A Phase III Randomized Study of Low Dose Rate Compared to High Dose Rate Prostate Brachytherapy for Favorable Risk and Low Tier Intermediate Risk Prostate Cancer
Phase: NA
Conditions: Prostate Cancer
Sponsor: British Columbia Cancer Agency

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HDR vs. LDR Monotherapy Version Dec 8, 2017  
 
 
 
 
A Phase III Randomized Study of Low Dose Rate 
compared to High Dose Rate Prostate Brachytherapy for 
Favorable Risk and Low Tier Intermediate Risk Prostate 
Cancer 
 
H17-02904 
 
Principle Investigator: Juanita Crook 
Co-PI: Francois Bachand 
Physics: Drs. Deidre Batchelar, Michelle Hilts, Cynthia Araujo 
Radiation Oncology: Dr. David Kim, Dr. David Petrik, Dr Ross Halperin 
Radiology: Dr Brenda Farnquist 
Pathology: Dr. Terry Bainbridge 
Laboratory: Dr Julian Lum 
 
 
British Columbia Cancer Agency 
Cancer Center for the Southern Interior 
399 Royal Avenue 
Kelowna BC V1Y 5L3 
250 712 3958 
jcrook@bccancer.bc.ca 
 

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HDR vs. LDR Monotherapy Version Dec 8, 2017  
 
 
Introduction 
 
Prostate cancer is the most common non cutaneous malignancy in Canadian men and 
the third leading cause of cancer death; approximately 23,600 cases were diagnosed in 
2014 and despite the decline in PSA screening, the majority are still non-metastatic. 
Definitive treatment, using either surgery or radiation, is associated with satisfactory 
disease-free rates of 80-95% at 5 years and 70-90% at 10 years for favorable and 
intermediate-risk disease. Unfortunately, quality of life may suffer due to short and/or 
long-term surgical or radiation side effects. Active surveillance is commonly offered in 
Canada for favorable risk disease, but about one-third of newly diagnosed men (about 
8,500 annually) have intermediate-risk disease for which active surveillance is generally 
not recommended. Since treatment is necessary to avoid progression to metastases and 
eventual death from prostate cancer, an improved side effect profile would be 
welcome(1). 
 
Background and rationale 
 
Low-dose rate brachytherapy (LDR) using Iodine-125 seeds is a highly effective option 
for favourable and low-tier intermediate-risk prostate cancer (2-4). Mature data from 
Canadian institutions report PSA-progression-free survival (PFS) in the range of 90-95% 
at 5-10 years (5). High-dose rate brachytherapy (HDR) used as a single modality 
(monotherapy) is accepted in both North America and Europe as an alternative to LDR 
(6-8), but the more mature data for HDR brachytherapy involves multi-fraction regimens 
of 4 or more fractions. Such HDR fractionation schemes achieved very comparable PFS 
at 5 years > 93% (8-10). Recently, however, advances in imaging and software have 
resulted in more efficient HDR delivery with reduction in the number of fractions to two 
(often given in separate implants) or even in one single large fraction. Early results with 
follow-up of only 2-4 years are promising (5,6,11,12). Emerging recent data with 5-6 
years of follow up report 91-93% bNED rates for 2 fractions, although less favorable for 
a single fraction (13,14)The larger fractions dose is calculated to be radiobiologically 
equivalent to the multi- fraction regimens and the interest in pursuing this form of 
brachytherapy relates to an improved side effect profile, specifically lower rates of acute 
and late urinary toxicity compared to LDR(15). 
 
HDR has several potential advantages over LDR:  
 
Dose optimization by manipulation of dwell times and dwell positions of the 
“stepping source” can correct for slight deviations in needle placement 
 
Potential to reliably push extra prostatic dose where it is needed 
 
Critical organ doses (rectum, urethra) can be tightly controlled 
 
Fewer radioprotection issues for patients and staff 
 
The low α/β ratio for prostate cancer (1.2-1.5) imparts a radiobiological 
advantage to large fraction sizes(16-18).  
 
HDR is cost-effective since a single radioactive source delivers treatment to a 
large number of patients(7) 
 
Potential disadvantages of HDR compared to LDR: 
 
Efficacy equivalent to that of LDR brachytherapy has not been established in 
controlled clinical trials 

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HDR vs. LDR Monotherapy Version Dec 8, 2017  
 
 
Efficacy data is shorter term for HDR, with fewer reports with 5 years or more of 
follow up for fractionation schemes of two or a single large fraction(13,14,19-22), 
compared to LDR where10- year data are available  
 
Experience with HDR in BC is much less than that with LDR and is as yet still 
only available in one of the provincial cancer centers. 
 
