About Brachytherapy Treatment for Prostate Cancer
Q. A friend of mine went to someone in the South who required that he move there for two months so he could receive external radiation there using a special technique that would “cut out the cancer with radiation” after he had the brachytherapy implant. Is this possible?
A. No. No form of external radiation combined with brachytherapy can “cut out the cancer or the prostate.” All techniques using brachytherapy alone or brachytherapy combined with low-dose external radiotherapy are intended to destroy the normal glandular tissue and any small amount of cancer that may have invaded into and around the capsule of the prostate. Also, with precise attention to dosimetry planning and especially operative technique, it is possible to treat most early stage patients with brachytherapy alone and not require the addition of any external beam radiotherapy. The requirement for external beam therapy in addition to seed implantation for all patients, including the most favorable ones, may reflect a lack of confidence in the ability of a given implant team to achieve optimal implants.
Q. My doctor says he wants me to be in the hospital the night before, as well as the night after the implant. Is this necessary?
A. With appropriate lab testing ahead of time, most patients can arrive at the hospital in the morning, get the implant started 1-2 hours after arriving, and be discharged by mid-day. In our experience, all are admitted the same day as the implant, and less than 5% spend the night after the implant in the hospital.
Q. How soon will you check my PSA after the implant has been done?
A. For patients receiving the implant alone (without external beam or androgen blockade), we generally get the first PSA at 6 months. Earlier PSA values are not generally accurate and may be artificially high due to the inflammation caused by the treatment. If a patient receives androgen blockade for any length of time, we generally wait until 2-3 months after the shot should have worn off (e.g. 5-6 months after the 3-month Zoladex shot or 6-7 months after the Lupron 4-month shot).
Q. My PSA was 5.0 before implant alone, and only decreased to 2.1 at six months. Should I be worried about this?
A. No. It often takes 18 months or longer for the PSA to come down to its nadir, or low point. Many patients show a gradual and slow declining trend over a two year period, but still come down to a value below 0.5 ng/ml. Generally, the 6 month PSA is approximately half of the pre-treatment value.
Q. How low should my PSA go after brachytherapy?
A. We would like to see the PSA eventually reach a low less than 0.5 ng/ml. This appears to be the ideal range, though most patients who get to any value under 1.0 will do well in the long term. Patients who reach a value less than 0.5 will be more likely to remain low and therefore appear to be cured. Note that this is different from patients who undergo surgical removal of the prostate, since any detectable PSA means there is likely cancer present. In patients who have surgery and removal of the prostate, for example, the PSA after prostatectomy level if cured should be less than 0.2 ng/ml.
Q. Will it be necessary to biopsy my prostate to see if the cancer has been destroyed?
A. No. In the past, biopsies were often required. However, we now know that if the PSA reaches a nadir less than 0.5 and stays there, no biopsy is needed. If the PSA begins to rise and we would consider adding some other therapy or doing something different, only then might it be important to determine if cancer is still present in the prostate.
Q. If the PSA is less than 0.2 after surgery or less than 0.5 after brachytherapy, does that mean a man is cured?
A. No, but it means that there is a good chance of it. Since prostate cancer is slow-growing, it may take years for any remaining prostate cancer cells to grow enough to change the PSA. We generally need to see the PSA stay down for 10 years after treatment to consider a man cured after treatment.
Q. My urologist claims that he can spare the nerves regulating erections when he takes out my prostate and that I will not be impotent. Is this correct?
A. The nerve-sparing prostatectomy was a major advance in the surgical technique. Dr. Patrick Walsh, who developed it, claims good results in the majority. However, the vast majority of urologists who do this procedure frequently do not find the results to be as good, nor do most patients. Nerve-sparing surgery works better in men under 60 and best in men under 50. Overall, less than half of men who undergo nerve-sparing radical prostatectomy will be able to have satisfactory erections without other help, such as Viagra. Other factors, such as history of smoking or hardening of the arteries, also may affect results.
Q. Does brachytherapy result in erection difficulties?
A. It can. In 20-40% of cases, and especially if brachytherapy is combined with external beam for high-risk disease patients, erection difficulties may occur. After implantation, potency depends on many factors, especially pre-treatment sexual function, age, use of hormones, smoking history, etc. However, these are often patients in whom a nerve-sparing prostatectomy would not be recommended due to the extent of disease. The good news is that recent reports have shown that up to 75% of the men with erection problems after a prostate implant respond very well to Viagra.