Fact Sheet on Brachytherapy

What is the significance of brachytherapy (internal radiation) in the treatment of localized prostate cancer? What are the effectiveness and side effects compared to surgical removal of the prostate and external radiation alone? How do the different patient groups benefit from brachytherapy? The West German Prostate Center at the KLINIK am RINK will inform you on the basis of the latest scientific findings.

 

Brachytherapy is as good as or more effective than surgery

If prostate cancer is detected in time - at a time when the tumor is confined to the prostate - brachytherapy alone or in combination with external radiation and hormone therapy has the highest biochemical recurrence rate (no re-increase of PSA in the blood after therapy). This applies to both the early and advanced stages of the disease. However, external radiation alone leads to equally good results compared to radical surgery.

The equivalence or superiority of brachytherapy compared to surgical removal of the tumor has been clearly demonstrated in a large number of studies over the last few years; most recently very impressively in a retrospective analysis published in 2020 by Kaiser Permanente, Los Angeles Medical Center (1). In this analysis, the biochemical recurrence rate for patients who received brachytherapy was 82 percent 10 years after treatment, compared to 57 percent after external radiation and only 52 percent after surgery.
A 10-year follow-up of the so-called PROTECT study, also published in 2020, as well as the meta-analysis of 52,000 patients published by Prof. Peter Grimm in 2012, could also prove the equivalence or superiority of brachytherapy to surgery.  
The recommendations of both the German Society of Urology (DGU) and the German Society for Radiotherapy (DEGRO) in their guidelines are also based on the current consensus on the effectiveness of brachytherapy.

# Tip: Prostate Cancer Results Study Group (PCRSG)
The Prostate Cancer Results Study Group (PCRSG) under the leadership of Prof. Grimm has developed a patient tool that makes it possible to compare the cure rates of all modern forms of therapy, depending on the risk profile of the tumor. For further information, please visit https://prostatecancerfree.org/.

Literature

(1 ) Goy BW, Burchette R, Soper MS et al: Ten-Year Treatment Outcomes of Radical Prostatectomy Vs External Beam Radiation Therapy Vs Brachytherapy for 1503 Patients With Intermediate-risk Prostate Cancer. Urology 020 Feb;136:180-189. doi: 10.1016/j.urology.2019.09.040. Epub 2019 Nov 5.

(2) Neal DE, Metcalfe C, Donovan JL et al.: Ten-year Mortality, Disease Progression, an Treatment-related Sitde Effects in men with Localised Prostate Cancer from the ProtecT Randomised Controlles Trial Accordingto Trreatment Received.  Eur Urol. 2020 Mar;77(3):320-330. doi: 10.1016/y.eururo.2019.10.030. Epub 2019 Nov 24.

(3) Grimm P, Ignace Billiet I, Bostwick D et al. Comparative analysis of prostate specific antigen free survival outcomes for patients with low, intermediate and high risk prostate cancer treatment by radical therapy. Results from the Prostate Cancer Results Study Group. BJUI 109, Suppl. 1, 22-29, 2012

 

Brachytherapy in combination with external radiation is most effective in patients with a high-risk tumor

Several studies, including a US study by scientists from the University of California in Los Angeles (1), show that brachytherapy in combination with external radiation therapy leads to the best cure rate in prostate cancer patients with a fast-growing, aggressive tumor. For example, mortality due to prostate cancer after 5 years was only 3 percent for patients treated with brachytherapy in combination with external beam radiotherapy, compared to 13 percent after external beam radiotherapy alone and 12 percent after surgery. The study was published in 2017 in the renowned scientific journal JAMA.

# Justification
If the prostate is removed surgically, it often happens that there are already extensions of the tumour outside the incision margin, which continue to grow after the operation. In brachytherapy, on the other hand, marginal areas of the prostate are also included in the radiation therapy. Therefore, tumors with capsule overgrowth can be better treated with radiation than with surgery.


Literature

(1) Kishan AU, Cook RR, Ciezki JP, et al: Radical prostatectomy, external beam radiotherapy, or external beam radiotherapy with brachytherapy boost and disease progression and mortality in patients with gleason score 9-10 prostate cancer. JAMA 2018; 319 (9): 896-905

 

Metastases: Lower risk after combined brachytherapy than after surgery

The influence of the type of treatment on the risk of developing metastases at a later point in time was clearly shown in the JAMA study of 2017 (1), which was conducted on around 1800 patients: According to this study, the probability of metastasis formation after a combined therapy of HDR afterloading and external radiation was statistically significantly lower than after surgical removal of the prostate. This is also reflected in the mortality rate due to the consequences of metastasis formation. After 7.5 years, the mortality rate was 17 percent in the group of patients whose tumor had previously been removed by surgery and only 10 percent in patients who received combined brachytherapy.

# Recurrence after prostate cancer treatment
Statistics show that in 10 to 15 percent of cases, cancer recurs within the first few years after treatment. This can occur as a "local recurrence" in the prostate or as metastasis in other organs or tissues.

Literature

(1) Kishan AU, Cook RR, Ciezki JP, et al: Radical prostatectomy, external beam radiotherapy, or external beam radiotherapy with brachytherapy boost and disease progression and mortality in patients with gleason score 9-10 prostate cancer. JAMA 2018; 319 (9): 896-905


Fewer side effects and higher quality of life after brachytherapy than after surgery

Long-term studies show that brachytherapy not only improves healing rates in some cases, but also has significantly fewer side effects, long-term consequences and less loss of quality of life. In 2011, the Journal of Clinical Oncology published a scientific study (1) in which the long-term consequences of prostate cancer surgery were compared with those of brachytherapy. The so-called SPIRIT study (Surgical Prostatectomy vs. Interstitial Radiotherapy Intervention Trial) showed a clear superiority of brachytherapy with regard to urinary incontinence and sexual function. According to this study, patients who received a seed implantation showed hardly any incontinence, better erectile function and a significantly higher quality of life than patients who had their prostate removed in surgery. Brachytherapy was also far superior to surgery in terms of patient satisfaction.

