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Brachytherapy: Healthcare Professional Guide

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Brachytherapy: Healthcare Professional Guide Healthcare Professional Guide Brachytherapy: The precise answer for tackling prostate cancer Because life is for living Radiotherapy: a cornerstone of Brachytherapy: treating prostate prostate cancer care cancer ‘from the inside, out’ Prostate cancer is the most commonly diagnosed Radiotherapy can be basically divided into malignancy in Western men, and the incidence is rising. external beam radiotherapy (EBRT), and In the US for example, there were over 192,000 new internal radiotherapy, frequently referred to as cases of prostate cancer diagnosed in 2009,1 while in brachytherapy. Unlike EBRT, brachytherapy involves Europe, figures for 2006 identified 350,000 new cases.2 placing a radiation source internally, into the prostate. The advent of prostate-specific antigen (PSA) screening This brochure provides an overview of the significant in the early 1990s in Western countries has contributed benefits of brachytherapy that make it an important to this dramatic increase in diagnosis rates and the and preferred treatment option for many men with opportunity to successfully treat prostate cancer early.3 prostate cancer. Although mortality from prostate cancer remains considerable, effective treatment options mean many men can realize good cancer control and Benefits of brachytherapy in prostate cancer; quality of life. Innovation in prostate cancer treatment delivering radiation from the ‘inside, out’: is therefore key to addressing the current and future • Demonstrated efficacy: Cancer control and long-term needs of patient care. survival rates similar to EBRT and surgery.4 • Precision: Radiation dose delivered precisely to target In recent years, cancer treatment goals have shifted tumor area and does not travel through healthy tissue.5,6 from life preservation to cure with the preservation of • Minimized risk of side effects: Surrounding healthy quality of life. Radiotherapy plays an important role tissue is spared from unnecessary radiation or surgical in prostate cancer management and has witnessed trauma leading to reduced side effects and favorable remarkable progress during the last two decades. This functional outcomes profile in terms of urinary and results from scientific and technical advances in imaging erectile function compared to EBRT and surgery.6,7 modalities, computerized planning and delivery, and • Minimally invasive, short recovery time: Avoids the hardware. In addition to providing clinical efficacy and need for extensive surgery, and with shorter recovery times associated with brachytherapy than with surgery.8,9 safety, radiotherapy offers choice, convenience and • Convenience: Significantly shorter treatment times efficient use of healthcare resources. It thus remains a of days compared to several weeks associated with cornerstone of prostate cancer treatment, alongside EBRT, allowing patients to get back to their everyday surgery and hormone therapy. life sooner.8,9 • Cost-effective: Favorable investment, maintenance and cost-effectiveness profile.10 2 The precise answer for tackling prostate cancer Treating prostate cancer Treatment options Tumor classification and risk status The main treatment options for prostate cancer include Tumor characteristics, such as stage (clinical extent of active surveillance, watchful waiting, surgery the disease), Gleason score (assessment of biopsies) and (radical prostatectomy) and radiotherapy (EBRT PSA level, are all predictive of cancer outcomes. These or brachytherapy). measures are used to assign patients to risk groups (Table 1),3 based on their prognosis, and help guide Two different brachytherapy techniques can be used: decisions on the best treatment option or combination low dose rate (LDR) brachytherapy in which radioactive for each patient. sources are permanently implanted into the prostate tissue and high dose rate (HDR) brachytherapy, in Both LDR and HDR brachytherapy can be utilized which the source is temporarily placed into the as monotherapy or in combination with other prostate tissue. treatments such as EBRT. LDR brachytherapy utilized as monotherapy is most effective in low- and intermediate- There is no one recommended ‘standard’ treatment risk patients4,11 and may also be used in combination for prostate cancer, as evidence suggests comparable with EBRT in intermediate-risk patients.8,11 HDR efficacy between the different options.10 Thus, other brachytherapy has demonstrated excellent outcomes differences such as treatment-related side effects, across all risk groups, notably in high-risk patients in impact on patients’ quality of life and functional combination with EBRT12 or in low- and intermediate- outcomes, patient convenience, patient preference and risk