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Awareness in Efficacy 

| Gregory S. Merrick, M.D. 

Thanks to the innovative minds of its patient-focused pioneers, brachytherapy remains a valuable treatment for prostate cancer. It remains current because it has evolved, and continues to do so thanks to new technologies for superior planning, imaging and dosimetry that make it a potent, effective modality for prostate cancer treatment.

Brachytherapy procedures have changed significantly in the past several decades. Today’s procedures bear little resemblance to those of the ‘80s, ‘90s and ‘00s. Despite meaningful scientific evidence that brachytherapy significantly improves outcomes for prostate cancer patients, particularly in combination therapy with IMRT/EBRT and hormone therapy, its “popularity” is in decline.

Surgeons like to do surgery. Radiation oncologists, particularly those most recently entering clinical practice, like to focus on their technical prowess and tools like external radiation therapy techniques, less so in the clinic or OR. This stems from limited opportunities to develop the skill sets necessary to effectively deliver brachytherapy procedures and limited exposure to the value of the procedure to patients and clinicians. Reduced numbers of newly trained, skilled brachytherapy practitioners has translated into overall reduction of cases performed and thousands upon thousands of men being treated for prostate cancer with other potentially suboptimal modalities.

Rather than curse the darkness we will shine a light on the mounting evidence that brachytherapy’s role and potential to deliver superior outcomes, including distant metastasis free survival rates and superior quality of life results, for a large and growing number of prostate cancer patients worldwide.

Gregory S. Merrick, M.D.

Dr. Merrick is the Director of the Urologic Research Institute for the Ohio University School of Medicine. He is past chairman of the multi-disciplinary American College of Radiology Prostate Cancer Appropriateness Committee and past president and Chairman of the Board of the American Brachytherapy Society. Currently, he is the genitourinary section editor of the Journal of Brachytherapy and serves as a manuscript reviewer for 18 peer reviewed scientific oncologic and urologic journals.

He has published approximately 400 original scientific studies on multiple urologic disease states, has co-authored two text books and has lectured across the United States and abroad.

His research has advanced brachytherapy patient selection, technique, treatment and post-operative management, has evaluated multi-institutional patterns of care via the Procura database, redefined prostate biopsy techniques for the diagnosis of prostate cancer and for active surveillance patient selection, evaluated mechanisms of erectile dysfunction, participated in large studies evaluating investigational drugs for castrate resistant metastatic prostate cancer and is currently evaluating approaches to improve renal cryosurgery as a curative approach for early stage kidney cancer.

Brachytherapy’s Basis in Efficacy and Precision Evolution

“Brachytherapy has clearly demonstrated superior efficacy compared to other modalities in many, many [prostate cancer] cases,” Dr. Merrick told us. Modern brachytherapy dates to the development of transrectal ultrasound and template guided techniques grounded in the work of Dr. Blasko and his colleagues in Seattle in the late 1980s and early 1990s. We all owe Dr. Blasko and his pioneer colleagues enormous amounts of gratitude for the current state of the procedure which has since benefited significantly from advancements in dosimetry, planning and imagery.

“Even in the ‘early days’ of the procedure, complication rates for brachytherapy compared to radical prostatectomy and EBRT were acceptable. No definitive therapy for prostate cancer is free from side effects, lasting or temporary, in varying degrees and duration. Rectal complications from brachytherapy for prostate cancer treatment [even] in [the early days] were serious, but rare, and are almost unheard of today.

“While erectile dysfunction occurs in a significant number of current day prostate cancer cases treated with brachytherapy, those cases respond very well to oral medications. Most men treated with brachytherapy alone or in combination are back on the job or living life as they knew it prior to their treatment within a few days, understanding the primary side effect will be an irritative bladder that typically resolves in a couple of months.

“Significant advancement in MRI technology has given clinicians the ability to further delineate anatomical structures for planning and implementation of dose restrictions to healthy tissues and structures surrounding the prostate will potentially further increase cure rates and decrease side effects or other complications.

Evidence Shows Higher Cure and Survival Rates for Brachytherapy vs. Radical Prostatectomy and Prostate EBRT in Mono-Therapy and Combination Therapy

In 2017, “[ASCENDE-RT] researchers were able to conclude that five- and 10-year distant metastasis-free survival rates were significantly higher with EBRT plus brachytherapy (94.6% and 89.8%) than with EBRT (78.7% and 66.7%, p=0.0005) or radical prostatectomy (79.1% and 61.5%, p<0.0001). It became strongly evident that even among the highest-risk patients, the brachytherapy boosting resulted in a treatment regimen that proved most effective.” – Radiology Today

More recently, “a 2018 study of 1809 men with Gleason grade group 5 disease, Kishan et al7 found improved prostate cancer–specific mortality and distant metastasis outcomes in patients treated with EBRT with BT compared with those treated with EBRT alone or RP.” – JAMA Network

“Long-term studies with mature data substantiate the importance of brachytherapy especially for high-risk prostate cancer cases,” Dr. Merrick said. “I believe we will see additional data that expands on these findings and that the next generation of urinary morbidity data will show further reduction in an already acceptable rate of urethral structures.

“This is because dose matters, and no other treatment can approach the dose delivery brachytherapy affords directly to the area of interest, ablating the gland leaving no functional prostate tissue behind. The vast majority of cured patients have undetectable PSAs.”

The Critical Need for Academic Training Centers to Expand Their Curricula and Cohorts

In 2015, Petereit, et. al. reported in the Journal of Clinical Oncology, “…the volume of prostate brachytherapy procedures used to train radiation oncology residents is suboptimal. Compton et al reported that the average number of interstitial prostate procedures decreased by 25% over a 5-year period when assessing the resident case load from the Accreditation Council of Graduate Medical Education resident case logs.”

“More academic training centers need to emphasize brachytherapy in their resident training programs,” Dr. Merrick said. “While it is true reimbursement rates affect what many institutions are willing to offer patients, reimbursement rates for brachytherapy and radical prostatectomy have decreased by approximately the same magnitude for both procedures. But that has not changed the interests of many urologists or academic centers.

“Additionally, department chairs assembling teams should recruit attending physicians and residents with a cross-section of procedural orientations with complementary, not overlapping, skills. Once awareness of the current data on the efficacy and value of brachytherapy couples with a commitment to training the next generation of radiation oncologists and urologists on the state-of-the art procedure, all concerned should benefit. It is imperative for academic centers to step up and include a group of academic based brachytherapists willing to spend time teaching the next generation of physicians this relatively straightforward and high value procedure.

“Radiation oncologists themselves need to get out of the basement and into the OR. And not only into the OR, but into a connected, visible role in all aspects of medicine and their community. They need to be delivering lectures to primary care physicians, internists, urologists and residents alike. They need to be actively managing patients in clinical environments and in community environments educating men on their health be it ED, obesity, exercise, hypertension, etcetera. The academic community responsible for their education should be making sure they do so.”

Theragenics applauds the American Brachytherapy Society’s “300 in 10” initiative to train more than 300 brachytherapists in the next 10 years. We are proud to support their efforts and are grateful to Dr. Merrick for sharing his insights and helping us to celebrate 40 years of innovation here at Theragenics. We stand ready to support academic centers interested in creating more robust radiation oncology training programs that include brachytherapy within their curriculum.

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