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 Mira Keyes, MD, FRCPC, FABS
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
Point-Counterpoint: Surgery vs. Brachytherapy for Intermediate and High-Risk Prostate Cancer – Brachytherapy
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.”
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Brachytherapy: The Royal Flush of Radiation Treatment for Men with High-Risk Prostate Cancer
Mira Keyes, MD, FRCPC, a Clinical Professor at the University of British Columbia (UBC) and a radiation oncologist at the Vancouver Centre of the British Columbia Cancer Agency (BCCA), discusses the benefits of prostate brachytherapy (PB) for men with high- and very high-risk prostate cancer. Dr. Keyes explains PB has excellent long-term outcomes (with the best cure rates of all radiation therapy [RT] treatments), requires less androgen deprivation therapy (ADT), has less downstream toxicity and lower cost than alternatives, calling it a “royal flush” treatment when used as a boost with external beam radiation therapy (EPRT).
Read MoreADT and Brachytherapy: The Good, the Bad, and the Ugly
As part of a special course on brachytherapy for prostate cancer from the American Brachytherapy Society and Grand Rounds in Urology, Mira Keyes, MD, FRCPC, FABS, Clinical Professor at the University of British Columbia (UBC) and a radiation oncologist at the Vancouver Centre of the British Columbia Cancer Agency (BCCA), discusses the pros and cons of using androgen-deprivation therapy (ADT) with brachytherapy to treat prostate cancer. After briefly discussing how ADT affects the tumor microenvironment, Dr. Keyes goes over the numerous clinical trials that have investigated how to combine external beam radiation together with hormone therapy. She explains that these trials found that the combination increases overall survival ~10-13% over ADT or EBRT alone, and longer ADT has a greater impact on OS, even with high radiation therapy dose. Dr. Keyes observes that ASCO considers brachytherapy a standard of care and recommends it be combined with ADT for unfavorable intermediate-risk and high-risk disease. She then considers the findings of ASCENDE-RT, the HDR UK trial, and the TROG 0.304 RADAR trial, all of which looked at the combination of ADT and brachytherapy, and discusses several ongoing randomized controlled trials on the role of ADT with prostate brachytherapy. Dr. Keyes also discusses a systematic literature review of ADT + prostate brachytherapy which concludes that the addition of ADT to brachytherapy provides no benefit to cancer-specific survival with ADT, and no benefit to overall survival with ADT, but does provide up to a 15% benefit to biochemical progression-free survival. She also notes that some believe dose escalation (prostate brachytherapy boost) may obviate the need for ADT in some high-risk patients. Dr. Keyes looks at a different meta-analysis which found that the addition of ADT to external beam radiation therapy provided a greater oncologic benefit than a brachytherapy boost and that there was a high probability that intermediate-risk and high-risk prostate cancer treated with EBRT + ADT would have superior overall survival to high-risk patients treated with EBRT + brachytherapy boost. Dr. Keyes argues that this paper misses the fact that the benefit of brachytherapy is that if brachytherapy is used, the duration of ADT can be reduced in unfavorable intermediate-risk and high-risk patients, which has a significant positive impact on quality of life and overall survival. She notes that ADT has numerous negative effects on quality of life, including erectile dysfunction, dementia, osteoporosis, metabolic syndrome, and more. Dr. Keyes particularly focuses on the negative cardiovascular effects from ADT, noting that observational data shows excess cardiovascular morbidity and mortality in patients on ADT with pre-existing cardiovascular disease. She concludes that ADT should be avoided in low- and intermediate-risk prostate cancer patients treated with monotherapy, that ADT for only 12 months in unfavorable intermediate- and high-risk patients is supported by randomized controlled trials, that ADT can be omitted in selected unfavorable intermediate- and high-risk patients, and that shorter ADT duration will improve quality of life and may increase overall survival by decreasing cardiovascular disease morbidity.
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