(well this isn't quite the one you quoted? Anyway the long and short
of it is that it looks like more Grays (Gys) you get, the longer you
can be cancer free after?)

Lets see if I can steal you that article for you?:::::::: snap::::

External Radiotherapy and Prostate Cancer

Pauline Gastelblum, , Martine Roelandts and Paul Van Houtte

Department of Radiation Oncology, Institut Jules Bordet, Brussels,
Belgium

Available online 28 February 2006.

Conclusions
External radiotherapy is very effective to treat localized PCa and
even more locally advanced disease, especially using a conformal 3-D
approach. But further improvements have still to be made for a more
individualized approach.

-----------------

External radiotherapy has been used for more than 5 decades to treat
with curative intent prostate cancer. During the last decades, major
technical improvements have allowed an increase in the doses delivered
to the tumour, thus improving the outcome while reducing the radiation-
induced late effects. Several questions including how to select for
each individual patient the optimal treatment and the best radiation
approach still are not solved.

The management of early prostate cancer remains a controversial issue
between tenants of a wait-and-see policy, hormonal manipulation or the
different local treatments including cryotherapy, hifu, prostatectomy,
brachytherapy or external radiotherapy. There are several ways to
evaluate the treatment efficacy, but the ultimate endpoint should
still be overall survival or disease-free survival. Therefore, a long
observation period is necessary. Toxicity is another endpoint and is
easier in that it requires probably a shorter period of observation (a
few years). There are no large-scale randomised trials comparing the
different treatments, so we must look to the experience of each
modality, taking into account all the bias of possible patient
selection: Patients treated with external radiotherapy usually are
older or with more co-morbidity than those selected for a
prostatectomy. Nevertheless, we are evaluating our results nowadays on
the basis of treatments performed 10 or 15 years ago. Furthermore,
during this period, a lot of changes have occurred, either in terms of
the diagnostic procedure (e.g., prostate specific antigen [PSA],
magnetic resonance, positron emission tomography eras), the treatment
modality and the method of reporting results (the definition of local
control, freedom from PSA failure or toxicity).

External radiotherapy offers a series of theoretical advantages: There
is no major limitation to the tumour extent or to the patient co-
morbidity. The drawbacks mainly are due to the treatment duration
(from 6 to 8 weeks), the irradiation of normal organs such as the
bladder or the rectum, a less accurate staging compared with surgery
and a few contraindications related to the treatment delivery: The
patient must be able to lie down on a table without exceeding the
table tolerance (usually around 150 kilos) or have a computed
tomography (CT) scan (those are uncommon situations).

External radiotherapy has been used for more than 5 decades to treat
prostate cancer, even before the PSA era and modern technology. What
have we learned from those studies conducted mainly in North America?
First, in term of efficacy, using conventional irradiation for local
control became increasingly poor as the stage or Gleason score
increased. In the historical experience of Bagshaw et al. [1], the 10-
and 15-year survival rates were 58% and 36%, respectively, for stage B
(intracapsular tumour), and 36% and 22%, respectively, for stage C
lesions (extracapsular extension) in a series of 841 patients treated
before the PSA and CT era. In a more recent series, Hanks et al. [2]
reported that for 120 patients treated with 70 Gy and followed for 12
years, the biochemical control rate was only 58% for T3 disease,
compared with 72% for T1 lesions.

In radiation oncology, there is a direct relation between the dose and
the probability of local control. Several series have suggested a
higher control rate with an increasing radiation dose: In Hanks et
al's [3] experience, the 5-year biological-free survival was 31% for
doses below 70 Gy and 81% for doses above 72 Gy for patients with a
PSA between 10 and less than 20. Zelefsky et al. [4] observed in their
series that this benefit was mainly for patients in the intermediate
and unfavourable risk group (for the intermediate group, the 4-year,
PSA relapse-free survival rate reached 79% after the higher radiation
dose). Several randomised trials [5], [6], [7] and [8] have addressed
this question: They have demonstrated clearly a benefit from higher
total doses, but the results may be more important for some subgroups
such as the intermediate risk group (Table 1). Furthermore, several
trials conducted by the MRC, the Radiation Therapy Oncology Group
(RTOG), the NKI or the FNCLCC in France are now completed, and data
for an additional 2000 patients will be available to see the role of
radiation dose and modern radiation technique.

Table 1.

