More Details About Prostate Cancer Treatment

What should I do if I find out I have prostate cancer?

A diagnosis of prostate cancer can be frightening, but it need not be. Remind yourself that most cancers today are detected in their early stages when adequate treatments provide a cure rate of more than 90%. At our clinic, we have found that several of the following recommendations help patients and families cope with this diagnosis:

Become informed so that you and your family understand the disease better. The American Cancer Society and National Cancer Institute can provide a great deal of useful information.
Ask for interpersonal emotional support.
Turn to faith and trust.
Figure out what patients and family members can contribute in terms of starting a healthier living program.
Join one of the many support groups available for prostate cancer patients. USTOO is a good place to start your research.

On the medical side, you and your family may find it beneficial to do the following:

Study all of your treatment options.
Seek opinions from your family physician and specialists in surgery, radiation, and medical oncology.
Actively participate in selecting your type of treatment.
Recognize that the goal of any treatment should be two-fold: to cure the cancer and preserve the best quality of life.

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 is 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 (radical prostatectomy and external beam radiation) were so challenging for patients that one wanted to wait to institute therapy.

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 health reasons and 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, CT and bone scans may be performed in conjunction with a specialized biplane ultrasound exam of the prostate. Rarely, some men will have a large gland requiring hormonal downsizing prior to the seed implant, or they 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 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 captures images of the prostate at 5mm increments. These images are then entered into the treatment planning computer to produce 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 is not required. 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 to assure 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 at our other facilities, 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. The Grado-Ragde study was one of the first ones 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 reported results were less favorable with high-grade tumors (Gleason 8–10). Initially, most patients were treated with Pd-103, but when no increased advantage was seen compared to I-125, we learned to base radioactive seed selection on availability of the correct strength and number of seeds available. Some inherent advantages 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 is 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 Health-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 O.R., 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 performed. 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 scheduled.

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 O.R., 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 in which the needles are to be inserted. The nurse will then insert a Foley catheter into the bladder and inject some contrast material into 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 show a picture of the prostate area on a television monitor. Dr. Grado will then insert 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 placed 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 that 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 any radiation emission to ensure he is within the required safety limits. The patient is then taken to a recovery room where he is 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 (toll-free number: (888) 539-6300), or you can fax your appointment request to (480) 614-6333; we will get back to you by the next working day with an appointment. We make every effort to accommodate your schedule and realize the apprehension 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. 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 available records on their prostate cancer diagnosis or treatment. If there is a recent physical exam, EKG, and chest x-ray, these are helpful 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 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 performed, if you had not had one, 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. Occasionally, other diagnostic films 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. Locally, the perineum (under the scrotum) can be slightly tender to the touch or when sitting, and there may be some bruising. 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 you do not engage in any heavy lifting for 30 days; this may cause increased pressure in the pelvic area. Walking, swimming, and golfing are fine if you avoid overdoing it. Exertional activities can cause more bleeding into the prostate gland after the procedure, which might 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. However, the implants then 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/her 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 sufficient 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?

The term brachytherapy literally means “close-up” therapy. 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 performed about 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.

How effective is prostate brachytherapy?

According to published studies, brachytherapy has an overall (including both low and high risk patients) 70% success rate after 12 years, with few complications or side effects reported. In low-risk patients with the cancer still confined to the prostate, the success rate using brachytherapy is 90 – 100%. The overall brachytherapy success rate surpasses the ten-year success rate of 59%, according to studies that evaluated follow-up results for radical-surgery patients.

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 scientific 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 weeks with minimal or no medical intervention. However, evidence of significant urinary retention, which may occur in about 5% of patients and will require an indwelling Foley catheter or intermittent catheterization. This problem 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 1 to 3 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 can be 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 treat 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 cannot divide to make new cancer cells 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. Other 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 an urologist and/or radiation oncologist.

Is it true that only small prostate glands can be implanted?

Physicians with limited 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 in volume, about 7 ounces (or a 2.5–3 inch diameter sphere), have been implanted using a special technique we have developed.

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.

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