Salvage treatment – dispelling the myths

Due to its intimate nature, it is understandable that you may feel uncomfortable when it comes to discussing your symptoms or treatment options for prostate cancer.

But with the wide range of options now available, and the varying outcomes and side effects these treatments might present for patients with different lifestyle choices, it is now more important than ever that you should feel confident in discussing your condition and empowered to seek specialist advice on all the possible treatment options available – some of which offer far better long-term outcomes in both sexual function and continence.

Closed thinking

Whether it is a GP, an oncologist, urologist or specialist nurse, you are likely to be influenced by the first person you talk to, particularly on what treatment path you should take. Most patients only see a urologist for advice on radiotherapy when they should get the opinion of multiple specialists.

​For example, many patients will be guided towards surgery, also known as radical prostatectomy. It has been the default treatment for prostate cancer for many years. Yet studies have shown that radical prostatectomy – despite advancements such as robotic surgery – has the greatest impairment of sexual function and urinary continence when compared with active monitoring and radical radiotherapy. In addition, many radical prostatectomy patients go on to have further treatments at a later stage.

High Dose-Rate (HDR) Brachytherapy

Brachytherapy can be either a permanent single implant that delivers low-dose rate radiation (LDR-B) or a temporary implant that delivers a higher dose rate over multiple sessions (HDR-B).  HDR brachytherapy does NOT deliver a higher total dose of radiation to the prostate.

Both techniques deliver high radiation dose localised to the prostate gland. 

Original research from Leeds Teaching Hospitals NHS Trust (2019), as published in Elsevier’s Journal of Clinical and Translational Radiation Oncology, has revealed that men with intermediate – and high-risk prostate cancer treated with a low-dose rate brachytherapy boost in combination with external beam radiotherapy (LDR-EBRT) achieve more effective PSA control over a five year period than men treated with a high-dose rate brachytherapy boost (HDR-EBRT).  This study found that patients treated with HDR–EBRT were more than twice as likely to have evidence of persistent cancer after treatment compared with those who underwent LDR-EBRT.

Radiation dose escalation has been shown to result in improved biochemical progression free survival (bPFS) – or improved PSA control – in localised prostate cancer. Dose escalation can be delivered in multiple ways: through technical improvements in external beam radiotherapy (EBRT) delivery alone; through brachytherapy; and through a combination of both therapies. One of the most important radiation studies in the modern era treating intermediate and high risk prostate cancer compared EBRT alone with LDR+EBRT.  This showed a significant outcome improvement for the addition of LDR brachytherapy compared to EBRT alone (ref).  No equivalent study has been performed with HDR brachytherapy.

Dispelling myths

In comparison, low dose-rate brachytherapy (LDR-B) has been a highly effective treatment for prostate cancer patients for over two decades. In addition to offering significantly improved outcomes regarding both sexual function and incontinence, according to data from the Prostate Cancer Results Study Group, LDR-B treatment achieves 95% of patients’ disease-free at 15 years.

Brachytherapy has significantly evolved over the past two decades and now provides the ability to give a very effective, targeted prescription of radiotherapy, resulting in improvements in already excellent disease control, as well as potency preservation and continence. 

Low dose-rate brachytherapy (LDR-B) is an internal form of radiotherapy, which involves the insertion of tiny radioactive capsules, called seeds, into the prostate gland itself. It is targeted only at the site of the tumour so the radiation kills the cancer cells without causing major damage to surrounding healthy tissue. Seeds the size of a grain of rice containing the radiation are passed through fine needles and positioned directly into the prostate gland. It is not major surgery and you will only spend a maximum of one day in hospital. Generally, LDR brachytherapy has a low complication rate, and you will return to your usual pre-treatment activities within a couple of days, rather than weeks, as is the case post- surgery.

4D Brachytherapy

4D Brachytherapy is an even quicker, single procedure, real-time implant technique, which uses a routine diagnostic scan to calculate the number of seeds required for the LDR-B implant. The process offers better targeted treatment and, through the single procedure process, a better patient experience. The replacement of one of the steps of the traditional procedure undertaken in the operating theatre (under a general anaesthetic) with a simple out-patient procedure performed as part of routine prostate cancer diagnosis significantly improves the process. 

Salvage treatment

The other question often raised by patients is that of recurrence. What treatment options area available should cancer reappear? There’s a bit of a myth that patients who originally decided to opt for LDR-B cannot have salvage treatment at a later stage. It is mistakenly believed that high levels of treatment-related toxicities and difficulty with performing the procedure may impede follow-up treatment. Yet, the reality is that in fact 95% of patients opting for LDR-B treatment are proven to have over 15 years’ disease-free.

And, on the rare occasions that recurrence occurs, surgery remains a distinct possibility. Salvage robotic prostatectomy appears to be a reliable treatment with good oncological outcomes and acceptable continence rates. However, you should consider other treatment options, like a top-up LDR-B implant, HDR brachytherapy, and hormone treatment – where patients can remain on a minimally invasive treatment regime to successfully manage any recurring disease.

Conclusion

The bottom line is that there are plenty of initial treatment and salvage options for prostate cancer patients and the informative choice is key. Radical prostatectomy is not the only definitive and curative option. Instead, patients should demand accurate, informed discussion about the pros and cons of every treatment, from process to both short- and long-term outcomes.

Only by being fully informed can the most appropriate treatment option for each individual be established.

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