Results of randomised trials of dose escalation Authors
--------------------------------------------------------------------------------
No. of patients
--------------------------------------------------------------------------------
Eligible patients
--------------------------------------------------------------------------------
Hormonal treatment
--------------------------------------------------------------------------------
RT dose
--------------------------------------------------------------------------------
Results
--------------------------------------------------------------------------------
Comments
--------------------------------------------------------------------------------

Pollack [11] 305 T1-T3 None 70 Gy 64% 6-yr biochemical-free survival
   78 Gy 70%
Dearnaley [6] 126 T1b-T3bN0 3 months neoadjuvant 64 Gy 59% 5-yr
biochemical-free survival
   74 Gy 71%
Lukka [7] 936 T1-T2 None 66 Gy/33 fr 47% 5-yr biochemical- and
clinical-free survival
   52.5 Gy/20 fr 40%
Zietman [8] 393 T1b-T2b None 70.2 Gy* 61% 5-yr biochemical-free
survival
 PSA <15  79.2 Gy* 80%

PSA = prostate specific antigen; RT = radiotherapy.
* Treatment was performed by photon and proton beams.

A major concern is certainly the risk of late toxicity, which may have
a detrimental effect on the patient's quality of life. The risk of
radiation-induced late effects is not only related to the dose and
volume but also to the technique used [9]. Over the last years,
radiation technology has made major improvements in the different
steps of the treatment: the imaging, the treatment planning and the
treatment delivery. We have been moving from the two-dimensional (2-D)
approach to the conventional 3-D approach, to the conformal 3-D
approach (3-D CRT), to intensity modulated radiotherapy (IMRT) and
finally to the 4-D approach. This technical evolution allows moving
from a dose of 70 Gy or less to a dose in excess of 70 Gy, with the
ultimate goal of increasing the local control while decreasing the
risk of acute and late complications.

In the old RTOG protocol conducted during the 1970s, the treatment
planning was based on orthogonal X rays and contour: Severe late
effects including bowel obstruction or proctitis requiring major
surgery (grade 4 complications) were reported [10]. The introduction
of CT, modern 3-D treatment planning and the conformal approach
shaping the beams by blocks or through a multileaf collimator allow an
increase in the dose to the tumour while reducing the dose to the
bladder and the rectum: For example, in the M.D. Anderson trial, a
dose of 70 Gy was delivered with a conventional technique, while a
conformal approach delivered 78 Gy; the volume of the bladder
receiving a dose of 60 Gy was reduced from 37% to 28%, and similar
figures were reported for the rectum [11]. Furthermore, Dearnaley et
al. [12] conducted a randomised trial comparing a conventional to a
conformal technique for delivering a dose of 64 Gy: The rate of grade
2 gastrointestinal toxicity (bleeding and proctitis treated with
simple medication) decreased from 15% to 5%. Grade 3 toxicity (a
complication requiring some minor surgery) is now a rare event in most
modern series (Table 2) [4], [5], [6] and [8].

Table 2.

Radiation-induced gastrointestinal and genitourinary late effects
Authors
--------------------------------------------------------------------------------
Gastro
--------------------------------------------------------------------------------
Intestinal
--------------------------------------------------------------------------------
Genito
--------------------------------------------------------------------------------
Urinary
--------------------------------------------------------------------------------

Pollack [5]
Classical RT 70 Gy 16 1 11 2
Conformal RT 78 Gy 28 10 15 4

Dearnaley [12]
Conformal RT 64 Gy 11 0 8 3
Conformal RT 74 Gy 18 3 13 5

Zelefsky [4]
IMRT 80 Gy 1.5 0.5 9.5 0.5

Zietman [8]
Photons+protons
70 Gy 15 1 18 2
79 Gy 17 1 20 1

IMRT = intensity modulated radiotherapy; RT = radiotherapy.

In 3-D conformal radiotherapy, margins are added around the clinical
target volume to take into account movement of the tumour (in the
present case, the prostate), patient movement or the problem of
patient repositioning during the 7 weeks and uncertainties in the
clinical target volume delineation process. Several studies have
demonstrated clearly that, during the course of a radiation treatment,
the prostate moved, particularly in the anterior-posterior direction,
because of variation in bladder or rectal filling. Increasing the
margins from 1 to 1.5 cm increased the risk of late effects: In
Dearnaley et al's [6] randomised trial, 5% of the patients treated
with 1.5-cm margins experienced grade 3 gastrointestinal toxicity, but
none with a 1-cm margin did so. There are several approaches to
reducing the margins, especially at the level of the rectum: IMRT or
image guided radiotherapy (IGRT). IMRT is a 3-D CRT in which the
amount of photons delivered within a field is modulated; this approach
allows treatment of concave forms or modulation of the dose within the
target volume. This concave shape allows protection of the rectal
wall. The aims of IGRT are to improve the reproducibility of the
radiation delivery and to verify daily the position of the prostate,
allowing reduction of the margins and thus a decrease in the toxicity.
Different techniques are available and are under investigation:
fiducial markers implanted in the prostate, daily echography, CT
inside the radiation facility either as a separate machine or part of
the linear accelerator or cone beam added on the gantry.

