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How Brachytherapy Changed the Treatment of Prostate Cancer 

| Featuring John Blasko, M.D. 

“Brachytherapy changed the treatment of prostate cancer with its patient first approach, improved patient experience and excellent results.”

Dr. John C. Blasko (ret.) was part of the team of innovators that brought ultrasound guided prostate brachytherapy to men seeking prostate cancer treatment in the 1980s. He remained a forward thinking, patient-first innovator and teacher of this procedure to the benefit of hundreds of clinicians worldwide and untold number of patients. Dr. Blasko generously shared time with us in his retirement, sharing his experience in, and contribution to, the evolution of prostate brachytherapy dating back to the late 1980s.

The enthusiastic support, interest and insights from urologists like Dr. Hakaan Ragde and Dr. Hans H. Holm, and from dedicated, forward looking radiation oncologists like Dr. Blasko, gave access to this important treatment alternative to hundreds of thousands of men afflicted with prostate cancer. Join us as we Celebrate 40 years of innovation in prostate cancer treatment in this interview with Dr. Blasko.

Transperineal, ultrasound guided Iodine-125 (I-125) prostate brachytherapy was introduced in the 1980’s. Since that time, the procedure has improved significantly over the past four decades and additional isotopes are now available. Today’s procedures bear little resemblance to those of the 80’s, 90’s and 00’s. After decades of evolution, today’s meaningful published data and Level 1 evidence demonstrates that brachytherapy improves outcomes for prostate cancer patients, particularly when combined with external beam radiotherapy (EBRT) for more advanced disease.

Why did you feel that it was important to re-introduce brachytherapy when you did?

“In the mid-1980’s, radical prostatectomy and EBRT were the standards of care for prostate cancer treatment. Both approaches had flaws and less than stellar results. In the 1960’s and 70’s, prostate brachytherapy was attempted with a retropubic, ‘hand and eye’ surgical approach. Lacking any meaningful guidance ability, seed placement in the prostate was haphazard at best, resulting in frequent underdosage. The results of the retropubic approach published in the late 1970’s and early 80’s were generally poor and the procedure had been largely abandoned. At the time, there was speculation in the literature that the dose rate of I-125 was too low to cure cancer and that use of the isotope should be dismissed.

“Against this backdrop, in 1983 Hans Holm published details of a novel transperineal, closed, ultrasound guided I-125 brachytherapy procedure for prostate cancer in the Journal of Urology. Although the clinical results published were not great either, it was my opinion that Holm’s choices of dose and patient selection may have been responsible for the outcomes rather than a fundamental failure of the isotope. I found the technical approach intriguing and promising for improved accuracy of seed deposition and patient tolerance. Serendipitously, a local urologist, Haakon Ragde, had observed Dr. Holm perform the procedure in Dr. Holm’s Danish practice and expressed interest in it for his patients.

“The question I was then faced with was, should we begin a procedure that had no track record, using an isotope that was discredited but an approach that appeared to have potential advantages?  Was the existing track record of I-125 poor because of fundamental radiobiologic shortcomings or was it physical placement and dose distribution issues that could be overcome by technology?

“My own review of the retropubic implant literature suggested that even though the overall results were poor, in the rare event that a good dose was achieved and the cancer stage was relatively early, the outcomes were actually quite good. I decided to place my bet on dose distribution and proceed with the program believing we could unlock high potential efficacy and patient friendliness with ultrasound and perineal template guidance.

“Our initial efforts were hampered by the lack of commercially available equipment. We had to build our own stabilizing devices, borrow needles for implantation that were designed for other medical procedures, and design our own treatment planning software to determine desired dose distribution. But, recognizing brachytherapy’s classic advantage of delivering a high dose to a limited volume, we had hopes that this procedure would offer high cure rates and low morbidity in a brief outpatient setting with high patient acceptance.

