Prostate cancer is the most common cancer in men across the United Kingdom, and arguably, the most intimate too, which can cause many men to feel embarrassed when it comes to discussing their symptoms or treatment options with a specialist. Indeed, it can be all too easy to dismiss potential symptoms of prostate cancer as “just part of getting older”. Yet, with an expected surge in late diagnosis as a result of COVID-19, it’s more important than ever that men feel confident in discussing any health concerns they might have, as well as being educated about the options they have.
Education is Key
Once prostate cancer has been diagnosed, one of the biggest decisions for a gentleman to decide is what treatment pathway they would like to opt for. This can vary depending on whether the cancer is contained within the prostate, which side of the prostate the lesion(s) may be on, and how aggressive it may be – which is why an early diagnosis is key to ensure that men have the most options.
The first person men speak to in the counselling process – whether that is an oncologist, urologist or specialist nurse – will of course have a very strong influence on the eventual decision regarding chosen treatment. Even patients opting for a second opinion will, more often than not, still follow the advice of the first clinician. It is therefore essential that the first discussion openly and honestly discusses all the potential options – not just surgery to remove the prostate (radical prostatectomy).
Today, while clinical guidelines include low dose rate Brachytherapy (LDR-B), radical prostatectomy, hormone treatment, radiotherapy or active surveillance, the treatments being offered can be highly postcode dependent.
A recent study revealed radical prostatectomy has the greatest impairment of sexual function and urinary continence when compared with active monitoring and radiotherapy with hormones. In addition, many radical prostatectomy patients go on to have further treatments at a later stage. With few patients being offered alternative treatments, it’s important that men feel confident to ask – especially when there are so many new advancements taking place.
Radiation therapy, however, includes a range of treatments and dosing including external-beam based therapies, high-dose-rate (HDR) or low-dose- rate (LDR) brachytherapy, and combinations of beam and brachytherapy, with or without hormone therapy. Choosing amongst these can be a daunting task.
Low Dose-Rate Brachytherapy
Low dose-rate brachytherapy is a type of internal radiotherapy, which involves the insertion of tiny radioactive capsules, or 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 cells. It has been a highly effective treatment for prostate cancer for more than 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 over 10 years. So why are more patients not being offered this option?
One of the issues is without doubt closed thinking. Radical prostatectomy has been the default treatment for prostate cancer for many years. In contrast, 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. Critically, it is not limited in its applicability: virtually any patient with localised prostate cancer can receive a brachytherapy implant if that is the desired treatment.
As advancements continue apace, one recent innovation of LDR brachytherapy is 4D brachytherapy, which involves a single stage, real-time implant technique that uses simple prostate measurements under ultrasound or MRi to calculate the number of seeds required for the procedure. Replacing the standard ‘two-step’ technique, the process means that patients no longer require two anaesthetics and the pre-planning scan can take place alongside the clinical visit, taking approximately 45 minutes in theatre.
This development has been made possible thanks to the scientific approach to treatment planning. It offers better targeted treatment, reduced treatment-related toxicity and an overall improved patient experience. Additionally, the new monotherapy implant technique provides cost benefits of over 40% in comparison to the traditional two-stage approaches, as well as greater time savings – in turn, improving efficiency and reducing potential complications.
A vast number of research studies have been conducted around 4D brachytherapy, all of which highlight the benefits of the treatment option. A recent 2020 study compared low-dose-rate prostate brachytherapy treatment plans, applying the 4D brachytherapy technique, using both TRUS and MRI to obtain prostatic measurements. These findings revealed that MRI could be successfully integrated into 4D brachytherapy, meaning a diagnostic MRI scan could be used for planning, replacing the pre-procedural TRUS-based assessment scan.
There is little doubt that brachytherapy is a good option for a high number of prostate cancer patients. The biggest barrier to its wider uptake in the UK is, of course, the availability of brachytherapy services. There remains great geographic variability in this regard. But as evidence of its impact on treatment and patient experience mounts, there is confidence that access will improve, particularly as the numbers of men likely to be referred with prostate cancer seems likely to increase as elective procedures start to resume.
Saheed Rashid, Managing Director, BXTAccelyon, comments: “While the importance of men and their families researching all the treatment options available to them and discussing these with their consultant must be emphasised, there is an increasing body of evidence to suggest that, of the curative-intent treatment options, Low-Dose-Rate Brachytherapy as a mono- or combination therapy, has favourable outcomes and fewer adverse side effects.
“As a treatment, this option has been proven for over 25 years, and advancements such as 4D brachytherapy and NHS England supported toxicity barriers have further improved the patient experience.”