Sowing the seeds of knowledge in brachytherapy

Claire Deering, Brachytherapy Clinical Nurse Specialist at Royal Surrey County Hospital NHS Foundation Trust, explains why it’s important for prostate nurse specialists to build and share their knowledge of brachytherapy – even in centres where it isn’t currently offered.

These are exciting times in the treatment of prostate cancer in the UK. The emergence of brachytherapy as a primary treatment option alongside radical prostatectomy (RP) and external beam radiotherapy (EBRT) is providing greater choice for many patients. Although brachytherapy is not suitable for everyone – and indeed not readily offered to everyone – in patients where it is appropriate, it’s a great option. Evidence shows that brachytherapy not only achieves efficacy equivalent to traditional treatments, it also offers important advantages in quality of life, convenience and patient experience. It’s no surprise that patients are increasingly asking about it. At our own centre at the Royal Surrey County Hospital (RSCH), a growing number of referrals come from curious patients who have heard about brachytherapy through the course of their own research and want to find out if it’s an option for them. But we’re not on our own; it’s a similar story in trusts right across the NHS.

Such growing interest once again shines a light on the important role that clinical nurse specialists (CNSs) play in helping patients make choices about their care. Oncology CNSs are at the heart of multidisciplinary teams (MDTs) and, as a report from the National Cancer Programme as far back as 2010 shows, make an invaluable contribution to supporting patients across the whole care pathway. An essential component of that support is the informed communication of in-depth knowledge about both the disease and all available treatment options. We are in a unique and privileged position where patients quickly recognise that we’re on their side – and they look to us for guidance. We must repay that trust. In the case of prostate clinical nurse specialists, this leads to an interesting conundrum: a high number of prostate CNSs do not yet have access to brachytherapy services – meaning that their exposure to it, and as a result, their understanding of it, is naturally limited. However, although local availability of brachytherapy is variable across the country, patient awareness of the treatment is becoming less restricted. It is our clinical duty to be able to give them informed and neutral answers.

Understanding of brachytherapy among prostate CNSs should not be dictated by postcode. It’s incumbent on all of us to learn about every aspect of the disease and its treatment – and to share that knowledge for the benefit of patients. In prostate cancer, the science and technology for each treatment specialty is evolving. We must evolve in time with that science and be there to provide balanced and responsive guidance as new trends emerge. The National Cancer Patient Experience Survey (NCPES) in England indicates that cancer patients who have access to a CNS generally report better experiences of care and understanding of the disease. Moreover, as 2014 research from Prostate Cancer UK shows, they’re more likely to believe that their information needs have been met and feel in control of their own decisions. Our work empowers patients to make the right choices about their care – and the research continually shows that it’s pivotal to the patient experience.

In fact, impact on the patient experience is one of brachytherapy’s strongest suits. The treatment is proven to present a reduced risk of side effects compared to RP and EBRT. Recent studies show the risk of incontinence after brachytherapy is far lower than is the case in surgery, radiation and active surveillance. It’s also associated with shorter recovery times and reduced overall treatment times – making it less disruptive on patients’ lives.

The impact on overall survival (OS) following brachytherapy is also important. Evidence increasingly shows that there is very little, if any, survival benefit advantage between all the major treatments. Brachytherapy is in fact so successful at sterilising the gland that it’s pretty much the equivalent of removing the prostate. Comparative effectiveness studies show that LDR monotherapy brachytherapy reports recurrence-free survival rates (RFS) similar to those for EBRT and RP in both low and intermediate risk patients1,2. And it’s proving effective in high-risk patients too. Level one randomised controlled studies now show that, in high-risk prostate cancer patients, an LDR brachytherapy boost in combination with EBRT, survival rates are higher than in radiotherapy alone 3,4.

For prostate CNSs, these studies are significant, providing evidence-based fuel to support patients in their decision-making. For me, that evidence is borne out by first hand experiences of patients that come through our service. As a brachytherapy nurse specialist, it’s comforting to have both the research data and the real-world evidence to reassure patients that the only decision we’re asking them to make is to choose the treatment with the side-effect profile that’s likely to suit them best.

Of course brachytherapy is not appropriate or recommended for everyone, with clear NICE guidance determining its use in the UK. As patient awareness and interest in the treatment grows, it’s as much our responsibility to inform patients when the treatment is unsuitable as it is to empower them with full information when it may be an option. As prostate CNSs, it’s our role to steer them to the right treatment. In fact, on occasions patients may present with urinary symptoms that may, at first glance, appear to preclude them from having brachytherapy as an option. It may, however, be possible – in very specific cases – to perform a modified TURP to optimise a patient’s urinary symptoms first, opening them up to the possibility of brachytherapy.

There is little doubt that brachytherapy is a good option for a high number of prostate cancer patients. The biggest barrier to its wider uptake in the UK is, of course, the availability of brachytherapy services. There remains great geographic variability in this regard. As a passionate advocate of brachytherapy, I long for the day when there is equitable access and more flexible use of the treatment across the UK. As evidence of its impact on OS and patient experience mounts, I’m ever confident that access will continue to increase. But as we await further resources to be invested in brachytherapy services, prostate CNS education cannot afford to neglect this important treatment option. Clinical nurse specialists are firmly established as true ‘patient champions’; our patients know we’re on their side. As patient interest in brachytherapy grows, it’s our duty to ensure we do all that we can to understand it – regardless of whether our centre provides the service – and to share that understanding with our peers and, crucially, our patients.

It’s time to sow the seeds of knowledge of brachytherapy.

Potters L, Morgenstern C, Calugaru E et al. 12-year outcomes following permanent prostate brachytherapy in patients with clinically localized prostate cancer. J Urol 2005; 173: 1562–1566
Sylvester JE, Grimm PD, Wong J, Galbreath RW, Merrick G, Blasko JC. Fifteen-year biochemical relapse-free survival, cause-specific survival, and overall survival following I(125) prostate brachytherapy in clinically localized prostate cancer: Seattle experience. Int J Radiat Oncol Biol Phys 2011; 81: 376–81
Morris W. James et al. Androgen Suppression Combined with Elective Nodal and Dose Escalated Radiation Therapy (the ASCENDE-RT Trial): An Analysis of Survival Endpoints for a Randomized Trial Comparing a Low-Dose-Rate Brachytherapy Boost to a Dose-Escalated External Beam Boost for High- and Intermediate-risk Prostate Cancer. International Journal of Radiation Oncology • Biology • Physics , Volume 98 , Issue 2 , 275 – 285