I have heard that prostate cancer
is so slow growing that some physicians recommend no treatment,
particularly with surgery or external radiation. Why should I
consider treating it at all, and specifically with seed implants?
Treatment of prostate cancer presents a dilemma. On the rare side, some
patients may not actually need treatment because their cancer appears to
be growing so slowly or other medical problems take a greater precedence.
On the other hand, prostate cancer is the second most common cause of cancer
death in men and should not be taken lightly. Treatment of symptomatic
disease is always more difficult than if the patient is not having any
problems. With experience, a physician can reasonably predict how a cancer,
may behave, but there is no foolproof way to detect how aggressive a cancer
will be in any specific patient. This is why most men choose some type
of treatment of early stage prostate cancer. In the past several years
before prostate brachytherapy was improved, the other definitive treatments
for prostate cancer were so symptomatic for patients (radical prostatectomy
and external beam radiation), that
one wanted to wait to institute therapy when there was a problem. Treatment
of symptomatic disease is always more difficult than if the patient is not
having any problems.
How
do I know that I am a candidate for seed implantation?
All men who are candidates for a radical prostatectomy may be candidates
for a seed implant alone, if they have stage A or stage B disease. Men
who are not candidates for a prostatectomy because of a health reasons
and may be poor anesthesia risks, may be candidates for seed implantation
because of its low anesthesia risk. Occasionally, a patient may require
external radiation therapy prior to the seed implant if they have advanced
disease or markedly elevated PSA. Patients at risk of disease outside the
gland (stage C) receive a short course of external radiation (5 weeks)
followed by the seed implant as a boost to the prostate gland. To determine
if the cancer is outside the gland a CT scan and bone scan may be performed,
in conjunction with a specialized biplane ultrasound exam of the prostate.
Rarely, some men will have a large gland which requires hormonal downsizing
prior to the seed implant, or may have a significant internal prostate
defect from prior surgery which makes the implant technically difficult.
What is mapping of
the prostate?
A
biplane ultrasound exam of the prostate is used to help determine
the stage of the prostate cancer and is also used to make a
three-dimensional model of the prostate. This will be used
for constructing a computerized dosimetry plan of the prostate
and for determining the correct number and placement of seeds.
The ultrasound procedure is performed in the office after the
physical exam and takes images of the prostate at 5mm increments.
These images are then entered into the treatment planning computer
to make a three-dimensional model of your prostate. Using the
specialized treatment planning computer, the exact placement
of each seed will be determined and a map or template of your
prostate is developed. This will be used in the operating room
as a guideline or map
for the seed placement.
You sometimes ask
for a CT scan for pubic arch evaluation at the time of consultation.
Why is this done?
An important evaluation in conjunction with the volume study is a CT scan
which is utilized to decide whether a seed implantation can be technically
performed by evaluating the position and shape of the prostate gland in
relation to the pubic arch. The implant requires placing needles into the
prostate. If the pubic bone, which is shaped like an upside down V or an
arch is too narrow, it can be difficult or impossible to place the needles
accurately. Determining whether the pubic arch will prevent a good implant
is obviously valuable as additional equipment will be needed in the operating
room. Many patients have small enough glands that this test does not need
to be done. For those patients that have larger glands or arch interference
that is identified on the ultrasound exam, shrinking the gland with hormonal
therapy can often make the patient an implant candidate. The CT also demonstrates
the position of the prostate to other pelvic structures including lymph
nodes.
Why do some men receive external radiation in addition to seed implants?
If the cancer extends or penetrates through the prostatic capsule, a short
course of external beam radiation encompassing the prostate and tissue
around the prostate must be administered. This insures that any microscopic
prostate cancer cells adjacent to the gland are encompassed by the radiation
prior to the prostate seed implant. The seed implant effectively concentrates
the radiation to the cancer cells in the prostate gland. The seed implant
will also kill some cells immediately outside the gland, but the seed implant
is a local treatment. External radiation is given for assurance that all
the cells around the prostate are treated. If the biplane ultrasound shows
no evidence of the prostate cancer outside the prostate (the capsule of
the prostate is intact and not distorted) then there is no need to go through
a course of external radiation. If it is determined that a short course
of radiation is required then you can receive the radiation in Scottsdale
or Glendale, Arizona, or can be referred to a local radiation oncologist
near you.
What factors do
you consider when picking an isotope?
Factors of importance include prostate gland size and shape, correct number
and activity of radioactive seeds, and any prior therapy to the prostate
gland, Sometimes tumor location or characteristics may play an important
role. Gleason grade is another determinant for picking an isotope. When
we analyzed the patients we had treated, we did not see any correlation
between isotope selection and grade in terms of outcome or result. The
Grado Ragde study was one of the first studies that observed this finding.
