High Dose Rate Remote Afterloading Brachytherapy for Prostate Cancer
   
 

What is Prostate HDR Brachytherapy ?

Prostate HDR Brachytherapy is a method of giving the prostate an extremely high but perfectly shaped dose of radiation. It is accomplished by temporarily placing needles into the prostate, then controlling how a radioactive seed is passed throughout each of the needles.

Prostate brachytherapy was popularized in the 1990's with permanent seed implants. HDR (High Dose Rate) is far more advanced than seed implants - it uses computer- planning and computer-control to precisely give the radiation only where desired. Using this computer control, a single radioactive pellet is temporarily inserted and guided through the needles placed into the prostate. This single radiation seed, along with the needles, is then removed.

The end result is that an extremely high dose of radiation can be precisely shaped and given into the prostate where the cancer is, while controlling the dose to surrounding normal tissue - such as the bladder, urethra, and rectum. This dramatically limits the side effects of this treatment, while giving the radiation even more accurately.

This process has several advantages over a permanent seed implant. The plan and radiation delivery is based on where the needles actually are, not upon trying to get the seeds into the place you want. Also, it is based on the needles' location in the prostate; with a seed implant the prostate changes shape and stretches while the seed needles are being placed. Because the HDR seed is computer controlled, it can stay at any point in any needle for the desired amount of time - precisely controlling the radiation at each point; seeds are all of the same strength in any one patient, so the dose cannot be adjusted as readily. Because of the physics of permanent seeds, the center of the prostate gets a higher radiation dose - and this is where the urethra is located. HDR , on the other hand, allows the urethra to be kept much “cooler” (less radiation) -far less than is given with seed implants. Finally, research is showing that prostate cancer is more sensitive to a few large doses of radiation than it is to “standard” daily doses of radiation, or radiation slowly given. This is exactly what HDR does - allows large doses of radiation to be given in a few treatments.

 
 

High Dose Rate Unit
Click on image for a larger version

   
Central Indiana Cancer Centers has a highly experienced brachytherapy team, consisting of physicians (radiation oncologists), physics staff, brachytherapy nurses, and therapists who provide Prostate HDR Brachytherapy treatments on a regular basis. We are proud to have performed over 500 Procedures as of the end of December 2005. We have been safely performing these procedures regularly since February of 2001. At that time we were one of only a few programs in the nation offering this treatment.
     

The Procedure

Patients are brought into the Operating Room and placed under spinal or general anesthesia. Tiny tubes or catheters are inserted under ultrasound guidance into the prostate. Usually 15-18 of these tubes are placed in the prostate. These tubes are attached to a holder called a "template", which is then attached to the skin. The bladder and rectum are checked to assure no damage. A urinary catheter is temporarily placed in the bladder. The patient is awakened in the recovery room. The patient is then transferred by ambulance to the Cancer Center for the rest of the treatment process.

 
Template-Needles
   
     

The Planning

Once the patient arrives at the Cancer Center , he is taken to the CT scanner to verify accurate catheter placement and for treatment planning. The CT pictures of the prostate, implanted tubes and all nearby organs are sent to the treatment planning computer. The patient waits in a private area until the plan is finished. The physician marks the prostate, urethra, bladder and rectum on the CT images. 3-D reconstruction is used to plan the volume and shape of tissue to be treated, and the radiation dose. The physician works closely with the physicist to determine exactly how to deliver this exact radiation dose through the tubes. In patients who have cancer growing outside of the prostate, or into the seminal vesicles, the "target" is flared out to cover these areas with full-dose HDR radiation as well. Usually additional needles are placed into these areas in the operating room to aid in delivering higher doses of radiation to these areas of cancer involvement.

 

 

HDR Planning Screen
Click on image for a larger version

These are CT slices through the prostate, showing the radiation dose to be given. Each dot is one of the needles; the colored lines show the intensity levels of the radiation. The blue circle in the center is the urethra - note how the radiation dose is "cooled off "around the urethra. The bladder is the lighter gray area above the prostate on the top two slices: the rectum is just behind the prostate on all 4 slices. Note how the radiation dose is tightly shaped to the prostate.

   
     

The Treatment

After the planning is completed the patient is moved into the treatment room. Each of the needle tubes is attached to the HDR machine's connecting tubes. Each of the tubes has to be carefully checked to ensure that it is attached correctly. Once the radiation tubes are correctly hooked up, the treatment is given. Generally, the treatment lasts ten to fifteen minutes. During this time, the patient is constantly monitored by the physician, the physicist, and nurses outside the room with remote cameras and microphones.

