If prostate cancer has been diagnosed, graded and staged, there is much to consider before reaching a prostate cancer treatment decision. Patients often feel that they must make a decision quickly. However, it is essential that a patient allows adequate time to educate himself, and reaches a well-informed decision regarding his options. A patient should ask his cancer care team questions.
Ideally, seeking a second opinion with a radiation oncologist and brachytherapist (a radiation oncologist who specializes in brachytherapy) is worthwhile. Prostate cancer is a complex disease, and physicians may differ in their opinions.
Low Dose Rate (LDR) Seed Brachytherapy
Treatment of prostate cancer using seed brachytherapy was pioneered in the 1960s as an effective alternative to surgery. The word brachytherapy is derived from the Greek prefix brachy, meaning “short” or “close”, because the seeds containing radioactive material are implanted directly into the cancerous prostate gland.
Also referred to as seed implants or seeds, brachytherapy is a one-time, minimally invasive procedure usually performed in an outpatient setting under general anesthesia. The procedure itself involves the placement of tiny radioactive seeds inside the prostate using ultrasound equipment.
The seed implants immediately emit radiation and kill the malignant cells inside the prostate. The time it takes for the radiation to deliver its total dose depends on the seed (isotope) used. There are currently 3 isotopes commonly used in prostate brachytherapy: Cesium131, Iodine125, and Palladium103. Brachytherapy seeds themselves are compatible with human tissue. After the procedure, patients are taken to recovery and are typically discharged a couple hours later. Most patients resume normal activities within 24-48 hours.
The rise in the number of men diagnosed with prostate cancer has led to a growing need for improved treatment options that can offer excellent cure rates with minimal side effects at a low cost. Brachytherapy has numerous advantages over other treatment options.
Cure rates in low risk patients are equal to or better than surgery or external beam radiation therapy (EBRT). For intermediate and high-risk patients, brachytherapy combined with EBRT has resulted in superior outcomes when compared to surgery1, 2.
With the seed implant, there are no incisions or stitches required such as in the case of surgery. Furthermore, there is minimal, if any, post-operative pain3.
When looking at urinary side effects, incontinence rates are usually less than 1%4. For surgery, rates can be as high as 10%5.
Approximately 6-25% of patients who receive brachytherapy will experience a decrease in sexual function6 versus approximately 50% of patients who undergo surgery7. Erectile medications and other aids have proven to be very effective.
When compared to EBRT, patients undergoing prostate brachytherapy experience much lower rates of bowel irritation with prostate brachytherapy8.
Since brachytherapy is an outpatient procedure, no hospital stay is required. Furthermore, the seed implant is complete in one visit whereas a number of months are required to complete a course of external beam radiation. Patients are not required to take weeks off of work such as in surgery. As we see younger and younger patients with full-time jobs, it is important that they do not interrupt their work schedule for a prolonged period of time. Patients are able to resume normal activity within a day.
Blood loss during an implant is minimal when compared to surgery9.
When compared to prostatectomy (surgical removal) or many weeks of external beam radiation, prostate brachytherapy is the most cost-effective treatment10.
What is Brachytherapy?
With the widespread use of prostate-specific antigen (PSA) screening and increasing life-expectancy, more men are being diagnosed with localized, low-risk, low-grade prostate cancer. For men with small, localized prostate tumors, we offer a safe and effective treatment approach called focal therapy. Focal therapy is a general term for destroying small tumors inside the prostate, while preserving normal tissue and function.
Focal therapy is the middle ground between active surveillance and radical therapy, offering much less morbidity with cancer control. Focal destruction of cancer, with preservation of the surrounding organ, has already been used widely in the oncological treatment of kidney, liver, breast, and brain.
In a carefully selected patient, focal therapy can minimize side effects, including changes in urinary and sexual function. Such side effects with focal therapy may be less severe than those associated with more aggressive treatments.
We will perform a thorough evaluation to confirm that the prostate cancer is small and localized and that a more extensive treatment isn’t required to eliminate a larger or more aggressive tumor. This may or may not include undergoing a stereotactic transperineal prostate biopsy (STPB).
Following focal therapy, we’ll carefully monitor your progress with PSA testing and examination.
