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Treating prostate cancer with brachytherapy

There is certainly no shortage of studies being done on the various treatment options for prostate cancer, but there remains a tremendous need for larger randomized studies that will give us more definitive answers. Unfortunately for the patient, much of the information now available is confusing and not necessarily directly comparable.

Surgery, radiation or waiting
Treatment of patients with localized prostate cancer usually involves choosing between radical prostatectomy, radiation therapy—either external beam radiation or brachytherapy—a combination of the above or watchful waiting.

Radical prostatectomy has long been considered the choice that offers the best chance for cure—a good option for an otherwise healthy man with a long life expectancy. But it’s not without complications, which include incontinence and impotence. Watchful waiting might be used if a patient does not want surgery or radiation, has a very slow growing type of cancer or has other medical problems.

Radiation therapy can mean external beam radiation available in the outpatient setting and now internally through brachytherapy or seed implants.

The right therapy for the right patient
Matching the right treatment for the right patient is very important. There are many things to consider–the patient’s age and overall health, stage of the prostate cancer and most importantly, the patient’s wishes and desires for treatment. The patient most likely to do well with brachytherapy will have a PSA value of less than 10, a Gleason score of less than six (out of a possible 10) and no tumor that can be felt during an examination.

What is a Gleason score?
The Gleason system is a way of grading cancerous tumors. The higher the score means the higher the grade of the tumor and higher grade tumors grow and spread faster.

Asking hard questions
So it’s not surprising that Ragde’s brachytherapy group did well. These men had favorable prognostic features, including a PSA level of less than 10, a Gleason score of less than six and normal digital rectal exams. But when considering the Ragde research, we need to ask questions the study did not fully address. For example, did these patients need to be treated at all? Would watchful waiting have given the same results? Would they have done as well or better with surgery? And finally, is 12-year data long enough?

Long-term data needed
Believe it or not, 12 years may not be long enough for prostate cancer follow-up. Because prostate cancer often grows slowly, this disease may take much longer to play out—up to 20 years. So the 12-year data most likely isn’t going to give us the definitive answers we need about which therapies work best.

PSA testing is picking up prostate cancers earlier than in the past. It is very difficult to compare prior studies before PSA testing was used.

Making the decision
At Yale, brachytherapy is an outpatient procedure and is done by a urologist and a radiation oncologist working together. This type of treatment tends to be patient-driven. The procedure is attractive to patients because the potency rates and the recovery time tend to be better when compared to surgery. A 50-year-old man is most likely going to search out the option that gives him the best chance of long-term survival; for a 70-year-old man, brachytherapy might be an attractive option.

Do your homework
I tell my patients to ask lots of questions and do as much research as possible. Get opinions from surgeons and radiation oncologists. Patients can never have too much information before making their decision.

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Dr. Colberg is a urologist and a member of the medical staff at Yale-New Haven Hospital, as well as assistant professor of surgery and director of uro-oncology at the Yale University School of Medicine.