Dynamic Adaptive Radiation (DART) is cutting edge arsenal of technologies utilized in combination for truly "individualized" 4-Dimensional IG-IMRT treatment delivery. This involves using up-to-the-moment "captured" image data to adapt a patient's treatment to constantly evolving information which occurs during a 4D IG-IMRT treatment course. It is well known that changes such as tumor position, size and shape occur not only during a several week treatment regimen, but also on a daily basis when patients are undergoing treatment. DART allows us to realize the single most important goal ever achieved with radiation therapy: Delivering the exact dose to the exact place at exactly the precise time, every time, even when the target (tumor) moves, shrinks or changes shape - a revolutionary and unprecedented accomplishment in the treatment of prostate cancer!

No. This is truly one time in your life when the newest and best technology will not cost you more than the older, more common approaches. In fact, in terms of a cure and quality of life, you'll get more for your money. Most of the costs of brachytherapy and DART are covered by Medicare and most major insurance plans.

There has been much discussion of what constitutes a cure, or biochemical freedom of disease. Many physician practices have tried to assign a specific PSA nadir (lowest point) to identify the patient as ''cured''. However while a low PSA is important, the goal is not merely a low number but a cure in practical terms. Patients should be cautious of being over-treated just to achieve a low PSA result. Over-treatment may mean a more aggressive protocol than necessary to effectively eradicate the cancer.

The Dattoli Cancer Center considers a patient "cured" when his PSA is significantly reduced and remains at that reduced level consistently for the remainder of his life. Most patients achieve a PSA of <0.2, although this is not mandatory. For example, a particular patient of Dr. Dattoli''s has had a PSA of 2.0 for 18 years. We certainly do not think his treatment failed! For the purpose of determining our success rate in published studies, we employ a strict nadir cutoff of PSA of <0.2 for the purpose of comparing our results with the published results of other treatment modalities. A PSA of <0.2 is what is expected of successful treatment with radical surgery which removes the prostate gland, the primary source of PSA. With radiation therapy, the prostate gland is not removed and continues to secrete some PSA into the bloodstream after treatment. In terms of our published results, we hold ourselves to a higher standard than most other non-surgical treatment centers.

The Dattoli Cancer Center is the only place in the world that offers this combination of leading edge technologies and pioneering medical specialists. Dr. Dattoli has more experience in brachytherapy than any other practicing radiation oncologist in the world. Dr. Sorace has been at the heart of research and development in this field for over a decade. The breadth of our diagnostic and treatment technology is unmatched anywhere.

The success rates of our team have been documented. Highly respected in their field, both doctors have been widely published and are in great demand as lecturers. Despite their many obligations, they have maintained their primary mission and focus: to provide the very best cancer care available - one man at a time.

The color-flow Doppler prostate ultrasound, introduced to the west coast of Florida by the Dattoli Cancer Center in 2000, brought a new perspective to diagnosing and treating prostate cancer. The Doppler technology reveals sites of suspected tumor growth indicated by brilliant color areas of increased blood flow within the gland. This information is crucial in planning the prostate biopsy, as it gives the physician color targets for the biopsy cores. Most biopsies for prostate cancer are performed utilizing conventional transrectal ultrasound equipment which portrays images in hues of grey, resulting in randomly spaced biopsy cores that may often miss a cancer entirely.

With the recent addition of a brand new Sonocubic computer program, physicians at Dattoli Cancer Center can look at suspected tumor growth from 360 degrees, rotating the image on the monitor to view the transparent structure from all sides, and enhancing the information needed to perform the all-important biopsy. Additionally, this same sophisticated technology is used for therapeutic reasons (that is, for patients who have already had a biopsy) allowing for the pinpoint targeting of cancerous lesions when using both DART with 4D image-guided intensity modulated radiation (IG-IMRT) and brachytherapy (seeding).

