Cyberknife for prostate cancer “still developing and can’t stand on its feet”

We need more stories that raise questions about new technologies.

Cardiac electrophysiologist Wes Fisher tweeted this week about a Chicago Sun Times story that he said was a promo piece for ablation for atrial fibrillation but failed to discuss the risks of the procedure.

We’ve blogged twice this week about more questions about the explosion in the use of robotic prostatectomy and another journalist pointed out fawning coverage of the technology called NanoKnife.

Also this week, an article in Radiology Today concludes that:

“While early results appear promising, critics in radiation oncology say longer-term data are needed before widely offering the (Cyberknife) treatment to men.”

But we see billboards on freeways luring patients with vague messages.

CyberKnife billboard.jpg

The Radiology Today story quotes former practicing and well-known urologist Gerald Chodak:

“The five-year data that were recently presented are positive, Chodak says, but five years is not long-term and until the long-term data are available, he wouldn’t recommend offering SBRT as an option for patients with prostate cancer, which one man in six will get in his lifetime.

Chodak also fears that “money is driving this more than anything else.” Facilities are investing millions in CyberKnife machines and may be expanding to prostate treatments largely to get more use out of them, he says.

Rohit Inamdar, a senior medical physicist and senior associate in the Applied Solutions Group at the ECRI Institute in Plymouth Meeting, Pa., a nonprofit organization that evaluates medical products and processes, agrees with Chodak that the clinical evidence on the use of the CyberKnife for prostate cancer is “a little early … and a little weak. It’s still developing and cannot stand on its feet.”

Inamdar is also concerned about the financial issues. Some physicians might be presenting CyberKnife as an option for their patients because they’ve invested $5 million in the equipment and can’t afford to have it sit idle, he says.

“One fear I have is that it’s like a hammer looking for the nails,” Inamdar says. “If you paid $5 million for it and you’re paying for staff, now you have to put it to use.”

Robotic surgery.
Ablation zapping of atrial fibrillation.

You name it – we need a better public discussion about evidence for new technologies, about cost-effectiveness, and about the tradeoff of benefits AND harms.

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Walter Nikesch

July 22, 2011 at 1:09 pm

the statement that “money is driving this more than anything else” is correct but not quite the way you think. You need to understand that modern state of the art radiation therapy equipment (i.e. Varian True Beam) and associated planning and record and verify computers cost about the same as a cyberknife. Also most hospitals that buy a cyberknife also have regular radiation therapy treatment units. For prostate ca the regular units require about 42 treatments. Using IMRT techniques the hospitals realize about about twice the reimbursment dollars for the 8+ weeks of standard external beam treatments than is generated by the 5 cyberknife treatments. So for facilities that offer both treatment modalities there is financial incentive NOT to use cyberknife. In fact many facilities that do NOT have cyberknife use your arguments to try to keep these very lucrative patients within their system. The 5 year cyberknife data does indeed look promising. Also the 10 year hypofractionation data using invasive HDR techniques (similar dose/treatment as cyberknife) is also very good. And there is no reason to believe cyberknife won’t have similar 10 year results. All men with prostate cancer should do the research on line themselves and make an informed decision. But also note that one week of Cyberknife treatments costs significantly less that 8-9 weeks of IMRT external beam treatments saving medicare or your insurance lots of money.

John Hemmer

August 15, 2011 at 12:03 pm

I have to agree with Walter Nikesch, “money drives it” but not the way this article intends. I had prostrate cancer treatments via Varian True Beam. Prior to treatment I was given 2 options Robotic Surgery or True Beam. When I mentioned Cyberknife treatments, the Radiation Oncologist pooh-poohed it and actually got very defensive. Because I could get all 43 treatments done by Christmas, I decided not to fight the system. Halfway through my treatments the Treatment Center had another Varian True Beam system installed. Business was booming!
So lets see… I could have 5 Cyberknife treatments at probably less than 2/3 the cost of the 43 Varian True Beam treatments, resulting in fewer side effects for me, less out-of-pocket cost for me and less cost for my Health Insurers and finally, most important, more money for the Radiation Center and the Radiations Oncologist and Urologist who fed me into the system. So yes, it is about money.

Fred Kinder

August 19, 2011 at 10:54 pm

Prostate Cancer is big business. Men must take time to understand the risk of each option to allow for an informed choice.
The CyberKnife is about money! It takes money away from urologist and radiation oncologist pushing IMRT.
Most people including urologist do not understand the CyberKnife radiobiology. It delivers hypo fractionation using a dose plan much like HDR Brachytherapy which has a 30 year history. Total dose of 35-38Gy.
The first PCA patient was treated with RT(Protons or X-Rays) in 1909. The cancer was cured but the patient suffered from radiation toxicity as did his care givers.
IMRT delivers a relatively low dose(1.8Gy) per session. The total dose delivered today is 80-84Gy. This is a large increase for the 60-68Gy dose of 10-15 years ago.
There is no long Term Data for IMRT at todays prescribed dose.
The CyberKnife Five year data tells a very useful story, side effects are lower that surgery and IMRT. Cure rate is as high or higher than any other option.
There is no data showing Proton Therapy is as good as IMRT and no data showing them as safe and effective as the CyberKnife. The CyberKnife is lower cost than IMRT and Proto Therapy. Radiation oncologist get paid per session, do the math 40-45 payments vs 4 or 5 payments for the CyberKnife.
I encourage patients to understand all options before making a choice.


