There will be 164,690 new cases (19% of all cancers in males) and 29,430 prostate cancer death in the US in 2018(1)
Treatment options in general include active surveillance, radical prostatectomy with or without adjuvant and salvage radiation, prostate brachytherapy with or without adjuvant EBRT and or ADT. Updated guidelines for patient selection, workup, treatment, post implant dosimetry, and follow-up are provided in ABS guidelines for LDR and HDR(2).
Prostate brachytherapy (PB) is a standard treatment option of patients with organ confined prostate cancer. Excellent long-term results have been published for all risk groups(3). Low Dose Rate (LDR) Monotherapy is appropriate for low and low-tier intermediate risk prostate cancer. For most men with high-tier intermediate risk cancer, brachytherapy boost with Low Dose Rate (LDR) or High Dose Rate (HDR) brachytherapy, in combination with External Beam Radiation Therapy (EBRT) with or without Androgen Deprivation Therapy (ADT) for 9-12 months is appropriate. LDR or HDR brachytherapy boost in combination with EBRT and ADT (12-36 months) is appropriate for high risk disease. HDR monotherapy is still evolving and early results are encouraging. Based on 3 RTC showing superior PSA outcomes with EBRT and Brachytherapy boost vs EBRT alone(4)(5),(6) 2017 ASCO/ CCO prostate brachytherapy guideline recommends patients be offered prostate brachytherapy if eligible, establishing prostate brachytherapy as a standard of care in prostate cancer in all risk groups(7).
As per ABS guidelines, absolute contraindications for LDR include:
There are significant uncertainties regarding the role of androgen deprivation therapy (ADT) with brachytherapy. Existing evidence shows no benefit of adding ADT to PB in low-risk and favorable IR patients. Unfavourable IR, favourable HR patients and those with suboptimal dosimetry may have up to 15% improvement in PSA PFS, with uncertain impact on Cause Specific and Overall Survival(8).
Long term outcomes will dependent on treatment given and risk group stratification. They may vary between institutions. In general, long term outcomes in all risk groups are very favourable PSA progression free survival with long 10 year follow up, suggesting ablative effects of brachytherapy. Low and low- tier intermediate risk patients, have 85-95% long term PSA RFS, Intermediate risk 70-95%, and 85-90% in combination with EBRT (either LDR or HDR boost). Patients with high risk disease have up to 50% chance of PSA control, addition of EBRT increase PSARFS to 60-70% and addition of both, EBRT and ADT, up to 85%(3).
125I – Monotherapy 140-160Gy
125I – Boost 108-110Gy
103Pd – Monotherapy 110-125Gy
103Pd – 90-100Gy
131Cs – Monotherapy 100-115Gy
131Cs – Boost 70-80Gy
Moderate irritative ad obstructive urinary symptoms are expected in 50% of the patients. Median time for IPSS to return to baseline is 12 months. Ten years after PB, the majority of patients (>90%) will have very little or no urinary symptoms. Worse toxicity is seen with larger prostate volume, and worse baseline urinary function. Incidence of acute urinary retention is < 5-10%, and is more likely in patients with worse baseline urinary function, significant median lobes, and those with larger prostate size. Incidence of TURP (transurethral resection of the prostate) and urethral strictures requiring dilatation is <1-2% with monotherapy(9). Incontinence develops in 40% and 15% of those who undergo TURP and urethral dilatation for stricture respectively. Mild self-limiting rectal irritation affects 20%-30% of patients in the first 1-2 years after the implant. Rectal bleeding is reported in 2-7% of patients. Grade 4 rectal fistula is rare (0.5%). 5 year Erectile function (EF) after brachytherapy depends on pre-treatment function, comorbidity and age. EF preservation rate at 5 years for ages <55, 56-59, 60-64, 65-69, and > 70, is about 80%, 75%, 60%, 40%, and 25%, respectively. 50 % of EF decline is related to aging(10). EBRT and LDR boost have more long term GU and GI toxicity than PB alone (RTOG 0232 https://www.astro.org) (late grade > 2: 53% vs 37%, late grade >3: 12% vs 7%). Likewise, EBRT and LDR boost have more late long term GU and GI toxicity than EBRT alone with cumulative incidence of grade 3 GU toxicity of 18% vs 5.2% and grade 3 GI toxicity of 8.0% vs. 3.2%. (11)
Formal training in LDR brachytherapy is available in several institutions ion the US Canada and Europe. In Addition, ABS is making hands on workshops available for residents and junior staff on annual bases (link here).
The fundamental aspects of training include proficiency in:
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