A metabolic workup involves a number of tests that tell us whether or not the cancer has spread beyond the prostate gland. This is crucial in deciding on the type of treatment that will be appropriate for each patient. Historically, prostate cancer has been both under-staged and under-graded, which means that the extent and severity of the disease has often been underestimated, and therefore, not adequately treated. To enhance your opportunity for cure, we believe that we should turn over every stone possible, using the most sophisticated techniques to assess every case, including 3-D color flow Doppler ultrasound, MRI of the prostate with endorectal coil or spectroscopic vs. dynamic MRI, helical scans to evaluate lymph nodes, special blood tests, bone scans, Prostascint®/Fusion studies, and Combidex® or Sinerem® MRI as indicated. Remember, even if we find something serious as far as the spread and/or aggressiveness of the disease, this will be addressed with an appropriate form of therapy tailored for each patient. At other centers where the workup is not adequate, where the tests are not as extensive, it is what is not found and not treated which can later come back to haunt the patient. We believe in the most comprehensive testing with all of our patients to avoid that kind of unacceptable outcome.

As we are dedicated to finding the most appropriate cure for each patient, we will certainly be willing to schedule a consult with you to determine what we might be able to do to help you. There are a number of possible options that can be considered if a patient experiences biochemical failure (rising PSA or other indicator) after having been treated at another center with external beam radiation or brachytherapy. As a rule of thumb, the earlier a recurrence is detected, the better the chances that a "salvage therapy" can lead to a cure.

"Radio-resistance" is an out-dated term from the early years of conventional radiation therapy, or even 3-D conformal radiation which was the state-of-the art in the 1990s. It's highly unlikely that any tumor can survive the extraordinary, yet safe, doses delivered by DART with 4D IG-IMRT combined with Palladium-103 (Pd-103) brachytherapy. With these combined therapies, tumors often receive in excess of 20,000 cGy. In addition, in many cases, hormonal therapy prior to radiation has been shown to enhance the radio-sensitivity of the cancer, making treatment all the more effective.

Yes, however, not DART with 4D IG-IMRT alone, but salvage palladium seed implantation plus/minus abbreviated DART may well be a viable option for you. Your case will be carefully evaluated to determine your candidacy. Hormones are typically used prior to the seeding. Dr. Dattoli has performed salvage seeding for over 15 years.

Yes. DART utilizing 4D IG-IMRT will provide the lowest dose to healthy tissue and organs surrounding the prostate, minimizing the risk of side effects, and give you the best shot at a cure. In this type of case we often utilize hormones in conjunction with external radiation.

Drs. Dattoli and Sorace have pioneered unique designs to allow seed implantation even in these more challenging situations involving previous TURPs. Each patient is carefully evaluated to determine their candidacy for seeds and to minimize potentially unwanted incontinence.

The argument that there is insufficient long-term follow-up date for brachytherapy is patently false. In fact, a number of studies of seed implantation, including Dattoli et al. (ASCO 2009), and Sylvester et al (2007) have mean and medium long-term follow-ups that surpass all surgical series published in the PSA era. In this regard, outstanding results (biochemical outcomes) have been reported for younger patients with brachytherapy and this group has the most to gain (reduced risk of urinary incontinence and/or erectile dysfunction). In our practice, we commonly treat men in their early 40's (as well as patients in their 50's, 60's and older). Younger men, after all, have the most to lose in terms of quality of life - becoming impotent and/or wearing diapers for decades.

Absolutely not – the opposite is true! It is extremely rare for patients to have local relapse when treated initially by our team. However, if the cancer should return in the prostate (local recurrence), patients still have a full menu of options including reseeding, surgical removal (by an expert), cryotherapy, biothermy, HIFU and hormonal therapy, not to mention vaccine therapies and other innovative treatments that are on the way. If you decide you want salvage surgery, there are a number of highly proficient surgeons around the country, though we may not recommend your local urologist. Some urologists are reluctant to take on patients who have been previously treated with radiation, and many surgeons lack the expertise and experience to perform the operation. As such, selecting the very best doctor for salvage prostatectomy - an "artist" with a proven track record -- significantly improves your chances for a successful outcome.