Our analysis included all grades, stages, and PSA levels. We did not exclude
patients because of the size or shape of their prostate gland unless it
was over 6 cm wide and too large for the template. The earlier open laparotomy
implant experience with I-125 seeds with moderate grades (2-6) was quite
favorable but results were reported not so favorable with high-grade tumors
(Gleason 8-10). Initially, the majority of patients were treated with Pd-103,
but when no increased advantage was seen compared to I-125, we have now
based radioactive need selection on availability of the correct strength
and number of seeds available. Some inherent advantaged of one isotope
over the other may be utilized in the selection for a particular patient.
A final decision on the best isotope to use may never be reached, as it
will require a controlled study and many patients to determine if one isotope
is better than the other for any specific disease type.
What is the procedure
when I arrive at the hospital?
Before you arrive, you will be given pre-procedure instruction at your
office visit with Dr. Grado. The procedure will be done at Scottsdale Heath-Care
Shea (Scottsdale North) in Scottsdale, Arizona. You will check into the
hospital 1-2 hours before the procedure. When you arrive you will check
into the pre-op area and the nurses will obtain a brief medical history
and start an IV which will enable them to administer antibiotics and other
medications. The anesthesiologist will meet with you to discuss his/her
plans and role during the procedure. In the operating room, (most patients
do not remember this), the anesthesiologist will put you to sleep using
a light general anesthetic. Most patients are given a general anesthetic
but occasionally a patient may receive a spinal because of patient or anesthesiologist
preference. Once you are ready, you will be prepared for the procedure.
Dr Grado will first insert needles into the prostate gland with ultrasound
and fluoroscopic guidance through which the radioactive seeds are passed.
After the procedure, you will be transferred to the recovery room. You
will be in the recovery room for approximately 1 hour where you will be
closely monitored You will then be transferred to an extended recovery
room where your family can join you. You will have a PSA and CT of the
prostate obtained. You will again be given discharge instructions and taught
self intermittent catheterization if needed. You will be given a prescription
for antibiotics and pain medication if required. Before discharge an appointment
time to see Dr. Grado the next day will be provided.
What happens during
the implant surgery?
From the pre-op area patients are brought to the surgical suite on a gurney.
Most patients do not remember this because they have been given a medication
to help them relax. In the operating room the anesthesiologist will give
you some medication by IV and by a mask that will let you fall asleep.
A nurse will prepare the area of skin that the needles are to be inserted.
The nurse will then insert a Foley catheter into the bladder and inject
some contrast material into the the bladder. The ultrasound probe will
be placed into the rectum to localize the prostate. A measurement of the
prostate will be obtained and compared to your pre-op volume study. A fluoroscopic
x-ray unit will also show a picture of the prostate area on a television
monitor. Dr. Grado then 
inserts
afterloading needles through the perineum (between the scrotum and the
rectum) into the prostate gland following the plan very closely. The needles
will be placed one row at a time. The accuracy of each needle's placement
is confirmed by both biplane ultrasound and fluoroscopic image. The seeds
are then dropped individually one by one. Again fluoroscopy and ultrasound
are used to confirm each seed's placement within the gland. The actual
seed implant only takes about 30 minutes but is dependent on the size of
the gland. At the completion of the procedure, the implanted prostate volume
is evaluated to insure the proper placement of the radioactive seeds. Once
the seeds are in place the patient is surveyed for the amount of radiation
they are emitting to make sure they are under the safe limits. The patient
is then taken to a recovery room where they are monitored for 1 hour.
How do I set up an
appointment and what is the waiting period?
You can call our office at (480) 614-6300, or you can fax your appointment
request to (480) 614-6333 and we will get back to you by the next working
day with an appointment. We also have a toll free number (888)-539-6300.
The availability of appointments are, of course variable, but we do make
every effort to accommodate your schedule and realize the apprehension
that is felt by having to wait for an appointment under these circumstances.
If you are from out of town we can give you an appointment date and a procedure
date, usually within the same week so that you are here for the briefest
period of time. We can typically see you on a Monday or Tuesday and provided
you are a candidate for the procedure, perform the procedure on Thursday.
Then you may leave on Friday.
What do I need to bring with me to my
appointment?
We ask that all patients bring any records
on their prostate cancer diagnosis or treatment that may be available.
If there is a recent physical exam, EKG and chest x-ray, these
are helpful to bring for the anesthesiologist to review. If the
patient has not had an EKG or chest x-ray, these can be ordered.
We may need to confirm the prostate cancer diagnosis and have therefore
selected a pathologist who has specialized in prostate cancer,
to provide a second review for our patient's pathology slides.
