CLINICAL INVESTIGATION Prostate

PROSTATE BRACHYTHERAPY IN MEN $75 YEARS OF AGE

GREGORY S. MERRICK, M.D.,* KENT E. WALLNER, M.D.,y ROBERT W. GALBREATH, PH.D.,*z

WAYNE M. BUTLER, PH.D.,* SARAH G. BRAMMER, B.S.,* ZACHARIAH A. ALLEN, M.S.,*

AND EDWARD ADAMOVICH, M.D.x

*Schiffler Cancer Center and Wheeling Jesuit University, Wheeling, WV; yPuget Sound Healthcare Corporation, Group HealthCooperative, University of Washington, Seattle, WA; zOhio University Eastern, St. Clairsville, OH; and xDepartment of Pathology,

Wheeling Hospital, Wheeling, WV

Purpose: To evaluate cause-specific survival (CSS), biochemical progression-free survival (bPFS), and overall sur-vival (OS) in prostate cancer patients aged $75 years undergoing brachytherapy with or without supplementaltherapies.Methods and Materials: Between April 1995 and August 2004, 145 consecutive patients aged $75 years underwentpermanent prostate brachytherapy. Median follow-up was 5.8 years. Biochemical progression-free survival wasdefined by a prostate-specific antigen level #0.40 ng/mL after nadir. Patients with metastatic prostate cancer orhormone-refractory disease without obvious metastases who died of any cause were classified as dead of prostatecancer. All other deaths were attributed to the immediate cause of death. Multiple clinical, treatment, and dosimet-ric parameters were evaluated for impact on survival.Results: Nine-year CSS, bPFS, and OS rates for the entire cohort were 99.3%, 97.1%, and 64.5%, respectively.None of the evaluated parameters predicted for CSS, whereas bPFS was most closely predicted by percentage pos-itive biopsies. Overall survival and non-cancer deaths were best predicted by tobacco status. Thirty-seven patientshave died, with 83.8% of the deaths due to cardiovascular disease (22 patients) or second malignancies (9 patients).To date, only 1 patient (0.7%) has died of metastatic prostate cancer.Conclusions: After brachytherapy, high rates of CSS and bPFS are noted in elderly prostate cancer patients.Overall, approximately 65% of patients are alive at 9 years, with survival most closely related to tobacco status.We believe our results support an aggressive locoregional approach in appropriately selected elderlypatients. � 2008 Elsevier Inc.

Prostate cancer, Brachytherapy, Elderly, Survival.

Int. J. Radiation Oncology Biol. Phys., Vol. 72, No. 2, pp. 415–420, 2008Copyright � 2008 Elsevier Inc.

Printed in the USA. All rights reserved0360-3016/08/$–see front matter

doi:10.1016/j.ijrobp.2008.01.017

INTRODUCTION

Because of the long natural history of prostate cancer, the de-

finitive treatment of clinically localized disease is controver-

sial, particularly in elderly men with presumed multiple

concomitant medical morbidities. Even in younger patients,

cardiovascular disease and second malignancies far outweigh

prostate cancer as competing causes of death (1, 2). Despite

these findings, prostate cancer remains the third and second

leading cause of cancer death in men aged 60–79 years and

$80 years, respectively (3). Although active surveillance re-

sults in high progression-free survival (PFS) and overall sur-

vival (OS) rates in men with low- and intermediate-grade

disease (4), elderly patients often present with higher-grade

and/or higher-stage disease and in general are treated less ag-

gressively than younger patients (5, 6).

Using the Surveillance, Epidemiology and End Results

Medicare data, Wong et al. (6) demonstrated a survival

Reprint requests to: Gregory S. Merrick, M.D., Schiffler CancerCenter, Wheeling Hospital, 1 Medical Park, Wheeling, WV26003-6300. Tel: (304) 243-3490; Fax: (304) 243-5047; E-mail:gmerrick@urologicresearchinstitute.org

benefit favoring local treatment in multiple patient cohorts,

including those aged 75–80 years at diagnosis. Men under-

going treatment within 6 months of diagnosis were 30%

less likely to die of prostate cancer during the subsequent

12 years of follow-up than those who did not receive active

treatment within that interval (6). Importantly, the analysis

was limited to patients with clinically organ-confined (Stage

#T2c) and well- or moderately differentiated cancer, with

the exclusion of poorly differentiated malignancies. Other

studies have also demonstrated the value of aggressive

treatment in elderly patients. Equivalent cause-specific sur-

vival (CSS) and/or biochemical PFS (bPFS) has been re-

ported in older vs. younger patients without increases in

acute or long-term morbidity (7–9). In contrast, Sung

et al. (10) reported that patients aged $80 years were

less likely to respond to treatment and usually died of un-

related causes, whereas Johnstone et al. (11) reported a trend

Conflict of interest: none.Received Oct 31, 2007, and in revised form Dec 27, 2007.