A more difficult situation is likely to be encountered by the patient who chooses surgery first and experiences a recurrence, since there are fewer treatment options left after the prostate is removed. Following surgery, many patients are faced with a rising PSA, which indicates treatment failure. It is often unclear whether the PSA is rising due to cancer left behind in the prostate bed versus cancer in the blood stream. Patients are typically given the benefit of the doubt and are treated to the prostate area with local radiation. Doctors can’t treat the entire body with radiation, so the likelihood of cure is diminished if the cancer has spread beyond the prostate. Salvage therapy may also lead to increased side effects with damage to bowels, bladder and urethra, while the overall chance of curing the patient lies only between 10-30%, depending on how quickly after surgery the recurrence is detected an how high the patient's PSA level has risen. Better results may be achieved when more advanced, tailored radiation (DART/4D IG-IMRT) is utilized rather than conventional "broad beam" radiation, which is more commonly utilized for post-surgical salvage therapy..

After DART with 4D IG-IMRT and/or seeding, if the PSA rises indicating recurrence, there are numerous salvage options available, including but not limited to re-seeding, cryosurgery (or in some cases "focal cryosurgery", biothermy (combining heating and freezing), HIFU, as well as salvage prostatectomy by an experienced surgeon.

As mentioned earlier, the risk of impotence and/or incontinence is greatly reduced with DART and seeding, in comparison to the risks resulting from surgery. The open surgical procedure typically requires hospitalization and a lengthy recovery period. Because most surgeries require a major incision, there is an increased risk of infection and other surgical complications. While still controversial and unproven with long term results, newer laparoscopic and robotic techniques even increase the length of the procedure, thus increasing the risk of potential complications (blood clots to the lungs, infection). Many laparoscopic/robotic procedures are aborted and converted to the more formal open surgery when vessels are nicked or when the rectum is lacerated. At our center, we have published superior results with combination therapy (brachytherapy and external radiation with or without hormones) with intermediate and high risk patients (Stage T3, PSA >10, Gleason Score 7-10, elevated PAP) compared to surgery -- with more than 82% of these patients enjoying successful long-term outcomes. Many of these patients would be considered incurable with conventional or robotic-assisted surgery. With our combined radiation protocol, the vast majority of patients are cured within 6 years, while even the best surgical teams such as Johns Hopkins continue to have late biochemical treatment failures 10 and even 14 years after surgery.

It should be noted that the limitations of the open radical prostatectomy also apply to laparoscopic and robotic surgical techniques: the operation is necessarily performed "in the blind," in the sense that the patients' workup tests do not allow the surgeon to know with any certainty in advance whether or not the cancer has spread beyond the prostate gland. In other words, the risk of having "positive surgical margins" is the same regardless of which surgical technique is used. In our opinion, this means there is an unacceptably high risk of failure with all forms of radical surgery.

Yes, there are many published series that make the case for seeding over surgery. While there are no randomized studies comparing the different types of treatments, numerous independent studies have contrasted statistical data from both options (seeding and surgery), comparing the results of different specialities as reported by the leading practitioners at centers of excellence. For low-risk patients, brachytherapy with or without external radiation appears to be comparable to surgery as far as likelihood of cure, but with less risk of serious, long-term complications. For intermediate and high risk patients, a number of recent studies have shown brachytherapy, especially when combined with the most sophisticated external radiation, to be significantly more effective at curing prostate cancer than surgery, and again, with a much lower risk of long-term side effects (ie. erectile dysfunction and incontinence).

