What is Dynamic Adaptive Radiotherapy?
Dynamic Adaptive Radiotherapy (DART) is a cutting edge arsenal of technologies that employs up-to-the-moment “captured” image data to adapt a patient’s radiation treatment to constantly evolving information, which occurs during the course of treatment. DART is an amalgam of all the imaging and radiation delivery technologies associated with 4-Dimensional Image-Guided Intensity Modulated Radiotherapy (4D IG-IMRT).
It is well known that changes such as tumor position, size and shape occur not only during a several week treatment regimen, but also on a daily basis when patients are undergoing treatment. DART allows us to realize the single most important goal ever achieved with radiation therapy: delivering the exact dose to the exact place at exactly the precise time, every time, even when the target (tumor) moves, shrinks or changes shape. This is a revolutionary and unprecedented accomplishment in the treatment of prostate cancer. For more information, click the “What is DART?” link under the homepage menu for NON-SURGICAL TREATMENT.
What is brachytherapy?
Also called “radioactive seed implantation,” brachytherapy involves implanting radioactive sources (isotopes in the form of seeds or pellets) directly into the prostate gland and tumors, either permanently or temporarily. Brachytherapy offers the ability to place radiation sources exactly into the tumor site and to combine seeds with external radiation to optimize outcomes and minimize side effects. The procedure is minimally invasive and performed in an outpatient setting. For more information, click the “Brachytherapy” link under the homepage menu for NON-SURGICAL TREATMENT.
Are DART and brachytherapy considered experimental?
Absolutely not. These treatment modalities are FDA and Medicare approved. DART is a highly sophisticated by-product of prior radiation delivery systems. Numerous recent studies have already shown that it is possible to escalate doses significantly with DART and/or brachytherapy in order to more effectively eradicate the cancer, while dramatically decreasing morbidity (unwanted long-term side effects). We have thousands of patients who have been treated successfully and will vouch for our treatment protocols.
Will all this new technology cost more for patients who come to your center?
No. Medicare and most insurance cover this type of advanced radiotherapy. This is truly one time when the newest and best technology will not cost you more than the older, more conventional forms of radiation therapy. In fact, in terms of cure with DART, you'll get more for your money. And the same applies to brachytherapy, which is often combined with DART and is also covered by Medicare and most insurance providers.
What are the differences between the Dattoli Cancer Center and other medical centers that treat prostate cancer?
The Dattoli Cancer Center is the only place in the world where this combination of leading edge technologies and pioneering medical specialists are found. Dr. Dattoli has more experience in brachytherapy than any other radiation oncologist in the world. The breadth of our diagnostic and treatment technology is unmatched anywhere. The success rates of Team Dattoli lead the world and are well documented in leading peer-reviewed medical journals. Despite Dr. Dattoli’s many professional obligations, he remains committed to his primary mission: to provide the very best cancer care available – one patient at a time.
Why do you require such an extensive laboratory testing and workup for your patients?
A metabolic workup involves a number of lab tests that tell us whether or not the cancer has spread beyond the prostate gland. This is crucial in deciding on the type of treatment that will be appropriate for each patient. Prostate cancer has been historically both under-staged and under-graded, which means that the extent and severity of the disease has often been underestimated, and therefore, not adequately treated. To enhance your opportunity for cure, we believe that we should turn over every stone possible, using the most sophisticated techniques to assess every case, including 3-D Color-Flow Power Doppler Ultrasound and Dynamic Contrast-Enhanced Magnetic Resonance Imaging (DCE-MRI) to evaluate lymph nodes, as well as special blood tests and bone or PET scans as indicated.
Remember, even if we find something serious as far as the spread and/or aggressiveness of the disease (e.g. lymph node and/or bone metastases), this will be addressed with an appropriate form of therapy tailored for each patient. At other centers where the workup is not adequate, where the tests are not as extensive, it is what is not found and not treated which can later come back to impact the patient. We believe in going the extra mile with all of our patients to avoid that kind of negative outcome.
How do you know if and when you are "cured" after radiotherapy?