Accepted for publication Jan 3, 2008.

415

for greater biochemical failure with increasing age (p =

0.073) (11).

Androgen deprivation therapy (ADT) may adversely

impact overall survival in elderly patients (2, 3, 12–16).

In a Medicare population, Keating et al. (12) reported

that luteinizing hormone-releasing hormone (LHRH) ago-

nists increased the incidence of diabetes, coronary artery

disease, myocardial infarction, and sudden death. Saigal

et al. (15) reported that ADT resulted in a 20% higher

risk of serious cardiovascular morbidity compared with

men who did not receive ADT (15). Consistent with these

findings, D’Amico et al. (16) reported that ADT was asso-

ciated with an earlier onset of fatal myocardial infarctions

in men aged >65 years who were treated with 6 months

of ADT compared with men who did not receive such

therapy. In a younger population of patients undergoing

brachytherapy, including those with high-risk disease,

Merrick et al. (1, 2) reported that ADT did not improve

cause-specific or overall survival, despite an increase in

bPFS in high-risk patients.

Because of controversies regarding the optimal manage-

ment of elderly patients with prostate cancer, we evaluated

CSS, bPFS, and OS in patients aged $75 years undergoing

permanent prostate brachytherapy with or without

supplemental therapies.

METHODS AND MATERIALS

Between April 1995 and August 2004, 145 consecutive patients

aged $75 years underwent permanent prostate brachytherapy by

a single brachytherapist (G.S.M.). All patients underwent brachy-

therapy more than 3 years before analysis, and no patient was lost

to follow-up. Before the formulation of a treatment plan, all biopsy

slides were reviewed by a single pathologist (E.A.). Preplanning

technique, intraoperative approach, and dosimetric evaluation

have been described in detail elsewhere (17, 18). Patients were clin-

ically staged by medical history and physical examination, including

digital rectal examination and serum prostate-specific antigen (PSA)

determinations. Bone scans and computed tomography (CT) of the

abdomen/pelvis were obtained for patients with higher- but not

lower-risk disease. Since 1999, prostatic acid phosphatase level

was obtained for all patients. No patient underwent seminal vesicle

biopsy or pathologic lymph node staging. Table 1 summarizes the

clinical, treatment, and dosimetric parameters of the patient popula-

tion stratified by ADT. Of the 145 patients, 32 presented with low-

risk disease (PSA #10 ng/mL, Gleason score #6, and clinical stage

#T2a), 80 presented with intermediate-risk disease (one adverse

factor: PSA 10.1–19.9 ng/mL or Gleason score 7 or clinical stage

T2b), and 33 presented with high-risk disease (PSA $20 ng/mL

or Gleason score $8 or clinical stage $T2c, or two to three of the

intermediate adverse features).

Of the 145 patients, 76 were hormone naı̈ve, 46 received short-

course ADT (#6 months), and 23 received extended-course ADT

(>6 months). Androgen deprivation therapy was initiated 3 months

before implantation and consisted of an LHRH agonist and antian-

drogen. In short-course ADT the mean and median duration of ADT

was 4.2 and 4.0 months, respectively, whereas in the extended-

course ADT regimen the mean and median duration of ADT was

13.1 and 12 months. For all patients, the range of ADT duration

was 3–36 months.

416 I. J. Radiation Oncology d Biology d Physics

Of the 145 patients, 80 (55.2%) received supplemental radiother-

apy (XRT). In general, patients received 45 Gy in 1.8-Gy fractions

using 15–18-MV photons delivered with a conformal technique us-

ing four fields (opposed lateral and anteroposterior/posteroanterior)

with custom treatment devices to spare as much normal tissue as

possible. For patients with a <10% risk of pelvic lymph node in-

volvement, the target volume consisted of the prostate gland and

seminal vesicles. For patients with a >10% incidence of pelvic

lymph node involvement, the pelvic lymph nodes were also

included in the target volume. In all cases, supplemental XRT was

delivered before brachytherapy.