Follow-up studies have been in place since the beginning of our practice in 1990. Other large programs, including the Taira et al at the University of Washington in Seattle reported in 2010 a greater than 90% seeding success rate after 12 years of follow up with seeding alone. Our data, using combination external beam and seeds, has demonstrated a greater than 80% success rate after 16 years even with patients having locally advanced, high-risk malignancies (Stage T3, PSA > 10, Gleason Score 7-10, elevated PAP) while patients having early or intermediate stage disease have enjoyed a greater than 90% success rate. (Note that the longest surgery data follow-up is only 15 years from Johns Hopkins and the "median follow-up" on our patients is longer than any surgical series. Using Dr. Patrick Walsh's data from Johns Hopkins, Pierorazio et al reported in 2010 on high risk surgical patients as indicated by Gleason score, concluding "The results of our study have shown that 80% of the men with Gleason sum 8-10 who undergo RP will have experienced biochemical recurrence by 15 years" (Urology. 2010 Mar 27).

Bittner et al conducted a previous retrospective study at the University of Washington and concluded "A thoughtful review of the literature would suggest that interstitial brachytherapy offers a therapeutic advantage over other local treatment modalities and should be considered standard treatment for aggressive organ-confined prostate cancer" Oncology, Williston Park, 2008 Aug;22(9):995-1004).

We believe that a seamless, coordinated treatment plan, combining external beam radiation and seeding, offers the best results for our patients. The unique configuration of technologies available here is designed to work together, so the external radiation plan (DART with IMRT) and brachytherapy planning perfectly complement each other. It would be very difficult to integrate another center's therapy with the combinations we have here. Indeed, most other centers do not have the most advanced diagnostic and treatment technologies that we utilize on a daily basis. Even though many centers now offer IMRT, we are not aware of any that possess the combination of latest generation technologies to deliver true DART. Our highest level of confidence rests in our own ability to provide you with the very best treatment available anywhere in the world.

High Dose Radiation (HDR) brachytherapy commonly refers to temporary catheter insertion into the prostate using Iridium-192, which is a very penetrating isotope (radiation spreads far from the isotope), expending the dose quickly and therefore with a potential risk of irradiating all neighboring tissue and organs. This is NOT a new form of brachytherapy, although it is currently being promoted as such. In fact, Dr. Claude Henschke at Memorial Sloan-Kettering Cancer Center was using it in 1963, with the only difference being that he did no have today’s microprocessors and imaging techniques available to him. There is less long term data available on temporary HDR outcomes and side effects compared to the permanent Pallidium-103 seed implants that we utilize. We believe there may be greater risk of complications with HDR brachytherapy because of the extremely penetrating high dose of radiation delivered by Iridium-192 (1000 to 2000 cGc in a matter of minutes, affecting the entire body). HDR also poses challenges of convenience for the patient and practicality. If performed in one session, the patient must remain in a semi-lithotomy position (legs pulled up) for as long as 72 hours, with needles remaining in the prostate throughout that duration.

Bear in mind that 4D IG-IMRT with DART is also a form of high dose rate radiation employing micro-beamlets precisely targeting the affected area(-s) in minutes, but without affecting surrounding normal tissues as does HDR brachytherapy. We believe that this degree of pinpoint accuracy with HDR 4D IG-IMRT makes HDR using Ir-192 with catheters obsolete. Meanwhile, we also believe that the use of both High Dose Rate IG-IMRT coupled with ‘round the clock’ (for 3 months) Pd-103 treatments provides the best of both worlds. Essentially, we are exposing the cancer to two different complementary forms of radiation in order to provide the greatest chance of cure. Cancers don’t like change, which is why we deliver this one-two punch from two different radiation sources!

Proton Therapy is a form of radiation therapy that utilizes protons rather than photons to treat cancers, though protons are often combined with photons using a technique known as "proton boost." Proton Therapy cause fewer complications than does traditional external radiation therapy (EBRT), but its precision in sparing healthy tissue is now surpassed by 4D IG-IMRT with DART and/or brachytherapy in the most skilled hands This is especially true in light of the inverse treatment planning used with 4D IMRT and Image-Guided IMRT (4D IG-IMRT) made possible by SonArray™, Portal Vision electronic On-Board imaging, Portal Dosimetry, cone beam helical CT tomography and respiratory gating, which are all state of the art methods of motion management, none of which are currently available with proton therapy.

