Jonathan M. Feddock, MD
Marcus E. Randall, MD, FACR, FASTRO
Dr. Marcus Randall and Dr. Jonathan Feddock have a decades-long history in fighting cervix and vaginal cancer and have a unique specialization in recurrent cancers and re-irradiation treatments. Both are strong believers in interstitial brachytherapy and permanent seed implants as part of a successful treatment toolkit, performing interstitial procedures 2-3 times a week with very solid outcomes. The use of Cesium-131 is their isotope of choice in most cases, and both doctors explain here why the shift from temporary to permanent isotopes is so important.
“Let’s say a patient has an early cervix cancer and has a radical hysterectomy that should have cured the patient,” stated Dr. Randall. “If the cancer returns in the vagina, the patient no longer has a uterus or a uterine canal, so using removable implants becomes more difficult. Permanent implants became a more viable method to deliver the brachytherapy.”
It all started in 1986, as Dr. Randall explained: “I was approached with a case where the patient had already received radiation treatment for a gynecologic cancer. It was normally thought that she could not receive any more radiation, but I suggested using a permanent radiation implant, with a short half-life isotope. This was a relatively novel treatment at the time, and it turned out to be very successful. The subsequent cases built on this success and I have continued with this treatment for the last 30 years.”
Dr. Feddock highlights the importance of ensuring interstitial treatments do not fade from view. “It’s unfortunate that as many radiation oncologists move through their careers, very few receive in depth training with interstitial techniques with the exception of prostate cancer, but even those procedures are declining” said Dr. Feddock. “It takes a mentor with the specific experience to teach these techniques and really get a radiation oncologist to think about them. I was fortunate to be exposed to permanent interstitial brachytherapy and how successful it can be as an additional brachytherapy option that can be used to complement other techniques such as intracavitary brachytherapy for gynecologic cancers.”
“Over the past several years, we have seen an unfortunate decline in the utilization of brachytherapy for all cancers. More importantly, the data is pretty clear that survival outcomes are superior when brachytherapy is a component of definitive treatment. A major focus right now from the major organizations such as the American Brachytherapy Society is to improve the knowledge, education, and accessibility of advanced brachytherapy techniques,” he continued. “What we need to do is figure out new ways of performing brachytherapy that are more straight-forward and applicable. Permanent interstitial brachytherapy easily fits these needs. The equipment and facility requirements are minimal – shielded vaults and afterloaders are not needed, and nearly all procedures can be performed under local anesthetic and as an outpatient.”
Why Cesium-131
Initially, Dr. Randall and Dr. Feddock used Gold-198 as their preferred permanent isotope for interstitial treatments, but have now switched to Cesium-131—and for good reason. “The reason we switched to Cesium-131 around 2010 is that Gold-198 has a very high energy,” explained Dr. Randall. “It results in a relatively high amount of radiation exposure for me and the rest of my team. With Cesium-131, the energy is low and it has a short half-life so we can use it as a permanent isotope, and use it in a way that’s much safer for the treating team. Radiation exposure, except to the tumor itself, is minimal.”
“Of course, we had to be comfortable that the results would be as successful with this isotope. With the help of Isoray (a provider of Cesium-131 and other brachytherapy products) and our own physician and medical physics team, we determined how to distribute the isotope and determine the correct dosage. We no longer use any Gold-198 (Au-198) for permanent implants due to the strong results we have experienced with Cesium-131.”
Results using interstitial as part of a comprehensive treatment package, versus other stand-alone options
Both physicians agree that interstitial treatments should normally be part of a larger treatment plan, but both are also concerned about the trend to eliminate these treatments and focus solely on other methods. “With the advent of intensity- modulated radiation, more people are receiving external-beam IMRT without brachytherapy,” said Dr. Randall. “This approach has been tried to some extent with gynecologic cancers, but the data overwhelmingly shows that brachytherapy is a critical component in cervix cancer treatment if you want the best outcomes.”
The only real “replacement” for brachytherapy would be a pelvic exenteration. “While this is a competing modality from a curative point of view, it’s an operation with significant morbidity and mortality associated with it,” explained Dr. Randall. “It’s very expensive and leaves a patient without a rectum, or bladder, or both. There are not many surgeons experienced with this, and those that are do it only in very selected cases as it is such a bad operation.”
“We see also chemotherapy being used in certain cases, but this is not a curative treatment option,” he continued. “It may result in some growth restraint or shrinkage—with a lot of side effects—but it does not have the potential to cure the cancer.”
Looking ahead
While the number of brachytherapy treatments for gynecologic cancers is falling in some places to the detriment of patients, Dr. Randall also sees some positive elements to this trend, in that better screening and HPV vaccines are shrinking the number of larger cancers that require surgery and brachytherapy treatment. But he also sees a limited number of brachytherapy programs around the country where residents can develop the experience needed to offer this treatment.
Dr. Feddock reinforced the need for qualified practitioners in brachytherapy, for while the total number of cases may be dropping, the effectiveness of this treatment when administered appropriately is only getting stronger. “With the increased adoption of 3-dimensional treatment planning, we’re gaining a deeper understanding of how to more effectively plan and deliver brachytherapy treatments. We’re learning more how it’s the total volume of normal tissue irradiated that really affects toxicity and side effects. This is why interstitial implants make the most sense. Every woman facing a pelvic exenteration should at least be evaluated for interstitial re-irradiation. I feel very strongly about this.”
If you or a loved one has recently been diagnosed with prostate cancer and want to know about all of your available treatment options, including brachytherapy, please contact patienteducation@isoray.flywheelstaging.com
If you are a physician and would like to know more about Cesium’s ability to improve patient outcomes, email customerservice@isoray.flywheelstaging.com
Marcus E. Randall, MD, FACR, FASTRO
- Professor and Chair, Department of Radiation Medicine and Markey Foundation Endowed Chair in Radiation Medicine
MD, University of North Carolina at Chapel Hill, School of Medicine, Chapel Hill - Residency at University of Virginia Medical Center, Charlottesville
- Previously chaired the Radiation Oncology Committee. Current Co-chair of Uterine Corpus Committee of Legacy GOG (Now NRG Oncology)
- Certified by the American Board of Radiology
- Fellow of the American College of Radiology and American Society for Radiation Oncology
- Past Editor of the world’s leading multi-disciplinary textbook for gynecologic cancers, Principles and Practice of Gynecologic Oncology
Jonathan M. Feddock, MD
- Associate Professor of Radiation Medicine, UK Healthcare
- MD, University of Kentucky College of Medicine, Lexington
- Residency at University of Kentucky, Lexington
- Member of the Radiation Oncology Committee of the legacy Gynecologic Oncology Group, (Now NRG Oncology)
- Chair of the Markey Cancer Center Research Audit Committee
- Member of the Data Safety and Monitoring Committee.
- Certified by the American Board of Radiology in Radiation Oncology
- Research interests include developing novel treatments for breast and gynecologic cancers, the development of Cesium-131 interstitial implants and education on offering this treatment, narcotic/opiate abuse and dependency among cancer patients, and minimizing long-term toxicity from therapy in pediatric patients
UK Healthcare
- UK HealthCare comprises the hospitals and clinics of the University of Kentucky
- UHC Rising Star Award in 2013 and a national leader in patient safety in 2015
- From 2004-2015, hospital discharges increased 88 percent, while the complexity of the cases treated moved the organization from the 25th percentile of academic medical centers to the 75th.