You will want to bring any films that have been taken and the radiologist's
report on these films. This would include any bone scans and CT
scans. We require a bone scan if your PSA is above 10, the patient
is believed to have stage C disease, or if the patient is having
any significant bone pain. A CT scan is done to look for any enlarged
lymph nodes, to see the prostate gland's position in the pelvis,
and to look for any pubic arch interference. If you have not had
a CT scan done this may be obtained during your evaluation. Occasionally
there are other diagnostic films that may be done. All these films
are necessary during the evaluation process for the procedure.
When will I feel back
to normal?
As with any procedure, the patient response and recovery is varied. The
procedure typically results in minimal side effects compared to other treatments
available. Locally, the perineum (under the scrotum) can be slightly tender
to the touch or to sitting and there may be some bruising noted. This will
typically last a few days. Most patients who are out of town travel home
the next day. We do give you a pain medication but 90% of the patients
only require a small dose of Acetaminophen (Tylenol®). After the procedure
patients may be tired because of the anesthesia but should return to normal
in 1 day. We request that you do not do any heavy lifting for 30 days this
may cause an increase pressure in the pelvic area. Walking, swimming and
golfing are fine if you avoid over doing it. Exertional activities can
cause more bleeding into the prostate gland after the procedure, which
result in some swelling.
My physician said that radioactive implants were tried many years ago and
proved ineffective. Is that true?
Over 20 years ago, Memorial Sloan-Kettering Cancer Center pioneered prostate
implants. Following that lead, many hospitals nationwide performed seed
implants. In those days, however, the implants were performed using an "open" method,
which involved surgery to expose the prostate gland. The open method required
the urologist to feel the prostate gland with his fingers to determine
where to place the seeds - an extremely imprecise method. Because it relied
entirely on the doctor's skill and experience, in most cases the placement
of the seeds was poor by today's standards. Poor placement of the seeds
meant that there were areas where the seeds were too far apart creating "cold
spots" in the prostate. Because these cold spots did not provide a
high enough amount of radiation to kill the cancer cells, the cancer often
returned over time. Although many patients who were treated with the open
technique had recurrences of their cancer, scientific reviews have shown
that patients who were treated by experienced physicians who achieved good
seed placement did as well as patients who underwent radical prostatectomies
or external beam radiation - despite the unsophisticated techniques. Today
the guesswork is gone. With the development of transrectal ultrasound (TRUS),
there is now a precise way to guide the seeds and insure that there is
no cold area in the prostate. Physicians who are not yet familiar with
the improved implantation techniques still
remember the problems from using the open implant method.
What
is prostate brachytherapy and how effective is it?
The term brachytherapy literally means ''close-up'' therapy. In this case,
radioactive seeds are deposited into the prostate during an outpatient
visit. According to published studies, brachytherapy has an overall (including
both low-and-high risk patients) 70% cure rate after 12 years, with few
complications or side effects reported. (In low-risk patients with the
cancer still confined to the prostate, the cure rate using brachytherapy
in 90 - 100% The overall brachytherapy cure rate surpasses the ten-year
cure rate of 59% reported by studies that followed up radical surgery patients.
Its cure rate also compares favorably to the inconclusive results for patients
treated with external beam radiation.
What is prostate brachytherapy?
The technique places radioactive seeds (isotopes) into the prostate to
deliver a well confined but potent dose of radiation directly to the
cancer. The radiation field may be precisely tailored to cover only the
prostate. We use low energy radioisotopes with shod tissue penetrations
such as Iodine 125 and Palladium 103. Beyond the prostate the radiation
falls off rapidly, preventing radiation injury to adjacent tissue and
minimizing treatment- related complications, such as incontinence and
impotence. Our surgeons have done on the order of 7,000 brachytherapy
procedures and have been pioneers in this work. Brachytherapy is rapidly
gaining in popularity; the American Urological Association recently predicted
that it would soon replace radical prostatectomy as the gold standard for
treating early prostate cancer.
What kind of patient
is best suited for seed implantation?
Brachytherapy is an effective treatment for patients who have early prostate
cancer. It is also an attractive option for patients whose poor health
suggests that a radical prostatectomy surgery should be avoided. When a
patient's cancer has spread out beyond the prostate gland, a combination
of external radiation and seed implantation provides one of the most effective
treatments. The scientfic evidence also shows that if the cancer should
come back despite the implanted seeds, the patient may be safely and effectively
treated with a second implant.
How long does a seed
implant take and how long does it take to recover from the procedure?
The implant procedure is done under anesthesia. It takes from 30 to 45
minutes when done by an experienced physician, At Southwest Oncology Centers,
patients generally leave the outpatient facility after a few hours, and
most resume their usual daily activities within a day or two.