It should be emphasized that the radio-biological effect (RBE) of protons (its cancer-killing properties) is nearly identical to the high-energy photons that we utilize at our center with 4D IG-IMRT. This being the case, we strongly favor 4D IG-IMRT with DART in view of the highly sophisticated beam arrangements which are utilized, state-of-the-art prostate immobilization and far more mature data which has been accrued with high energy photons in general. Published series have already demonstrated advantages of IMRT to 3-D conformal radiation at high dose levels. Meanwhile, we are not aware of any proton series utilizing higher doses than 3-D conformal radiation, which delivers significantly lower doses than IMRT.

The preponderance of data indicates that higher doses equal higher cure rates. It is not yet possible to safely escalate protons to doses as high as those used with IMRT -- not to mention 4D IG-IMRT coupled with a Palladium-103 boost. There is compelling evidence demonstrating that it requires far higher doses of radiation to eradicate prostate cancer than the current dosimetry associated with protons (even when combined with photons). These higher doses are accomplished with 4D IG-IMRT and Pd-103 which also have the advantage of maximally sparing adjacent normal tissues while escalating doses to specific tumors within the prostate gland. Neither of these goals can be achieved with protons.

We believe that the utility for protons resides in the treatment of tiny brain tumors, not prostate cancer -- due to the size and location of the latter and the inability to maximize the effect in the prostate of what is called "the Bragg Peak" (basically, the characteristic pattern of energy deposition occurring when a charged proton particle moves through matter). Because of the physics, side effects with protons are likely to be much higher even at lower dose levels than with high energy photons. This actually contradicts what many patients are currently being told by advocates of Proton Therapy. This is another area where patients are well-advised to do their homework when it comes to evaluating novel treatments that are not supported by long-term studies.

No, because with Palladium-103 the patient is already receiving 3 times the dose that Iodine-125 delivers without risking the higher rates of rectal, bladder and urethral injury that have been reported historically when doing seeds first, followed by radiation. There are a few centers that use this approach and have published results, but with a paucity of data on long-term side effects. For further discussion, see "Why not seeds first?"

We prescribe hormonal therapy to patients when appropriate on a case by case basis. IIt has long been known that prostate cancer is to some extent dependent on and nourished by the male sex hormone, testosterone. This is one of a group of hormones known as androgens. Since testosterone stimulates the growth of prostate cancer cells, depleting or ablating the body's testosterone tends to shrink the size of many tumors, specifically, those that are hormone-sensitive.

The goal of hormonal therapy is to decrease the production of testosterone in the body, inhibiting the growth and progression of the cancer. Hormonal therapy, also known as Androgen Ablation Therapy (ADT), can shrink a man's prostate by 50%. When combined with radiation therapy, hormones have been shown to make cancer cells more sensitive to radiation therapy (known as "radiosensitization"), significantly improving outcomes for high risk patients.

Hormonal treatment is typically optional for patients having intermediate risk features (as indicated by Stage, PSA, Gleason Score, and PAP results) but encouraged for patients having high risk features. With the low-risk or mildly aggressive cancers, unless the size of the gland is markedly large, we don't normally give the conventional hormonal therapy (combined hormonal blockage using an anti-androgen and an LHRH agonist), since this form of therapy may result in typically temporary although potentially longer lasting unwanted side effects such as erectile dysfunction, hot flashes and potential weakness or fatigue.