The term “cured” often refers to patients who are in remission after treatment, showing no signs of cancer. Their PSA level indicates biochemical freedom from disease. Many physician practices have tried to assign a specific PSA nadir (lowest point) to identify the patient as cured. However, while a low PSA is important, the goal is not merely a low number but an actual cure. Patients should be wary of being over-treated just to achieve a low number.
The Dattoli Cancer Center considers a patient cured when his PSA is significantly reduced and remains at that reduced level consistently for the remainder of his life. Most patients achieve a PSA of <0.2, although this is not mandatory for cure. For example, one of Dr. Dattoli’s patients has had a PSA of 2.0 for more than 18 years. We certainly do not think his treatment failed. When reporting our success rate in published studies, we employ a strict nadir cutoff of PSA of <0.2 for the purpose of comparing our results with the published results of other treatment modalities, in particular radical surgery, which utilizes the same nadir value for determining biochemical disease-free survival (bNED) – when biochemically there is no evidence of disease. We hold ourselves to a higher standard for treatment success rates than most other treatment centers.
If I've had external beam radiation therapy or brachytherapy elsewhere, but have experienced a recurrence of cancer, can I try either therapy again at your center?
As we are dedicated to finding the highest level of cure for each patient, we will certainly be willing to schedule a consult with you to determine what we might be able to do to help you. There are a number of possible “salvage therapy” options that can be considered if a patient experiences biochemical failure (rising PSA or other indicator) after having been treated at another center with external beam radiation therapy (EBRT), brachytherapy, cryosurgery or HIFU. As a rule of thumb, the earlier a recurrence is detected, the better the chances that a salvage therapy can lead to a cure.
If a patient has failed external beam radiation therapy, typically, we would not utilize DART alone as salvage therapy, but salvage Pd-103 seed implantation plus/minus an abbreviated course of DART may well be a viable option. Your case will be carefully evaluated to determine your candidacy. Hormonal therapy is typically used prior to or along with radiation for such local recurrence cases.
If my prostate surgery failed and my PSA is rising with recurrence in the prostate bed or lymph nodes, am I still a candidate for DART?
Yes. DART will provide the least dose to healthy tissue and organs surrounding the prostate (or prostate bed), minimizing the risk of side effects, and give you the best chance for a cure. In this type of postsurgical case, we often use hormonal therapy along with DART, again on a case-by-case basis.
If I have undergone transurethral resection of the prostate (TURP) for treating Benign Prostatic Hyperplasia (BPH), am I a candidate for your brachytherapy procedure?
Dr. Dattoli has pioneered unique treatment designs to allow seed implantation even with patients who have had prior TURPs. Each patient is carefully evaluated to determine his candidacy and to minimize side effects such as incontinence. Likewise, patients who receive photoselective vaporization of the prostate (PVP) for treating BPH can also be effectively treated with brachytherapy alone or combined with DART.
Why are younger men told that they should have radical surgery rather than seed implantation since there is no long-term data on seeding?
That argument that there is insufficient long-term follow-up for brachytherapy series is patently false. In fact, numerous studies of seed implantation, including superior 16-year published results by Dr. Dattoli (Outcomes for Patients with Prostate Cancer having Intermediate and High-Risk Disease, treated with Brachytherapy and Supplemental External Beam Radiotherapy, J Oncol. August 2010).
That Dattoli Team study reports long-term follow-ups that surpass all surgical series published in the PSA era. In this regard, outstanding results (biochemical disease-free outcomes) have been reported for younger patients with brachytherapy, and this group has the most to gain (reduced risk of urinary incontinence and/or erectile dysfunction). In our practice, we commonly treat men in their early 40’s, as well as patients in their 50’s, 60’s and older. Younger men, after all, also have the most to lose if they choose surgery – suffering from erectile dysfunction and wearing diapers for years.
My urologist told me that if I have radiation therapy and the cancer returns, I can no longer have surgery. Is this true?
Absolutely not – the opposite is true! First, it is extremely rare for patients to have local recurrence when treated initially by our team. If however, the cancer did return in the prostate, patients still have a full menu of options including reseeding, radical surgery, cryosurgery, biothermy, HIFU and hormonal therapy, as well as a number of vaccine therapies and immunotherapies. If you are inclined toward surgery after failed radiation, there are a number of proficient surgeons that we can recommend.
