The concern that I had about brachytherapy, and about radiation in general, is whether it can cause secondary cancers in adjacent organs 10 or 15 years down the line. It's a concern that was shared by my urologist and by a general oncologist I spoke with. It's a particular concern for relatively younger men.
Each patient’s goals and priorities in the treatment of their prostate cancer should individually be evaluated and considered to individualize treatment plans. Due to the individual variation in the perception of quality of life—everyone sees this differently—objective evaluation of outcomes and side effects is difficult to generalize.
Brachytherapy has in recent years become a widely accepted mode of treatment for prostate cancer, and rates of BCR are outstanding for patients with a favorable risk profile; generally on par with the surgical results for patients. [Generally, good candidates for seeds have PSA less than 10 ng/mL, Gleason score of 6 or less, negative DRE, no history of BPH, and prostate volume below 60cc.] Adding in external beam radiation (in addition to seeds) yields the best BCR results.
The short-term side effects of brachytherapy are well documented. However, the consequential late effects are less widely known and (therefore) less widely communicated. For the young-ish patient, the concern over secondary cancers (raised by Jazzman 1) appears to be less significant than the other known consequential late effects of brachytherapy…but few new patients know to inquire deeply enough into these HRQoL (Health Related Quality of Life) issues and the time-scale of reported outcomes.
American society often celebrates immediate gratification, and doctors tend to describe the immediate effects of a particular therapy. Most studies only examine short-term; however, long-term effects may result in serious and debilitating problems or negatively affect QoL. The young-ish patient who chooses seeds in order to reduce risk of erectile dysfunction (ED) may find significant reduction 3-6 years later. The trade-off for immediate gratification (retaining erectile function in the short-term after treatment) may or may not have been worth it in the long-term (permanent loss of functionality at an “early” age). Dr Michael Zelefsky, MSK’s Chief of Brachytherapy Service, reports 53% of patients potent before brachytherapy developed ED within 5 years of therapy. Radiation thickens the walls of blood vessels, limiting blood supply th the nerves responsible for erections. On the upside, the PDE-5 inhibitors (Viagra, Cialis, Levitra) are a generally effective solution for most men, but they become a permanent solution (versus a generally temporary solution, for only the short-term, after surgery).
Urinary incontinence, rectal bleeding and frequency…also consequential late effects of brachytherapy. Again, given that men have often been accused of thinking with our dxcks, the young-ish patient may be tempted to not think about blood-stains in the back of his pants 5- or 10-years down the road, but probably should. Greater than 20% of brachytherapy patients required TURP or colonoscopy to manage chronic urinary retention or moderate to severe proctitis; the number shot up to over 40% for combined external beam radiation plus seeds. These problems are not biochemical recurrences or secondary cancers treated by oncologists; rather, many patients rely on their primary care physician, gastroenterologist, or colorectal surgeon for the management of late complications after brachytherapy.
With these factors in mind, the site www.prostate-cancer.com issues this words of caution:
While brachytherapy is an effective prostate cancer treatment option, men who are much younger and in good health and who can reasonably expect to live another 20 years, may want to consider other treatments. Most of the conclusive data in LDR or HDR therapy does not extend past the twenty year mark. Most long-term studies do not extend past 10 to 15 years.
Here’s some troubling quotes (with references):
· There is a perception among many urologists that complications of brachytherapy may be underreported. http://onlinelibrary.wiley.com/doi/10.1002/cncr.20446/pdf
· Brachytherapy-induced erectile dysfunction is more common than previously reported. http://www.psychiatrictimes.com/sexual-disorders/content/article/10165/105988?pageNumber=2
· Although early proponents of prostate brachytherapy suggested that this treatment has a minimal effect on HRQoL (health-related quality of life), studies have found that it significantly affects HRQoL… http://www.urotoday.com/prod/pdf/reviews/BJU1_sept2004.pdf
Enthusiasm for brachytherapy may be appropriately curbed with the inclusion of these longer term factors.
References (in addition to those cited above):