University of British Columbia Archives

Expanding Treatment Options at Ambulatory Surgical Centers: LDR Brachytherapy for Prostate Cancer

Posted by E. David Crawford, MD | Feb 2025

H1: LDR Brachytherapy for the Treatment of Prostate Cancer

E. David Crawford, MD, Professor of Urology, University of California, San Diego, California, Mira Keyes, MD, FRCPC, Clinical Professor Radiation Oncology, University of British Columbia, BC Cancer, Vancouver Cancer Centre, Vancouver BC, Canada, and Steven M. Kurtzman, MD, Director of Prostate Brachytherapy, Western Radiation Oncology, Mountain View, California, discuss low-dose rate (LDR) brachytherapy as a treatment for prostate cancer.

H2: Benefits of Brachytherapy for Prostate Cancer

Dr. Crawford explains that brachytherapy gets excellent results in prostate cancer patients across different risk and demographic groups, Gleason scores, and PSA levels. Dr. Keyes then shares the clinical rationale for performing LDR brachytherapy in ambulatory surgical centers (ASC).

H3: Prostate Cancer Treatment Strategies: Benefits of Brachytherapy on Different Risk Groups

Dr. Keyes explains that patients eligible for the low-dose rate brachytherapy, also referred to as seed implants, include all prostate cancer patients. She highlights that hormone treatment duration is significantly shorter when brachytherapy is included in the treatment plan. For example, in high risk prostate cancer patients, randomized controlled trials show that six months of androgen deprivation therapy (ADT) is enough when combined with brachytherapy. Avoiding 12 or 24 months of ADT, which is necessary when external beam radiation is utilized, helps decrease unwanted side effects for patients.

Finally, Dr. Keyes discusses toxicity in brachytherapy treatments and asserts that data cited on this topic often utilize older studies. Dr. Keyes emphasizes considering results from more recent publications.

H4: Expanding Treatment Options at Ambulatory Surgical Centers: LDR Brachytherapy for Prostate Cancer

Next, Dr. Kurtzman discusses how to set up high quality programs in ambulatory surgical centers and his opinion that LDR brachytherapy is an underutilized treatment for prostate cancer. He examines LDR brachytherapy’s high cure rates, low-long term complication rates, convenience for patients, financial benefits, and reasons LDR brachytherapy is not as prevalent.

Additionally, Dr. Kurtzman presents his strategy for bringing prostate brachytherapy programs to communities and reasons to perform it at ASCs, including fostering a genuine collaboration between urologists and radiation oncologists. Overall, he highlights how incorporating LDR brachytherapy into urology practices and ASCs fosters collaboration between urologists and radiation oncologists.

Conclusion

This 20-minute discussion concludes with Dr. Crawford’s comments on the importance of multidisciplinary care for better patient outcomes and strong interdisciplinary collaboration between urologists and radiation oncologists.

Appendix

Dr. Keyes also provided analysis of some recent studies that review:
Results showing 77% of patients in low and intermediate risk groups have PSA equal to or less than 0.2 five years after treatment with 1-2% recurrence, suggesting brachytherapy is very consistent with very low risk of prostate cancer recurrence
The ASCENDE RT trial that compared external beam radiation and LDR brachytherapy boat or dose-escalated external beam boost, and LDR boost in intermediate and high risk patients. Trial results showed a huge difference in PSA outcomes
If hormone treatment is needed for high risk prostate cancer patients who are also treated with external beam radiation with brachytherapy boost
Outcomes of intermediate and high risk patient groups treated with brachytherapy versus radical prostatectomy that showed positive outcomes for patients treated with brachytherapy, particularly in high risk groups
A study evaluating outcomes of patients with very high risk groups with Gleason 9 and 10 treated with prostate brachytherapy boost, external beam radiation, or prostatectomy. The study showed very favorable outcomes for patients treated with brachytherapy

Focal Brachytherapy for Prostate Cancer

Posted by Juanita M. Crook, MD, FRCPC | Oct 2023

Juanita M. Crook, MD, FRCPC, discusses the use of focal brachytherapy for prostate cancer treatment. She highlights the importance of patient selection, technical considerations, efficacy, and post-focal therapy monitoring. Dr. Crook demonstrates the significance of accurate localization through mpMRI and template mapping biopsies for precise treatment planning for patients with favorable-risk disease and a low disease burden.