The major advance that has lead to the improvement in HDR delivery is the introduction 
of intra-operative Ultrasound-based HDR treatment planning (23,24) which allows 
needle placement, treatment planning and treatment delivery in a single 2-hour 
procedure under anaesthesia. 
 
The reasons to consider HDR as an alternative to LDR brachytherapy 
1. Reliability of dose delivery: Although highly effective, there are some drawbacks 
to LDR seed implants. The procedure is highly operator-dependent and, even in 
the most experienced hands, there can be discrepancies between planned and 
actual seed positions. Although uncommon in experienced hands, areas with too 
much or too little dose cannot be corrected after the implant is completed.  
 
2. Acute Toxicity: With an LDR implant, the radiation dose is delivered over 6 
months (half-life of Iodine-125 is 60 days; 87.5% of the dose is delivered in 3 half 
lives) compared to 15-20 minutes for HDR. For this reason LDR is associated 
with a more prolonged recovery period, especially concerning acute urinary 
toxicity compared to HDR (15,25)(7,10,17). The median time to return to baseline 
urinary function after LDR brachytherapy is 6 months and is achieved by 80% in 
12 months. In the BCCA experience, acute urinary RTOG grade 3 toxicity was 
16%(26) (23). A recent prospective non randomized comparison of QOL after 
HDR vs. LDR brachytherapy boost (combined with 4.5 weeks of external 
radiotherapy) similarly showed a return to baseline International Prostate 
Symptom Score (IPSS) at 6 months with LDR compared to only 12 weeks with 
HDR(27). No randomized trial has yet reported on HDR and LDR brachytherapy 
side effects and Quality of Life. 
 
3. Late Toxicity: Late grade 3 toxicity is reported between 0 and 3% for HDR 
brachytherapy compared to LDR where long-term grade 3 urinary toxicity was 
still 10% at a median follow up of 55 months (28). 
 
LDR prostate brachytherapy is still the most common approach in British Columbia; over 
5000 cases have been performed in British Columbia since 1998. However, HDR 
brachytherapy is widely accepted when used as a boost in combination with EBRT, and 
HDR boost is available as a standard treatment option at the Center for the Southern 
Interior in BC. Based on the findings of the  non -randomized prospective study 
completed at CCSI reporting decreased urinary and bowel toxicity for men treated with 
external beam radiotherapy and an HDR brachytherapy boost compared to an LDR 
boost(27), a randomized phase III trial is under way (H13-02139). Since in that study 
the EBRT component was identical for both arms, we hypothesize that the improvement 
in QOL seen with HDR would translate to the monotherapy scenario.  In 2016 we 
commenced a Randomized Phase II Pilot study (H15-01203) to compare HDR to LDR 
monotherapy with a QOL endpoint. The target accrual was 60 patients and if this 
number was achieved in 24 months or less, we planned to expand the trial to a total of 
200 patients. We completed accrual to H15-01203 in under 18 months and propose to 
continue, with minimal change to the protocol. The acceptance of undergoing 2 HDR 

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procedures instead of a single LDR implant has been very high. Acute toxicity has been 
minimal (grade 1-2 only) and to date there is no late toxicity in the HDR arm. All 60 
participants remain under follow up. 
 
Hypothesis and Objectives 
HDR monotherapy for favorable and low tier intermediate risk prostate cancer will result 
in improved Quality of Life as determined using the Expanded Prostate Cancer Index 
Composite (EPIC) and QOL scores in the urinary domain, and faster IPSS (International 
Prostate Symptom Score) resolution compared to Iodine 125 permanent seed implant. 
The standard arm of the trial is LDR brachytherapy and will be compared to the 
experimental arm, HDR monotherapy, in a randomized Phase III Study. Feasibility of 
patient acceptance has been demonstrated in the initial pilot (H15-02103), with accrual 
of 60 patients within 18 months. Thus a larger-scale phase III randomized trial will 
continue for a total of 200 patients (60 in the randomized Pilot H15-02103 + 140 
additional). 
 
