Surgery versus brachytherapy

[Momto3]

Gleason score of 6 (3 + 3), PSA 3.3 (biopsied because of PSA velocity), 12 samples, 2 showed grade T1c (4% and 3%)

It is my understanding that prostatectomy after traditional radiation is difficult, at best.  Does the same hold true if a patient needs surgery after brachytherapy?  Also, what is the typical follow up for patients who choose surgery or brachytherapy?  Thanks for taking the time to provide this service.

[Ash Tewari, MD, M.Ch.]

Hi Momto3

Prostatectomy after Radiation therapy is a little more difficult, due to the fibrosis that occurs. Dissection planes thus become more difficult to define. This can be seen with external beam RT as well as brachytherapy. There is an individual variation with some cases being more difficult than others.

Long term results are available after surgery or brachytherapy.Some studies have reported progression rates of 40-60% after radiation therapy [Reference 1], and this is seen as an asymptomatic rise in serum PSA. Of course factors like PSA and Gleason scores are important predictors, and you could use one of the available nomograms to assess risks.

Benefits of Radical prostatectomy have been reviewed. In one study comparing radical prostatectomy with watchful waiting, radical prostatectomy has been shown to reduce disease-specific mortality, overall mortality, and the risks of metastasis and local progression. The absolute reduction in the risk of death after 10 years is small, but the reductions in the risks of metastasis and local tumor progression are substantial.[Reference 2]. In another study, treatment for localized prostate cancer was found to differentially affect HRQOL outcomes. Urinary control and sexual function were better after External Beam RT, although bilateral nerve-sparing surgery diminished these differences among potent men undergoing Radical Prostatectomy. Brachytherapy caused more obstructive and irritative symptoms, while both forms of radiation caused more bowel dysfunction [Reference 3]

References:

1. Stephenson AJ, Eastham JA. Role of Salvage Radical Prostatectomy for Recurrent Prostate Cancer After Radiation Therapy. J Clin Oncology: 23:32: 8198-8203

2. Bill-Axelson A, Holmberg L, Ruutu M, Haggman M, Andersson SO, Bratell S, Spangberg A, Busch C, Nordling S, Garmo H, Palmgren J, Adami HO, Norlen **, Johansson JE; Scandinavian Prostate Cancer Group Study No. 4.Radical prostatectomy versus watchful waiting in early prostate cancer. N Engl J Med. 2005 May 12;352(19):1977-84.

3.Litwin MS, Gore JL, Kwan L, Brandeis JM, Lee SP, Withers HR, Reiter RE.Quality of life after surgery, external beam irradiation, or brachytherapy for early-stage prostate cancer. Cancer. 2007 Apr 23; [Epub ahead of print]

[gkloanman]

Hey there,

I live in California and my family out east says brachytherapy for prostate cancer is extremely popular and many doctors choose to perform that procedure.  I was wondering if it was the same around California and the westcoast and exactly how many seeds are implanted in an individual per procedure.  Also, do the doctors (oncologists) themselves buy the type of seed they want or is it up to somebody else?  Please let me know Thank you!

[Momto3]

Thanks for your input.  Not sure if you've faced this decision, but it is surely a tough one.  Surgeons tend to opt for sugery and radiologists prefer radiation and/or brachytherapy.  While short term effects are important, we must also research and understand potential long term effects.  So far, the brachytherapy seems to be a viable option, but we have yet to have the study performed to determine whether it could be done for certain.

As for major medical centers, we are closest to Duke and are hoping to add their expertise to our repetoir of information.  Any suggestions on doctors?  

Thanks for any further suggestions, input!

[TWOCENTCIGAR]

It all depends on WHO is delivering the procedure! A "radical" is exactly that and I would never let anyone cut out my prostate! Just ask NY Yankee Manager Joe Torre that! He had surgery and upon sending the specimen to the pathology lab, they learned he had positive margins and therefore required radiation! Not to mention the incontinence and impotence rates associated!  Then again, Mayor Gulliani had a seed implant!  Imagine that!!!  

I would elect prostate brachytherapy with a stranded technology! I'd also reccomend a premier Radiation Oncologist and hospital! (ie. Mt. Sinai of New York City and Dr.'s Cesserati or Stock) Where do you live?  Surprised these Urologists arent reccomending cryosurgery for the reimbursement!

Providing of course he's an ideal candidate for treatment! Active surveilance never hurt anyone as MOST men die with prostate cancer and RARELY from it!

Hope this helps!

[Momto3]

Thank you for your informative answer!!  Although we asked the urologist as many questions as we could think of, we forgot to ask about follow up.  Is there a difference in follow up for surgery versus brachytherapy?