What are the advantages of brachytherapy (seeding) over radical surgery?
As mentioned earlier, the risk of side effects such as erectile dysfunction and/or incontinence is greatly reduced with seeding, in comparison to the risks associated with surgery. The surgical procedure typically requires hospitalization and a lengthy recovery period. Newer laparoscopic and robotic techniques decrease the length of the procedure, but still risk potential complications (blood clots to the lungs, infection, etc.). Many laparoscopic/robotic procedures are aborted and converted to the traditional open surgical approach (by hand) when vessels are nicked or the rectum is lacerated.
At our center, we have published superior results with combination therapy (brachytherapy and external beam radiation therapy with or without hormones) with intermediate and high-risk patients (Stage T3, PSA >10, Gleason Score 7-10, elevated PAP) compared to surgery — with more than 80% of our patients enjoying successful long-term outcomes with minimal side effects.
It should be noted that the limitations of the open radical prostatectomy also apply to laparoscopic and robotic surgical techniques. Either way, the operation is performed “in the blind” in the sense that the patient’s workup tests do not allow the surgeon to know with any certainty in advance whether or not the cancer has spread beyond the prostate. In other words, the risk of having “positive surgical margins” and thus cancer left behind is the same regardless of which surgical technique is used. In our opinion, this means there is an unacceptably high risk of failure with all forms of radical surgery.
Is there sufficient published data to support the choice to have seed implantation over surgery?
Yes, there is. While there are no randomized studies comparing the different types of treatments, numerous independent studies have contrasted statistical data from both options (brachytherapy and surgery), comparing the results of different specialties as reported by the leading practitioners at centers of excellence. Follow-up studies have been in place since the beginning of Dr. Dattoli’s practice in 1990. Other large programs, including the Northwest Tumor Institute and the University of Washington in Seattle have reported an approximate 80% seeding success rate after 12 years of follow up.
Our data, using combination external beam radiation and seeds – which we favor for most patients over seeds along – has demonstrated a greater than 80% success rate after 16 years even in patients having locally advanced high-risk malignancies (Stage T3, PSA > 10, Gleason Score 7-10, elevated PAP), while patients having early or intermediate stage disease have enjoyed a greater than 90% success rate (Dattoli MJ, et al, J Oncol. August 2010, 471375). The longest surgery data follow-up is 15 years, while the median follow-up on our patients is longer than any surgical series. Researchers at Johns Hopkins including Dr. Patrick Walsh reported in 2010 on high risk patients undergoing radical prostatectomy (RP): “80% of men with Gleason sum 8–10 who undergo RP will experience biochemical recurrence at 15 years” (Urology. 2010 Sep; 76(3): 715-721). We believe such results with radical surgery are woefully unacceptable.
What is HDR brachytherapy?
High Dose Radiation (HDR) brachytherapy refers to temporary catheter insertion into the prostate often using Iridium-192, which is a very penetrating isotope (radiation spreads far from the isotope), expending the dose quickly and consequently to all neighboring structures.
This is not a new form of brachytherapy, although it is often promoted as such. In fact, Dr. Claude Henschke at Memorial Sloan-Kettering Cancer Center was using it as early as 1963, with the only difference today being microprocessors and advanced imaging techniques. There is less long-term data on temporary HDR outcomes and side effects compared to the permanent Pallidium-103 seed implants that we utilize at our center. There may be a greater risk of complications with HDR brachytherapy because of the extremely penetrating high dose of radiation delivered by Iridium-192 (1000 to 2000 cGy in a matter of minutes) affecting the entire body.