Primary objective: 
To evaluate the difference in QOL in the urinary domain between LDR and HDR 
brachytherapy. The urinary domain of the EPIC prostate cancer specific QOL 
questionnaire will be assessed at baseline, 1, 3, 6, 12, 24 and 36 months after the 
procedure. The EPIC has been shown to be the most robust instrument for assessing 
prostate cancer-specific quality of life (33-35). For each domain, a function and bother 
score can be calculated (0-100) with higher scores indicating better function and less 
bother.  
 
Secondary objectives: 
 
The EPIC score in the bowel and sexual domains will be evaluated at baseline, 
1, 3, 6, 12, 24 and 36 months.  
 
The IPS Score will be assessed at baseline, 1, 3, 6, 12, 24 and 36 months .The 
IPS Score, designed to assess lower urinary tract symptoms in men, is widely 
used to assess urinary function after prostate cancer treatment. The time to 
return to baseline +/- 3 points will be determined.  
 
Acute and long-term toxicity will be graded using the Common Terminology 
Criteria for Adverse Events (CTCAE V4) at each follow up time point 
 
TRUS- MRI fusion will be developed within our planning software to facilitate 
treatment planning 
 
Two standard predictors of outcome will be evaluated as secondary objectives to 
assess treatment efficacy; 
 
PSA nadir predicts for long-term outcome following radiotherapy (29-34) 
and will be recorded every 6 months to 5 years and then annually to 10 
years 
o Prostate re-biopsy will be performed at 36 months after radiotherapy (35-
37) to assess the local efficacy of radiation.  
 
For those patients consenting to targeted biopsies under anaesthesia at the start of their 
brachytherapy procedure (separate optional consent) 
 
MRI-TRUS fusion accuracy will be verified by targeted biopsies under 
anaesthesia at the beginning of each brachytherapy procedure (LDR or  HDR).  

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HDR vs. LDR Monotherapy Version Dec 8, 2017  
 
 
Biopsy material will be sent for genetic testing to determine Cell cycle 
Progression scores for both arms of the trial to ultimately correlate with outcome.  
 
 
This proposal represents the first instance of collaboration between the BC Cancer 
Agency and Myriad Genetics where evaluation of the CCP score will be performed 
(Prolaristm).  With further experience and follow up the CCP score may become 
increasingly important in helping to determine appropriate treatment. A recent 
presentation at the American Urologic Association Meeting (2015) reported that the use 
of the Prolaristm test for 1206 men with localized prostate cancer resulted in alteration of 
treatment in 48%, ¾ being for a less aggressive approach and ¼ for more aggressive. 
Indiscriminate over-treatment of indolent disease is not acceptable but a blanket 
conservative approach to prostate cancer known to be of “moderate” aggressiveness is 
also not without severe adverse consequences. In addition to reducing the toxicity of 
treatment, more reliable means of selecting patients for aggressive treatment are 
urgently needed. CCP scores may allow appropriate triage of intermediate risk patients 
to focal therapy, brachytherapy monotherapy, combined EBRT + brachytherapy, or 
combination with systemic agents. In H15-02103, the scores for these intermediate risk 
patients range from 2.2 (well within the low risk category) to 4.3 (within the high risk 
range). Continued data collection and follow up will help us to interpret the significance 
of these findings. A total accrual of 200 patients will permit multivariate testing of both 
treatment type and CCP score (as well as standard prognostic variables) to determine 
their effect on biochemical failures and patterns of failure. 
 
Biopsies to assess the effect of the first fraction of HDR on the tumour: 
 
 
Biopsy prior to the second fraction of HDR will assess the effect of 13.5 
Gy (Fraction 1) on oxygenation, and cell cycle distribution. Thus, biopsies 
in the HDR arm will be taken at two times points: prior to the 1st fraction 
and 14 days later prior to the second fraction of HDR.  Half of the sample 
is collected and flash frozen into freezing media, the other half is placed 
into paraffin for downstream formalin fixation.  All samples are decoded 
and anonymized for shipment to Dr. Lum and collaborators for analysis. 
 
 
Transcriptomic profiling:  Drs. Collins and Hach (Vancouver Prostate 
Centre) will assist in performing targeted transcriptomic profiling using 
recently published data (PMID: 28330676).  
 