 

HDR machine with connecting tubes
Click for a larger version

 
   

Results

This procedure has been performed in the United States since 1989. The results, including cure rates, appear to be equal or superior to any other method of prostate cancer treatment including permanent seeds, conformal external beam, cryotherapy, or surgery. The cure rates are good even for locally advanced prostate cancer. See (see Comparing Results) below. For “low risk prostate cancer ( PSA <10, Gleason <=6, non-bulky disease) the disease control rate is 93-97%! For “intermediate” or “high risk disease, the control rates are 87% or higher.

 

Radiation Safety

Since the treatment is given only within the prostate, the radiation is limited to the prostate gland with much lower doses to the tissues just around the prostate. Unlike permanent seeds, after the treatment is completed NO radiation is left in the body to expose others.

 

Typical Side Effects and Toxicity

During the treatment:

•  Mild discomfort with the catheter in the bladder
•  Discomfort in back or legs from lying still for several hours

After the treatment:

•  Burning with urination - usually lasts 1 -2 days only.
•  Blood in urine when voiding -- usually lasting a few days.
•  Mild discomfort on bottom with bruising, Most noticeable when sitting. Pain medicine can be used but is rarely needed.
•  Urgent and frequent urinating. This usually lasts around 1 week and then calms down quickly.

Later-occurring side effects:

  • Stricture - scar tissue just below the prostate that limits urine flow, and can cause burning with urination or difficulty emptying the bladder. This can require dilation by urologist. Stricture occurs in about 5% of patients.
  • Impotence - occurs in only 30-50% of patients (see Comparing Results) below.
  • Bladder irritability - having to urinate urgently or more often. This is usually intermittent (not always present), and occurs in around 5% of patients.
  • Other rare side effects could occur - discuss with your radiation oncologist.
 

Treatment Regimens

There are two methods of giving prostate HDR - HDR Monotherapy, or combination treatment. In HDR Monotherapy, all radiation is given through the HDR needles -there is no external beam radiation. In combination treatment there are both HDR treatments as well as external beam treatments. (see Comparing Results)

HDR Monotherapy:
HDR Monotherapy is used for “low risk" prostate cancer- PSA <10, Gleason <= 6, and non-bulky disease. On occasion it can be safely used for Gleason 7 disease if all other factors are good.

HDR Monotherapy involves placing the needles in the operating room, and then giving the first HDR treatment as outlined above. After the first treatment that afternoon, the patient is moved back to the hospital and kept overnight in the hospital room. The needles are left in place, so the patient must lay in bed through the night. Pain medicine is given if needed, and the nursing staff rolls the patient on each side periodically for comfort and to prevent blood clotting. The next morning the patient is moved back to the Cancer Center . A CT scan is obtained to make sure the needles have not moved out of place. Occasionally a few of the needles have moved a little, and the radiation oncologist readjusts the needles so they are in the exact same position as the prior day. The second HDR treatment is then given. The patient stays at the Cancer Center , and the third treatment is given in 6 hours. The needles and catheter are then removed, and the patient is released to go home.

This entire treatment is then repeated one to two weeks later, by placing the needles in the operating room, and giving 3 doses of radiation during that same and the next day. At this point all treatment is completed!

HDR Combination Treatment:
Combination treatment can be used for “low risk" prostate cancer above, if the patient chooses not to stay overnight in the hospital with the needles in place.
Combination treatment can also be used for “intermediate” or “high risk" prostate cancer - those with PSA >=10, Gleason 7 or higher, or cancer in both sides of the prostate.

HDR combination treatment consists of two single HDR doses, plus 5 weeks of external beam radiation. In this setting the daily external beam radiation treatments are started. In one to two weeks the first HDR treatment is given all in one day. (The needles are placed in the operating room, the patient is brought to the cancer center and the HDR treatment given through the needles. The needles are removed, and the patient is sent home the same day.) The external beam radiation then continues on a daily basis. In about 2 weeks the second HDR treatment is given. The external beam radiation then resumes the next day, continuing until a total Of 25 radiation treatments (plus the 2 HDR 's) have been given. Thus, all treatment is given in 27 working days.

Why add external beam? There are 2 reasons to use combination treatment. The main use is for patients with intermediate or high risk prostate cancer. In these patients there is a higher risk of cancer microscopically involving the seminal vesicles or lymph nodes. External beam radiation is added to provide radiation coverage of these structures to try to kill any cancer that may be hiding in them.

The second use is in low-risk patients. Some patients with low-risk prostate cancer want the higher disease-control delivered by HDR , but without having to stay overnight in the hospital with the needles in place. Other patients with low-risk disease may have other health issues that make being immobilized overnight somewhat risky - history of congestive heart failure, blood clots, patients on blood thinners that cannot be held temporarily, etc. In these patients the benefits of HDR radiation can be achieved without increasing the risk of other health problems by giving combination treatment. (Most patients on Coumadin or other blood thinners can still have HDR treatment by “bridging” or temporarily stopping the thinner for the treatment, then resuming the blood thinner.)

