Prostate cancer treatment, prostate cancer brachytherapy

	1-877-DATTOLI (328-8654)

You are not alone in your quest for answers related to prostate health. We've compiled a list of the most frequently asked questions that come from people like you. From general questions about our practice to complex topics - we have provided answers to help you gain a better understanding of the Dattoli mission as well as information related to prostate cancer, research and treatment. For you convenience, we have categorized the questions and implemented a search feature; if your question is not addressed here, please contact us.

What are the long-term results for brachytherapy?

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 (a skilled radiation oncologist will have completed not hundreds of cases, but thousands, and will have personal statistics supporting successful treatments for many years). So here we have a treatment that not only provides higher quality of life but even greater quantity!

Explain where and how the seeds are implanted.

Each case is different. 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 the 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. Sophisticated 3-D color flow Doppler ultrasound imaging technology guides the placement of the seeds into the correct locations while avoiding the neurovascular bundles.

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 number of seeds with other patients may be a comparison of apples and oranges.

Are there advantages to Palladium-103 over other isotopes?

Yes, there are several significant advantages and that is why we strongly prefer this isotope. The radiation emitted from Palladium-103 (Pd-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). Coupled with Palladium’s short half-life (approximately 17 days) and less penetrating characteristics (steep radial dose fall-off), this makes Pd-103 ideal for greatest tumor eradication with maximal protection of surrounding tissues.

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

What are the possible side effects from brachytherapy?

The two major side effects of any aggressive prostate cancer treatment are the risk of erectile dysfunction (impotence) and incontinence. With Palladium-103 seed implants, erectile dysfunction occurs in about 15-20% of cases; incontinence is virtually unheard of following Palladium implants. 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, complete or partial erectile dysfunction is experienced in most cases of surgical removal of the prostate gland. Up to 40% of surgical cases also result in some degree of incontinence.

Why not seed first?

When prostate cancer spreads, it grows 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 and cancers are rendered non-viable when IG-IMRT is used upfront.

Additionally, 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 has been documented in contemporary brachytherapy literature.

For additional information on this topic, you may consult these two publications:

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.

How do I find a real "expert" in brachytherapy?

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 has done and what their success rate is. Ask to speak to numerous patients who will share their experiences with you, and especially patients who were treated up to a decade ago and beyond.

Dr. Dattoli and Dr. Sorace, over their 15-year partnership, have performed many thousands of prostate brachytherapy procedures… more than any practice in the world. Their success rate using brachytherapy and radiation (currently 4D IG-IMRT with dynamically adaptive radiation threatment – DART) is in excess of 90% in intermediate and low-risk prostate cancers and greater than 80% even in the most locally advanced high risk prostate cancer. To quote Dr. Dattoli, “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!”

What is the advantage of "combination therapy?

Having the availability of each type of therapy at a single center allows the physician to tailor make a treatment plan specifically for each individual case (versus a one-size-fits-all approach). Patients have the advantage of using any combination of hormones, 4D IG-IMRT radiation and/or brachytherapy to achieve a maximum degree 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 modalities. Cancers don’t like change!

Why do so many patients choose the combination of 4D IG-IMRT with "DART" and seeds?

Brachytherapy as the sole treatment modality is indicated 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 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 presentation). This is not piling on the radiation or giving a lot of both but rather a little of each (a blend which is more thorough than seeds alone or surgery alone). For intermediate or advanced stage tumors, brachytherapy is typically prescribed in combination with other kinds of treatment, for example, IG-IMRT, hormones, etc.

How do you localize the prostate, the cancer(s) and its relationship to surrounding structures?

To ensure that the target is reached 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 is used to assess and fine-tune the position of the patient and surrounding healthy organs just prior to each daily treatment. Real-time rotational helical Cone Beam CT tomography is utilized along with Portal Vision and an On-Board Imager device is utilized to capture the location of the target and its relation to immediate surrounding adjacent tissue. Even a respiratory video gating program is available 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 wireless network. Immobilization is paramount to success and the above methods maintain a daily tracking accuracy of equal or less than .3 mm/0.3 degrees!

