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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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
Utility of Micro-Ultrasound in Prostate Cancer Active Surveillance
Adam Kinnaird, MD, PhD, FRCSC, discusses micro-ultrasound’s utility in active prostate cancer surveillance. In this 11-minute presentation, he outlines the evolution of prostate biopsy techniques and highlights micro-ultrasound’s ability to provide high-resolution imaging that detects prostate cancers invisible to conventional ultrasound. The Primus Scoring System, akin to the PI-RADS system for MRI, aids in classifying findings with promising accuracy in detecting clinically significant prostate cancer.
Dr. Kinnaird presents comparative studies showing micro-ultrasound as non-inferior to MRI in biopsy-naive patients. Preliminary data from trials reveal high concordance between micro-ultrasound and MRI. He highlights advancements in artificial intelligence, such as AI-driven heat maps for targeted biopsies, which show potential for improving diagnostic accuracy in both biopsy-naive and active surveillance settings.
The talk emphasizes the promise of micro-ultrasound in reducing overdiagnosis, improving patient outcomes, and potentially complementing or replacing MRI in specific clinical contexts.
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Genomics and Natural History of MRI Invisible vs Visible Cancers – Implications for Clinical Practice
Laurence Klotz, MD, FRCSC, explores the genomics and natural history of MRI-visible versus invisible prostate cancers and their clinical implications.
In this 12-minute presentation, he highlights that while MRI is transformative in identifying significant prostate cancer, it misses about 15% of “invisible cancers.” Recent research reveals that the invisibility of these tumors correlates with favorable genomic profiles, including fewer genetic aberrations and reduced aggressivity.
Dr. Klotz presents compelling evidence linking visible tumors to adverse molecular features and worse clinical outcomes, whereas invisible cancers are largely indolent. He underscores the potential of radiogenomics in guiding treatment decisions, advocating for management strategies based on imaging rather than solely histology.
Dr. Klotz considers avoiding unnecessary systematic biopsies in favor of targeted MRI approaches can minimize patient anxiety and reduce overdiagnosis of insignificant cancers. However, challenges remain in addressing gray areas, such as PI-RADS 3 lesions and visible but low-grade cancers, which may require more nuanced management.
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Optimization of Prostate Biopsy – Micro-Ultrasound versus MRI (OPTIMUM)
Laurence Klotz, MD, FRCSC, introduces the OPTIMUM trial, a landmark international study comparing micro-ultrasound and MRI for prostate cancer detection. In this 9-minute presentation, Dr. Klotz explains that micro-ultrasound, operating at 29 MHz, offers three times greater resolution than conventional ultrasound. Using a PRIMUS scoring system analogous to PI-RADS, micro-ultrasound demonstrates its utility in identifying highly sensitive lesions.
Dr. Klotz details the trial’s three-arm design, which involves MRI with conventional ultrasound, MRI with micro-ultrasound, and micro-ultrasound alone to assess non-inferiority and complementary detection capabilities.
Dr. Klotz emphasizes the trial’s importance for minimizing bias and improving diagnostic practices, particularly given its potential to replace or complement MRI. He highlights the study’s robust design, comprehensive objectives, and international collaboration, anticipating its transformative impact on prostate cancer diagnosis and management.
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