 
Immunohistochemistry:  Drs. Lum and Hach will perform immune-
histochemical analysis of numerous immune markers and correlate it with 
their localization in the epithelium or stroma.  A multi-parametric 
alogorithm will be applied to co-register markers of hypoxia and 
vasculature with immune signatures.  Dr. Lum has several REB approved 
protocols to conduct similar studies in prostate/GU/ovarian/HCC/breast 
cancer (H14-02968, H13-00481, H15-01650, H06-03666, H15-01686). 
 
Assessment of this effect is extremely important in understanding why fractionated HDR 
prostate brachytherapy seems to be so much more effective than a single 
fraction(14,38).  
 

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Patient eligibility: 
 
Favorable risk and low-tier intermediate-risk prostate cancer with estimated life 
expectancy of at least 10 years.  
 
Clinical stage T1c-T2b, PSA < 20, Gleason < 8  
 
ECOG 0-1 
 
Low tier intermediate-risk prostate cancer is defined by;  
o a single NCCN intermediate risk factor (either Gleason 7(3+4) and PSA < 
10 ng/ml OR Gleason 6 and PSA 10-20 ng/ml) 
  
 
Extensive favorable-risk disease is defined as:  
o clinical stage T1c-T2a 
o PSA < 10 
o Gleason 6  
o  ≥ 50% of biopsy cores containing cancer 
o PSA density > 0.2 ng/cc  
 
 
Selected intermediate risk patients not defined above 
o - T1c/T2a 
o - PSA < 10  
o -Gleason 4+3 
o -< 33% of cores involved  
o -Max tumour length in any core 10 mm 
 
 
No androgen deprivation therapy (ADT)  
 
Prostate volume by TRUS ≤ 60 cc.  
 
Not eligible for, or accepting of, active surveillance according to NCCN 
guidelines.  
 
Signed study specific informed consent.  
 
Exclusion criteria 
 
Prior radical surgery for carcinoma of the prostate,  
 
Prior pelvic radiation  
 
Prior chemotherapy for prostate cancer, 
 
Prior TURP or cryosurgery of the prostate 
 
Claustrophobic or unable to undergo MRI 
 
Investigations: 
All of the required investigations are standard of care for a patient undergoing prostate 
brachytherapy. 
o CBC, electrolytes, creatinine, glucose, INR 
 
PSA/testosterone 
 
Pathology review of diagnostic biopsy 
 
ECG 
 
Staging bone scan and CT abdomen/pelvis 
o Multiparametric MRI of the prostate. (This imaging modality is standard of 
care in staging of both intermediate and favorable risk prostate cancer in 
many health jurisdictions. Recently it has become more readily available 
in BC and is being incorporated into the treatment paradigm. In this study 

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HDR vs. LDR Monotherapy Version Dec 8, 2017  
 
it will be used for demonstration of the dominant intraprostatic lesion for 
both dose prescription and biopsy guidance) 
 
Additional investigations: 
 
2 biopsy cores taken from the region of interest under anesthesia using 
a transperineal template-guided approach and a Bard Magnum Biopsy 
Gun and 18 gauge biopsy needles (same gauge as implant needles) 
just prior to brachytherapy to confirm what was interpreted on mpMRI 
as the location of the dominant site of cancer (separate consent for this 
biopsy) 
 
Follow up biopsy at 36 months in Diagnostic Radiology under TRUS 
guidance to evaluate pathologic eradication of tumour 
 
Brachytherapy 
 
Arm 1: Low-dose rate brachytherapy using Iodine-125 seed implant 
 
LDR brachytherapy requires a preplanning Transrectal Ultrasound (TRUS) 3-6 weeks 
before the procedure to plan the number and location of the required seeds and to allow 
the order and delivery of these seeds to the Cancer Centre. The actual brachytherapy 
implant will be performed within 8 weeks of randomization. It is performed under general 
or spinal anesthesia as an outpatient procedure under TRUS guidance and takes about 
1 ½ hours. The patient is discharged home when they have recovered from anesthesia 
and are able to void. The prescription dose for Iodine-125 is 144 Gy delivered to the 
prostate plus a margin (5mm laterally and caudally, 0 mm cranially and posteriorly, and 3 
mm anteriorly. Four weeks later the patient returns to the Cancer Centre for Quality 
Assurance (QA) which involves the combination of a CT and an MRI (single sequence; 
non multiparametric) of the prostate region. A dose-volume histogram (DVH) will be 
generated and the following values shall be reported:  
 
prostate V100 (percentage of the prostate volume receiving at least 100% of 
the prescription dose) 
 
D90 (isodose enclosing 90% of the prostate volume) 
 
V150 (percentage of the prostate volume receiving at least 150% of the 
prescription dose)   
 
urethra D5 (dose to maximally irradiated 5% of urethra) 
 
rectum RV100 (volume in cc of rectal wall receiving 100% of prescription 
dose.  
 