patients as monotherapy.8 cost-effectiveness all become important considerations. The various options that exist in brachytherapy Brachytherapy aims to put the patients’ needs treatment provide the opportunity to create highly at the center of treatment planning and delivery individualized treatment plans depending on without compromising on efficacy. patients’ needs. Intermediate- Parameter Low-risk risk High-risk Tumor stage T1–T2a T2b–T2c or T3a or Brachytherapy works ‘from the Gleason score 2–6 7 or 8–10 or inside, out’ Pre-treatment prostate- ≤ specific antigen (PSA) 10 ng/mL 10–20 ng/mL >20 ng/mL Table 1. Prostate cancer risk groups (Adapted from NCCN Practice Guidelines in Oncology: Prostate Cancer, 2010) 3 External beam radiotherapy (EBRT) works ‘from the outside, in’ The precise answer for tackling prostate cancer 3 Low dose rate (LDR) brachytherapy Features Key benefits LDR brachytherapy, also known as ‘seed therapy’, • Demonstrated efficacy: Comparable efficacy to involves the precise and permanent implantation of surgery and EBRT.12 LDR monotherapy is considered a radioactive ‘seeds’ into the prostate using specially 4 standard of care for low-risk patients. 125 designed needles. These iodine 125 ( I) or palladium • Precision: Real-time intra-operative treatment planning 103 103 ( P) sources deliver a high total dose of radiation and delivery in one step allows accurate dose delivery (typically 125–145 Gy) at a very low dose rate (<40 precisely to the target tissue. This results in reduced side cGy/h) over a period of weeks to months, until the seeds effects and shorter treatment times.9 become inactive.8,11 • Minimized risk of side effects: As radiation doses to surrounding healthy tissue are minimized, LDR Indications brachytherapy is well tolerated with reduced side effects such as incontinence and erectile dysfunction, Currently, LDR monotherapy is considered the optimal and better long-term quality of life compared to 4,10 treatment for patients with low-risk disease but other treatments.7,13,14 is also used in intermediate-risk patients with a • Convenience: Significantly shorter treatment time of 11 favorable risk-factor profile. 1 day compared to around 7 weeks with EBRT allowing LDR brachytherapy is also used in combination with patients to return to their normal life quicker, often 3,9,12 EBRT in intermediate-risk patients to deliver the returning to work the next day. Compared to surgery, LDR brachytherapy offers shorter recovery times.10 increased doses required to treat those with a poorer • Easy to use: The integration of planning, imaging risk profile, without the increased toxicity and side and delivery simplifies the treatment process.11,15 effects associated with using a higher dose of Outcomes are reproducible and new robotic seed 8,11 EBRT alone. implantation techniques have improved the accuracy of seed placement.16,17 Low dose rate brachytherapy for both low-risk and selected intermediate-risk cancers achieves exceptional cure rates. Even with dose escalation, it will be difficult for EBRT to match the proven track record of brachytherapy seen over the past decade.19 LDR brachytherapy ‘seeds’ 4 The precise answer for tackling prostate cancer Efficacy Side effects and functional outcomes LDR brachytherapy: monotherapy The precision of LDR brachytherapy minimizes LDR monotherapy provides exceptional cancer radiation doses to surrounding, healthy tissues. control and long-term survival rates in both low- The reduced risk of side effects and improved and intermediate-risk patients, with comparable functional outcomes and long-term quality of life efficacy to EBRT and surgery.11,12 LDR monotherapy is compared to other treatment options, allows LDR considered an optimal choice for patients with brachytherapy patients to return to their everyday low-risk disease.4,10 life quickly. Studies in Europe and the US have shown cancer Urinary function: Short-term urinary bother is reported control rates of 87–94% at 10 years follow-up in in the first 6 months following LDR brachytherapy but low-risk and 70–95% at 7 or more years follow-up in return to pre-treatment levels within 1 year.7,21 There is a intermediate-risk patients.4 low risk of long-term urinary incontinence with LDR brachytherapy (1%),13 which is much lower than rates These treatment responses are maintained long-term, reported with surgery.22 with excellent survival rates seen with more than 10 years of follow-up. Disease-specific and actuarial Gastrointestinal function: Rates of gastrointestinal overall survival rates of 95% and 85% respectively, toxicity after LDR brachytherapy are low (5–8%) have been reported.18 and greatly reduced compared to EBRT.12,19 LDR brachytherapy has demonstrated comparable Sexual function: Lower risk of erectile dysfunction efficacy to surgery and superior efficacy to
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