Prostate cancer is the most common cancer in men in the UK, and arguably the most intimate too, which can cause some patients to feel embarrassed when it comes to discussing their symptoms or treatment options with a specialist. This Prostate Cancer Awareness Month, with diagnoses on the rise, it’s more important than ever that men feel confident in discussing their condition and empowered to seek all the possible treatment options – some of which offer far better long term outcomes in both sexual function and continence.
Too many patients currently are being offered radical prostatectomy, a serious operation to completely remove the prostate gland and surrounding tissue, without also being advised on less intrusive alternatives with equally high success rates, such as LDR Brachytherapy.
The first person men speak to in their counselling process – whether that is an oncologist, urologist or specialist nurse – will of course have a very strong influence on the eventual decision regarding chosen treatment. Even patients opting for a second opinion will, more often than not, still follow the advice of the first clinician. It is therefore essential that the first discussion openly and honestly discusses all the potential options -not just radical prostatectomy. Today, while the NICE guidelines include low dose rate Brachytherapy (LDR-B), radical prostatectomy, radiotherapy or surveillance, the treatments being offered to patients can be highly postcode dependent.
A recent study* revealed radical prostatectomy has the greatest impairment of sexual function and urinary continence when compared with active monitoring and radical radiotherapy with hormones. In addition many radical prostatectomy patients go on to have further treatments at a later stage. With few patients being offered alternative treatments, it’s important that men feel confident to ask.
Low dose rate Brachytherapy is one such example, which has been a highly effective treatment for prostate cancer for more than two decades. In addition to offering significantly improved outcomes regarding both sexual function and incontinence, according to data from the Prostate Cancer Results Study Group, LDR-B treatment achieves 95% of patients disease free at over 10 years. So why are more patients not being offered this option?
One of the issues is without doubt a lack of up-to-date thinking. Radical prostatectomy has been the default treatment for prostate cancer for many years – and the shift from open surgery to robotics has had minimal impact on the overall patient outcome. In contrast, brachytherapy has significantly evolved over the past two decades and now provides the ability to give a very effective, targeted prescription of radiotherapy, resulting in improvements in already excellent disease control, as well as potency preservation and continence. Critically, it is not limited in its applicability: virtually any patient with localised prostate cancer can receive a brachytherapy implant if that is the desired treatment.
Low dose-rate brachytherapy is a kind of internal radiotherapy, which involves the insertion of tiny radioactive capsules, or seeds, into the prostate gland itself. It is targeted only at the site of the tumour so the radiation kills the cancer cells without causing major damage to surrounding healthy cells. Seeds the size of rice containing the radiation are passed through fine needles and positioned directly into the prostate gland. It is not major surgery and usually, patients will only spend one day in hospital. Generally LDR brachytherapy has a low complication rate, and most men return to their usual pre-treatment activities within a couple of days.
4D Brachytherapy, an even quicker, one stage, real time implant technique, uses a simple clinic based ultrasound scan to calculate the number of stranded and loose seeds required for the procedure. The process offers better targeted treatment and, through the one stage process, a better patient experience. For patients, the replacement of one of the steps of the traditional procedure undertaken in the operating theatre (under a general anaesthetic) with a simple out-patient procedure significantly improves the process.
Patient choice is key – and that demands accurate, informed discussion about the pros and cons of every treatment, from outcomes to process. All of the treatments approved by NICE clearly have a role to play in successfully treating prostate cancer. But before a patient is pushed straight to radical prostatectomy, the full breadth of options, including both LDR and 4D Brachytherapy, should be discussed in detail with every patient.
Saheed Rashid, Managing Director, BXTAccelyon