DART is also a form of high dose rate radiation but delivered externally employing micro-beamlets and precisely targeting the affected area(-s) in minutes, but without affecting surrounding normal tissues as does HDR brachytherapy. We believe that this degree of pinpoint accuracy with DART and 3D-Color-Flow Power Doppler Ultrasound-guided permanent brachytherapy make temporary HDR catheters obsolete. We also believe that the use of DART coupled with Pd-103 treatments provide the best of both worlds as far as cancer-killing dose and accuracy. Essentially, we are exposing the cancer to two different complementary forms of radiation in order to achieve the greatest chance of cure. Cancers don’t like change, which is why we deliver this one-two punch from two different radiation sources, both internal and external. Most cancers today are most effectively treated with combined modalities. Note that cure rates have improved with most cancers (e.g. breast, lung and colorectal) when using not one but two or three different treatment modalities.
How does Proton Beam Therapy compare with the most advanced External Beam Radiation Therapy?
Proton Beam Therapy (PBT) causes fewer complications than does traditional external beam radiation therapy (EBRT), which utilizes photons; however, the newest and most advanced technology for external radiation therapy with photons surpasses both Proton Beam Therapy and traditional external beam radiation therapy. This form of EBRT, known as Dynamic Adaptive Radiotherapy (DART), utilizes all of the treatment and imaging modalities associated with 4-Dimensional Image-Guided Intensity Modulated Radiation Therapy (4D IG-IMRT).
A number of technological innovations are employed, including but not limited to PortalVision™ with Exact Arm positioning, 4th Generation Cone Beam Tomography, Varian Exact Couch™, the AlignRT surface guidance system, On-Board Imaging, 2nd Generation Respiratory Gating, and CT SIM+™ with RapidSIM™ deformable fusion. These systems are utilized in concert to allow for the analysis of organ motion in real-time (the 4th dimension) to achieve unsurpassed accuracy. All these technologies are non-invasive. Thanks to Align RT, even tattoos are unnecessary.
Once motion is detected and monitored, numerous software programs activate to adapt the radiation and target the organ site, which may have moved. Using all of these sophisticated imaging and tracking technologies, DART can actually hit a continually moving target! This ability to optimize and adapt to changes is the basis for genuine DART. None of this is even remotely possible with protons.
The preponderance of data over many years indicates that higher doses lead to higher cure rates. It is not possible to safely escalate protons to high doses like those achieved with 4D IG-IMRT — not to mention DART coupled with a Palladium-103 boost. There is significant evidence demonstrating that it requires far higher doses of radiation to eradicate prostate cancer. This is accomplished with DART and Pd-103, which also has the advantage of maximally sparing adjacent normal tissues while escalating doses to specific tumors within the prostate gland — neither can be achieved with protons.
It should be emphasized that the radiobiological effectiveness (RBE) – the cancer-killing ability of photons – in the high dose range used at our center with DART is identical to that of protons. This being the case, we strongly favor DART because of the highly sophisticated beam arrangements which are available here for state-of-the-art prostate targeting, as outlined above, and far more mature research data which has been accrued over the years with high energy photons in general compared to the more limited history of protons. To date no randomized study has demonstrated the superiority of protons over even early generations of IMRT to justify the increased cost of protons. Many insurance companies no longer reimburse proton beam therapy and Medicare has dramatically limited reimbursement for protons.
Some physicians utilize what they call "simultaneous radiation," first using Iodine-125 seed implants followed by external beam radiation to give a greater dose. Do you ever use this approach?
No, because with Palladium-103 seed implants you’re already receiving 3 times the dose that Iodine-125 delivers without risking the higher rates of rectal, bladder and urethral injury that have been reported when doing seeds first, followed by radiation. The order of external radiation and seed implantation is very important, and we believe that brachytherapy should be utilized as a boost after a course of external radiation.
When prostate cancer spreads, it grows microscopic extensions. A good analogy is the palm of your hand representing the tumor, and your fingers representing the “spider legs” or extra-prostatic extensions of the cancer outside the prostate. Within just a few weeks of receiving external beam radiation and/or hormonal therapy, those extensions begin to retreat back into the prostatic tumor.
We have learned that by targeting the tumor and its extensions first with DART, with or without hormones, the seeding procedure is more effective and serves as a boost, while not leaving the migrating cells in the regions outside of the prostate untreated. The surrounding field is sterilized by the daily radiation, and cancers are rendered non-viable when external beam radiation is used upfront.