With the above state-of-the-art technology, we can make up-to-the-minute treatment decisions while managing organ motion and dynamically adapting the radiation treatment (DART).

Do your patients go on hormonal therapy?

It 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%.

Hormonal treatment is typically optional for patients having intermediate risk features 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 effect such as erectile dysfunction, hot flashes and potential 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 receptors. These 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 formal ADT.

What is HDR?

High Dose Radiation commonly refers to temporary catheter insertion into the prostate using Iridium-192, which is a very penetrating isotope, expending the dose quickly and to all neighboring structures. 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 today’s microprocessors. Bear in mind that 4D IG-IMRT is also a form of high dose rate radiation with micro-beamlets precisely targeting the affected area(s) in minutes 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 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. Cancers don’t like change!

Is there sufficient data to support the use of seeding over surgery?

Yes, there is. Numerous independent studies have contrasted statistical data from both options. Follow-up studies have been in place since the beginning of our practice in 1990. Other large programs, including the Northwest Tumor Institute and the University of Washington in Seattle report an approximate 80% seeding success rate after 12 years of follow up. Our data, using combination beam and seeds, has demonstrated a greater than 80% success rate after 13 years even in 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 14 years from Johns Hopkins and the "median follow-up" on our patients is longer than any surgical series).

What is the advantage of seeding over surgery?

As mentioned earlier, the risk of impotence and/or incontinence is greatly reduced with seeding, in comparison to the risks resulting from surgery. The 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. Newer laparoscopic and robotic techniques even increase the duration of the procedure, thus increasing potential complications (blood clots to the lungs, infection) and many laparoscopic/robotic procedures are aborted and converted to the more formal open approach when vessels are nicked or the rectum is lacerated.

If I choose seeding now, what are my options if I fail later?

This has become a common scare tactic used by surgeons: "If you have radiation, you can never have surgery." The question which really should be asked is "what do I do if I undergo prostatectomy and my cancer returns?"

After prostatectomy, “broad beam” rather than tightly tailored radiation is typically offered with only 10-30% (depending on PSA level) of patients being cured, while side effects from the initial surgery are compounded. Otherwise, hormones are offered, which have considerable side effects, and also fail to control cancer after 2 to 3 years because the cancer becomes immune or resistant (like infections becoming resistant to antibiotics over time).

After 4D IG-IMRT and/or seeding, numerous options are available including but not limited to re-seeding, cryosurgery (freezing), biothermy (combining heating and freezing), HIFU, not to mention salvage prostatectomy by an EXPERIENCED SURGEON.

My urologist told me that if I have radiation and the cancer returns, I can no longer have surgery. Is this true?

Absolutely not – the opposite is true! Firstly, it is extremely rare for patients to have local relapse when treated initially by our team. If however, the cancer did return in the prostate, 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 are on the way. If you desire surgery, there are many proficient surgeons who we can recommend (and it my not be your local urologist).

The real problem is for the patient who chooses surgery first since there are few options left. For example, following surgery, patients are often faced with a rising PSA. It becomes 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 (you can’t treat the entire body with radiation!). This may be associated with increased complications with damage to bowels, bladder and urethra while the overall chance of benefiting the patient lies only between 10-30%.

Why are younger men told that they should have radical surgery and not seeding since there are no long term reports on seeding?

The argument that there is insufficient long-term follow-up of brachytherapy series is no longer valid. In fact, numerous series including our own and the Seattle group have mean and medium long-term follow-up that surpasses surgical series published in the PSA era. The answer has to do with the ability of an older person to withstand surgery. It is the same with any kind of surgical procedure. The older one is, the more difficult it is to tolerate anesthesia and the trauma of invasive procedures. Older people heal more slowly and are more apt to develop infections and other complications.

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 - being impotent and wearing diapers for decades.

What is dynamic adaptive radiotherapy, or DART?

DART- "Dynamic Adaptive Radiation" is cutting edge technology for truly "individualized" IGRT 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 becoming increasingly 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. DART achieves the single most important goal ever achieved in Radiation Treatment: 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 -an extraordinary accomplishment!