D90 to the MRI-identified dominant lesion(s) 
Evaluation criteria: Prostate D90> 100% but less than 130% of the prescription 
dose, prostate V100> 90%. 
 
Arm 2: High dose rate brachytherapy 
 
HDR brachytherapy has been available at the Center for the Southern Interior since 
June 2011 with over 200 procedures performed and an experienced team of 5 Medical 
Physicists and 2 Radiation Oncologists. It is a Provincial Standard of Care for use as a 
boost combined with external beam radiotherapy for more advanced prostate cancers. 
 
HDR brachytherapy will be performed within 8 weeks of randomization, using US-based 
planning systems such as available from Varian. The procedure is performed as an out 

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HDR vs. LDR Monotherapy Version Dec 8, 2017  
 
patient procedure under either spinal or general anesthesia and takes ~ 2 hours Similar 
to LDR brachytherapy, the patient is set-up in dorsal lithotomy and TRUS images are 
acquired, followed by needle insertion. When all needles are appropriately placed and 
locked in the template, repeat TRUS imaging is performed with the needles in place for 
needle track identification and treatment planning. When the plan is complete and 
approved, transfer tubes are connected to each needle and the treatment is delivered 
using a stepping source of high activity Iridium 192 attached to a cable such that it steps 
through each needle in turn at 3 mm increments delivering the required dose at that site. 
Treatment takes 15-20 minutes depending on the exact strength of the source on the 
treatment day. The needles are then removed and the patient awakened and transferred 
to the recovery suite for discharge the same day after recovered from anesthesia and 
able to void. 
The dose prescription is 27 Gy in 2 fractions, with one fraction per implant, 1-2 
weeks apart. The following dosimetry parameters will be met:  V100 > 95% (> 95% of 
prostate volume receives prescription dose) 
  V125: 55-65% (55-63% of prostate volume receives 125% of prescription) 
  V200 < 8% 
  UV115%: 0 (urethral max dose < 115% 
  RV1cc; 7.5 Gy (1 cc of rectal wall receives < 7.5 Gy per fraction) 
  D90DIL: 125%-150% of prescription (for those patients where DIL visible) 
  
Evaluation During and After Protocol Treatment: 
 
At baseline, 1, 3, 6, and 12 months and then yearly up to 5 years, patients will be 
evaluated with IPSS and EPIC questionnaire. PSA measurements will be done every 6 
months during the first 3 years then annually.  
 
The mpMRI demonstrating intra prostatic tumour will be electronically registered (fused) 
with the TRUS images in order to transfer the target for treatment planning.  For patients 
consenting to biopsy, 2 biopsy cores will be obtained under anesthesia using a template-
guided transperineal approach, and targeting the demonstrated lesion as seen on 
mpMRI. Biopsies will be formalin fixed and processed in the pathology department at 
Kelowna General Hospital for pathologic interpretation to confirm the presence of tumor, 
7 unstained slides with 5u sections will be sent to Myriad Genetics (Laboratory in 
Munich) for micro-dissection and evaluation. 1 fresh frozen core will be sent to Dr Julian 
Lum at the Deeley research Center Vancouver Island. 
  
Prostate re-biopsy will be performed at 36 months and assessed for the presence or 
absence of residual tumour. Cores will be evaluated by Dr. Terry Bainbridge, the BCCA 
reference pathologist in Kelowna. 
 
Statistical analysis and justification of sample size 
 
This initial randomized Phase 2 study accrued 60 patients in 18 months, demonstrating 
feasibility and acceptance of the protocol.  Patients are very willing to accept 
randomization to treatment that required 2 implant procedures and thus 2 anesthetics. 
We are embarking on an expanded protocol to include a total of 200 patients.  
 
