Prostate Cancer Overview and Treatment Choices

PROSTATE SEED BRACHYTHERAPY

Brachytherapy is the most effective radiation treatment for prostate cancer and has the the highest patient satisfaction regarding sexual function.1, 2, 3

Brachytherapy is performed as a simple outpatient 45 minute procedure under general anesthesia. Patients return to all activities the following day. There is no risk to spouses, children or pregnant women from the brachytherapy seeds.

1. Eur J Cancer. 2015 Nov;51(16):2345-67
2. Brachytherapy. 2015 Mar-Apr;14(2):142-7
3. Can Urol Assoc J. 2013 Jan-Feb;7(1-2):51-8

 

Prostate Cancer in the U.S.

According to the most recent statistics available from the American Cancer Society (2010), Prostate cancer is the second most common cancer found in men and is the #2 cause of male cancer death. As of 2010 there are approximately 217,730 new cases of prostate cancer diagnosed annual and 32,050 men die annual form the disease. More than 2 million men who have had prostate cancer at some point are still alive today. The good news is that the death rate from prostate cancer is decreasing and it is being found earlier. Most clinicians agree that improvements in screening technologies and treatment options are contributing to these improved outcomes.

  • #2 cause of male cancer death
  • 217,230 new cases per year
  • 32,050 deaths per year
  • 75% gland confined at diagnosis without evidence of spread

Taking an active role in your treatment plan is the first step in making an informed decision about your health. There may be more than one treatment option to choose from and doctors may differ in their opinions about the best way to treat your particular cancer. You should take some time in coming to a decision about your treatment and weigh the potential outcomes with common side effects of each treatment option. Your quality of life during and after your treatment should be well considered. You should take into account the following factors when assessing each treatment option.

  • Age (and anticipated life expectancy)
  • Overall health condition
  • Treatment goals (relive symptoms and minimize side effects)
  • Ability to tolerate side effects
  • Time commitment to treatments
  • Insurance coverage or treatment costs

 

An Overview of Treatment Choices...

Watchful Waiting - Is It Logical or Suicidal?

Since prostate cancer can be slow growing your doctor may suggest watchful waiting as one way to manage your cancer. Typically suggested for older men or those with more complex health problems watchful waiting includes frequent visits to your physician. They may perform regular PSA tests, rectal exams, and ultrasounds to see if the cancer is growing. It is important to note that not all physicians mean the same thing when speaking of 'watchful waiting' so it is extremely important to have a clear discussion with your physician.

Article highlights;

  • "Population based studies in Sweden and Denmark have shown that 62% and 63%, respectively, of patients diagnosed with localized prostate cancer will die from the disease if not treated immediately." Labrie F. Prostate 2000 May 15;43(3):215-22(Laval U)
  • "In the watchful waiting group there was a 52% likelihood of treatment initiation within 5 years of the diagnosis." Koppie T et al. J Urol 2000 Jul;164(1):81-8 (UCSF)

 

Radical Prostatectomy (Surgery)

If your physician determines that your cancer is confined to the prostate gland they may recommend surgery. In a radical prostatectomy your surgeon will make a small incision or cut in order to gain access to your prostate. The prostate gland and a small amount of the surrounding tissue will be removed. You may be under general anesthesia (asleep) or you may be given medicine to numb the lower half of your body. The average hospital stay is several days and you should expect to spend 4-6 weeks away from work. After your surgery you will require a catheter for 1-3 weeks to allow you to urinate comfortably while you heal. The catheter will be removed at a follow-up appointment.

Laparoscopic radical prostatectomy also called robotic assisted prostatectomy has been gaining in popularity in some areas. The surgeon sits at a computer screen away from the patient and controls robotic arms that cut away the prostate through many small incisions or cuts. There is little difference to the patient in terms of the surgical experience however the recovery times may be slightly less. The most important factor should you choose this form of treatment is the experience of your physician using this equipment. You should understand how many procedures your physician has performed prior to agreeing to this treatment path.

With either of the above approaches you should carefully weigh the risks of surgery as a treatment option. As with all major surgical procedures, there is a risk associated with the use of anesthesia, as well as a risk of heart attack or stroke, bleeding problems or infection as a result of the surgery. The major side effects of surgical removal of the prostate are incontinence (loss of control of urination) and impotence (in ability to obtain or maintain an erection sufficient for sex). Since the nerves for bladder and sexual function run close to the prostate there is a risk of damaging one or both of these nerves. This damage is often permenant.