October 15, 2011 at 2:36 pm

Does anyone have data on the side effects of Cyberknife versus Naonknife? I’m 77, in excellent health, no heart problems, no medications. I find Urologists recommend the procedure they’ve used and highly critize all other approaches. It makes it tought to decide especially when I’ve been told twice that, at my age,and having Stage 1C that I’m better off doing nothing

    Don Hoffman

    March 14, 2012 at 6:48 pm

    Please let me know if get any response to your request for information on side effects. It appears that since my treatment, I have been experiencing severe and continuous backpain. I am not sure of a connection, but the time frame fits perfectly.

Walter Lipman

January 16, 2012 at 3:10 pm

I now have questions that I ask everyone who seeks to treat me: What country club(s) do you belong to? What is the overall length of the boat you own?

Anyone who cannot answer “none”, and “What boat?”, respectively, is someone who isn’t touching me.

The tales of doctors banding together to purchase some sort of machine which then must be used to amortize its cost are legion, and hospital-systems doing so are just another take on the same theme of profit through procedure. You can call it many things, but quality medical care it is not.

Informed Medical Decision Making, thankfully, is the one tool we laypeople have to cut through it all.

Harry pappas

February 17, 2012 at 12:18 pm

I had cyberknife for prostate cancer and for almost two years all was fine. Then the bottom fell out !
I had six turps for bleeding and retention , finally I had to remove my bladder and prostate!! As the surgeon said they were burned like toast. I now have an Indiana pouch! When I hear the advertisements for cyberknife claiming they have no cases of over exposure I get so upset. I would like to get the word out so others can make a balanced decision.

Catherine Bonetti

March 7, 2012 at 1:52 pm

Dear Mr. Pappas,

My name is Catherine Bonetti and I work for Accuray the manufacturer of the CyberKnife System. I would like to speak with you more about your experience. Can you please call me at toll free 888-522-3740, ext 3401 or 408-789-4301 or send an email to Thank you, Catherine

david samadi

April 8, 2012 at 6:11 am

Cyberknife Robotic Radiosurgery, is a misleading term. It is not a surgery it is only radiation, It is true that is based on Hypofractionated radiation so you can give a high dose of radiation in a short period. Having said that this treatment is still experimental and has no long term data no matter how you look at.
There is also no scientific data to show it’s safety compare to IMRT. The complications from this treatment is not handled by radiation oncologist and that is why they are not aware of it, bladder bleeding and prostate bleeding is managed by urologists and rectal bleeding by GI docs. The side effects kicks in few years after and at that time it is very hard to manage the complications or recurrence. Very difficult to perform surgery after radiation. You can use low dose radiation after surgery, it is true that there are many robotic prostate surgeons that should not be doing surgery, but if you choose an experienced surgeon with high volume and good outcome, not only your cancer is removed, your sexual function and continence will be in place. choose wisely . The data on cyberknife is short and very small group of patients, not ready for prime time as treatment for prostate cancer

Robert Arthur

April 10, 2012 at 12:07 pm

While I respect and admire the medical profession, in recent years physicians have become business-people as much, or more so, than healers. This is just a product of our times rather than a any sinister motivation on the part of physicians.

Six years ago I was diagnosed with Gleason-Score-6 prostate cancer. With total trust in my urologist I submitted to his recommendation for the treatment of brachytherapy. Fortunately, in pre-testing it was found my prostate volume was too large (98 cc.) which precluded this form of therapy. My urologist immediately recommended other radiation methods following a time of prostate shrinkage using finasteride.

During this period I did considerable research on my own which led me to believe that any sort of aggressive treatment was premature, yet on every quarterly visit my doctor highly recommended aggressive treatment. He even offered to join me “off shore” should I elect HIFU treatment somewhere in the Caribbean. Even on my last visit, with a slight uptick in my PSA (a finasteride corrected equivalent of a little under 8 PSA) after 5 years of decline, he immediately urged aggressive treatment. Oddly though, after I declined, he extended the next visit to 6 months out instead of the usual 3. I may be wrong, but that seems inconsistent.

Anyway, sometimes I think their revenue stream is as important to physicians as the welfare of the patient…just saying.

Ketan Mehta

May 5, 2012 at 11:33 pm

Thanks to all. This is very helpful discussion. I am fifty and about six months ago diagnosed with prostate cancer and gleason score of six. I am leaning to just take time and watch but being advised I should get rid of it. I am not sure to do radiation or cyberknife. I am reading about all options and still unsure. I would greatly appreciate experiences of others. Thanks