Dr. Edward Soffen, the physician who recently unveiled ground-breaking research demonstrating the effectiveness of brachytherapy in salvage procedures, shared his thoughts on how best to ensure a successful execution of this highly effective treatment in the fight against prostate cancer. As the sole brachytherapy practitioner in a group of 11 oncologists, Dr Soffen performs 50-70 procedures a year, and clearly explains here the specific techniques that will ensure reduced OR time and consistently positive outcomes.
“When I started in radiation oncology in the early 90s, it was a time when prostate brachytherapy was in decline,” Dr. Soffen admitted. “At the time, this procedure was performed in a free-handed fashion, and data from Sloan Kettering in that era suggested that the treatment was very effective if you had a good geometric implant. But there were often hot and cold spots in practice, as this used to be hard to achieve.”
But Dr. Soffen believes strongly in the effectiveness of brachytherapy when the procedure is performed properly. “In the 1000+ patients that I’ve treated, there has not been a single local recurrence,” he stated. “This tells me that the treatment is extremely effective with a good implant. The key is that you have to be confident when you go into the OR that the patient will leave with an excellent geometric implant.
“Obtaining this level of quality today is not hard to do, it’s just a question of strategy,” he continued. “If the procedure is planned out in advance with a physicist, time in the OR is actually reduced, and can make life easier for both surgeon and patient. Basically, a bit of effort on the front-end provides a big boost to the productivity of the procedure and yields better outcomes overall.”
The physician outlined some of the pre-planning efforts that he feels are essential for ensuring a geometric implant:
- Always perform a pubic arch study on patients to ensure that the pubic bone will not interfere with getting needles into the entire gland.
- Perform a preplan ultrasound to calculate in advance the exact coordinates where the seeds will be placed.
- Order the seed in the specific pattern that they will be placed in the needles.
- Use stranded seeds to ensure the seeds don’t move or embolize, but do not strand the top seeds so they can be removed by a urologist if they are interfering with the bladder.
- Use Cesium-131, as the doctor feels that the half life is shorter, shortening symptoms related to treatment.
- Perform a CT scan a month after the procedure to examine the seed implant and review the dose distribution.
Dr. Soffen explained how following these steps reduces the overall time spent in the OR. “Inserting the needles and then planning the procedure in the operating room in real time may take up to 2-3 hours,” he said. “When planning the procedure with a physicist in advance, the patient is anesthetized and wakes up in less than an hour. The dose distribution between preplanning and intraoperative planning has been studied and there’s no difference if good techniques is used. I use my plangrid as a 98% model of what I’m going to do and then modify as needed if the prostate has changed shape due to hormone therapy etc.”
How to gain brachytherapy experience
Dr. Soffen believes that the best way to be consistently effective with brachytherapy is to learn by doing. “You can’t learn by simply watching this,” he stated. “You have to do it. You have to get residents in while they’re ready, willing, and eager to learn, and then put the needle in their hand. It’s why I’ve proctored many people over the years as a way of passing this knowledge forward.”
But the physician believes there is a long way to go in acclimating enough residents to get the most out of brachytherapy. “One of the problems is the high number of residency training programs that do not offer this treatment,” said Dr. Soffen. “It becomes a case of you do not believe in what you don’t know. Residents with this bias will then go out into the community and there is no real push to bring this highly effective treatment into the hospitals they serve. We need to ensure that radiation oncologists both understand and have the procedural capacity to offer brachytherapy.”
When to use brachytherapy
Dr. Soffen highlighted three categories of prostate cancer patients that are strong candidates for brachytherapy:
- Low-risk prostate cancer—He feels this is the most effective form of localized treatment with the least amount of toxicity, and uses brachytherapy as a standalone treatment.
- Medium/High-risk prostate cancer—He uses brachytherapy as a boost after 5 weeks of external beam radiation therapy (EBRT), as recent data shows a significantly higher cure rate for EBRT+brachytherapy versus EBRT alone.
- Salvage prostate cancer patients—He uses brachytherapy on men who were previously treated with EBRT and had a reoccurrence of cancer that is biopsy proven.
Dr. Soffen explained his reasoning for using brachytherapy as a salvage treatment. “After some time, years after external beam treatments, a majority of patients with biopsy-proven local recurrences without evidence of the cancer metastasizing can be salvaged with seed implantation. Local prostatectomy will most likely result in incontinence, but a brachytherapy seed salvage procedure is the best option.” As evidence of this, the physician cited his own recently published research, which showed distant metastasis-free survival, and overall survival rates were 94% and 85%, respectively.
Beyond the outcomes, it’s also the reduction in side effects that makes this treatment so important. To maximize this benefit, Dr. Soffen primarily uses the isotope, Cesium-131, when performing brachytherapy, due to the shorter half-life. “The erectile preservation with brachytherapy is better than EBRT or surgery,” he concluded. “There’s virtually no urinary incontinence, making this a much better option.”
Edward M. Soffen, M.D.
- Attending radiologist at University Medical Center at Princeton (UMCP) and a member of Princeton Radiology Associates since 1992
- Prior positions include:
- Clinical Assistant Professor at the Robert Wood Johnson Medical School
- Assistant Professor at the University of Pennsylvania School of Medicine
- Attending radiation oncologist at the Fox Chase Cancer Center and CentraState Medical Center
- A Consultant in Radiation Oncology and Endovascular Brachytherapy at the Deborah Heart and Lung Center
- Received his B.A. in biology from Johns Hopkins University in 1979 and his M.D. from Temple University School of Medicine in 1986
- Completed an internship at Cooper University Medical Center, and a residency in Radiation Oncology at the Hospital of the University of Pennsylvania School of Medicine
- Certified in Radiation Oncology by the American Board of Radiology in 1991
Dr. Soffen is a member of the American Society of Therapeutic Radiology and Oncology, the American College of Radiology, the Radiology Society of New Jersey, the Mercer County Medical Society, and the American Medical Association. He is a Board Member of the Oncology Society of New Jersey and the Breast Cancer Resource Center. Dr. Soffen received the New Jersey Best Doctor Award in Radiation Oncology in October 1998.
- Regional leader in the diagnosis and treatment of disease for over 50 years
- 23 board-certified and sub-specialized radiologists and eleven board-certified radiation oncologists on staff
- Facilities include 6 imaging centers, 2 radiation therapy centers, and 4 hospitals
- Facilities are FDA ambulatory care accredited, with modality specific accreditation by the American College of Radiology and Radiation Oncology