Expert Discussion on LDR Brachytherapy for Prostate Cancer
Drs. Keyes, Kurtzman, and Crawford highlight how LDR brachytherapy improves patient outcomes and collaboration between urologists and radiation oncologists.
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Talks by E. David Crawford, MD
Expanding Treatment Options at Ambulatory Surgical Centers: LDR Brachytherapy for Prostate Cancer
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
Overview of Liquid Biomarkers
E. David Crawford, MD, professor of Urology at the University of California, San Diego, discusses advancements in risk stratification and biomarkers for prostate cancer detection. In his 10-minute presentation, he highlights the challenges of inconsistent screening guidelines, criticizing the current fragmented approach to PSA screening and underscoring the need for simplified, standardized messaging for primary care providers.
He advocates using a PSA cutoff of 1.5 ng/mL as a threshold for identifying at-risk individuals. Molecular markers, combined with PSA levels, improve precision in detecting clinically significant cancers and reducing overtreatment. Dr. Crawford outlines the complementary roles of PSA testing, molecular diagnostics, and multiparametric MRI in refining prostate cancer risk assessments.
Dr. Crawford introduces novel liquid biomarkers and their evolving role in guiding treatment decisions, cautioning that they serve as data points rather than definitive answers. Drawing analogies, he illustrates the multifactorial approach required for accurate prostate cancer diagnosis, akin to assessing risk in complex scenarios.
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Updates on the RADAR Series
E. David Crawford, MD, reviews the RADAR series and addresses concerns about excessive CT and bone scans for prostate cancer. He reflects on the progression of prostate cancer imaging practices, originating from discussions at meetings over the last 12 years. This led to the formation of the RADAR series, which categorizes diagnostic and monitoring strategies into stages: newly diagnosed disease, biochemical recurrence, and castrate-resistant cases.
In this 11-minute presentation, Dr. Crawford discusses RADAR 1 through 7. Each version builds on earlier guidelines and focuses on goals to enhance diagnosis and treatment. RADAR 1, one of the most widely cited guidelines in prostate cancer, established criteria to limit imaging based on factors like PSA levels and Gleason scores. RADAR 2 introduced “therapeutic layering,” recommending combination therapies for metastatic cases. RADAR 3 then integrated advanced PSMA imaging for cases where traditional scans yield ambiguous results. The most recent update, RADAR 8, discusses targeted focal therapy, advocating for accurate targeting to maximize treatment outcomes.
Throughout, the RADAR series has prioritized adaptive, patient-centered imaging and treatment strategies, backed by extensive collaboration within the medical community. This progression reflects the continual refinement of prostate cancer care, with imaging now positioned as a vital, evolving tool for improving patient management and reducing overtreatment.
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PET Tumor Board: Case #6
In this discussion, E. David Crawford, MD, Jack A. Vickers Director of Prostate Research and Professor of Urology at the University of California, San Diego, leads a discussion of the case study of a 63 year old patient with a strong family history of prostate cancer. He presents this case study to a panel of experts comprised of:
Wayne G. Brisbane, MD – Assistant Professor of Urology at the University of California, Los Angeles.
Phillip J. Koo, MD – Division Chief of Diagnostic Imaging and Northwest Region Oncology Physician Executive at the Banner MD Anderson Cancer Center.
Daniel P. Petrylak, MD – Director of Genitourinary Oncology, Professor of Medicine and Urology, Co-Leader of Cancer Signaling Networks, and Co-Director of the Signal Transduction Program at Yale University Cancer Center.
Dr. Crawford informs the panel that the patient, a physician with a history of low-grade prostate cancer, initially presented with a PSA of 4.9 ng/ml, his germline test was negative, and his MRI revealed a 40g prostate with a PI-RADS 3 lesion at the left base. After a negative SelectMDx scan and low-risk OncotypeDX score, along with a course of finasteride which lowered his PSA to 1.43 ng/ml, Dr. Crawford asks the panel to weigh in on further steps.
Dr. Brisbane suggests exploring reclassifying the patient’s risk score, given his family history, in order to qualify them for a PSMA. Dr. Petrylak supports the suggestion, mentioning that it has been common practice to reimage patients after finasteride use.
Dr. Crawford shows the results from the patient’s POSLUMA scan which showed uptake in multiple foci. Dr. Koo digs into the results, noting that there are alternate explanations for the results showing multiple uptakes. Given the patient’s risk profile, the panel suggests a confirmatory biopsy of the prostate in the highest activity areas.
Dr. Crawford reveals that the patient’s confirmatory biopsies showed the presence of Gleason 6 (3+3) prostate cancer in the uptake areas. Given the discordance between the biopsies and the scans, the panel discusses possible next steps, including sending the biopsy samples for Decipher testing, treating the patient with targeted focal therapy, and options for whole-gland therapy. The panel also discusses the dangers of over-reliance on scan results in treatment selection and cautions against over-treatment.
This is the sixth in a series of discussions on PSMA PET supported by Blue Earth Diagnostics. For the first installment, click here. For the second installment, click here. For the third installment, click here. For the fourth installment, click here. For the fifth installment, click here.
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