The brachytherapy target volume consisted of the prostate gland

with periprostatic treatment margins including the proximal 1.0 cm

of the seminal vesicles (17, 18). The minimum peripheral dose was

prescribed to the target area with margin. Of the 145 patients, 119

(82.1%) were implanted with 103Pd and 26 (17.9%) with 125I. Stan-

dard implant doses were used for monotherapy and boosts regimens.

At implantation, the prostate gland, periprostatic region, and base of

the seminal vesicles were implanted (17, 18).

Patients were monitored by physical examination, including dig-

ital rectal examination and serum PSA determinations, at 3–6-month

intervals. The endpoint of the analysis was CSS, bPFS (definition:

PSA #0.40 ng/mL after nadir), and OS (2, 3). No patient underwent

postimplant biopsy. Multiple clinical, treatment, and dosimetric

parameters were evaluated for impact on CSS, bPFS, and OS.

Cause of death was determined for each deceased patient. Patients

with metastatic prostate cancer or hormone-refractory disease with-

out obvious metastases who died of any cause were classified as

dead of prostate cancer. All other deaths were attributed to the

immediate cause of death.

Clinical, treatment, and dosimetric parameters were compared

across the three ADT treatment groups. Continuous and categoric

data were compared by one-way analysis of variance (ANOVA)

and c2 test, respectively. A Tukey post hoc test was conducted

with the continuous data when results from ANOVA were found

to have a statistical level of significance. The equality of the survival

distributions (CSS, bPFS, and OS) was determined with a Kaplan-

Meier curve and its associated log–rank test. Nine-year survival per-

centages were displayed for each Kaplan-Meier survival curve. A

Cox regression was used to determine the univariate predictors of

failure. As a means of identifying multiple predictors, variables

with a p value #0.10 were included in a multivariate model of

a Cox regression. The Center for Disease Control and Prevention’s

web-based interactive database (WISQARS) was used to determine

the rate of cardiac deaths for men aged 75–81 years. For all tests,

a p value of #0.05 was considered significant. Statistical analysis

was performed with SPSS 15.0 software (SPSS, Chicago, IL).

RESULTS

Table 1 summarizes the clinical, treatment, and dosimetric

parameters stratified by ADT status. The mean (�SD) and

median age at the time of implant was 76.4 � 1.5 years

and 76.0 years, respectively, with overall mean and median

follow-up of 6.0� 2.4 years and 5.8 years. Patients receiving

>6 months of ADT presented with a statistically higher PSA

level (p < 0.001), Gleason score (p < 0.001), greater percent-

age positive biopsies (p = 0.039), and smaller prostate vol-

umes (p = 0.012). There were no additional statistical

differences between the three cohorts, including age at im-

plant, follow-up, body mass index (BMI), Day-0 postimplant

Volume 72, Number 2, 2008

Table 1. Clinical, treatment, and dosimetric parameters for the 145 patients aged $75 y at implant

Parameter Hormone naı̈ve (n = 76) ADT #6 mo (n = 46) ADT >6 mo (n = 23) p Total (n = 145)