Nowadays, the clinical target volume is defined mainly by using an
algorithm evaluating the risk of tumour extension on the basis of
different prognostic factors (the PSA value, the Gleason score, the
clinical tumour extension). A better imaging procedure allowing
assessment of the tumour inside the prostate or its possible extension
will be another step forward in optimising the radiation delivery
[13].

Heavy ions are another interesting approach: Protons or heavy ions
offer a significant advantage in dose distribution, compared with
photon beams. They have a preferential deposition of energy near the
end of their path through the tissue. So, by a specific selection of
their energy, the so-called Bragg peak may correspond to the target
volume with a steep gradient of the dose protecting the surrounding
tissue. Furthermore, heavy ions such as carbon ions also have
biological advantages, compared with proton beams. At present, this
approach is certainly an experimental approach, and the experience is
very limited: At Chiba, 201 patients were treated from June 1995 to
February 2004 [14]. The stage varied from T2a to T3, and 94 patients
had a PSA above 20. The 5-year, biological-free survival rate was
83.2%. Two patients experienced a grade 2 gastrointestinal toxicity,
and 12, a grade 2 genitourinary toxicity.

Several randomized trials [15] and [16] have shown that adjuvant
androgen deprivation improved the results after a radical
radiotherapy, particularly for locally advanced prostate cancer. There
are many unsolved questions including the duration of the treatment
and the selection of patients: For patients in the intermediate risk
group, combining a hormonal manipulation with radiation may avoid the
issue of escalating the total dose, thus decreasing the risk of
radiation-induced toxicity.

There are many questions about the radiation technique including the
optimal clinical target volume for each individual patient and the
possible benefit of a hypofractionated radiation schedule [17].
Indeed, there are some suggestions that the alpha/beta ratio for a
prostate cancer is quite low (<2 Gy), while this value for proctitis
may be relatively higher. This difference will confer some therapeutic
advantage in using fewer fractions with doses higher than 2 Gy for
each fraction. Current trials are ongoing to answer this question. If
those trials show an advantage or even similar results for the shorter
fractionation schedule, this approach would be more convenient for the
patients.

In conclusion, external radiotherapy is a very effective treatment
modality for treatment of prostate cancer, and major technical
advances have been observed during the last few years. However, there
are still a lot of questions concerning selection of the best
treatment for each patient: the more adapted radiation treatment
modality based on the different prognostic factors but also on the
patient's request and needs.
....................

well, again, the graphs didn't steal well at all, they line up under
each other in the journal; but it seems a good idea to me? So now I'm
wondering why my people say I ought not to get it? I guess I'm too far
gone. Maybe they are trying to kill me off or something? You think?
Certainly, the surgeons and the radiation oncologists and the medical
oncologists and the urologists totally disagree about if I should have
this or not---actually, the only one in favor being the radiation
oncologist. My intuition is that I shouldn't bother with it, that I
should just stick with the hormones and the Ramones :~) but what do i
know?

That sort of thing seems to happen a lot.

I guess you ended up with surgery instead of
radiation treatment of the cancer?

Interesting question, Nick.

When I talked to the radiologist about his machine,
I was surprised to learn that the energy of the photons
was 2-million electron volts (Mev), which is pretty
deep into what used to be called the gamma-ray
range.  (The energy of X-ray photons is more in the
range of tens of thousands of electron volts [kev],
which isn't energetic enough to get through thicker
sections of bone.)  The IMRT machine actually
contains a linear accelerator for the electrons that
produce gamma rays when they slam into a
metal plate.

(Gamma rays and X-rays are, along with visible
light and radio waves, all part of the electromagnetic
spectrum.  [Photons of visible light have energies
in the range of ~2 electron volts.])

Two-Mev photons would probably, I would bet, be
scattered by the metal parts; therefore, 'shadows'
would be cast upon regions that were supposed
to be irradiated. So, that's my estimate, based on
a tiny bit of my work that has involved high-energy
photons and particles.  Others no doubt would
know more on this interesting question.

Two-Mev gamma-ray photons are at about the
midpoint in the range of the gamma-ray energy
spread from a nuclear explosion (as I recall).  It
seems ironic that so many people who are afraid of
nuclear energy will readily submit to having their
bodies blasted with gamma rays.  Me, I am in favor
of nuclear energy, but I do have qualms about
having gamma rays shot through me each day
for 7 weeks.

best wishes,

         Bob