Dr. Crook discusses the evolution of active surveillance in managing low-risk patients. She also emphasizes the need for careful candidate selection, considering factors like unilateral disease, lower intermediate risk, PSA levels, and life expectancy.

Dr. Crook touches upon various focal therapy scenarios which should be tailored to the patient’s specific case. She discusses options which fall under the umbrella of focal therapy such as low dose rate (LDR) or high dose rate (HDR) brachytherapy, cryotherapy, and HIFU.

Treatment of Oligometastatic Disease

Posted by Juanita M. Crook, MD, FRCPC | Oct 2023

Juanita M. Crook, MD, FRCPC defines the clinical criteria for oligometastatic prostate cancer, highlighting the significance of accurate staging and advanced imaging techniques in identifying patients who may benefit from targeted treatments. She emphasizes new evidence suggesting that aggressive local and systemic therapies can achieve prolonged disease control and possibly cure in select patients.
Dr. Crook presents various treatment modalities, including stereotactic body radiotherapy (SBRT), surgery, and systemic therapies such as androgen deprivation therapy (ADT) and novel hormonal agents. She presents data from recent clinical trials demonstrating the efficacy of SBRT in controlling metastatic lesions. Additionally, she explores the role of metastasis-directed therapy (MDT) in delaying the initiation of systemic treatments and reducing treatment-related side effects.

Clinical Trials for BCG-Naive and BCG-Unresponsive NMIBC

Posted by Amirali Salmasi, MD | Jul 2023

Amirali Salmasi, MD, delves into a comprehensive discussion on risk stratification and treatment options for BCG-naive and BCG-unresponsive bladder cancer. In his enlightening presentation, Dr. Salmasi provides a thorough examination of the diverse risk groups, elucidating the distinctions between low risk, intermediate risk, and high risk based on tumor grade and size. Moreover, he delves into the crucial aspects of adequate BCG treatment and outlines the criteria for BCG unresponsiveness, enhancing our understanding of these critical factors.

Furthermore, Dr. Salmasi takes us on an exploratory journey through the realm of treatment approaches for bladder cancer. He shares insights on the exciting possibilities offered by sequential chemo, hyperthermia, immunotherapy, and targeted therapy, elaborating on their respective mechanisms and potential benefits. To bolster his insights, Dr. Salmasi highlights key studies and trials conducted, underscoring the promising outcomes that have been observed.

Point-Counterpoint: Surgery vs. Brachytherapy for Intermediate and High-Risk Prostate Cancer – Brachytherapy

Posted by Mira Keyes, MD, FRCPC, FABS | Jul 2023

Mira Keyes, MD, FRCPC, presents an informative discussion on the benefits of brachytherapy compared to surgery and external beam radiation for prostate cancer treatment. She highlights the elusive outcomes and challenges of current treatments, emphasizing the importance of patients’ quality of life and cost considerations.

Dr. Keyes explores how brachytherapy outperforms surgery in terms of PSA (prostate-specific antigen) and metastasis-free survival outcomes in high-risk and unfavorable intermediate-risk patients. These findings suggest that brachytherapy can effectively target and control aggressive forms of prostate cancer.

Additionally, she addresses the misconception that brachytherapy is only suitable for certain risk groups, explaining its effectiveness across all risk stratifications. This broader applicability of brachytherapy allows more patients to benefit from this targeted treatment option, potentially reducing the need for invasive surgeries.

The presentation also delves into the topic of toxicity, showcasing the manageable side effects of brachytherapy compared to surgery. By minimizing damage to surrounding tissues, brachytherapy reduces the risk of complications such as urinary incontinence and erectile dysfunction, which are more commonly associated with surgery.

This lecture is part of a Point-Counterpoint debate. Its opposing lecture is “Point-Counterpoint: Surgery vs. Brachytherapy for Intermediate and High-Risk Prostate Cancer – Surgery.”