Abishek Solanki, MD., M.S., a radiation oncologist at Loyola University Medical Center tells us about an overlooked treatment option for men with prostate cancer.
Interview conducted by Ivanhoe Broadcast News in June 2016.
Let’s talk about this procedure, explain how it works?
Dr. Solanki: When it comes to the treatment of prostate cancer men have a lot of options. The classic three options are surgery; external beam radiation where the radiation comes from the outside in and usually it’s given over the course of about eight to nine weeks; and brachytherapy, which is radiation given internally where the source is inside the body. For prostate cancer, there are two forms of brachytherapy; there’s low dose rate prostate brachytherapy, and high dose rate brachytherapy, or LDR and HDR. The low dose brachytherapy is what’s classically known as seeds, where about 80 to 100 seeds are surgical placed inside of the prostate, distributed evenly, trying to spare the middle where the urethra runs through, but the idea is that these seeds remain in the person permanently until whenever the radiation dose over about six to eight months and then slowly, gradually, essentially fizzle out. The high dose rate brachytherapy or HDR brachytherapy is different. There’s a temporary radiation source and the way the procedure works is just like with the seeds, there’s a surgical procedure but instead of leaving permanent seeds behind you put in tiny tubes that are distributed throughout the prostate and those tiny tubes then are used later in that day with a single robotic radiation source to go into each one of those tubes and deliver the radiation dose to each area of the prostate based on the radiation plan we make beforehand. Once that’s done we remove everything and the patient goes home.
Are there some people who qualify more for the HDR then the LDR?
Dr. Solanki: The general principles of brachytherapy are similar whether it is LDR or HDR but it is easier to implant men who have a larger prostate size with HDR because you don’t need to use a ridged template that stays in the same position, you can use a freehanded approach. That’s the primary rationale for people who may favor HDR over LDR, but it’s an option for the same group of men.
Absolutely, so what are the pros for HDR let me touch on that a little?
Dr. Solanki: The key pros I think are: the radiation is delivered right then and there later that day as opposed to having a permanent source inside you that slowly delivers radiation over six to eight months. You can avoid the radiation safety precautions like having pregnant women in close proximity or having children in close proximity. The other benefit is how the radiation doses are delivered. With seeds prior to the procedure you do a special procedure called the volume study, where you place the patient in the exact same position they will be in the OR and you essentially just take pictures of the prostate. The idea is that you use those pictures to make the radiation plan, so you decide where you are going to place the seeds and how you are going to place them; when you go to the OR you replicate that as best as you can. Once you placed the seeds there can be movement of the prostate or there may be swelling of the prostate, so the seeds may not end up in geographically the exact location you want them to be. For the most part with a careful implant you can get them pretty close but there can be some slight differences because once you place them you place them. With the HDR we go to the OR and we place the patient in the same position but we place the catheters first, the tubes first and we do the CT scan afterwards to do the radiation planning; and so we know exactly where the tubes are and so we can deliver the radiation dose based on exactly where they are at and try to avoid the bladder and rectum as much as possible.
Are there any drawbacks?
Dr. Solanki: For patients who are just getting brachytherapy alone, it’s two surgical procedures instead of one; that the primary drawback. The day tends to be a little longer for each of those days, as opposed to the LDR day; the LDR day tends to be an hour and a half, whereas, with the HDR it’s usually several hours at our clinic.
But, then again, it sounds like the recovery time or at least the two month waiting period, you just don’t have the (interrupted by doctor)
Dr. Solanki: You just don’t have to have the radiation precaution safety for two months.
Do you know how many patients have done the HDR?
Dr. Solanki: We’ve had about thirty-five patients to have done it so far since September, but Dr. Hartrider and myself who are both the brachytherapy therapists have both trained at other institutions and did cases prior to that.
How many have you done?
Dr. Solanki: Realistically about fifty.
How long has it been around?
Dr. Solanki: Each brachytherapy has been around since the 80’s and 90’s actually; but it’s not utilized as much as the seeds. One of the reasons why is from a resource prospective for the staff and the clinic, it’s a little bit harder. As you can imagine with seeds, what we primarily do is the planning and study then you place the seeds and you’re done. Whereas, with the HDR what happens is you’ll go to the OR and they actually come and stay in your clinic for some time and you do the planning on that day. There is a little of a time crunch. You have to free your day up a little bit more to do it. Which is okay, it’s a good treatment option but I think because of that a lot of clinics haven’t really embraced it that much; because it’s easier from a workflow perspective to do the seeds. It’s been around like I said since the 80’s and 90’s and I think is it’s getting more and more interest as time goes by and as the data comes out showing that it’s an effective and safe treatment.
Do you think it’s a better treatment option for most of them?
Dr. Solanki: I think it’s a good treatment option from my perspective, I think it’s better than seeds in a way that you can be more precise about how the radiation in dose is delivered. There’s not really any randomized data comparing LDR and HDR which would be the best quality data to really see the difference. From series it suggests that the side effect profile is relativity similar but potentially the way some studies suggest that the rectal toxicity may be a little bit lower with HDR compared with the LDR; but again there’s no randomized data to show that. The other from our experience here at Loyola, we find that the time frame of the short-term side effects the acute toxicities is a little bit different. With LDR for the first six months, men do notice some of the urinary side effects that are kind of gradually developing and gradually go away. Whereas with HDR it seems like it’s the first month when people start to notice these urinary side effects and then resolve after that first month. It may be a difference in the time frame as well.