It should be noted when seeds are placed in the prostate first, they may later cause scattering of the external radiation when it collides and is displaced by the seeds, with the possibility of irradiating healthy surrounding tissue. The available published literature regarding seeds before external radiation has reported higher rates of rectal injury. Finally, we are concerned that placing seeds first in intermediate to high-grade cancers may even spread cancer into the blood stream, resulting in clinical failure at other sites within the body. This has been documented in contemporary brachytherapy literature.
Do your patients receive hormonal therapy in addition to radiation?
It has long been known that prostate cancer is to some extent dependent on and nourished by the male sex hormone, testosterone. This is one of a group of hormones known as androgens. Since testosterone stimulates the growth of prostate cancer cells, depleting or ablating the body’s testosterone tends to shrink the size of many tumors, specifically, those that are hormone-sensitive. The goal of hormonal therapy is to decrease the production of testosterone in the body, inhibiting the growth and progression of the cancer. Hormonal therapy, also known as Androgen Ablation Therapy (ADT), can shrink a man’s prostate by as much as 50%.
Hormonal therapy is typically optional for patients having intermediate risk features (as indicated by Stage, PSA, Gleason Score, and PAP results) but encouraged for patients having high-risk features. With the low-risk or mildly aggressive cancers, unless the size of the gland is markedly large, we don’t normally give the conventional hormonal therapy (combined hormonal blockage using an anti-androgen and an LHRH agonist), since this form of therapy can result in temporary or potentially longer lasting menopause-like side effects such as erectile dysfunction, hot flashes and fatigue. With long-term use of hormones (one year or more), ADT may also cause increased risk of osteoporosis, cardiovascular disease, strokes, diabetes, and cognitive dysfunction.
We often prescribe a milder, modified version of hormones that act as blocking agents (e.g. oral anti-androgens), not allowing the testosterone to bind with the prostate cancer receptors. These medications are often combined with other oral agents such as 5-alpha reductase inhibitors, which prevent testosterone from converting to dihydrotestosterone (DHT), a metabolite that is 10 times as potent as testosterone in stimulating prostate cancer growth. We also use cabergoline to suppress another powerful stimulant of prostate cancer, prolactin, by inhibiting the pituitary production of prolactin. This agent can also help preserve sexual function. In addition we prescribe non-hormonal drugs that have anti-cancer effects such as Metformin, Lipitors and Celebrex.
This type of hormonal therapy that we prescribe is just enough to arrest the cancer and allow the patient to make a more relaxed decision about treatment, without the side effects associated with more aggressive ADT. Hormonal Therapy is often administered intermittently for 6 to 12 months. With intermittent Hormonal Therapy (IHT), the patient’s testosterone level recovers when off hormones and his quality of life (QOL) improves dramatically.
Many medical centers advertise Intensity Modulated Radiotherapy (IMRT); but are all IMRT treatment systems equivalent and equally effective in treating prostate cancer?
No. Many centers that advertise IMRT actually have early generation equipment that is already antiquated. It’s one thing for a center to offer IMRT, but it’s another to demonstrate that every microbeam has actually struck the desired target that is moving and smaller than the size of a dot. Only with the most sophisticated ancillary technology associated with DART can such a claim be made.
As mentioned earlier, that advanced IMRT technology, 4-Dimensional Image-Guided Intensity Modulated Radiation Therapy (4D IG-IMRT), includes but is not limited to PortalVision™ with Exact Arm positioning, 4thGeneration Cone Beam Tomography, Varian Exact Couch™, the AlignRT surface guidance system, 3rd generation SonArray® 3D virtual ultrasound acquisition, On-Board Imaging, 2nd Generation Respiratory Gating, and CT SIM+™ with RapidSIM™ deformable fusion. This is the technological basis upon which DART is uniquely realized to full potential at our center.
What are the advantages of the combination radiotherapy offered at your center?