 

Frequently Asked Questions

How does radiation work?
Radiation is a beam of pure energy that destroys the DNA (the building block of a cell). It can damage both normal cells and cancerous Cells (if it is given to normal cells). However, with the correct dose, the normal cells can repair the damage.

What is High Dose Rate Brachytherapy ( HDR )?
HDR is a process of giving very high doses of radiation in a very short time. The delivery of the radiation is precisely controlled. It uses a computerized system to control the movement and location of a pellet of a very strong isotope called Iridium. The pellet is passed through connecting cables using computer guidance, into tubes which have been placed into the tumor. This allows the tumor to be treated from the inside with precise control. Since the radioactivity of the pellet is very strong, the treatment can be given in a few minutes. This avoids a long hospitalization but gives the benefit of treating the tumor from the inside.

What are the benefits of HDR Brachytherapy?

  • Greater precision of treatment - the radioactive source's location, and the time it stays at each location, are precisely controlled.
  • Higher effective dose than other methods of radiation - a high dose of radiation given in a short time can be more damaging to cancer cells than the same dose spread out over a longer time frame. This is especially true for prostate cancer.
  • Better Control of side effects - by allowing more precise control of the radiation source location, and by placing the radiation into the cancer directly, it doesn't have to pass through normal organs to get to the desired location.
  • Minimal recovery time. Patients can go home several hours after the treatment with few restrictions.

Is HDR the only treatment I will have?

Using HDR alone is an option for patients with "low risk" prostate cancer, as noted above. (see Treatment Regimens) Patients with higher risk prostate cancer should have not only 2 HDR treatments, but also 5 weeks of external beam treatment: patients with "low risk" prostate cancer may choose this as an option as well. (see Treatment Regimens)

 

 
 

Please Note: THIS SECTION IS STILL UNDER CONSTRUCTION

Comparing Prostate Cancer Treatments

Most patients with prostate cancer have many good options from which to choose external beam radiation, surgical prostatectomy, brachytherapy ( HDR or seeds), etc. Deciding which is best for you can be difficult and confusing. The tables below are designed to try to help you in comparing the treatment Options.
(NOTE: Data in the medical literature varies greatly, and is dependent upon many factors - including techniques in use at the time the literature was published, nature of the cancers treated (termed “selection bias”), definitions used for disease control and for side effects, how thoroughly patients are questioned about side effects, and even the beliefs of the publishing doctors. No true “head-to-head” comparison studies exist, so comparison of data can only be done for general comparison purposes.)

 
 
Low Risk Prostate Cancer
Treatment
HDR
(combined with external beam)
External beam/IMRT Radiation**
Prostatectomy***
Seeds****
Cryotherapy*****
Disease Control
93-97%
XXX%(CICC)
x
x
x
x
Incontinence
(leakage)
<1% (CICC)
<1%
x
x
x
Impotence
30-50%
30%
50-100%
50%
Rectal Injury /Bleeding
<1% (CICC)
15%
x
x
x
Stricture (scarring)
5%
x
x
x
x
Need for Catheter after procedure
5% (CICC)
x
x
x
x
"Salvage" Options
(treatments possible if cancer returns only in prostate)
Cryotherapy
HDR,Cryotherapy, Seeds,
? Surgery
External Beam
HDR(CICC data),
Cryotherapy
? HDR, ? External Beam, ? Surgery
(not known)
 
* From William Beaumont and California Endocurietherapy data; CICC data as noted
 
 
Higher Risk Prostate Cancer
Treatment
HDR
(combined with external beam)
External beam/IMRT Radiation**
Prostatectomy***
Seeds****
Cryotherapy*****
Disease Control
87%
XXX%(CICC)
x
x
60-70%
x
Incontinence
(leakage)
<1% (CICC)
<1%
x
x
x
Impotence
30-50%
30%
50-100%
50%
Rectal Injury /Bleeding
<1% (CICC)
15%
x
x
x
Stricture (scarring)
5%
x
x
x
x
Need for Catheter after procedure
5% (CICC)
x
x
x
x
"Salvage" Options
(treatments possible if cancer returns only in prostate)
Cryotherapy
HDR,Cryotherapy, Seeds,
? Surgery
External Beam
HDR(CICC data),
Cryotherapy
? HDR, ? External Beam, ? Surgery
(not known)
 
* From William Beaumont and California Endocurietherapy data; CICC data as noted
 

Contact:

HDR Coordinator - Teresa Dallas, R. N. (317) 964-5219

Physicians:

Morgan E. Tharp, M.D.

G. Irene Minor, M.D.

Michael C. Hardacre, M.D.

 
Print This Page
 
 
   
 
   
Central Indiana Cancer Centers is
an Affiliate of US Oncology. A premier
cancer care services company.