Outcomes for Seed Brachytherapy.
Comparison show that the long-term cure rates from all modern prostate cancer
therapies is equal1. One treatment does not offer any cure advantage over the other.
Seed brachytherapy offers equivalent outcomes to that of surgery, including robotic
surgery. Multiple international, high-level, evidence-based treatment guidelines
attest to this.2,3,4,5
We are the most experienced seed treatment centre in Australia and have done
nearly a thousand implants since we started in 1998. Figure 1 shows the diseasecontrol for all the men we have treated, including both “low-” and “intermediaterisk” men, are included here. The rate is 90.2% (shown as a proportion 0.902 on the
graph). The cancer control for “low-risk” men is better than 92% at 10 years (not
shown here).
Figure 1
It therefore comes down to what options are suitable for you and what treatment
offers the lowest risk of toxicities, important to you. Below are some of the common
risks and differences between surgery and brachytherapy. Obviously it is important
to discuss all the risks with the appropriate specialist.
Perioperative Death
This doesn’t happen after seed brachytherapy: patients usually go home the same
day as the implant. After radical prostatectomy in large series the mortality rate has
been reported as between one in a hundred or one in two hundred67 . In one study
in men 80 or older one in twenty-five was dead with thirty days of the surgery6.
Urinary bother and irritation
This is the most common troublesome side effect of seed brachytherapy. Often men
will have bladder irritation initially for 1 – 2 months. However this is likely to settle.
The vast majority of men have returned to their normal urinary function by one
year. Less than 5% will have ongoing, “permanent” urinary problems. Significant
problems requiring intervention or a catheter are very rare.
Incontinence
No matter how clever the surgeon, or advanced the technology, the stats show that
around 5%-10% of men having a radical prostatectomy will have serious
incontinence8 With seed brachytherapy serious incontinence is a rare event seen in
<1% of patients9,10.
Impotence
Figure 2
Predicted Erection Recovery at 2y, %
It is widely know that radical prostatectomy will practically always cause complete
failure to have useful erections. These very uncommonly get back to the prior
function, even with the new nerve-sparing procedures. Seed brachytherapy patients
usually do not have the problems with their erections. A recent large American
study illustrates this11. They looked at over a 1000 men treated with either surgery
or brachytherapy and were able to derive a very accurate predictive model that
allowed estimation of the chances of “functional erections” in men after nervesparing surgery, non-nerve-sparing surgery, or seed brachytherapy, depending on
their erectile function before hand (Figure 2)
100
Seed Brachytherapy
NS Radical Prostatectomy
NNS Radical Prostatectomy
75
50
25
0
0
10
20
30
40
50
60
70
80
90
100
Pretreatment Sexual Function Score
Chance of functional erections, by treatment for prostate cancer.
For 60 year old, normal weight, PSA initially ≤10. Predictive curves
calculated from model, for Seed Brachytherapy, Nerve-Sparing (NS),
and Non-Nerve-Sparing (NNS) Radical Prostatectomy.
Source: Alemozaffar M, et alia “Prediction of erectile function following treatment for prostate cancer.” JAMA 306;11:1209 2011.
Alemozaffar M, et al. Prediction of Erectile Function following Treatment for
Prostate Cancer. 2011 JAMA 306; 11:1209.
This showed that if men had “100%” erections prior to treatment, at two years
after brachytherapy 92% were OK, whereas after standard surgery this was not
much better than 25%.
Following surgery, some men notice “penile shrinkage” and this can be a concern
to patients and their partners. This is not seen following seed brachytherapy.
Bowel problems
Men often note a minor change in bowel habit after brachytherapy, but not enough
to bother them. Sometimes there is a small amount of bleeding, but this usually
settles spontaneously. The risk of bowel damage is very unlikely in the long term.
Surgery does not usually cause bowel damage.
References
Kupelian et al. Radical prostatectomy, external beam radiotherapy &lt;72 Gy, external
beam radiotherapy ≥72 Gy, permanent seed implantation, or combined seeds/external
beam radiotherapy for stage T1–T2 prostate cancer, IJROBP, 58(1) 2004, Pages 25-33
1
2Australian
National Health and Medical Research Council “The panel at this time
considers these interventions to be options for the treatment of localised prostate cancer
because the data currently available in the literature do not provide sufficient clear-cut
evidence to indicate the unquestioned superiority of any one form of
treatment.” Australian Cancer Network Working Party on Management of Localised
Prostate Cancer. Clinical Practice Guidelines: Evidence-based information and
recommendations for the management of localised prostate cancer. NHMRC 2002
European Society of Medical Oncology. “Options include active surveillance, radical
prostatectomy, external beam radiotherapy, brachytherapy with permanent implants or
high dose rate brachytherapy with temporary implants… Ten-year prostate cancer specific
survival approaches 100% for each management option”.Horwich A, Parker C, et al
Prostate cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and
follow-up. Annals of Oncology 2010.
3
Australian Prostate Cancer Collaboration “It is not known which type of treatment is
the best for localised prostate cancer. Therefore… it is important to think about the quality
of your life after you have had treatment.” Localised prostate cancer. A guide for men
and their families. 2006
4
American Urological Association "interstitial prostate brachytherapy, external beam
radiotherapy, and radical prostatectomy are appropriate monotherapy treatment options
for the patient with low-risk localized prostate cancer. Thompson I, Aus G, Burnett AL, et
al “Guideline for the Management of Clinically Localized Prostate Cancer: 2007
Update” AUA 2007
5
Bubolz T, Wasson JH, Lu-Yao G, et al. Treatments for prostate cancer in older men: 1984–
1997. Urology 2001; 58(6):977–82.
6
Lu-Yao GL, McLerran D, Wasson J, et al. An assessment of radical prostatectomy. Time
trends, geographic variation, and outcomes. The Prostate Patient Outcomes Research Team.
JAMA 1993 May 26; 269(20):2633–6
7
Stanford et al. Urinary and sexual function after radical prostatectomy for clinically
localized prostate cancer: the Prostate Cancer Outcomes Study. Urinary and sexual function
after radical prostatectomy for clinically localized prostate cancer: the Prostate Cancer
Outcomes Study.JAMA 2000; 283:354.
8
Crook, J., Fleshner, N., Roberts, C., & Pond, G. (2008). Long-Term Urinary Sequelae
Following 125Iodine Prostate Brachytherapy. The Journal of Urology, 179(1), 141–146.
9
Peinemann, F., Grouven, U., Bartel, C., Sauerland, S., Borchers, H., Pinkawa, M.,
Heidenreich, A., et al. (2011). Permanent Interstitial Low-Dose-Rate Brachytherapy for
Patients with Localised Prostate Cancer: A Systematic Review of Randomised and
Nonrandomised Controlled Clinical Trials. European Urology, 60(5), 881–893.
10
Alemozaffar M, et al. Prediction of Erectile Function following Treatment for Prostate
Cancer. 2011 JAMA 306; 11:1209.
11