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What is the status of brachytherapy (internal radiation) in the treatment of localized prostate carcinoma? How do efficacy and side effects compare to surgical removal of the prostate and external beam radiation alone? How do different patient groups benefit from brachytherapy? The West German Prostate Center at the KLINIK am RINK will inform you on the basis of current scientific findings.
If prostate cancer is detected early enough - at a time when the tumor is confined to the prostate - brachytherapy alone or in combination with external beam radiation and hormone therapy has the highest biochemical recurrence-free rate (no rebound of PSA in the blood after therapy). This is true for both early and advanced disease stages. Meanwhile, external irradiation alone leads to equally good results compared to radical surgery.
The equivalence or superiority of brachytherapy over surgical removal of the tumor has been clearly demonstrated in a large number of studies over the past years; most recently very impressively in a retrospective analysis published in 2020 by Kaiser Permanente, Los Angeles Medical Center (1). In this, the biochemical recurrence-free rate for patients who received brachytherapy was 82 percent 10 years after treatment compared with 57 percent after external beam radiation and only 52 percent after surgery.
A 10-year follow-up of the PROTECT study (2), also published in 2020, as well as a meta-analysis (3) of 52,000 patients published by Prof. Peter Grimm in 2012 also demonstrated the equivalence or superiority of brachytherapy to surgery.
The recommendations of both the German Society of Urology (DGU) and the German Society for Radiotherapy (DEGRO) in their guidelines are based on the current consensus on the effectiveness of brachytherapy.
#Tip: Prostate Cancer Results Study Group (PCRSG)
Prostate Cancer Results Study Group (PCRSG) under the leadership of Prof. Grimm has developed a patient tool that makes it possible to compare the cure rates of all modern forms of therapy depending on the risk profile of the tumor. Find out more at https://prostatecancerfree.org/
Literature
(1)Goy BW, Burchette R, Soper MS et al: Ten-Year Treatment Outcomes of Radical Prostatectomy Vs External Beam Radiation Therapy Vs Brachytherapy for 1503 Patients With Intermediate-risk Prostate Cancer. Urology 020 Feb;136:180-189. doi: 10.1016/j.urology.2019.09.040. Epub 2019 Nov 5.
(2) Neal DE, Metcalfe C, Donovan JL et al: Ten-year Mortality, Disease Progression, an Treatment-related Sitde Effects in men with Localised Prostate Cancer from the ProtecT Randomised Controlles Trial Accordingto Trreatment Received. Eur Urol. 2020 Mar;77(3):320-330. doi: 10.1016/j.eururo.2019.10.030. Epub 2019 Nov 24.
(3) Grimm P, Ignace Billiet I, Bostwick D et al. Comparative analysis of prostate-specific antigen free survival outcomes for patients with low, intermediate and high risk prostate cancer treated by radical therapy. Results from the Prostate Cancer Results Study Group. BJUI 109, Suppl 1, 22-29, 2012.
Several studies, including a U.S. study by scientists at the University of California at Los Angeles (1), demonstrate that brachytherapy combined with external beam radiation results in the best cure rate for prostate cancer patients with a fast-growing, aggressive tumor. For example, prostate cancer-related mortality at 5 years was only 3 percent for patients treated with brachytherapy in combination with external beam radiation therapy, compared to 13 percent after external beam radiation alone and 12 percent after surgery. The study was published in 2017 in the prestigious scientific journal JAMA.
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If the prostate is removed surgically, it is often the case that there are already offshoots of the tumor outside the incision margin, which continue to grow after the operation. With brachytherapy, on the other hand, marginal areas of the prostate are also included in the radiation. Therefore, tumors with capsular overgrowth can be treated better with radiation than with surgery.
Literature
(1) Kishan AU, Cook RR, Ciezki JP, et al: Radical prostatectomy, external beam radiotherapy, or external beam radiotherapy with brachytherapy boost and disease progression and mortality in patients with gleason score 9-10 prostate cancer. JAMA 2018; 319 (9): 896-905
The influence of the type of treatment on the risk of developing metastases at a later stage was clearly shown by the JAMA study of 2017 (1), which was carried out on around 1800 patients: According to this, the probability of metastasis was statistically significantly lower after combined therapy of HDR afterloading and external beam radiation than after surgical removal of the prostate. This is also reflected in the mortality rate due to the consequences of metastasis. After 7.5 years, this was 17 percent in the group of patients whose tumor had previously been removed in surgery and only 10 percent in patients who received combined brachytherapy.
# Recurrence after prostate cancer treatment
According to statistics, a recurrence of the cancer occurs in 10 to 15 percent of cases within the first few years after treatment. This can occur as a "local recurrence" in the prostate or as a metastasis in other organs or tissues.
Literature
(1) Kishan AU, Cook RR, Ciezki JP, et al: Radical prostatectomy, external beam radiotherapy, or external beam radiotherapy with brachytherapy boost and disease progression and mortality in patients with gleason score 9-10 prostate cancer. JAMA 2018; 319 (9): 896-905
Long-term studies not only show better cure rates for brachytherapy in some cases, but also significantly fewer side effects, long-term consequences and less loss of quality of life. In 2011, the Journal of Clinical Oncology published a scientific study (1) in which the long-term consequences of prostate cancer surgery were compared with those of brachytherapy. The so-called SPIRIT study (Surgical Prostatectomy vs. Interstitial Radiotherapy Intervention Trial) showed a clear superiority of brachytherapy with regard to urinary continence and sexual function. According to this study, patients who received seed implantation had hardly any incontinence, better erectile function and a significantly higher quality of life than patients who had their prostates removed in surgery. Brachytherapy was also far superior to surgery in terms of patient satisfaction.