 

Radiation Therapy

Two forms of radiation therapy are available for the treatment of prostate cancer, internal or external. Both forms of radiation therapy employ a form of radiation to kill the cancer or shrink the tumor that is similar to an x-ray. External radiation therapy, also referred to as EBRT (external beam radiation therapy) and IMRT (intensity modulated radiation therapy) target the cancer from outside the body. Radiation therapy may be used along or in conjunction with the surgical removal of the prostate in order to remove any potential traces of cancer from the surrounding tissue. Radiation therapy, radical prostatectomy and brachytherapy have similar cure rates for early stage prostate cancer.

If you are considering external radiation as a form of treatment for prostate cancer you may want to consider the time commitment to treatment. While each treatment only lasts for approximately five minutes, these treatments are typically given 5 days a week over the course of 7 - 9 weeks. Possible side-effects to consider are bowel problems which are present in 10% - 20% of men and tend to dissipate over time, bladder problems or the need to urinate more frequently, impotence is roughly equivalent to that of surgery, lymphedema or fluid build up in the groin and legs, and a general feeling of tired for a few months after your treatment is concluded.

 

Brachytherapy

Brachytherapy treatment involves the placement of radioactive seeds, approximately the size of a small grain of rice into the prostate. Approximately 60 - 120 seeds are implanted through small needles into the prostate gland during this 1 hour outpatient procedure where you will be given either spinal or general anesthesia to make you completely pain free during the procedure. Your physician may request that you visit the facility a few days prior to the treatment in order to obtain current PSA scores and other data that will help in creating a treatment plan for you.

Since brachytherapy is considered a minimally invasive procedure these treatment are often given in an out-patient facility. Using ultrasound guidance or computer aided planning the seeds are placed in the prostate and arranged in a way to give off a uniform dose of radiation delivered exactly where it is needed. The seeds will remain in place after the procedure and slowly lose their radioactivity. Radiation safety precautions with palladium seeds are minimal. Contact with children and pregnant women is safe for all. It is recommended that you hold nursing age babies on your shoulder and not on your lap for the first month after the implant. Your doctor will discuss in greater detail specific precautions you should be aware of. You may return to normal activities in several days or strenuous activity may be restricted for a short period of time as you heal.

Should you choose brachytherapy for your prostate cancer treatment you should talk with a specialist regarding their particular approach to brachytherapy. The side effects for brachytherapy are lower than for other forms of treatment.

Dr. Doggett specializes in the use of computerized intraoperative treatment planning. To learn more about the specific benefits of this approach click here.

Article highlights:

  • "The brachytherapy study reported here, based on thousands of PSA determinations and a high post implant biopsy rate, documents that interstitial radiation is an effective treatment for early stage prostate cancer. Brachytherapy achieves long term disease free survival rates that are comparable to the best results reported from radical prostatectomy series and substantially better results than reported from conventional external beam therapy." Modern Prostate Brachytherapy CA Cancer Journal for Clinicians 2000;50:380-393 Ragde H. et al
  • "Long term results for ultrasound guided transperineal radioisotope prostate cancer seeding exist and based on PSA measurements appear to be equivalent to the results of comparable radical prostatectomy series and superior to the results of external beam radiotherapy series." What is the Role of Interstitial Brachytherapy? Doggett, SW in: Bowsher, W., Peeling, W., editors. Challenges in Prostate Cancer . 1st ed. Blackwell Science, London, 2000

Summary Permanent Seed Brachytherapy

  • PSA results equivalent to surgery, better than external beam
  • Urinary continency rate higher than surgery or external beam
  • Sexual potency rate higher than surgery or external beam
  • Shorter recovery time than surgery
  • Outpatient procedure
  • Less patient discomfort
  • Cost competitive
  • Surgery candidates are all seed candidate

Comparison Summary

  • PSA control rate for seeds and surgery is the same
  • PSA control rate for external beam radiation seems to be lower than for seeds or surgery
  • Urinary incontinency and sexual impotency rates are better for seeds than for surgery or external beam radiation
  • Recovery time for seeds is much shorter than for surgery