A blue heron poses in Charlotte Harbor, FL; Photo: BJ Gabrielsen
A updated review of brachytherapy by Dr. John Blasko of the Seattle Prostate Institute recently appeared in the May 2015 issue of the Prostate Cancer Research Institute (PCRI) Insights. Low dose rate brachytherapy for prostate cancer involves the insertion of small radioactive pellets (seed implants) into the prostate by transrectal ultrasound guidance in order to deliver a focused dose of radiation to the prostate. The seeds contain one of three possible radioactive isotopes, namely palladium-103, iodine-125 or cesium-137. While they have slightly different characteristics, they all emit a low energy radiation dose for a period of a few months and then become inert. This radiation dose is delivered to the prostate with very little reaching the sensitive surrounding organs such as the bladder and rectum. The seed implants have proven to be safe and effective for over 25 years. But how does brachytherapy compare with some of the other types of prostate cancer treatment?
Canadian researchers have recently completed analysis of a trial called ASCENDE-RT, a multi-center randomized trial of dose-escalated external beam radiation therapy (EBRT) versus brachytherapy for men with unfavorable-risk prostate cancer. A total of 276 men with high-risk disease and 122 with intermediate-risk disease all received twelve (12) months of androgen deprivation (hormonal) therapy (ADT) plus 46 Gy of whole pelvis external beam radiation (EBRT). Then half of the men (200) were randomly assigned to a conformal external beam boost of 32 Gy while 198 men were randomly assigned a brachytherapy boost of 155 Gy with iodine-125 seeds. Historically, seed implants have been used in one of two ways; as a stand-alone treatment for low-risk cancer or as part of a combination with modest doses of external beam radiation for intermediate and high-risk prostate cancer patients. In high risk cases, hormonal therapy (ADT) has also often been administered. Many radiation experts have contended that while seed implant boost is effective, the combination of hormones with intensity-modulated radiation therapy (IMRT) is just as effective and simpler to administer. The median observation time after radiation for the 398 men in the trial was 6.5 years enabling statistical projections to be made for 9 years. Using PSA measurements as success indicators, at 5 years, 77% of the men treated with hormone + IMRT alone were relapse-free compared to 89% of the hormone + IMRT + seed boost patients. At 9 years, the relapse free rates were more dramatic at 63% versus 83%, respectively. The researchers conclude that after 9 years of treatment, the PSA-based cure rate of the seed boost patients was improved by 20%! The rationale cited for this improvement is that brachytherapy delivers a higher and more effective dose of radiation to the prostate which is unachievable with external radiation alone. If prostate cancer survival were used as a study endpoint, no difference was seen between the seed boost and the EBRT alone groups. However this may be the case because not enough follow-up time has elapsed for PSA failures to manifest mortalities. An additional 6-7 years of follow up for the PSA failures would be required to translate into survival statistics.
Other innovations have occurred in the application of brachytherapy. Quality of life studies have demonstrated the favorable side effect profile of brachytherapy compared to surgery or IMRT. In addition, transrectal ultrasound imaging has made tremendous strides in clarity of images. There is now also the capability of merging and coordinating MRI imaging with transrectal ultrasound thus increasing the fine control of seed placement. The control of radiation doses to the urethra, bladder and rectum is also greatly improved. Comparative cost and effectiveness analyses by the Institute for Clinical and Economic Review at Harvard University concluded that brachytherapy for low-risk disease is the most effective and least expensive initial treatment compared to IMRT, proton beam or surgery. While the use of brachytherapy has decreased from 2002-2010, use of surgical and other treatments have increased primarily due to the introduction of new expensive technologies such as robotics, IMRT and proton beam. While these new approaches may generate more revenue for hospitals and physicians, the popularity of brachytherapy is growing rapidly in many countries where medical reimbursement costs are fixed. The author of this review concludes that “multiple studies over the past 25 years have demonstrated that brachytherapy either alone or in combination with external beam radiation is as effective and, – particularly in intermediate and high-risk disease -, superior to prostatectomy or IMRT alone for cure and potential quality-of-life. The ASCENDE-RT prospective, randomized trial proves the superior cure rates attainable with seed implantation.” It is also cost-effective.
The content of this post is for informational purposes only. Please discuss it with your personal health-care provider as needed.
