modalities. In other words, they need to re-test toxicity at those high does as well as outcomes.

So in that context, the financial arrangements associated with IMRT and the misleading advertising using stereotatic radiation therapy, we are embarking on our marketing. The intent is clear: to create doubt. Because doubt will lead to knowledge and education. If nothing else, if our marketing only causes one to explore and better understand their options of therapy, then it's a success.

Seed therapy is not for everyone. But everyone needs to understand the nuances of treating prostate cancer. Please do not hesitate to contact us with any questions.

Louis Potters, MD Medical Director