Age at implant (y) 76.0 (76.5 � 1.6) 76.0 (76.1 � 1.1) 76.0 (76.7 � 1.7) 0.274 76.0 (76.4 � 1.5)Follow-up (y) 5.6 (6.2 � 2.6) 6.0 (5.9 � 2.2) 5.2 (5.5 � 2.2) 0.490 5.8 (6.0 � 2.4)PSA (ng/mL) 7.2 (8.0 � 3.1) 7.3 (8.1 � 4.1) 11.4 (13.7 � 7.4) <0.001*,y 7.9 (8.9 � 4.8)Gleason score 7.0 (6.8 � 0.8) 7.0 (6.7 � 0.8) 8.0 (7.7 � 1.1) <0.001*,y 7.0 (6.9 � 0.9)Percentage positive biopsies 33.3 (37.0 � 22.8) 33.3 (37.2 � 24.3) 46.2 (51.8 � 29.3) 0.039 33.3 (39.2 � 24.7)BMI (kg/m2) 26.3 (26.5 � 4.1) 26.4 (27.1 � 3.4) 25.9 (27.0 � 3.3) 0.684 26.3 (26.8 � 3.7)Prostate volume (cm3) 34.4 (34.6 � 8.4) 34.5 (37.3 � 10.7) 28.2 (30.0 � 11.1) 0.012y 33.9 (34.7 � 9.8)Planning volume (cm3) 64.0 (62.7 � 12.0) 66.0 (67.9 � 13.7) 54.2 (56.9 � 15.5) 0.004y 54.2 (56.9 � 15.5)V100 97.4 (95.7 � 4.7) 98.2 (96.7 � 4.2) 97.5 (96.4 � 4.0) 0.450 97.7 (96.1 � 4.5)V150 65.5 (64.3 � 14.9) 69.1 (68.5 � 10.7) 73.1 (69.8 � 10.7) 0.114 68.0 (66.5 � 13.4)V200 33.4 (34.7 � 13.1) 36.1 (37.2 � 10.1) 38.9 (40.5 � 12.1) 0.124 36.2 (36.5 � 12.2)D90 115.9 (115.7 � 14.5) 120.8 (119.5 � 12.1) 117.3 (118.4 � 14.3) 0.322 118.2 (117.3 � 13.8)Most recent PSA level (ng/mL) <0.04 (0.04 � 0.11) <0.04 (<0.04 � 0.03) <0.04 (0.04 � 0.09) 0.219 <0.04 (<0.04 � 0.09)Clinical stage 0.177

T1b–T2b 70 (92.1) 44 (95.7) 19 (82.3) 133 (91.7)T2c–T3b 6 (7.9) 2 (4.3) 4 (17.4) 12 (8.3)

Isotope 0.397103Pd 60 (78.9) 38 (82.6) 21 (91.3) 119 (82.1)125I 16 (21.1) 8 (17.4) 2 (8.7) 26 (17.9)

XRT 0.791Yes 42 (55.3) 24 (52.2) 14 (60.9) 80 (55.2)No 34 (44.7) 22 (47.8) 9 (39.1) 65 (44.8)

Hypertension 0.512Yes 39 (51.3) 28 (60.9) 14 (60.9) 81 (55.9)No 37 (48.7) 18 (39.1) 9 (39.1) 64 (44.1)

Diabetes 0.353Yes 9 (11.8) 5 (10.9) 5 (22.7) 19 (13.2)No 67 (88.2) 41 (89.1) 17 (77.3) 125 (86.8)

Tobacco 0.935Never 29 (38.2) 18 (39.1) 11 (47.8) 58 (40.0)Former 43 (56.6) 25 (54.3) 11 (47.8) 79 (54.5)Current 4 (5.3) 3 (6.5) 1 (4.3) 8 (5.5)

Risk group <0.001Low 20 (26.3) 11 (23.9) 1 (4.3) 32 (22.1)Intermediate 45 (59.2) 28 (60.9) 7 (30.4) 80 (55.2)High 11 (14.5) 7 (15.2) 15 (65.2) 33 (22.8)

Perineural invasion 0.720Yes 21 (27.6) 13 (28.3) 8 (36.4) 42 (29.2)No 55 (72.3) 33 (71.7) 14 (63.6) 102 (70.8)

Abbreviations: ADT = androgen deprivation therapy; PSA = prostate-specific antigen; BMI = body mass index; XRT = radiotherapy.Values are median (mean � SD) or n (%).* ADT >6 mo significantly different from hormone naı̈ve.y ADT #6 mo significantly different from ADT >6 mo.

Brachytherapy in men $ 75 d G. S. MERRICK et al. 417

dosimetry, clinical stage, isotope, the use of supplemental

XRT, or concomitant medical morbidities to include hyper-

tension, diabetes, and tobacco use. For biochemically con-

trolled patients, the median posttreatment PSA level was

<0.04 ng/mL for all three cohorts.

Figure 1 illustrates the Kaplan-Meier curves for CSS,

bPFS, and OS for the entire study population. At 9 years,

CSS, bPFS, and OS rates were 99.3%, 97.1%, and 64.5%, re-

spectively. When arbitrarily stratified by grouping patients

into categories of age 75–77 years and 78–81 years, no statis-

tically significant differences were noted in CSS (98.0% vs.

100%, p = 0.665), bPFS (97.3% vs 96.3%, p = 0.769), or

OS (63.1% vs. 65.5%, p = 0.611). When the entire study pop-

ulation was evaluated according to ADT status, no statistical

differences in CSS (p = 0.662) or bPFS (p = 0.396) were

discerned. In addition, OS was not influenced by ADT status

(65.7% in hormone-naı̈ve and 64.8% in ADT-treated

patients, p = 0.266) (Fig. 2).