We estimate that HDR brachytherapy is associated with half the acute toxicity seen with 
LDR. For the 60 men receiving an HDR or LDR boost, on average, bowel domain scores 

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HDR vs. LDR Monotherapy Version Dec 8, 2017  
 
decreased by 20.1 points for LDR and 10.4 points for HDR. Four months after treatment, 
LDR patients still had significantly worse urinary health compared to HDR (p = 0.012). 
Urinary domain scores for LDR were on average 12.6 points lower compared to the pre-
treatment assessment, while for HDR patients the mean difference was only 1.4 points. 
A two sample T-test will be used to compare mean differences at each time point of 
assessment. For the expanded protocol a minimum of 172 patients would be needed to 
achieve 90% power with a difference between the means of 50%. 
A clinically significant change in an EPIC score is taken as 0.5 of the SD of the baseline 
score(39). Studies in this population have shown that the minimally important difference 
in EPIC score is 4.4 for the urinary domain, 3.1 in the bowel domain and 11.1 in the 
Sexual domain. More than 50% of patients treated with brachytherapy, plus or minus 
external radiotherapy, experience a small, but clinically significant, decrease in HRQOL 
within the urinary, bowel, and sexual domains(40),  In our  prospective non randomized 
QOL study of an LDR vs. an HDR boost, in the urinary domain at 6 months, the mean 
score was higher for HDR Brachytherapy (mean =84.97) compared to LDR 
(mean=78.80). The difference is greater than the minimally important difference. If one 
considers a change of >0.5 SD in 40% of patients to be acceptable at 12 months while a 
change >0.5 SD in >65% is unacceptable, as specified by Morton et al (19), this would 
require 78 patients per arm, or 156 eligible patients Allowing for 10% lost to follow up, 
ineligibility or incomplete forms, the required sample size would be 174 patients. 
The treatment effect with respect to all endpoints will be analyzed by the log rank test.  
All eligible and evaluable patients will be included in the intent-to-treat analysis. The 
cumulative incidence method will be used to estimate the five-year and 10-year rates of 
biochemical and clinical failure because of the competing risk of dying of other causes. 
Proof of reduced toxicity and improved QOL will help to establish HDR monotherapy for 
this group of patients, and will save the health-care system the costs of non-reusable, 
permanently implanted seeds for up to 300 patients per year ($750,000 for the province 
of BC). 
 
We do not expect to see a difference in PSA nadirs or prostate re-biopsy results and 
cannot mount an equivalence trial in this regard at a single center or even in a single 
province. Nonetheless, our data will offer additional support to the presumed 
equivalence already evident in the literature. A total accrual of 200 patients will permit 
multivariate testing of both treatment type and CCP score (as well as standard 
prognostic variables) to determine their effect on biochemical failures and patterns of 
failure. 
 
 
Assessments 
Follow up (months)    
Within 6 
months 
Within 3 
months 
1-3-6-12-18-24-30-36 
Annually 
Biopsy 
X 
 
X (36 months) 
 
History/physical 
 
X 
X 
X 
PSA/testosterone 
 
X 
X 
X 
CT/Bone scan/ 
mpMRI 
 
X 
 
 
IPSS/IIEF 
 
X 
X 
X 
EPIC 
 
X 
X 
X 

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HDR vs. LDR Monotherapy Version Dec 8, 2017  
 
Budget 
Permanent seed implant is the standard of care in BC for this group of patients and all 
costs are covered. 
HDR brachytherapy is available as a standard of care when used as a boost combined 
with EBRT and performed as a single procedure with a single fraction. All costs are 
covered and are considered to be roughly equivalent to the cost of an LDR implant. 
Since HDR monotherapy in this protocol is delivered in 2 fractions in 2 separate 
implants, the second of these procedures represents an additional cost. The 
approximate cost per 2 hour OR procedure is $2000. 
 
2 circulating nurses 
 
1 recovery room nurse (2 nurses/2 patients) 
 
1 anesthetist 
 
2 radiation therapists 
The cost of this additional procedure to the health care system is offset by the saving 
from not having to purchase single-use radioactive seeds. (average number of seeds per 
implant: 100; cost per seed $22 = $2200 per patient.. 
 
Pathology processing and interpretation $180 per patient. 
 
 
Cell Cycle Progression Gene profile using Prolaris test from Myriad Genetics: $1200 
USD per patient. 
Funding from Donated Funds (Man to Man) at $40,000 per annum covers the cost of 
Prolaris tests. Other applications pending from Varian and other Donated Fund sources 
 
 
 
 
 

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