The long-term data on outcomes after first-line treatment with brachytherapy for localized prostate cancer are becoming increasingly compelling, and studies have also suggested strongly that quality of life data are better after brachytherapy than after other forms of treatment.
A recent article by Taira et al. report on 12-year follow-up from 1,656 patients treated in a single series between 1995 and 2006. This is believed to be the largest single series of brachytherapy patients treated using modern brachytherapy techniques. The patients were categorized by risk group (low-, intermediate-, and high-risk) using the Mt. Sinai risk criteria, and all patients were treated with permanent interstitial seed implantation.
The results of this analysis show the following:
- Median follow-up was 7.0 years.
- The median minimum dose covering at least 90 percent of the target volume of the prostate at Day 0 was 118.8 percent of the dose initially prescribed.
- Biochemical progression-free survival (bPFS), cause-specific survival (CSS), and overall survival (OS) for the entire patient cohort at 12 years were 95.6, 98.2, and 72.6 percent, respectively.
- For low-, intermediate-, and high-risk patients
- bPFS was 98.6, 96.5, and 90.5 percent, respectively.
- CSS was 99.8, 99.3, and 95.2 percent, respectively,
- OS was 77.5, 71.1, and 69.2 percent, respectively.
- For biochemically well controlled patients, the median post-treatment PSA level was 0.02 ng/ml.
- bPFS was most closely related to the percentage of positive biopsy specimens and the patient’s risk group.
- The patient’s Gleason score was the strongest predictor of CSS.
- OS was best predicted by patient age, hypertension, diabetes, and tobacco use.
- At 12 years, biochemical failure and prostate cancer-specific mortality were
- 1.8 and 0.2 percent, respectively, for patients with a Gleason score of 5 or 6
- 5.1 and 2.1 percent, respectively, for patients with a Gleason score of 7
- 10.4 and 7.1 percent, respectively, for patients with a Gleason score of ≥8.
The authors conclude that, “Excellent long-term outcomes are achievable with high-quality brachytherapy for low-, intermediate-, and high-risk patients.” They also comment that their results “compare favorably to alternative treatment modalities including radical prostatectomy.”
The current study gives no information about the quality of life of these brachytherapy patients, but two other studies (one in academic medical centers and another in a community practice) have shown that brachytherapy is generally associated with the highest quality of life after first-line therapy by comparison with surgery and external beam radiation. However, more and better data on this topic would still be helpful.
It is worth remembering that the data in this report comes from a highly repected center with extensive experience in the use of brachytherapy. One cannot assume that every brachytherapy practitioner is capable of achieving this level of result. One also cannot assume that such results can only be accomplished at such a center. It all depends on the skill, focuse, and experience of the individual treatment team — just as it does for every other form of first-line therapy.
It is also worth noting a recent study suggesting that brachytherapy may not be quite such a good option for treatment of prostate cancer in men with very small prostates (≤ 20 cm<sup>3</sup>). A retrospective study of data from > 6,000 patients carried out by Nguyen et al. indicates that the all-cause mortality of such men after brachytherapy was about 33 percent higher than for men with prostates > 20 cm<sup>3</sup>. However, prostate size also had no impact on prostate cancer-specific mortality in this same set of men, so brachytherapy may not be the issue here. It is possible that very small prostate size is more generally associated with a higher risk for all-cause mortality.
Filed under: Living with Prostate Cancer, Management, Treatment Tagged: | brachytherapy, long-term, outcome, seed implantation
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How do you make sense of these claims regarding QofL in the context of the article published on 6/11 regarding regarding radiation’s long term impact on ejaculatory capacity?
If you can’t get an erection at all, the idea of orgasm becomes a somewhat moot point for a man. I suppose there is an historic context to this.
It used to be that the ability to have an erection at all after treatment for prostate cancer was rare, so the fact that most patients were also unable to ejaculate was kinda irrelevant.
