It's Prostate Cancer Awareness Month and although prostate cancer is the most common cancer in men, excluding skin cancers, it ranks relatively low in cancer mortality. In fact, many men with low-risk prostate cancers should be encouraged to avoid treatment entirely and pursue active surveillance, or “watchful waiting”. This is not true, however for the high-risk prostate cancers defined as having PSA blood tests of >20 or poorly differentiated tumors on biopsy, i.e. Gleason 8-10 cancer. These cancers are much more aggressive, and are often not controlled with surgery alone.
For decades, physicians treating prostate cancer have had to rely on retrospective patient outcome data to compare the various treatment options, which are known to be statistically unreliable. Fortunately, this past year an excellent controlled randomized trial was reported from British Columbia that now provides us with reliable long-term data.
The trial, known as the ASCENDE-RT trial, randomized patients with high-risk prostate cancer to either high dose intensity-modulated radiotherapy for 8 weeks (IMRT), or a reduced dose of IMRT with a seed implant boost (brachytherapy). All patients received hormonal therapy. At nine years, the number of patients with controlled PSAs was 62% for IMRT, and 88% for IMRT + seeds. This is truly good news for patients with high-risk prostate cancer to have a treatment that is nearly 90% effective, without need for surgery.
Prostate brachytherapy, or “seed implant”, is a technically demanding procedure requiring considerable experience to obtain results as reported in this study. I have performed over 600 seed implants since 1999, and have developed considerable expertise. Brachytherapy is a one-hour, outpatient procedure, performed with the urologist in the surgery center and patients can return to work the next day. The chief side effects are significant urinary and rectal irritation that can last several weeks.
If you or a loved one are diagnosed with prostate cancer, I strongly recommend that you consult with both a urologist and radiation oncologist, to better understand the complicated treatment options, before making a treatment decision.