We often prescribe a milder, modified version of hormones which do not reduce testosterone but rather act as blocking agents (e.g. oral anti-androgens), not allowing the testosterone to bind with the prostate cancer cell receptors. These drugs are commonly combined with other oral agents (e.g. 5 alpha-reductase inhibitors) which do not allow testosterone to convert to dihydrotestosterone (DHT), a metabolite which is 10 times as potent as testosterone in stimulating prostate cancer growth. This type of hormonal therapy is just enough to arrest the cancer and allow the patient to make a more relaxed decision about treatment, without the side effects associated with more aggressive forms of ADT. Hormonal Therapy is often administered intermittently for 6 to 12 months. With Intermittent Hormonal Therapy, the patient's testosterone level recovers and his quality of life (QOL) improves dramatically.

Absolutely not. This treatment modality is FDA and Medicare approved and is a highly sophisticated by-product of prior radiation delivery systems. Many recent studies have shown that it is possible to escalate doses significantly with IMRT in order to more effectively eradicate the cancer, while dramatically decreasing morbidity (unwanted long term side effects).

No, and patients are advised to take careful note of this in order not to be mislead by false claims. Many centers that advertise IMRT, actually have early generation equipment that is aleady obsolete. Some centers even describe 3D Conformal Radiation technology as "IMRT". It’s one thing for a center to offer IMRT, but it’s another to demonstrate DART capability, where every microbeam has actually struck the desired target which is moving, and smaller than the size of a dot. Only with the most sophisticated ancillary equipment can such a claim be made. As describe elsewhere on this website, that advanced DART/IMRT technology includes but is not limited to On-Board Imaging, image-guided 3D ultrasound and camera-based SonArray™, Exact Couch, Portal Vision, real-time cone beam helical tomography, respiration synchronized image acquisition for motion gating, Portal Dosimetry and real-time 4D physician review. Only with that specialized combined of advanced technology can such a claim be made. This is the basis behind genuine DART realize with 4D IG-IMRT.

Brachytherapy can be successfully utilized as the sole treatment for many patients who have been diagnosed with very early stage prostate cancer. After exhaustive research, patients learn that additional 4D IG-IMRT with DART at our facility doesn’t add to toxicity (side effects) but provides an umbrella of safety in the event that the cancer has made egress (leaks) into the tissues immediately outside the prostate, which is the case in 15-20% of even the most favorable, low-risk presentations. This is not piling on the radiation or giving a lot of both but rather a little of each - a blend which we consider more thorough than seeds alone or external radiation alone. For intermediate or advanced stage tumors, to achieve optimum results, brachytherapy is typically prescribed in combination with other kinds of treatment such as, for example, 4D IG-IMRT with DART, hormones, etc. Most patients make that choice by comparing the cure rates and risk of side effects with the other types of treatment currently available.

Having the availability of each type of therapy at a single center allows our physicians to design and tailor a treatment plan specifically for each individual case (versus a one-size-fits-all approach). Patients have the advantage of using an appropriate combination of hormones, DART with 4D IG-IMRT radiation and/or brachytherapy with or without hormones to achieve the greatest likelihood of cure. Note that cure rates have improved with most cancers, e.g. breast, lung and colorectal, etc. when using not one but two or three differing treatment modalities. In particular, cancer are especially vulnerable to when more than one kind of radiation source is utilized - cancers don’t like change!

4D IG-IMRT, or 4-Dimensional Image-Guided Intensity Modulated Radiation Therapy, takes 3D Conformal Radiation Therapy (3D-CRT) to a new level of precision and control. This revolution modality is also sometimes called IGRT, or Image-Guided Radiation Therapy. With this increased level of precision where microbeams are literally striking targets the size of a dot (referred to as a “voxel”), we are able to deliver increased doses to the cancer while reducing the risk of damage to the bowel and bladder while maximally preserving erectile function.

Historically, 3D-CRT was widely utilized during the 1990s and achieved very favorable results at 10 years and longer, with cure rates comparable to those achieved by radical surgery. Since that time, this relatively advanced technique for delivering external radiation has been surpassed by innovations in delivery and real-time imaging made possible by IMRT. With the increased radiation doses delivered and enhanced accuracy, 4D IG-IMRT has enabled the realization of DART, which is curing cancers previously thought to be incurable.

