By Steven Kurtzman, MD
Over 160,000 men are diagnosed with prostate cancer in the United States each year. These men face the daunting task of choosing a treatment. Multiple options are available, but most men are not armed with the necessary information they need to make an informed decision. Both urologists and radiation oncologists offer several treatments and very often give patients conflicting information, further clouding the decision making process. Despite this, it is still critical that patients seek out physicians with experience in various treatment modalities to hear the pros and cons of any particular option. The treatment(s) they choose will impact them for the rest of their lives. Treatment outcomes differ significantly with regard to cure rates, short term side effects, and risks of long term complications.
Unfortunately, it falls on the patient to make sure they are seeing all the specialists they need to be fully informed. To make the best decision, men should always get a second and probably a third opinion. Opinions should come from physicians with varied expertise: a urologist (surgeon), radiation oncologist, medical oncologist, and a brachytherapist (a physician who specializes in delivering radioactive seeds placed directly into the prostate).
Many physicians do not mention all treatment options. Some important questions patients need to ask include:
● What can a person with my disease-risk expect for cancer control following the treatment?
● What is the likelihood that I will need additional treatment and what treatments would be viable?
● What side effects can I expect in the days/weeks following treatment?
● What side effects can I expect in the months/years following treatment?
The most common treatments for localized prostate cancer include surgery and external radiation. An alternative treatment called “brachytherapy” employs implantation of low energy radioactive “seeds” directly into the prostate gland. The procedure is performed under anesthesia in an outpatient setting. The seeds are placed into the prostate under ultrasound guidance using needles placed throughout the gland. Because there is no cutting, patients can return to their normal activities immediately.
Brachytherapists can deliver a very high dose of targeted radiation to the prostate while dramatically reducing the exposure of the surrounding normal tissue (particularly the bladder and rectum). This combination of high dose delivery to the prostate and minimal dose to the surrounding normal tissue results in higher cure rates and lower complication rates.
Prostate brachytherapy has a long history of success. Many studies show low and low/intermediate risk patients do extremely well with regard to cure rates and minimal long-term complications with brachytherapy alone. Patients with high/intermediate and high-risk disease actually benefit most from brachytherapy. A recent randomized clinical trial (ASCENDE-RT) shows a 50% increase in cure rates for patients receiving hormonal therapy followed by brachytherapy and a shortened course of external radiation compared to hormonal therapy followed by a full course of external beam radiation therapy alone. Despite such compelling evidence, most radiation oncologists neglect to recommend brachytherapy.
Despite its superior cure rates, favorable post-treatment quality of life, and lower overall cost, brachytherapy has been used less frequently in the past few years due to financial conflicts of interests. Physicians make far more money performing other treatments. In addition, brachytherapy requires a specialized skill set that most radiation oncologists do not have. It is generally more time consuming for the physician to learn the technique, and offers far less payment than a full course of external beam radiation therapy. As a result, relatively few radiation oncologists discuss brachytherapy as a viable option when discussing treatments with their patients.
I urge newly diagnosed men to see a range of specialists before selecting treatment. After talking to a urologist, they should make independent appointments with a radiation oncologist, a medical oncologist, and a brachytherapist to ensure that they become fully informed of all options available for treatment. Patients should ask their physicians to justify their recommendations based on existing scientific literature. Patients should never accept statements like, “I’m a surgeon/radiation oncologist, so of course I recommend prostatectomy/external beam radiation.” Such statements are meaningless, and all treatment recommendations should be backed up with data showing both cure rates and complication incidences. Don’t be afraid to ask your doctor to support his recommendations!
Patients are also wise to investigate online sources of information that are free of any kind of bias. PCRI (www.pcri.org), UsToo ( www.ustoo.org ), and www.prostatecancerfree.org are all outstanding resources for prostate cancer support, education, and advocacy. If you would like to know more about the benefits of brachytherapy for prostate cancer treatment, contact PCRI’s helpline at 310-743-2116 or email firstname.lastname@example.org.
About Dr. Kurtzman
Dr. Steven Kurtzman is a board certified Radiation Oncologist in practice since 1996. He received his B.A. from Cornell University and his M.D. from the Case Western Reserve University School of Medicine. He completed his Residency in Radiation Oncology at The Hospital of the University of Pennsylvania. He has been in clinical practice in the San Francisco Bay area since 1998. Dr. Kurtzman’s practice has specialized exclusively with prostate brachytherapy since 1999. He has performed over 5000 prostate brachytherapy procedures to date. Dr. Kurtzman has also taught the procedure to fellow physicians both nationally and internationally. He has lectured extensively on prostate cancer and brachytherapy in particular. He has authored and co-authored multiple peer reviewed journal articles. He has also been a Principal Investigator in multiple clinical trials in the treatment of prostate cancer.