Now, a significant proporation of men are capable of erection post surgery and some post radiation too, which raise the issue of their ability to have an orgasm, but I don’t think we have a solution to that problem yet.
Interesting, our experience with clinicians of late is that they’re very quick to tell you that men can have orgasm without an erection, one just has to be “more creative.”
I just want to figure out who’s telling the truth about what. The contradictory and misinformation is mindboggling and thoroughly depressing.
Tracy:
A man can ejaculate without an erection and he can have an orgasm without ejaculation. However, those are technical statements.
Male orgasm with an erection but without ejaculation (“dry” orgasm) is well-known to be distinctly “different” than a normal male orgasm. (I have no personal experience.)
Similarly male orgasm without ejaculation and without an erection, while technically possible, is also going to be distinctly “different.”
No form of male orgasm that I am aware of is ever going to have the same level of “satisfaction” as the normal kind (that I am aware of).
Technically, the doctors are correct. Emotionally, with respect to QoL, who is kidding whom? I have no idea why any physician can’t just be honest about all of this. Basically I think they find the whole subject difficult to deal with and embarrassing to talk about. “Being more creative” doesn’t make a 50-year-old male have the same type of orgasm as he had when he was 18 either. However, men insist on pretending that we have and need the same level of “potency” at 50 as we had at 18. I suppose there are some men who do. I doubt that it is true for the vast majority of us. And where does “love” come into all of this?
Thank you for actually being honest.
I simply cannot understand the failure of urology as a profession to honestly inform men of the consequences of treatment. “Embarrassing to talk about” … If a urologist can’t bring himself to talk about sexual function, what medical discipline possibly can? Would we tolerate a neurologist who was too embarrassed to mention an inevitable cognitive side effect of brain surgery?
The lack of honesty is irresponsible, puerile, and prevents men from making fully informed treatment decisions, which also makes it unethical.
Tracy: They are just people, with all the normal frailties. Most of the Western world is incapable of an honest conversation about sexual function. If you want an honest convesation about sexual function from a urologist, go talk with one (like John Mulhall) who specializes in it — but he isn’t going to remove anyone’s prostate.
What stunning, outstanding treatment results, especially for the intermediate- and high-risk groups!
This recent study is consistent with the results published by Dr. Dattoli and some of the other studies of brachytherapy reviewed by the Prostate Cancer Results Study Group.
I think many of us are getting the impression you present in the first paragraph: “The long-term data on outcomes after first-line treatment with brachytherapy for localized prostate cancer are becoming increasingly compelling, and studies have also suggested strongly that quality of life data are better after brachytherapy than after other forms of treatment.” It is really encouraging to see such results accumulate.
Here are a couple of tangential thoughts.
First, is there any hope that the Radiation Clinics of Georgia (RCOG) will be updating their series? That update is growing more overdue wih every passing year, and it leads you to wonder why they are not publishing.
Second, HIFU and cryotherapy for low-risk cases are claiming to be in the same ballpark as surgery and radiation (especially seeds, or seeds plus EBRT and or hormonal therapy) as far as progression-free survival goes, but the stellar results you have presented to us are giving me doubts about these other, newer approaches.
Here’s how I’m looking at it. To start with, it appears from accumulating and consistent data from active surveillance programs that only about 30% of low-risk men actually will benefit from surgery or radiation, with the others not needing either to live a long and a good life. Therefore, with HIFU and cryo achieving about 90% progression-free survival rates, 20% above the easily achieved rate of 70% (active surveillance), the benefit is probably 20-30% of 67% (two thirds).
In contrast, the 98.6% progression-free survival for brachytherapy is 28.6% better than 70%, so the benefit seems to be 28.6%/30% or 95.3% benefit for brachy. Therefore, it looks like we can compare a benefit of 95.3% for brachy with a benefit of only about 67% for HIFU and cryotherapy — quite a difference! Does that seem a sound way of viewing it to you?
Thanks again for calling this study to the attention of the community.