To ensure that the target is covered accurately with each radiation treatment, the patient is immobilized in a custom-made cradle, and a special SonArray™ Acquisition and Targeting System, External 4-D Ultrasound and optimized infrared camera guidance are used to assess and fine-tune the position of the patient and surrounding healthy organs just prior to each daily treatment. During treatment, real-time rotational helical Cone Beam CT tomography is utilized along with Portal Vision and an On-Board Imager device to capture the location of the target and its relation to adjacent tissue and organs. A video respiratory gating program is employed to synchronize the beam with the patient’s breathing movements. Patients receive daily 4D IG-IMRT treatments over several weeks’ time and each treatment is approved by the doctors with the aid of amorphous silicon diodes (Portal Vision), and reviewed by the physician in real-time using a unique in-house wireless network.

Immobilization is paramount to success and the above methods maintain a daily tracking accuracy of less than or equal to 0.3 mm/0.3 degrees!

With our in-house technology, we can make up-to-the-minute treatment decisions while managing organ motion and dynamically adapting each radiation treatment - once again, that is the realization of DART utilizing the full potential of 4D IG-IMRT.

In selecting a physician for any type of treatment you will need to be assertive and do your homework. Don’t be shy about asking the doctor how many cases he or she treated, what their success rate is and whether or not he or she has published their results. Ask to speak to some of the doctor's patients who can share their experiences with you. Especially patients who were treated up to a decade ago or more ago may provide you with a long-term perspective on recovery, while patients treated more recently may be more familiar with the doctor's current treatment protocols and latest technology.

All of these considerations are important when deciding on a brachytherapist or radiation oncologist. A published track record and a doctor's ability to communicate clearly with you about all your options are paramount in obtaining the quality of care you deserve and winning the battle against the disease. As Dr. Dattoli puts it, “This is cancer. When it comes to the placement of seeds and IG-IMRT micro-beamlets, you want every shot to be a bulls-eye!” So make sure the physician you choose really is a sharpshooter and has the most sophisticated weapons available."

Our "Making My Decision" section provides additional suggestions on selecting a physician who is right for you.

When prostate cancer spreads, it grows microscopic extensions – a good analogy is the palm of your hand representing the tumor, and your fingers representing the “spiders” or extra-capsular extensions of the cancer. Within just a few weeks of receiving radiation treatment, those extensions begin to retreat back into the tumor.

We have learned that by targeting the tumor and its extensions first with IG-IMRT, with or without hormones, the seeding procedure is more effective and serves as a boost, while not leaving the migrating cells in the regions outside of the prostate untreated. The surrounding field is sterilized by the daily radiation and cancers are rendered non-viable when DART with IG-IMRT is used upfront.

Additionally, when seeds are placed in the prostate prior to external radiation, they may cause scattering of the radiation when it collides with and is displaced by the seeds, with the possiblity of irradiating healthy surrounding tissue. The available published literature using seeds before radiation has reported higher rates of rectal injury. Finally, we are concerned that placing seeds first in intermediate to high-grade cancers may even spread cancer into the blood stream, resulting in clinical failure at other sites within the body. This too has been documented in contemporary brachytherapy literature.

For additional information on this topic, you may consult the following two articles for historical background:

Zeitlin SL, Sherman J, Raboy A, Lederman G, Albert P. High dose combination radiotherapy for the treatment of localized prostate cancer. J Urol 1998; 160:91-96.

Patel J, Worthen R, Abadir R, Weaver DJ, Weinstein S, Ross G. Late results of combined Iodine-125 and external beam radiotherapy in carcinoma of prostate. Urol 1990; 36:27-30.

