Brachytherapy superior to Radical Surgery

Paradigm shifts in therapy of localized prostate cancer

If prostate cancer is detected in time, surgery, brachytherapy and external radiation offer the same cure rates. Since there has been no direct comparison of the methods based on randomized studies, surgery has been favored as the therapy of choice for a long time despite considerable side effects. A recent metastudy recently published in the British Journal of Urology International (BJUI) now shows for the first time that brachytherapy alone or in combination with complementary radiotherapy or hormone therapy is at least equivalent or even better in all stages of localized prostate cancer compared to radical surgery. The scientific confirmation of the high effectiveness of brachytherapy requires a rethink in the treatment of localized prostate cancer,"said Dr. Stephan Neubauer of the West German Prostate Center in Cologne, commenting on the latest results of the largest comparative study to date. "The surgery as a gold standard is thus once and for all no longer true."

Approximately 60,000 men in Germany are confronted with the diagnosis of prostate cancer every year and face the difficult task of choosing the "right" treatment. If the tumour is limited to the prostate (localised prostate carcinoma), brachytherapy (internal radiation), external radiation, surgery or active monitoring (active surveillance) offer the patient various treatment options.

In the recently published metastudy1, treatment outcomes of the different therapies were compared with each other for the first time in an extensive analysis of all studies published between 2000 and 2010. For this purpose, an international panel of prostate experts investigated the treatment results of more than 52,000 patients, separated by radical surgery (16,697 patients, 1381 of them with robot-assisted surgery), brachytherapy (a total of 22.479 patients, partly in combination with external radiotherapy and anti-hormone therapy), alone external radiotherapy (12,082 patients) or other procedures (532 patients with highly focused ultrasound, 227 patients with cryotherapy). The effectiveness of the therapy was measured by the so-called biochemical absence of recurrence, which is given if the PSA value in the blood does not rise again after treatment. Previously, patients were assigned to three risk groups - low, medium and high risk.

Brachytherapy achieves highest biochemical freedom from recurrence

The results speak a clear language: radiotherapeutic procedures are, in terms of their effectiveness, at least an equivalent or even superior treatment option compared to surgical removal of the prostate gland. Even if the best therapy for localized prostate carcinoma cannot be proven statistically, brachytherapy alone or in combination with external radiation and hormone therapy shows the highest biochemical recurrence-freeness. This applies to both early and advanced stages of the disease. The sole external irradiation shows the same results with regard to the absence of biochemical recurrence as compared to radical surgery.  

Dr. Neubauer and his colleagues from the West German Prostate Center call for a rethink at the highest stage. Considering surgery as the only treatment option for patients with localized prostate cancer has long since become obsolete, and sometimes even wrong. As pioneers of brachytherapy in Germany, they regret the fact that more than 60 percent of all patients with prostate cancer are still undergoing surgical treatment, while the modern form of radiation therapy has been used more frequently in the USA for many years.

And this despite the fact that, according to numerous studies2, apart from the now clear proof that no benefit in terms of healing can be proven, serious side effects such as incontinence and impotence after radical surgery are significantly higher than after brachytherapy,"emphasizes Dr. Gregor Spira, radiotherapist at the WPZ. Modern robotic assisted surgery, which is regarded as a "gentle" treatment option for the patient, also has more side effects than previously advocated. For example, a study3 in the US medical journal showed that impotence and incontinence are even more pronounced than in open radical surgery, despite the minimally invasive technique.

Experience is decisive

But just as with all treatment techniques, however, experience in radiotherapy is also decisive for the success of therapy:"Brachytherapy in particular places high demands on the experience and competence of the treating physicians," explains Dr. Neubauer. Numerous studies have shown that the quality can be significantly improved with the number of patients treated. When choosing a suitable therapy, it is therefore important to consider not only the type of procedure but also the specialisation and experience of the treating physicians,"says Neubauer. 

Literature:

  1. 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
  2. Naselli A, Simone G, Papalia R, Gallucci M, Introini C, Andreatta R, Puppo P: Late-onset incontinence in a cohort of radical prostatectomy patients. Int J Urol. 2011 Jan;18(1):76-9. 
  3. Jim C. Hu, MD, MPH; Xiangmei Gu, MS; Stuart R. Lipsitz, ScD; Michael J. Barry, MD; Anthony V. D’Amico, MD, PhD; Aaron C. Weinberg, MD; Nancy L. Keating, MD, MPH: Comparative Effectiveness of Minimally Invasive vs Open Radical Prostatectomy; JAMA. 2009;302(14):1557-1564.

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