Tobacco status significantly influenced OS (Fig. 3). The

9-year OS rate in never smokers, former smokers, and current

smokers was 76.6%, 58.9%, and 46.9%, respectively (p =

0.035). Neither hypertension nor BMI influenced OS.

Patients with and without hypertension had a 9-year overall

survival rate of 61.0% and 68.6%, respectively (p = 0.229).

When BMI was stratified into categories of <18.5, 18.5–

24.9, 25.0–29.90, and $30 kg/m2, BMI did not predict

overall survival (p = 0.706).

In univariate and multivariate analysis, none of the evalu-

ated parameters predicted for CSS, whereas bPFS was best

predicted by percentage positive biopsies. In contrast, bPFS

was not influenced by the use of supplemental XRT and/or

ADT. In terms of OS, ADT duration and tobacco use were

418 I. J. Radiation Oncology d Biology d Physics Volume 72, Number 2, 2008

predictive in univariate analysis; however, in multivariate

analysis only tobacco maintained statistical significance.

The greatest difference in OS was discerned between never

vs. current smokers (p = 0.013, relative risk 4.509).

To date, 37 patients (25.5% of the study population) have

died (Table 2). Of the 37 deaths, 31 (83.8%) were attributed

to cardiovascular disease (myocardial infarction 15, cerebro-

vascular accident/neurologic 6, and aneurysm 1) and second

cancers (lung cancer 2, gastrointestinal malignancy 5, leuke-

mia 1, and bladder cancer 1). Of the patients who died of car-

diovascular etiologies, hypertension and tobacco use best

predicted for such deaths. The mean time to cardiac death

was 3.5 years and was not statistically different when strati-

Years Since Implant

121086420

Su

rvival (%

)

80

60

40

20

04

100

Cause-Specific Survival, 99.3%

Overall Survival, 64.5%

Progression-Free Survival, 97.1%

n =145 138 116 68 31 9 1

Fig. 1. Kaplan-Meier curves for cause-specific, biochemical pro-gression-free, and overall survival. (Each curve represents thesame 145 patients and percentages represent 9-year survival).

Years Since Implant

14121086420

Overall S

urvival (%

)

100

80

60

0

Hormones, 64.8%

p = 0.266

Hormone Naïve, 65.7%40

20

Fig. 2. Kaplan-Meier curves for overall survival, stratified by an-drogen deprivation therapy status (percentages represent 9-year sur-vival rates).

fied by ADT status and duration (p = 0.479). Only 1 patient

has died of metastatic prostate cancer (6.5 years after brachy-

therapy). The mean and median OS for the 108 living patients

is 6.5 � 2.2 years and 6.3 years, respectively.

DISCUSSION

Because of the long natural history of prostate cancer, the

definitive treatment of clinically localized disease (especially

in elderly men) remains controversial, in part owing to a pau-

city of prospective randomized clinical trials. Even in youn-

ger patients, cardiovascular disease and second malignancies

far outweigh prostate cancer as competing causes of death

(1, 2). However, a recent prospective randomized trial com-

paring radical prostatectomy with observation reported im-

provements in disease-free survival and OS in men aged

Years Since Implant

14121086420

Overall S

urvival (%

)

100

80

60

40

20

0

Current smoker, 46.9%

p = 0.035

Former smoker, 58.9%

Never smoked, 76.6%

Fig. 3. Kaplan-Meier overall survival, stratified by smoking status(percentages represent 9-year survival rates).

Table 2. Cause of death, stratified by ADT

Cause of deathNo ADT(n = 76)

ADT #6 mo(n = 46)

ADT >6 mo(n = 23)

Total(n = 145)

Prostate cancer 1 (1.3) 0 (0) 0 (0) 1 (0.7)Myocardial

infarction7 (9.2) 4 (8.7) 4 (17.4) 15 (10.3)

Cerebrovascularaccident/neurologic

4 (5.3) 2 (4.3) 0 (0) 6 (4.1)

Aneurysm 0 (0) 0 (0) 1 (4.3) 1 (0.7)Lung cancer 1 (1.3) 0 (0) 1 (4.3) 2 (1.4)Gastrointestinal

malignancy1 (1.3) 3 (6.5) 1 (4.3) 5 (3.4)

Leukemia 0 (0) 1 (2.2) 0 (0) 1 (0.7)Bladder cancer 0 (0) 0 (0) 1 (4.3) 1 (0.7)Pulmonary 1 (1.3) 1 (2.2) 1 (4.3) 3 (2.0)Sepsis 1 (1.3) 0 (0) 0 (0) 1 (0.7)Gastrointestinal

bleed1 (1.3) 0 (0) 0 (0) 1 (0.7)

Total deaths 17 (22.4) 11 (23.9) 9 (39.1) 37 (25.5)

Abbreviation as in Table 1.Values are n (%).