The ProtecT study (Prostate Testing for Cancer and Treatment) (2) on around 1600 patients showed that patients suffer most after prostate surgery. After six years, 17 percent of the patients who had undergone surgery were still dependent on drafts for urine loss. While 67 percent had an erection that enabled them to have sex before the start of the study, after six years only 12 percent still had an erection. The results of a study by the BARMER health insurance company are similarly clear (3). According to this study, 70 percent of those operated on complained of erection problems, 53 percent of those operated on complained of sexual disinterest and around 16 percent complained of urinary incontinence. One in five also confirmed operation-related complications such as heavy bleeding or intestinal injuries.  

Literature

(1) Crook JM et al. Comparision of health-related quality of life 5 years after SPIRIT: Surgical prostatectomy versus interstitial radiation intervention trail. J ClinOncol.2011 Feb1; 29(4):362-8. epub 2010 Dec 13.

(2 ) Donovan JL, Hamdy FC, Lane JA, et al: Patient-Reported Outcomes after Monitoring, Surgery, or Radiotherapy for Prostate Cancer; ProtecT Study Group. N Engl J Med. 2016 Sep 14.

(3) Barmer GEK Hospital Report 2012

 

Less incontinence and impotence after brachytherapy than after robot-assisted surgery (DaVinci)

Removal of the prostate with the help of a surgical robot (DaVinci method) does not lead to a lower incontinence and impotence rate after the treatment compared to conventional surgery.  On the contrary: low case numbers can even jeopardize the quality of the therapy and increase the risk of complications.

This is the result of an Australian study (1) published in the renowned journal "The Lancet" in 2018. According to this study, after 6, 12 and 24 months, the same number of patients complained of incontinence and impotence - regardless of whether they had been operated on minimally invasively with the Da Vinci robot or openly with the conventional method. Similarly sobering results are shown in a review (2) published in 2017 and a study (3) of 2019 by the renowned Memorial Sloan Kettering Cancer Center in New York, where the authors of the study also found no improvement in the quality of life of men with regard to their continence and sexual function after undergoing robot-assisted surgery.

In terms of brachytherapy, this means that both seed implantation and HDR afterloading can achieve significantly better results in terms of continence and erectile function than after removal of the prostate using a surgical robot. This is based on large comparative studies on side effects, long-term consequences and quality of life.

Literature

(1) Coughlin GD, Yaxley JW, Chambers SK, Occhipinti S, Samaratunga H, Zajdlewicz L, Teloken P, Dunglison N, Williams S, Lavin MF, Gardiner RA: Robot assisted laparoscopic prostatectomy versus open radical retropubic prostatectomy: 24-month outcomes from a randomised controlled study. Lancet Oncol. 2018 Aug;19(8):1051-1060.

(2) Ilic D1, Evans SM, Allan CA, Jung JH, Murphy D, Frydenberg M : Laparoscopic and robotic-assisted versus open radical prostatectomy for the treatment of localised prostate cancer. Cochrane Database Syst Rev. 2017 Sep 12; BJU Int. 2018 Jun;121(6):845-853

(3) Capogrosso P et al: Are We Improving Erectile Function Recovery After Radical Prostatectomy? Analysis of Patients Treated over the Last Decade. Eur Urol. 2019 Feb; 75(2): 221-22

 

No increased risk for a second tumor after brachytherapy compared to surgery

Many men are afraid of developing a malignant tumour again after successful prostate cancer treatment. Radiotherapy in particular is suspected of promoting the development of intestinal and bladder cancer. For brachytherapy, however, the scientific study situation gives no reason for this fear.

For example, a large comparative study by the British Columbia Cancer Agency (1) on more than 6400 men showed that patients with localised prostate cancer who had undergone seed implantation had no higher risk of developing a second tumour five or ten years after treatment than men whose prostate had been removed in one operation. This applied not only to secondary malignancies outside the pelvis, such as lung cancer, but also to tumours of the bladder and rectum.

Another large-scale study from the USA (2) on 2120 patients also shows that men who undergo brachytherapy do not have to fear a higher risk of developing a second tumour. This applies to both seed implantation and HDR afterloading combined with external radiation.

# Reason

Thanks to state-of-the-art computer technology and the use of imaging techniques, brachytherapy makes it possible to determine the target area with millimeter precision and to irradiate the prostate with pinpoint accuracy. This has the advantage that the tumour is destroyed without damaging surrounding healthy tissue such as the bladder, colon or sphincter.

Literature

(1) Hamilton SN et al: Incidence of second malignancies in prostate cancer patients treated with low-dose-rate brachytherapy and radical prostatectomy. Int J Radiat Oncol Biol Phys.2014 Nov 15;90(4):934-41. doi: 10,1016/j.ijrobp.2014.07,032. Epub 2014 Sep 17.

(2) Huang J, Kestin LL, Wallace M et al: Analysis of second malignancies after modern radiotherapy versus prostatectomy for localized prostate cancer. Radiother Oncol 2011 Jan;98(1):81-6. doi: 10.1016/j.radonc.2010.09.012. Epub 2010 Oct 14.

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