Hi Bob...That's an interesting article.  It reports that Dr. Lee is
preparing to publish his 6-year results; it will be interesting to see
how his numbers come out.  Drs. Lee and Onik are clearly two artists
in the area of cryo.  Their results will be among the best.  Along
these lines the article you referenced states, "Dr. Gary Onik reported
negative biopsies in 82.6% of his patients at 3 months following
cryosurgery. Dr. Fred Lee found no cancer in 92% of his patients at 3
months."  This means that the PCa was not effectively removed from 17%
of Dr. Onik's patients and 8% of Dr. Lee's.  That's not a good
starting point.  Compare those 3 month numbers to Dr. Walsh's numbers
at 10 years, where only about 5-8% of his low risk patients have
biochemically failed!

Tha abstract that I posted previously on the 3rd Generation Cryo
technique comparison, a multi-institutional study, showed that 22% of
the low risk men had already failed at 12 months.  On top of that 8%
of the men remained on pads and 87% of the previously potent men were
now impotent.  By the way, one of the authors of this paper was Dr.
Jeff Cohen who was listed along with Dr. Onik as the originators of
the modern cryo procedure.  Again, I just don't see the good news in
these numbers in terms of cancer survival and morbidity...Best wishes
and good health, Ron

My experience with cryosurgery is almost uniformly negative.

First, a few comments on the above article:

(1) it is somewhat outdated; Medicare will cover the cost,
(2) incidence of impotence is well in excess of 80%, and
(3) IMO, success, defined as "Destroy all the cancer in the prostate and
 achieve a non-detected PSA," (Dr. Lee), is an elusive goal at best.

My experience, which is of course anecdotal, is this:

9/30: biopsy, ten probes plus one through a palpable nodule discloses,
on the right, "adenocarcinoma Gleason score 4+5 involving 6 of 7
      cores...perineural invasion..." On the left *benign prostate
tissue with acute and chronic inflammation*." This last turned out to be
important.

11/03: cryosurgery. According to the summary, it was a "full prostate
freeze."

7/04: due to rising PSA scores, another biopsy was performed, utilizing
twelve probes. Result: on the *left* base, "Adenocarcinoma...Gleason
score 4+4=8." The uro said he was surprised.

10/04: on the uro's referral (he apparently had no confidence in redoing
the cryo, notwithstanding that the possibiity of a repeat is one of the
sales points), completed IMRT treatment of 76Gy, plus some to seminal
vesicles and lymph nodes, including adjuvant ADT (Lupron).

As of yesterday, November 29, the rad onc says he thinks I'm cured,
although an indefinite course of ADT is to continue due to the
aggressive Gleason 8 nature of the tumor, which MAY have shed some cells.

Now, here's the kicker: I had the cores from the July '04 biopsy
restudied by Bostwick. Report confirms Gleason 8 adenocarcinoma at left
base. Regarding the right base, which is where the Gleason 9 tumor
supposedly frozen in 11/03 was situated, "atypical small acinar
(granulous mass) proliferation highly suspicious for but not diagnostic
of malignancy."

Swell. I'm presently unsure just what the 11/03 cryo really achieved.
Did it transform the Gleason 9 tumor to the above suspicious mass? Dunno.

Bottom line, if I hadn't been stampeded into the cryo, I would not have
done it. So far as I'm concerned, the result is poor, and the SE's,
which I accepted in expectation that the cryo would succeed, are
certainly not worth it. "Outrage" hardly touches the surface.

OK, maybe I had a fumbler for a uro. I don't know.

Regards,

Steve J
__
"It is mistaken to attribute to malice things that can be satisfactorily
explained by incompetence."
-- Napoleon Bonaparte

In my earlier post in this thread, I mentioned an article (The Journal
of Urology 2003; 170(4):1126-1130, Treatment of Organ Confined
Prostate Cancer with Third Generation Cryosurgery: Preliminary
Multicenter Experience) that, in my reading, didn't make a very
favorable case in support of using cryo to treat PCa.  While this
study sampled a lot of doctors and hospitals, it did not include any
of the cryo artists I am aware of like Duke bahn, Fred Lee or Gary
Onik.