Prostatecancer911.com is a website administered by Dr. David Samadi, a graduate of Stony Brook University Medical School, currently serving at Memorial Sloan Kettering Cancer Center in New York. Dr. Samadi’s specialties include prostate cancer treatment, robotic prostate surgery, SMART surgery technique and bladder and urologic cancer treatment. The website discusses the pros and cons of various forms of treatments and is a good introduction for newly-diagnosed men. Dr. Samadi is a frequent guest on health programs especially on the FOX News network. This information has also been included in the Medical Resources Section of this website.
Sulforaphane is a compound found in cruciferous vegetables such as broccoli. Researchers from Oregon State University and the Texas A&M Health Science Center report in the journal Oncogenesis (2014, Dec. 8;3:e131) a potential benefit for sulforaphane in treating metastatic prostate cancer. While a number of previous investigations have suggested a protective role for the compound, the current study adds additional evidence to the possible effectiveness of sulforaphane in cancer therapy. Researchers have identified an enzyme, SUV39H1, in prostate cancer cells that is affected by exposure to the compound. The amounts of sulforaphane provided by eating foods themselves are insufficient for cancer treatment, which would require supplemental doses. An on-going trial involving the use of sulforaphane in men at high risk of prostate cancer will determine the safety of high-dose supplements.
One of the “worries” associated with prostate cancer is dying from it which around 24,000 men do annually. One always hears that bone pain is the worst kind as it is difficult to medicate. However, there is help and hope available as described in the recent article below published under “prostatesnatchers” to which I recommend one subscribes. By the way, I recently participated in the meeting mentioned below sponsored by Bayer Pharmaceuticals. One of the strong messages emanating from this on-line meeting was the need to facilitate and encourage better communication between prostate cancer patient and his physician(s).
Posted: 09 Jun 2015 09:55 AM PDT
BY MARK SCHOLZ, MD
Many men tell me that they fear the process of dying—suffering and experiencing pain—more than they fear death itself. While I am no fan of pain, as a medical oncologist I have been responsible for the treatment of hundreds of patients with terminal cancer. I have learned that with good communication and proper medical management, pain can almost always be effectively controlled.
However, when reviewing the results of a recent patient survey at a meeting sponsored by Bayer Pharmaceuticals with a number of patient advocates, healthcare experts, and other physicians, it became sadly apparent that many patients are not being managed expertly. The survey indicated that many men with advanced cancer are suffering needlessly, mostly due to a lack of good communication with their doctors.
This survey of 410 men with advanced prostate cancer reported that two-thirds of men are trying to handle their pain by ignoring it! One-third of all the men surveyed felt that acknowledging pain made them more fearful, raising anxiety about the possibility that their cancer is progressing. A quarter of the men said, “It was difficult to talk about their pain,” relating that such discussions made them feel weak.
In other words, these men are using a common psychological defense mechanism called “denial.” One thing I have learned from years of experience treating patients is that denial can be a wonderful approach, but only if the situation is totally hopeless. I have observed men who appear to be in denial who are quite happy even when everyone knows that they are dying.
On the other hand, denial is a serious problem if what is being denied, in this case pain, can be fixed or remedied. If men who are in denial fail to discuss pain with their doctors, their access to a solution is blocked.
Using denial can effectively control pain for short periods of time, however, using it on an ongoing basis is psychologically exhausting. Also, while denial might work for the patient, it can’t fool their surrounding loved ones. They see the effects of pain in the patient manifesting as fatigue, depression, inactivity, impatience, insomnia and hopelessness. Ultimately, the caregivers who are not shielded by denial end up suffering even more than the patient.
Cancer patients experience pain from multiple causes, not just their cancer. Invariably, life itself is painful. However, most types of cancer pain can be resolved. The first step is to acknowledge its existence. The second step is to diagnose whether the pain is cancer-related. In the prostate cancer world, cancer-related pain is usually the result of bone metastases. Of course, not all bone pain is from cancer and not all bone metastases cause pain. If a man has pain in one of his bones and a bone scan shows a metastatic lesion in the exact same area as where the pain is occurring, then the probability is high that the pain is cancer-related.
The third step, once it has been confirmed that the pain is cancer-related, is to undertake the appropriate treatment. How to treat cancer-related pain is a topic big enough for another blog all its own. In my next blog I will also elaborate further on the correct medical approach used to distinguish cancer pain from non-cancer pain.
Someone has said, “Not knowing what to do is the worst kind of suffering.” Helping men find a workable solution for pain not only relieves their pain, but it also releases them and their caregivers from the uncertainty and anxiety that comes from not knowing what to do.