Brachytherapy can be successfully utilized as the sole treatment for many patients who have been diagnosed with very early stage prostate cancer. Studies have show that combining external beam radiation with brachytherapy doesn’t add to toxicity (side effects) but provides an umbrella of safety in the event that the cancer has made egress (leaks) into the tissues immediately outside the prostate, which is the case in 15-20% of even the most favorable, low-risk presentations. This is not piling on the radiation or giving a lot of both but rather a little of each – a blend which is more thorough than seeds alone or external beam radiation alone. For intermediate and advanced stage tumors, brachytherapy is typically prescribed in combination with other kinds of treatment such as DART plus/minus hormones.
Having the availability of each type of therapy at a single center allows the physician and his team to tailor a treatment plan specifically for each individual case versus a one-size-fits-all approach. Patients have the advantage of using any combination of DART and/or brachytherapy plus/minus hormonal therapy to achieve a maximum degree of cure.
How do you localize the prostate, the cancer(s) and their relationship to surrounding structures?
Even the simple motion of breathing can shift the position of the prostate gland. But we can track, anticipate and correct for such physiologic movement with our special 2nd generation Respiratory Gating System. This is an advanced video tracking technology that allows for real-time monitoring that accounts for patient breathing. Included in the DART suite are strict immobilization techniques utilizing Vac-Lock assistance, motion sensing tracking cameras, and AlignRT surface guidance, along with the Varian Exact Couch™ and PortalVision™ with Exact Arm positioning.
To ensure that the target is covered accurately with each radiation treatment, a special 3rd generation SonArray® 3D virtual ultrasound acquisition, External 4-D Ultrasound and optimized infrared camera guidance are used to assess and fine-tune the position of the patient and surrounding healthy organs just prior to each daily treatment. Real-time rotational helical Cone Beam CT tomography is utilized to capture the location of the target and its relation to immediate surrounding adjacent tissue. The video respiratory gating program is employed to synchronize the beam with the patient’s breathing movements.
When DART is used as a monotherapy, patients are treated Monday through Friday over 6 to 8 weeks (30 to 40 treatment sessions). Each treatment is approved in advance by the physician with the aid of amorphous silicon diodes (Portal Vision) and reviewed in real-time using a unique in-house wireless network. Immobilization is paramount to success and the above methods maintain a daily tracking accuracy less than or equal to .3 mm/0.3 degrees.
Where and how are the radioactive seeds implanted?
Each case is different, requiring a unique brachytherapy treatment plan to determine the placement of the seeds. Depending on the size and contour of the prostate, and the size, number and location of the tumor(s), a precise seeding map is designed for each patient. The seeds are tiny, less than 4.5mm long and about the width of a mechanical pencil lead. Under an outpatient procedure, the patient is anesthetized and the seeds are implanted through the perineum (the area of the body between the anus and the scrotum) using a patented needle-like device. Sophisticated 3-D Color-Flow Power Doppler Ultrasound imaging technology guides the placement of the seeds into the correct locations while avoiding the neurovascular bundles.
Dr. Dattoli often uses different strength seeds for each patient and various strength seeds within the prostate. For example, higher energy seeds may be positioned within the tumor, while lesser strength seeds may be placed near normal adjacent tissue. Comparing the number of seeds with other patients may be a comparison of apples and oranges, as the number implanted can vary widely.
Are there advantages to Palladium-103 over other isotopes?
Yes, there are several significant advantages and that is why we strongly prefer the Palladium this isotope. The radiation emitted from Palladium-103 (Pd-103) is high enough to deliver a strong, precisely targeted and continuous ‘round the clock’ dose to the prostate tumor. The cancer killing ability, or radiobiological effectiveness (RBE), is higher for Palladium than other commonly used isotopes, such as Iodine-125 or Iridium-192 and far more thoroughly studied than Cesium-131. Coupled with Palladium’s short half-life (approximately 17 days) and less penetrating characteristics (steep radial dose fall-off), this makes Pd-103 ideal for greatest tumor eradication with maximal protection of surrounding normal tissues. In addition, because of Palladium’s short half-life, temporary urinary symptoms after treatment are typically months shorter in duration than with treatments employing other isotopes such as Iodine.
What are the possible side effects of brachytherapy?
