Mira Keyes, MD, FRCPC, FABS

Mira Keyes, MD, FRCPC, FABS

University of British Columbia

Vancouver, British Columbia, Canada

Mira Keyes, MD, FRCPC, FABS, is a Clinical Professor of Radiation Oncology in the Division of Surgery at the University of British Columbia in Vancouver, Canada. Dr. Keyes' research interests include prostate brachytherapy, genitourinary oncology, and breast cancer.

Dr. Keyes earned her medical degree from the University of Novi Sad in Yugoslavia (now Serbia). She completed her fellowship in Radiation Oncology at the Royal College of Physicians and Surgeons of Canada in Vancouver. Dr. Keyes is a Fellow of the Royal College of Physicians and the American Brachytherapy Society.

Dr. Keyes has authored and co-authored over 120 publications, has been an invited speaker at many national and international conferences, and has received several grants, including a Canadian Institutes of Health Research (CIHR) and Michael Smith Foundation grant for translational research in prostate cancer. She is a founder of the British Columbia Cancer Agency Provincial Prostate Brachytherapy Program and Vice Chair of the group developing Brachytherapy Diploma Certification with the Royal College of Physicians and Surgeons of Canada, for the purpose of credentialing the brachytherapy training process at a national level. Dr. Keyes is a member of the editorial board of Brachytherapy Journal, the Canadian Association for Radiation Oncology, the Canadian Brachytherapy Group, the American Society for Radiation Oncology, and the European Society for Radiotherapy and Oncology.

Talks by Mira Keyes, MD, FRCPC, FABS

Brachytherapy: The Royal Flush of Radiation Treatment for Men with High-Risk Prostate Cancer

Brachytherapy: The Royal Flush of Radiation Treatment for Men with High-Risk Prostate Cancer

| Oct 2022

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).

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ADT and Brachytherapy: The Good, the Bad, and the Ugly

| Jun 2022

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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Brachytherapy for Prostate Cancer

| Feb 2022

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), gives an overview of brachytherapy for prostate cancer (PCa), making a case against its declining use based on its efficacy. She begins by introducing the American Brachytherapy society, which was founded in 1978 to provide insight, rationale, and research into the use of brachytherapy in the treatment of both malignant and benign conditions. Dr. Keyes then describes how brachytherapy was performed with radium tubes when it was invented in 1901, and was then subsequently done with needles beginning in 1915. She concludes her short history by marking 1983 as the beginning of the modern era of prostate brachytherapy, thanks to advances in imaging capabilities. Dr. Keyes discusses data showing that brachytherapy is associated with better survival in patients with local to advanced cervical cancer. She then goes over the processes for high dose rate and low dose rate brachytherapy for PCa, focusing on the quick recovery, high cure rates, and minimal to no incontinence or sexual dysfunction as benefits for both treatments. Dr. Keyes shows data on brachytherapy utilization for PCa depicting its decline since 2003 due to robotic prostatectomy use, PSA screening changes, active surveillance low-risk treatment recommendation changes, and higher reimbursement for IMRT and robotic surgery. She also discusses data showing that 10% of US cancer care spending is on prostate cancer, with the highest procedure cost per patient going to robotic surgery. Dr. Keyes compares the use of brachytherapy in the US to that of Canada, stating that Canada’s increasing use is due to a reimbursement system that incentivizes brachytherapy, and the education of the public, residents, general practitioners, and urologists. She concludes that the benefits of brachytherapy support its use for localized PCa in the US.

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