“In the immediate following years, colored by the perception of poor outcomes from the retropubic era, the medical community’s perception of the procedure remained quite negative, but patients were ecstatic about it.

“The limited side effects and “down time” compared to surgery and EBRT, the short outpatient experience and the dawn of the internet drove enthusiastic word-of-mouth demand. This exerted enough pressure on the urology community that they began to say, “If patients want to move forward with the procedure, I will participate”. Responding to this demand for training, our center trained groups of 10 to 20 physicians in a team setting every month for more than two decades.

“Even in those early years with limited equipment, it was obvious that the radiation dose distributions were vastly superior and reproducible compared to what was achieved previously and we were convinced that the future was bright for this procedure.” 

 How important was the era of the dawn of transperineal, ultrasound guided prostate brachytherapy?

“It was a huge technological breakthrough for prostate brachytherapy. For the first time we could treat prostate cancer in a patient-friendly, outpatient way without surgery or anaesthesia. We also gained a much more accurate view of a patient’s anatomy and tumor volume that enabled us to place the seeds with high accuracy in a matter of minutes. This was the key, the most fundamental step forward, in placement of the energy source where it was needed, and where it had the highest likelihood of sparing healthy surrounding tissue or structures.

“In the decades that followed, advancements in physics, the advent of high quality ultrasound equipment and a better understanding of dose constraints with respect to the urethra and rectum has contributed to continually improving cure rates and quality of life for men treated for prostate cancer with brachytherapy.

“Computer algorithms now help guide placement of the seeds. [This] associated planning enables physicians to be more accurate than ever in their targeting and seed placement. Today’s prostate brachytherapy, in terms of efficacy and post-treatment quality of life, is far superior to where the procedure began to mature in the mid-1990s.”

 

How has the brachytherapy experience and data been received by the urology community?

“The acceptance of the procedure by the urology community has been slow, gradual and incomplete. The lingering perception among the urology community that the procedure either simply does not work or is inadequate persists to this day.

“In medicine it is science, politics, instinct, education and economics that influence decisions. Some urologists enthusiastically support brachytherapy for prostate cancer treatment for many candidates. Others do not for a variety of reasons including procedure length, O.R. efficiency or lack thereof, absence of training or a number of personal biases. The focus on urinary side effects, for example, seems excessive, even when oncologic outcomes are not in question.”

Our commitment to the prostate brachytherapy community

“As we celebrate 40 years of innovation, Theragenics is working closely with ASTRO and ABS to address problems with reimbursement that currently limit the utility of a high value, patient-friendly procedure shown to deliver superior oncologic outcomes compared to more recently available, costly, yet less effective modalities that enjoy high levels of reimbursement,” said Theragenics CEO, Frank Tarallo. “We are also committed to advancing the evolution of this important procedure innovated over more than three decades ago thanks to the efforts of Drs. Blasko, Holm, Ragde, Sylvester, Grimm and many others.”

Theragenics is proud to support clinical partners around the world who continue to ensure men diagnosed with prostate cancer are made aware of every single treatment option available to them. Thanks to dedicated innovators like Drs. Blasko, Ragde and Holm and many others, brachytherapy has become a powerful, patient-friendly way to treat prostate cancer for a significant population of men requiring treatment.

John C. Blasko, MD (ret.), is, indeed, a pioneer in prostate brachytherapy. He is the former Medical Director and Director of Clinical Research for the Seattle Prostate Institute, and was a Clinical Professor in the Department of Radiation Oncology, University of Washington School of Medicine. He is past President and Board member of the American Brachytherapy Society. He received the American Brachytherapy Society Henschke award for outstanding contributions in brachytherapy and is a recipient of the University of Maryland Gold Key award for advances in medicine. Dr. Blasko has published several hundred articles, abstracts, and book chapters on the subject of [prostate brachytherapy.]

***

Editor’s note: all quotes are attributed to Dr. Blasko unless otherwise indicated as in the penultimate paragraph.

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