Brachytherapy in men $ 75 d G. S. MERRICK et al. 419

<65 years treated with radical prostatectomy (5). To date

there are no prospective randomized trials comparing either

brachytherapy or external beam radiation therapy with

observation.

Wong et al. (6) examined a large population-based sample

to evaluate long-term outcomes in men diagnosed with pros-

tate cancer in the PSA era. The study evaluated 44,630 men

diagnosed with prostate cancer between 1991 and 1999 and

who were aged 65–80 years with organ-confined (Stage

#T2c) and well- or moderately differentiated disease. Pa-

tients who received active treatment within the first 6 months

of diagnosis had a 10-year survival rate of 66% vs. 51% for

treatment vs. observation (6). These treatment-derived

survival rates are comparable to our 9-year overall survival

rates in a substantially older patient population that also in-

cluded high-risk disease (22.8% of the entire study popula-

tion) (Fig. 1, Table 1). These results are consistent with

a report from Blood and Pickles (19), who reported a median

survival of approximately 10 years in men as old as 80 years

at the start of external beam radiotherapy. Geinitz et al. (7)

evaluated 80 patients aged $75 years receiving external

beam radiotherapy, concluding that older patients had better

biochemical survival than younger patients at 4 years (76%

vs. 61%, p = 0.042). Similarly, Alibhai et al. (8) reported

improved life expectancy after external beam radiotherapy

for moderately or poorly differentiated prostate cancer in

patients who were aged $75 years.

Huguenin et al. (9) evaluated 59 patients aged $75 years

receiving conventional external beam radiotherapy, with the

conclusion that there was no increase in late toxicity or di-

minished quality of life. This is comparable to our previous

studies demonstrating that brachytherapy-related urinary

and rectal function were not related to patient age. However,

an inverse relationship was noted between patient age and

erectile dysfunction (20).

In a previous study, Merrick et al. (1, 2) reported that ADT

did not impact CSS or OS for any risk group; however,

improved bPFS was demonstrated in high-risk patients.

Consistent with the present study, cardiovascular disease

and second malignancies far outweighed prostate cancer as

competing causes of death. In contrast, Beyer et al. (13) re-

ported that short-course ADT resulted in a deleterious effect

on 10-year survival. At 10 years, 44% of hormone-naı̈ve but

only 20% of hormonally manipulated patients were alive. In

our study, ADT did not substantially influence 9-year OS in

comparably aged patients. Our 9-year survival rates are

substantially higher than those reported by Beyer et al.(Fig. 1) (1, 2, 13). To date, only 1 patient has died of

metastatic prostate cancer.

Our 9-year rates of CSS and bPFS of 99.3% and 97.1%,

respectively, compare favorably to results from our previ-

ously published studies, which had a preponderance of youn-

ger patients (1, 2). In the present study, tobacco status was the

strongest predictor of long-term survival. A 9-year OS rate of

76.6% was noted in elderly patients who never smoked. It

seems that nonsmokers are most likely to benefit from

aggressive therapeutic intervention. Even in current and

former smokers, 46.9% and 58.9%, respectively, are alive

at 9 years (Fig. 3). In this elderly population hypertension,

diabetes, and BMI did not predict for overall 9-year CSS or

OSS.

Shortcomings of the present study include its retrospective

nature and the fact that ADT use and duration were not

controlled for, ADT was administered for multiple reasons

(including cytoreduction or adverse pathologic features),

and the severity/duration of comorbid conditions (including

hypertension, diabetes, and obesity) were not documented.

CONCLUSIONS

After brachytherapy, high rates of CSS and bPFS are noted

in elderly prostate cancer patients. Overall, approximately

65% of patients are alive at 9 years, with survival most

closely related to tobacco status. We believe our results

support an aggressive locoregional approach in appropriately

selected elderly patients.

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