What are the complications
from seed implantation?
Since the seeds are implanted in the prostate with pinpoint accuracy, they
pose little risk to nearby, non-cancerous tissues. The result is a low
complication rate with
seed implants for incontinence or impotence.
What are the complications
from the brachytherapy procedure?
Some degree of voiding difficulties, manifested by symptoms such as urinary
frequency, urgency, and slow stream occurs in the majority of patients
post-implant. The symptoms will generally subside within a few days to
a few week7s with minimal or no medical intervention. However, evidence
of significant urinary retention, which may occur in about 5% of patients,
will require an indwelling Foley catheter or intermittent catheterization.
The retention is usually self-limiting
lasting from 1 to 4 weeks.
How common is impotence
after brachytherapy?
It has been our experience that only about 5% of patients under the age
of 70 have become impotent. Some of these patients have benefited from
using Viagra, as have some patients over 70.
How common is incontinence
after brachytherapy?
A seed implant done by an experienced physician does not cause urinary
incontinence. Few of our patients experience any problems, and those tend
to be minor and short-lived. Some urinary irritation is commonly experienced,
but in nearly all cases this problem resolves itself within one to three
months. One exception is in patients who have had prior prostate surgery,
such as transurethral resection (TURP) or have a TURP after brachytherapy.
For patients who have had the TURP first, the risk of developing incontinence
after brachytherapy is markedly reduced by modifying the way the seeds
are placed in the prostate. A TURP after a seed implant generally results
in a high rate of incontinence. At Southwest Oncology Centers, patients
are advised not to submit to any prostate or rectal surgery without checking
back with us.
What about having sex
after the procedure?
A
brachytherapy patient may resume sexual relations whenever
he feels ready.
How much radiation is
involved in brachytherapy?
To cure prostate cancer, we can implant seeds that emit energies as low
as 24-28 KeV*. The energies of diagnostic x-rays are in the realm of 80-120
KeV.
1 KeV=1,000 electron volts. By comparison, if the
radiation is delivered by external beam therapy, the energies of
several million electron volts are needed to
penetrate the tissue between the skin and the prostate.
Can you have a seed implant
after or before TURP?
Patients who have had prior transurethral prostate surgery stand some risk
of developing incontinence, but the risk can be markedly reduced by a modification
of the way the seeds are placed in the prostate. A TURP after a seed implant
generally results in a high rate of incontinence. At the Southwest Oncology
Centers, patients are advised not to submit to any prostate or rectal surgery
without checking back with us.
What are the seeds made
of?
The seeds consist of the radioisotopes Iodine 125 and Palladium 103 sealed in
minute titanium cylinders.
Which is the better seed,
Iodine or Palladium?
Physically the seeds look similar and both produce low-level radiation
destroying the cancer cells without harming the normal tissue adjacent
to the prostate. Although no clinical trials have been done to scientifically
compare their effectiveness, it appears that both isotopes provide equally
good results. The main difference between them is the length of radiation.
The radiation is completed in 6 months with Palladium, while with Iodine
it takes 12 months. Palladium and Iodine require different techniques.
How do radioactive seeds
kill cancer?
Radiation in the seeds kills cancer cells by damaging the DNA in the cell
nucleus. With damaged DNA, the cell can't divide any more. Seeds emitting
energies as low as twenty thousand electron volts can kill the cancer in
the prostate. In comparison, if the radiation is delivered by external
beam therapy, the energies of several million electron volts are needed
to simply penetrate the tissue
between the skin and the prostate.
Is it true that young
patients suffering from prostate cancer ought to be treated with
radical prostatectomy?
A search we made of the medical literature failed to show any evidence
that a young patient is better treated with surgery. Others researchers
have reached a similar
conclusion.
What kind of physician
typically performs prostate seed implantation and in what kind
of setting?
Prostate seed implantation is usually performed in an outpatient hospital
setting by a urologist and/or radiation oncologist.
Is it true that only
small prostate glands can be implanted?
Physicians in their early stages of brachytherapy experience would do well
to restrict their implantation to smaller glands. With greater experience,
relatively large prostates can be implanted without difficulty. At Southwest
Oncology Centers glands over 200 cubic centimeters, about 7 ounces or a
2.5 – 3 inch diameter sphere have been implanted using a special
technique we have developed.
What about hormone treatment
before seed implantation?
Although the early use of hormone therapy has not been studied In the case
of brachytherapy, it appears to increase the effectiveness of external
beam therapy. Consequently, it may also prove effective in brachytherapy.
However, because of the side effects of the hormones, they should probably
not be used in low-risk patients.