Are there any other side effects?
Dr. Solanki: The short-term side effects are frequency of urination, urgency of urination, sensation of incomplete emptying and loose stools and diarrhea. With the procedure itself you can have a little blood in the urine and blood in the stool um but that should clear up in a couple of days to weeks after the procedure is over. In the long-term most men actually don’t have a lot of urinary or bowel changes. Just about one out of five men would have urinary or bowel changes that require medicine like Flomax to help them with urination. But the chance of full toxicities is relatively low. Another long-term side effect that we counsel men about is having weakened erections because of the procedure itself and because of the radiation.
I guess when they go through this it just does away with the cancer and that’s it?
Dr. Solanki: That’s the idea, right. We treat the prostate gland and the prostate cancer tends to be in the prostate gland itself. We also try to target the seminal vesicle which is attached to the prostate gland because there can be some cancer that is in that area as well. You’ll essentially treat the whole gland while sparing the urethra, the bladder and the rectum and that should get rid of the cancer that’s there.
Does it matter what stage it is?
Dr. Solanki: It’s an option for patients who don’t have spread to the lymph nodes or spread outside of the prostate.
I think that was very thorough, anything else?
Dr. Solanki: Maybe I shouldn’t say, spread outside the prostate but to spread into other organs or the bones.
Yeah, that makes sense. I mean it sounds like as far as the procedure goes, that the surgery is kind of, in a way you still will have surgery.
Dr. Solanki: Yeah, it’s still an operative procedure.
Yeah.
Dr. Solanki: But it’s an outpatient procedure.
Explain again with the LDR kind of the restrictions afterwards?
Dr. Solanki: Okay.
Because of the radiation?
Dr. Solanki: Each center has their own specific restrictions that they counsel folks for but what we usually counsel folks for the first two months: if you are sexually active to use some sort of condom to prevent potential exposure, if one of the seeds come out in your urine to tell your partner. Then for small children or pregnant women or pets to not have them sit on your lap for the first two months; because of potential radiation exposure even though the risk is relativity low; even in that case.
As a precaution?
Dr. Solanki: Yes.
It sounds like it’s starting to pick up?
Dr. Solanki: I think more and more centers are starting to use this approach.
Why now?
Dr. Solanki: It’s a couple reasons, one, I think there’s more long-term data to show its efficacy and its safety before people were a little bit more cautious because the data were three to five years, where we have now we have more tenure and outcomes. I think the third reason is with our current healthcare climate and the economic issues that healthcare faces. Yet high value treatments that are effective and very safe. Also we are not as expensive as others; there are some high expensive treatments for prostate cancer. There is external beam radiation which is eight weeks or radiation. Then proton therapy treatment that’s received a lot of press and those tend to be more expensive than either of the brachytherapy options, LDR or HDR. It’s an option that is both cost effective, provides a great treatment option, and logistically it’s easier for patients. Instead of coming every day, Monday through Friday for eight weeks; they can come in from one to two treatments and be done.
It just sounds like overall that you know the side effects and just with the down time, and the, just in two days; but it sounds like that would be the option that a lot would just go for.
Dr. Solanki: A lot of them men do. The patients who tend to shy away are those that would prefer absolutely no pervasive procedures and some men who have severe urinary problems before treatment; those urinary problems can get worse. They have a higher chance of having urinary problems after a brachytherapy, so those men we sometimes counsel against doing it.
What about Mr. Hildabrand case, do you know about that?
Dr. Solanki: Sure. He’s a gentleman who is, otherwise, very healthy but yet an intermediate risk with prostate cancer. We performed a MRI to confirm that there wasn’t any extension outside of the prostate, or any clear extension in the seminal vesicles, and then we discussed the treatment and options with him. He felt more comfortable with moving forward with HDR brachytherapy. We treated him in a typical way, which we do two procedures where we place the catheters in and with radiation treatment later that day. He’s now about seven months out and he’s doing really well.
That’s what he says; he’s kind of back to normal just in his first two weeks.
Dr. Solanki: Yeah, exactly. The first month is the one most people say they have urinary frequency, urgency, some loose stools and things like that but after that most people tend to go back to normal.
I heard that probiotics really helped.
Dr. Solanki: Yes because the radiation can affect the bacterial flora of the bowel, there’s a lot of patients who do probiotics to help to kind of stabilize their GI function.
For him what are the chances of coming back?
Dr. Solanki: Well, so most studies suggest that eight out of nine or ten people in his situation the cancer wouldn’t come back, so the odds are in his favor.
END OF INTERVIEW
This information is intended for additional research purposes only. It is not to be used as a prescription or advice from Ivanhoe Broadcast News, Inc. or any medical professional interviewed. Ivanhoe Broadcast News, Inc. assumes no responsibility for the depth or accuracy of physician statements. Procedures or medicines apply to different people and medical factors; always consult your physician on medical matters.
If you would like more information, please contact:
Abhishek Ashok Solanki, MD, MS
708-216-2556
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