John Sylvester, MD, is a brachytherapy innovator. In 1987, he joined Dr. John Blasko, Dr. Peter Grimm, and Dr. Hakaan Ragde at the Prostate Cancer Center of Seattle refining the procedure for ultrasound-guided prostate seed implants. As of 2021, he had completed over 7,000 prostate brachytherapy procedures.

The evolutionary inclusion of ultrasound and MRI scans to prostate brachytherapy addressed limitations of the prior iteration of the procedure, and improved the patient experience, allowing for more accurate placement of seeds, better targeting of the cancer, and avoiding toxicity to structures in close proximity to the prostate. High-powered planning tools and highly customized seed stranding have further improved the elegance and efficacy of the treatment modality.

Brachytherapy: The State of the Art

Over his career, Dr. Sylvester has continued to innovate the procedure.

“Beyond those technologies mentioned, the current state of the art in prostate brachytherapy lies in patient selection and products like gels that improve separation between the prostate and the rectum further reducing toxicity to healthy tissue,” Dr. Sylvester said.

“At this point in time, it’s about not over-treating or undertreating patients in a highly customizable, elegant procedure that has improved for all concerned as it has evolved and stood the test of time.”

“I like to use MRI scans because they significantly reduce the number of surprises,” he continued. “We are also using genomic information to get a better handle on genetic aggressiveness to help us determine if candidates’ greatest potential for long-term recurrence-free survival involves seeds alone, or external beam radiation therapy plus seeds plus or minus androgen ablation therapy.”

The data on relapse-free survival continues to show brachytherapy’s value. Data from as far back as the late 1980s show prostate brachytherapy cure rates were superior to external radiation. Most importantly, Dr. Sylvester highlights, “Prostate cancer cure rates with treatment that includes brachytherapy are very high.”

Dr. Sylvester said approximately 60% of men diagnosed with prostate cancer are candidates for brachytherapy as a monotherapy or in some form of combination therapy.

“External beam has gotten better, but it is still not superior to brachytherapy in most cases. Neither is proton therapy.”

In many cases, brachytherapy matches superior cure rates, low rates of recurrence, and superior long-term side effect resolution or avoidance compared to other, frequently recommended and adopted modalities.

“In short, prostate cancer patients treated with brachytherapy experience some negative side effects in the short-term, but those tend to resolve quickly with superior cure rates, retention of sexual function and a lower likelihood of hormone treatment required down the road.”

“This is demonstrated by the recent seven-year outcome data for prostate cancer patients treated with SBRT in intermediate-risk cases that show 85% of patients were relapse-free. Prostate brachytherapy alone in the late 1990s showed 92% relapse-free patient survival at 9 years with the one-time outpatient procedure.”

Further, from a 2012 NIH update on the state of brachytherapy, Dong Soon Park cites Drs. Grimm and Sylvester, “…after their initial learning curve was achieved, I-125 brachytherapy improved the long-term outcomes of both low-risk and intermediate-risk patients compared with the patients initially treated at the same center with the improved implant technique.”

The initial 7-year PSA relapse-free survival (patients treated in 1986) results were 70% and 37% in the low-risk group and the intermediate-risk group, respectively. After improving the implantation technique (patients treated in 1987), the results dramatically improved; the 7-year PSA relapse-free survival rates in the low- and intermediate-risk groups were 87% and 80%, respectively. Intermediate risk patients treated in 1998 experienced a 92% 9-yr relapse-free survival.

“The [latest] data [also] unequivocally show the more aggressive the cancer, the worse surgery does for patients in terms of outcomes and quality of life compared to brachytherapy,” Dr. Sylvester said.

Enter Urologists

All physicians’ training, and subsequently their level of proficiency in, or comfort with, certain procedures or modalities creates an unavoidable bias in therapeutic recommendations to their patients.

“If an attending urologist tells a resident that surgery is better than any form of radiation therapy in their training, why would they question their professor?” Dr. Sylvester asked.

“It is also likely modern radiation data isn’t included or discussed in their training literature. They are told a younger prostate cancer patient should not have radiation, but there’s no data to support that. They are also concerned that if they do send a patient for radiation therapy instead of surgery, they won’t get that patient back.”

“When we see newer, younger urologists who haven’t been exposed to brachytherapy join a group with an experienced brachytherapy team, they light up when presented with long term data and when they see how well patients in practice are doing with lengthy follow up ranges,” Dr. Sylvester said.

But the disconnect between the urology and radiation oncology community persists. What’s needed to more closely align those practitioners along scientific and patient-centric quality-of-life parameters? Dr. Sylvester offers the following:

• Combine urology rounds. Get the residents talking to each other, sharing what they’re learning, and developing relationships. Dr. Neil Shore with GenesisCare is doing Grand Rounds lectures for radiation oncologists and Urologists, so both specialties are exposed to the same up-to-date information. Dr. Shore and I are working together to develop nationwide practice guidelines as well.

   

• Many urologists will say “if a patient recurs after surgery, he can get radiation later, but can’t get surgery after radiation if he recurs after primary radiation therapy”. Let’s do the math: Data from Johns Hopkins show that 24 out of 100 patients (intermediate risk) developed a recurrence post-surgery. Salvage radiation cures less than 50% of these patients resulting in a final “cure rate” of 88% for intermediate-risk patients treated with surgery initially. Brachytherapy alone yields 92% recurrence-free 9- year survival rates in those cases.

   

• For the next generation of radiation oncologists, get proficient in, and used to, doing procedures. Infection risks from transperineal brachytherapy for prostate cancer treatment presents less risk of infection. Learn how to do biopsies, and how to use newly available spacer gels. This not only expands your capabilities but working actively with colleagues in the operating room builds better outcomes for all concerned.

   

• For residents whose university hospitals do not include a prostate brachytherapy program, get elective time in private practice. The American Brachytherapy Society is working on one such program. The more residents learn and spend time doing hands-on procedures, will not only help their patients live higher-quality lives, but it will also help their practices downstream.

Theragenics would like to express our gratitude to Dr. Sylvester for taking the time to share his insights with our colleagues and community.

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