The two major side effects of any aggressive prostate cancer treatment are the risk of erectile dysfunction ED and incontinence. With Palladium-103 seed implants, erectile dysfunction occurs in about 15-20% of cases; incontinence is virtually unheard of following Palladium implants. In addition, 85-90% of those 15-20% of patients who experience erectile dysfunction are able to regain sexual function using erectile aids such as Viagra, Levitra, and Cialis. After brachytherapy there is typically a diminished ejaculate, whereas after radical surgery, there is no ejaculate.
Approximately 35% of surgical patients experience incontinence, while most experience at least some degree of stress incontinence. Most men who undergo traditional radical prostatectomy experience complete or partial erectile dysfunction. A surgical technique, pioneered by Dr. Patrick Walsh at Johns Hopkins during the early 1980s, attempts to preserve one or both of the neurovascular bundles (NVBs) located at the margin of the prostate during the radical prostatectomy. This nerve-sparing technique allows more patients to retain sexual function. However, because the technique requires shaving close to the side margins of the prostate, it is often reserved for patients whose cancer is most likely to be contained well inside the prostate gland, which is rare.
The success of the nerve-sparing procedure depends on the age of the patient and pathologic stage of the cancer. In the most favourable studies by the leading “artist” surgeons, men between the age of 50 and 60 have a 75% chance of retaining erectile function. Men over the age of 70 have only a 25% chance of retaining erectile function. The nerve-sparing procedure requires a high degree of surgical skill, and the results obtained by most surgeons are not as impressive as those reported by Dr. Walsh who pioneered the procedure.
If I choose brachytherapy now, what are my options if the treatment isn't successful?
Patients who have had seed implantation without initial success have the option of being re-seeded with or without DART. Although long-term results are not yet available, this approach appears to be promising, and typically involves using a different isotope the second time around. If the patient was first implanted with iodine, then Palladium can be used as a salvage therapy in the hope that the cancer will be more sensitive to the second isotope. If the first implant was technically mishandled, then a second implant affords the opportunity to correct misplacements that may have caused under-dosing.
Patients who underwent brachytherapy as a monotherapy and who experience treatment failure also have the salvage options of surgery, cryosurgery, hormonal therapy, and in some cases active surveillance (AS). In some cases, several months of hormonal therapy may be prescribed to reduce the size of the tumor prior to an attempt at salvage therapy with either surgery or cryosurgery (or focal cryosurgery if the recurrence is limited to one lobe). Patients may also consider biothermy, which combines cryosurgery and hyperthermia. High Intensity Frequency Ultrasound (HIFU) is another option, and as noted, researchers are working on a number of immunotherapy vaccines for which there are clinical trials underway.
What are the treatment options if combined radiotherapy (brachytherapy and external beam radiation therapy) fails?
Patients who have undergone combination therapy utilizing both external radiation and brachytherapy would not be advised to have any form of full-course radiation, because the initial combined radiation regimen did not eradicate the cancer and there would be a high risk of side effects. Patients who experience recurrence after combined radiotherapy have salvage options that may include surgery by an experienced surgeon, cryosurgery, hormonal therapy, biothermy, High Intensity Frequency Ultrasound (HIFU), and possibly Active Surveillance (AS).
Since I am unable to travel to your center in Sarasota, how can I find an expert in my area who is proficient in radiotherapy?
In selecting a physician for any type of treatment you will need to be assertive and do your homework. Don’t be shy about asking the doctor how many cases he or she has done and what their success rate is. Have his results published in a peer-reviewed medical journal? What are the side effects of the specific type of treatment offered by the physician? Ask to speak to a number of the doctor’s patients who are willing to share their experiences with you.
By way of comparison with regard to experience, over the past 30 years, Dr. Dattoli has performed many thousands of prostate brachytherapy procedures, more than any other practice in the world. His success rate is constantly improving with technological refinements in brachytherapy and external beam radiation delivery, which is now fully realized DART. At this point, Dr. Dattoli’s cure rates are in excess of 90% for men with intermediate and low-risk prostate cancers and greater than 80% even for those men with the most locally advanced, high-risk prostate cancer.