Active surveillance (expectant management) for men with prostate cancer is the postponement of immediate therapy, with definitive treatment (such as brachytherapy, external beam radiation or surgery) if there is no evidence that the patient is at increased risk for disease progression. Active surveillance is an accepted option for the initial management of carefully selected men with localized, well-differentiated prostate cancer thought to be at low-risk for progression. This means that men undergo periodic evaluations including PSA tests, digital rectal examinations (DRE), and prostate biopsies. If there is evidence that the cancer is growing, treatment is recommended with the intention of curing the disease. With appropriate surveillance, patients can be reclassified as being at higher risk for disease progression and receive definitive therapy without substantially decreasing the chance of cure.
Who are the best candidates for Active Surveillance?:
- Men who have the ability to live with cancer without worry reducing their quality of life
- Men who are willing to commit to the serial exams, PSA’s and biopsies
- Men who are most concerned about the potential side effects of treatments
- Men who value near term quality of life to a greater extent than any long term consequences that could occur
Each man should carefully weigh the potential loss of quality of life with treatment (radiation or surgery), against the possibility that the disease may progress requiring more aggressive therapy.
CPCC Active Surveillance guidelines:
- Stereotactic Transperineal Prostate Mapping Biopsy to ensure comprehensive results
- Gleason score 3+3=6 or 3+4=7 (if very low percentage of biopsy specimens)
- PSA less than 10 ng/ml
- No more than 2 positive cores or cancer involving no more than 50% of any core
- Prolaris score to measure the aggressiveness of the cancer
- PSA every 6 months
- DRE every 3 months
- Stereotactic Transperineal Prostate Mapping Biopsy every 2 years
Hormone therapy is a non-curative form of therapy. The end result is a decrease in testosterone level. This stops the cancer from progressing for a temporary time. Hormone therapy is often used in combination with IMRT or seed brachytherapy in high risk patients. It can also be used to reduce the size of the prostate gland prior to seed implant in a low risk patient. This type of therapy can be administered orally or via injection. Short-term side effects can include hot flashes, mood swings, fatigue and loss of sex drive. Long-term side effects can include weight gain, diabetes, osteoporosis, high cholesterol, breast tenderness and/or enlargement and possible cardiac complications.
- Klein, E. Cleveland Clinic Localized Prostate Cancer Registry. In low-risk prostate cancer, quality of life is key to treatment choice. Urology Times, August 1, 2008.
- Bittner, N et al. Interstitial brachytherapy should be standard of care for treatment of high-risk prostate cancer. Oncology. August 2008, p. 995-1017.
- Moran BJ, Gurel MH, Visockis J, Geary P. Post-operative pain and prostate brachytherapy. Int J Radiat Oncol Biol Phys 2003; 54: Issue 2 Supplement 0.
- Feigenberg SJ, Lee WR, Desilvio ML, et alL Health-related quality of life in men receiving prostate brachytherapy on RTOG 98-05. Int J Radiat Oncol Biol Phys. 2005 Jul 15;62(4):956-64.
- Steineck G, Helgesen F, Adolfsson J, et al: Quality of life after radical prostatectomy or watchful waiting. N Engl J Med. 2002 Sep 12;347(11):790-6.
- Robinson JW, Moritz S, Fung T. Meta-analysis of rates of erectile function after treatment of localized prostate carcinoma. Int J Radiat Oncol Biol Phys. 2002 Nov 15;54(4):1063-8.
- Frank, SJ et al. An assessment of quality of life following radical prostatectomy, high dose external beam radiation therapy and brachytherapy iodine implantation as monotherapies for localized prostate cancer. J Urol. 2007 Jun;177(6) 2151-6.
- Zelefsky MJ, Fuks Z, Hunt M, et al: High-dose intensity modulated radiation therapy for prostate cancer: early toxicity and biochemical outcome in 772 patients. Int J Radiat Oncol Biol Phys. 2002 Aug 1;53(5):1111-6.
- Rassweiler J, Hruza M, Teber D, et al: Laparoscopic and robotic assisted radical prostatectomy–critical analysis of the results. Eur Urol. 2006 Apr;49(4):612-24
- Quang et al. Technologic evolution in the treatment of prostate cancer. Oncology (21) 13. 1598-1603.
“My experience with Chicago Prostate Cancer Center has been exceptionally positive in every regard. It is scary stuff for the patient, and the positive tone for CPCC from the visual basics of external/internal design to the empathetic supportiveness and kindness of every member of the staff conveys to the patient a sense of comfort and the presence of expertise. Dr. Moran and his “operating staff” are superb in every regard.”
— John A. – Charleston, South Carolina