So to be "fair and balanced" I did a PubMed search on Duke Bahn.  I
found a number of publications, but thought the one I've included
below to be most relevant, and recent.  Since the study started in
'93, not all the men were traeted with the 3rd Generation cryo
technique.  Presumably the results, on average, would be even better
for men treated with the improvements contained in the 3rd Generation
equipment.  Also, I believe this targeted approach relates to partial,
rather than total, prostate freezing, e.g. the male lumpectomy.  I
thought the following points worth noting:
* The seven year projected results for low-risk men (61% using PSA>0.5
as the definition of failure) are far behind RCOG's or Walsh's 10-year
projected results for SI + EBRT and surgery respectively (both >90%
using a more stringent PSA>0.2 as a defintion of failure).
* The results for high-risk men are encouraging.  RT is generally
thought to be more effective than surgery as risk group increases.
RCOG reports a bNED of 61% (using the PSA>0.2 DOF) for high-risk men
at 10 years.
* Cryo's strength has always been that it is well tolerated (usually
an out-patient procedure) and easily repeatable.  Bahn finds that, of
those re-treated with cryo for recurrence or incomplete initial
removal, 68% are disease free after a mean follow-up of 63 months.
Not bad!
* It sounds like Bahn's morbidity data is much improved over that
reported in the multi-institutional study.
* Once again a large difference in success (30 points!) is noted
depending whether ASTRO or PSA cutpoints are used to determine
failure.  This takes me back to our earlier threads on the Cleveland
Clinic's paper earlier this year (International Journal of Radiation
Oncology*Biology*Physics, Volume 58, Issue 1 , 1 January 2004, Pages
25-33, Radical prostatectomy, external beam radiotherapy <72 Gy,
external beam radiotherapy 72 Gy, permanent seed implantation, or
combined seeds/external beam radiotherapy for stage T1–T2 prostate
cancer, Patrick A. Kupelian M.D., Louis Potters M.D., Deepak Khuntia
M.D., Jay P. Ciezki M.D., Chandana A. Reddy M.S., Alwyn M. Reuther
M.P.H., Thomas P. Carlson M.D., and Eric A. Klein M.D.) where they
compared various forms of RT (using ASTRO as the DOF) and RP (using
PSA>0.2 as the DOF) and concluded that the 7-year bNEDs were similar
for RT and RP, just because the numeric results happened to be the
same even though different definitions of failure had been applied.
In light of the now numerous studies that show large bNED differences
when ASTRO or PSA cutpoints are used, it's not clear to me how the
Cleveland Clinic conclusions made it into print. (I think I've
digressed)

Finally, let me note that there was another article I came across that
made a strong case for use of cryo to treat recurrence after RT
(sorry, I didn't note the reference)...Best wishes and good health,
Ron

Urology. 2002 Aug;60(2 Suppl 1):3-11. Related Articles, Links  
 
Targeted cryoablation of the prostate: 7-year outcomes in the primary
treatment of prostate cancer.

Bahn DK, Lee F, Badalament R, Kumar A, Greski J, Chernick M.

Prostate Institute of America, Community Memorial Hospital, Ventura,
California 93003, USA. dkbahn@cmhhospital.org

The efficacy and safety of the long-term experience with targeted
cryoablation of prostate cancer (TCAP) at a community hospital is
retrospectively reviewed. A series of 590 consecutive patients who
underwent TCAP as primary therapy with curative intent for localized
or locally advanced prostate cancer from March 1993 to September 2001
were identified. Patients were stratified into 3 risk groups according
to clinical characteristics. Biochemical disease-free survival (bDFS),
post-TCAP biopsy results, and post-TCAP morbidity were calculated and
presented. The mean follow-up time for all patients was 5.43 years.
The percentages of patients in the low-, medium-, and high-risk groups
were 15.9%, 30.3%, and 53.7%, respectively. Using a prostate-specific
antigen (PSA)-based definition of biochemical failure of 0.5 ng/mL,
results were as follows: (1) the 7-year actuarial bDFS for low-,
medium-, and high-risk patients were 61%, 68%, and 61%, respectively;
(2) the bDFS probabilities for a PSA cutoff of 1.0 ng/mL for low-,
medium-, and high-risk patients were 87%, 79%, and 71%, respectively;
and (3) the bDFS probabilities for low-, medium-, and high-risk
patients using the American Society for Therapeutic Radiology and
Oncology (ASTRO) definition of biochemical failure (3 successive
increases of PSA level) were 92%, 89%, and 89%, respectively. The rate
of positive biopsy was 13%. After a positive biopsy, 32 patients
underwent repeat cryoablation. For those patients who underwent repeat
cryoablation, 68%, 72%, and 91% remain bDFS using definitions of 0.5
ng/mL, 1.0 ng/mL, and the ASTRO criteria, respectively, after a mean
follow-up time since repeat cryoablation of 63 months. The rates of
morbidity were modest, and no serious complications were observed.
TCAP was shown to equal or surpass the outcome data of external-beam
radiation, 3-dimensional conformal radiation, and brachytherapy. These
7-year outcome data provide compelling validation of TCAP as an
efficacious treatment modality for locally confined and locally
advanced prostatic carcinoma.

PMID: 12206842 [PubMed - indexed for MEDLINE]