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Dean Conterato, M.D. — Concerns after Brachytherapy? Follow-up with Radiation Oncologist

I recently saw a patient who had seed implantation in 2003 for low grade prostate cancer.  After his implant, he continued to have his PSA evaluated regularly by his urologist and at first it decreased to about 0.5 after 4 months, but then it began to rise.  The patient at the same time had developed a lot of urinary burning.  A retest of his PSA showed that it had increased and a biopsy was recommended by his urologist.  The biopsy, not surprisingly, came back as positive and with “higher grade” cancer.  He then had a prostatectomy attempted, which could not be completed, so subsequently had cryotherapy.  His PSA is 0.1 and stable, but he is left impotent and with pain.

There are a few important lessons that need to be made in this patient’s case.  First, if he had come back to me with these biopsy results, I would have predicted that they would be positive and very likely worse.  Prostate cancer does not die off on biopsy in 4 months or even a year after radiation therapies.  The cancer cells only “die” when they try to divide and since prostate cancer grows very slowly it will be at least a year before the full affect of the radiation-cell-kill is apparent.  That is why PSA levels go down slowly for at least a year and sometimes much longer.

Second, pathologists have a very hard time knowing what is cancer and what is radiation side effects when they look at cells under a microscope.  There is no way of knowing!  The cells all look bizarre after exposure to radiation.

Third and very important to understand is that PSA is a blood test that tests a protein.  The test is NOT specific for prostate cancer and there are a lot of other reasons it can be elevated, not just the recurrence of cancer.

If this patient had come to me prior to his biopsy, I would have told him to wait and treat his prostatitis first.  If he had come to me after his biopsy, I would have also told him to wait.  When you see 95% or higher control rates of cancer in the prostate with seeds it is hard to believe that this is represented failure.  Truth be told, it was way too soon after the implant to judge this.  I believe that if he had just waited, he would have been fine – the odds were in his favor.

Finally, it is extremely important for patients undergoing brachytherapy (seed implantation) to consult with a radiation oncologist who is an expert in this field and to trust them.  I would advise anyone in this situation to go to their radiation oncologist first, before they go trying other treatments would could potentially increase their side effects.

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