4 Options—1 Choice: Advice from a Prostate Cancer Pioneer on Navigating Treatment


steven-kurtmanDr. Steven Kurtzman, a pioneer in Brachytherapy treatment, shared his insights here on what he feels is the best path forward in charting a path towards successful prostate cancer treatment. With a career-long focus on combating this deadly disease, Dr. Kurtzman understands that prostate cancer patients may currently feel overwhelmed with the myriad of treatment options available. He also feels that finding sound advice can be difficult. Many urology and radiation oncology practices tend to recommend treatments that their facility is most comfortable performing, but these might not be the best option. Dr. Kurtzman decided to share
what he feels are the pros and cons of the most common prostate cancer treatments, and what men with prostate cancer should consider when evaluating their treatment options.

Prostatectomy  

A prostatectomy is a surgical procedure to remove the prostate gland. Dr. Kurtzman believes this can be one of the least-desirable treatments. “Surgery is often the worst option,” he stated. “It has a significant recovery period (incisions that need to heal and a patient that needs to walk around with a catheter). It also has a higher morbidity rate in regards to potentially long-term side effects such as incontinence and impotence due to the invasive nature of surgery. In my mind, I find it extremely difficult to find an advantage for prostatectomy over organ sparing procedures. It never has a higher chance of curing patients (it’s even lower for intermediate and high risk patients) and always has the highest risk of incontinence and impotence.”  

External Beam Radiation Therapy

This type of treatment involves irradiating the cancer from outside of the body. External beam radiation has manageable short-term side effects, but it involves 9 weeks of daily treatments, usually Monday-to-Friday. “As a radiation oncologist, I’m not a big fan of external radiation as a standalone treatment,” shared Dr. Kurtzman. “Normal, healthy (and critical) tissue surrounding the prostate ends up receiving much more radiation than is necessary, which can raise its own set of complications, including problems with the bladder and the rectum. It also complicates delivering a high enough dose to the prostate itself given the limits of the surrounding normal tissues.  In other words, it has a poor therapeutic ratio of the delivered dose of radiation (higher dose to the normal tissue which decreases our ability to escalate dose to the prostate).”  

Brachytherapy

Dr. Kurtzman is a believer in brachytherapy, a technique where a radioactive source is implanted into the prostate to perform a much more targeted form of treatment that is designed to limit radiation exposure to areas outside of the prostate. “Brachytherapy has a higher therapeutic ratio when compared to external beam radiation,” he explained. “For this reason, the cure rate is as high or higher compared to other treatments, but with a much lower complication rate. With brachytherapy, there is no significant recovery period (other than several weeks of urinary irritative symptoms). In addition, the organ sparing nature of this treatment dramatically reduces the risk of incontinence and impotence associate with prostatectomy.  Relative to external radiation, brachytherapy dramatically reduces the dose of radiation to the bladder, surrounding vasculature and rectum thus reducing the incidence of both impotence and rectal damage.”  

Brachytherapy: Low-Dose Rate & High-Dose Rate

Brachytherapy can be broken into two categories: Low-Dose Rate (LDR) and High Dose Rate (HDR). The (biologically effective) doses between LDR and HDR are similar, however the dose rates are very different. With HDR, treatments are delivered over a few days. With LDR, specifically Cs-131, treatment takes over a month. This difference in treatment time is a function of dose delivered per unit time, often represented as centiGrays per hour.

HDR treatment involves placing multiple catheters into the prostate through which a highly radioactive iridium source is inserted sequentially to irradiate the gland. Treatments are delivered in anywhere from 1-6 fractions.  “The problem is that when you give high radiation in fewer fractions, you increase the risk of normal tissue not being able to recover,” said Dr. Kurtzman. “It’s too much at one time, as the dose penetrates much further out into normal tissue. There is a higher risk of urethral restructuring (affecting the patient’s ability to urinate) with this treatment.”

LDR is a low-dose rate implantation of a radioactive “seed” that applies a lower dose of radiation (approximately 10 times less than a high-dose treatment) in a consistently-released amount. This is the method that Dr. Kurtzman feels is the most effective. “With the low-dose brachytherapy using Cesium-131, we’re exploiting the fact that the seeds put out very low doses of radiation and we deposit those seeds right in the target that we want to treat. The result is that we have a beautiful, conformal dose of radiation therapy, escalating the dose to the prostate to ensure we’re getting all of the cancer. But since that low intensity of radiation does not penetrate far into areas it shouldn’t, the risk of complications is reduced.”

Dr. Kurtzman cites the available medical literature as one of his primary reasons for supporting low-dose rate brachytherapy. The Prostate Cancer Results Study Group is one of the leading authorities on prostate cancer. The organization has reviewed 31,000 articles from all available respected medical journals, published from 2000-2014, and the group has continued to update the results of their study twice per year.  This group found that while most therapies will be successful for low-risk patients, there appears to be a higher cancer control success rate for brachytherapy over external beam radiation therapy and surgery for all groups.

Brachytherapy: What to Expect

With low-dose rate brachytherapy, patients arrive about an hour before the scheduled treatment and the treatment itself lasts about an hour. It involves several needle placements while under anesthesia, but patients usually wake up without pain since no surgery is involved. “It’s similar to a biopsy, but easier,” explained Dr. Kurtzman. “Patients can go home and resume normal activities that same day, as there is almost no recovery period. In the short-term, there will be fairly significant difficulties in urination as the prostate will become swollen and inflamed after treatment. But since Cesium-131 has a short half-life, about 3-4 wks will be the worst of the symptom, and after that normal urination will resume quickly. This is compared to about 8 weeks of trouble with Palladium and months with Iodine.”

“After that, it’s all upside,” he concluded. “With all of the advantages compared to other treatments, low-dose rate brachytherapy is a no-brainer.”

If you or a loved one has recently been diagnosed with prostate cancer and want to know about all of your available treatment options, including brachytherapy, please contact patienteducation@isoray.com

If you are a physician and would like to know more about Cesium’s ability to improve patient outcomes, email customerservice@isoray.com

Dr. Steven Kurtzman

  •         Nationally renowned expert in “real-time” prostate brachytherapy
  •         Performed more than 3000 prostate brachytherapy treatments over the past 10 years using all available isotopes
  •         Director of Prostate Radiation Services at the Center of Advanced Radiation Therapy and Cyberknife Radiosurgery Center at El Camino Hospital
  •         Practices at Western Radiation Oncology centers in Campbell, San Mateo and Pleasanton, California
  •         Started prostate therapy program in 1998
  •         Training in radiation oncology from University of Pennsylvania

*The ACR (American College of Radiology) has recently included Cesium-131 in their guidelines for the treatment of low-risk prostate cancer.