The two major side effects of any aggressive prostate cancer treatment are the risk of erectile dysfunction (impotence) and incontinence. Many studies have shown that the risk of side effects with brachytherapy are much less than with surgery. With Palladium-103 seed implants, erectile dysfunction occurs in about 15-20% of cases; incontinence is virtually unheard of following Palladium-103 implants (less than 1%). Meanwhile, 85-90% of the 15-20% of patients regain their erectile function when using erectile aids (Viagra, Levitra, Cialis, etc.). With brachytherapy there is typically a diminished ejaculate. After surgery, there is no ejaculate. In contrast to brachytherapy, complete or partial erectile dysfunction is experienced in most cases of surgical removal of the prostate gland, even with the so-called nerve-sparking procedure. Up to 40% of surgical cases also result in some degree of incontinence.

Temporary side effects with seed implants are usually mild and reversible. The most common organ system involved with temporary side effects is the urinary tract, and this is because the prostate is nestled beneath the bladder and has the urethra running through it. Following implantation, most patients experience increase urinary frequency and urgency, a weakened stream, and occasionally urinary burning. Fortunately, these symptoms are temporary and resolve as the radioactivity of the seeds dissipates over.

With Palladium-103 implants, the 17-day half-life typically causes about two and a half to four months of some type of urinary symptomology. With Iodine-125 implants, the 60-day half-life causes urinary symptoms to persist as long as 10 to 12 months. During the period affected by urinary side effects, we do our best to micromanage the symptoms with a variety of medications such as alpha-blockers, and with dietary guidelines. The symptoms are not usually debilitating, but rather more of an annoyance, and patients are encouraged to continue their normal level of activity.

Yes, there are several significant advantages and that is why we strongly prefer this isotope. The radiation emitted from Palladium-103 is high enough to deliver a strong, precisely targeted and continuous ‘round the clock’ dose to the prostate tumor. The cancer killing ability, or radio-biological effectiveness (RBE) is higher for Palladium than other commonly used isotopes, such as Iodine 125 (I-125) or Iridium 192 (Ir-192) and far more thoroughly studied than Cesium 131 (Cs -131). The short half-life of Pd-103 (approximately 17 days) and less penetrating characteristics (known as "steep radial dose fall-off") make Pd-103 the ideal isotope for achieving the most effective tumor eradication with maximal protection of surrounding tissues. In addition, because of Palladium's short half-life, temporary urinary symptoms after treatment are typically months shorter in duration than with treatments employing other isotopes, such as Iodine.

We have found Pd-103 symptoms to be short-lived, predictable and therefore more easily managed, when compared to other commonly used isotopes.

Each case is different, requiring a unique brachytherapy treatment plan. Depending on the size and contour of the prostate, and the size, number and location of the tumor(s), a precise seeding map is designed for each patient. The seeds are tiny, less than 4.5mm long and about the width of a mechanical pencil lead. Under an outpatient procedure, the patient is anesthetized and the seeds are implanted through the perineum (the area of the body between the anus and the scrotum) using a patented needle-like device. The latest 3-D Color-Flow Doppler ultrasound imaging technology guides the placement of the seeds into the correct locations while avoiding the neurovascular bundles, which run down the side of the prostate and are essential for erectile function.

Dr. Dattoli commonly uses different strength seeds per patient and even uses different strength seeds in the same prostate gland. For example, higher energy seeds may be positioned within the tumor, while lesser strength seeds may be placed next to normal adjacent tissue. Comparing the number of seeds prescribed for you with other patients may be a comparison of apples and oranges, as the number implanted can vary widely.

The long-term survival rates for patients who have completed brachytherapy or combination therapy including brachytherapy under the care of a skilled radiation oncologist, are as good or better (typically greater than 90%, depending on the PSA, stage and grade) than those who have had surgical removal of the prostate. The biggest difference is in the quality of life after treatment, with far fewer incidents of erectile dysfunction while incontinence is virtually unheard of following brachytherapy in the best hands (the most skilled brachytherapist will have completed not hundreds of cases, but thousands, and will have published studies supporting successful treatments for many years. So here we have a treatment that not only preserves life, but also quality of life.