The ProtecT (Prostate Testing for Cancer and Treatment) study (2) on around 1600 patients showed that patients after prostate surgery suffer most from the consequences of treatment. For example, after six years, 17 percent of the patients who had undergone surgery were still dependent on templates due to urinary leakage. Whereas 67 percent still had an erection that enabled them to have sexual intercourse before the study began, only 12 percent still did after six years. The results of a study by the BARMER health insurance fund (3) are similarly clear. According to this study, 70 percent of those operated on complained of erection problems, 53 percent of sexual disinterest and around 16 percent of urinary incontinence. One in five also confirmed surgery-related complications such as heavy bleeding or bowel injuries.
Literature
(1) Crook JM et al. Comparision of health-related quality of life 5 years after SPIRIT: Surgical prostatectomy versus interstitial radiation intervention trail. J ClinOncol.2011 Feb1; 29(4):362-8. epub 2010 Dec 13.
(2) Donovan JL, Hamdy FC, Lane JA, et al: Patient-Reported Outcomes after Monitoring, Surgery, or Radiotherapy for Prostate Cancer; ProtecT Study Group. N Engl J Med. 2016 Sep 14.
(3) Barmer GEK Hospital Report 2012
Removal of the prostate with the aid of a surgical robot (DaVinci method) does not lead to a lower incontinence and impotence rate after treatment compared to conventional surgery. On the contrary, low case numbers may even jeopardize the quality of therapy and increase the risk of complications.
This is the result of an Australian study (1) published in 2018 in the renowned scientific journal "The Lancet". According to this study, the same number of patients complained of incontinence and impotence after 6, 12 and 24 months - regardless of whether they were operated on minimally invasively with the Da Vinci robot or openly with the conventional method. Similarly sobering results are shown by a review published in 2017 (2) and a study (3) from the renowned Memorial Sloan Kettering Cancer Center in New York from 2019. Here, too, the study authors found no improvement in the men's quality of life in terms of their continence and sexual function after they had undergone robot-assisted surgery.
With regard to brachytherapy, this means that both seed implantation and HDR afterloading can achieve significantly better results in terms of continence and erectile function than after removal of the prostate with the aid of a surgical robot. This is based on large comparative studies on side effects, long-term consequences and quality of life.
Literature
(1) Coughlin GD, Yaxley JW, Chambers SK, Occhipinti S, Samaratunga H, Zajdlewicz L, Teloken P, Dunglison N, Williams S, Lavin MF, Gardiner RA.: Robot assisted laparoscopic prostatectomy versus open radical retropubic prostatectomy: 24-month outcomes from a randomised controlled trial. Lancet Oncol. 2018 Aug;19(8):1051-1060.
(2) Ilic D1, Evans SM, Allan CA, Jung JH, Murphy D, Frydenberg M : Laparoscopic and robotic-assisted versus open radical prostatectomy for the treatment of localised prostate cancer. Cochrane Database Syst Rev. 2017 Sep 12; BJU Int. 2018 Jun;121(6):845-853.
(3) Capogrosso P et al: Are We Improving Erectile Function Recovery After Radical Prostatectomy? Analysis of Patients Treated over the Last Decade. Eur Urol. 2019 Feb; 75(2): 221-22
Many men are afraid of developing a malignant tumor again after successful prostate cancer treatment. Radiation therapy in particular is suspected of promoting the occurrence of colon and bladder cancer. For brachytherapy, however, the scientific studies do not give any reason for this fear.
For example, a large comparative study of more than 6400 men by the British Columbia Cancer Agency (1) showed that patients with localized prostate cancer who had undergone seed implantation had no higher risk of developing a second tumor both five and ten years after treatment than men whose prostates had been removed in surgery. This was true not only for second malignancies outside the pelvis, such as lung cancer, but also for tumors of the bladder and rectum.
Another large-scale study from the USA (2) on 2120 patients also demonstrates that men undergoing brachytherapy do not have to fear a higher risk of developing a second tumor. This applies to both seed implantation and HDR afterloading combined with external beam radiation.
# Reason
Thanks to state-of-the-art computer technology and the use of imaging techniques, brachytherapy makes it possible to precisely map the target area to the millimeter and irradiate the prostate with pinpoint accuracy. This has the advantage that the tumor is destroyed without damaging surrounding healthy tissue such as the urinary bladder, colon or sphincter.
Literature
(1) Hamilton SN et al: Incidence of second malignancies in prostate cancer patients treated with low-dose-rate brachytherapy and radical prostatectomy. Int J Radiat Oncol Biol Phys.2014 Nov 15;90(4):934-41. doi: 10.1016/j.ijrobp.2014.07.032. epub 2014 Sep 17.
(2) Huang J, Kestin LL, Wallace M et al: Analysis of second malignancies after modern radiotherapy versus prostatectomy for localized prostate cancer. Radiother Oncol 2011 Jan;98(1):81-6. doi: 10.1016/j.radonc.2010.09.012. epub 2010 Oct 14.