With over 6000 prostate cancer brachytherapy procedures to date and thousands of IMRT patients, Dr. John Sylvester is a leading authority on research to combat this deadly disease. He recently shared his thoughts on the most effective treatment combinations, and recommendations to patients on how to ensure they are receiving the highest-quality treatment.

Dr. John Sylvester

Citing a study he worked on in 2009, Dr. Sylvester believes that a radioactive seed treatment known as Brachytherapy, combined with external beam radiation treatment, had the highest success rate in intermediate risk patients compared to all other treatments, and that this success rate is significantly higher than surgery, external beam radiation, or proton beam radiation alone.

Brachytherapy is a treatment where tiny radioactive seeds are implanted into the prostate to perform a much more targeted form of treatment and limit radiation exposure to areas outside of the cancer. Dr. Sylvester broke down how well this technique performs in combination with other treatments, as opposed to utilizing surgery or external beam radiation alone.

“Surgery doesn’t work very well in unfavorable intermediate and high risk disease,” explained Dr. Sylvester. “The reoccurrence rates are too high as surgery cannot adequately treat disease that is microscopically outside the prostate. External beam radiation (IMRT or Proton beam) by itself is frequently just not potent enough to destroy all of the cancer inside the prostate. That’s why, in our clinic, the vast majority of patients with intermediate and high-risk prostate cancer receive a combination of external beam radiation (for the disease outside the prostate) and brachytherapy (for the disease inside).”

Dr. Sylvester also cites a phase III randomized study that was presented this year at the major cancer meetings (ASTRO, ABS, and GU ACSO). The results of this study showed that radioactive seed implant Brachytherapy combined with external beam radiation treatment and hormone therapy was dramatically better at eradicating prostate cancer than high dose modern external beam radiation and hormone therapy minus Brachytherapy. Nine years after treatment, the relapse free survival rate was 47.8% higher in the patients receiving seed implant brachytherapy.

Brachytherapy works, so why isn’t this highly effective treatment more common?

Dr. Sylvester estimates that about half of prostate cancer patients that opt to treat their disease receive surgery as the treatment, the other half receive radiation treatment of some form. The reality is that most academic centers offer very few Brachytherapy treatments, or none at all.

“Unfortunately, Brachytherapy is not the most popular treatment,” lamented Dr. Sylvester. “Surgeons are comfortable with surgery, as that is the treatment they are familiar with. A majority of patients are told the prostate must be removed to cure the cancer, which is just not true. Most academic radiation therapy centers do not train their residents how to do prostate brachytherapy because the professors are not very experienced at it. They are more comfortable with IMRT even though comparative effectiveness studies and the only randomized trial all show brachytherapy has dramatically higher success rates especially in the higher risk patients. In the private practice setting brachytherapy is not attractive as the reimbursement rate for doing the procedure is dramatically lower than IMRT or Proton therapy.

Dr. Sylvester believes that part of the problem in building awareness on the effectiveness of Brachytherapy as a prostate cancer treatment lies in education. He is hopeful that another upcoming study that is due to be published in a major medical journal in the coming year will help to raise the visibility of Brachytherapy with primary care physicians.

The ASCENDE-RT trial demonstrated a strong statistical improvement in outcomes for intermediate and high-risk prostate cancer patients when brachytherapy is combined with external beam radiation (EBRT) and hormone therapy (ADT) versus EBRT and hormone treatment alone. 

He feels that upcoming resident physicians also need to be trained on the treatment as the current experts in this field are aging. To address this shortcoming, the American Brachytherapy Society is offering training programs on this treatment for physicians.

Where can patients find Brachytherapy?

Brachytherapy currently is practiced in major metropolitan areas, such as Boston, New York City, Chicago, Seattle and San Francisco. That list has grown to include Charleston, SC, Green Bay, WI, Dubuque, IA, Longview, TX, Norfolk, VA and others. Dr. Sylvester suggests that patients living in an area that does not have an effective center for treatment receive external beam radiation locally, then travel to an area offering Brachytherapy to boost the effectiveness of the overall treatment plan. He recommends checking with the companies that produce radioactive seeds, such as Isoray, to find a quality Brachytherapy treatment location.

Dr. Sylvester strongly recommends seeking treatment from a physician that performs the procedure often. “With almost any major medical intervention, the higher the volume, the better you are at the procedure,” he explained. “If the provider is doing less than 20 cases a year, you should probably avoid it. In my case, I am performing 15-20 cases per month on average.”

“A CT scan should also be used to adjust the placement of the implant,” he continued. “This enables placement to be corrected in the operating room. When Brachytherapy is done correctly, you get hard data on the quality of the procedure.”

Who is a candidate for Brachytherapy?

Despite all of the advantages, not everyone will be a good candidate for Brachytherapy or external beam radiation treatment. “A patient with a large prostate and extensive urinary symptoms will not be an ideal candidate,” shared Dr. Sylvester. “Age is also a factor, as older patients tend to have a larger prostate.”

He pointed to the upcoming study that shows an 8% risk of urethral strictures and other urinary side effects with Brachytherapy treatment, compared to a 2.5% risk with external beam radiation alone. But the physician added a strong caveat to this stating: “You have to consider the 48% chance of a reoccurrence with external beam radiation. If that happens, a patient might have to go on hormones for the rest of their lives. This means the potential for much greater side effects, including impotency, hot flashes, metabolic syndrome, effects to blood sugar, increased risk of Alzheimer’s, weight gain, risk of osteoporosis, and cardiac issues. When considering long-term health, keep in mind that all of the data shows Brachytherapy has the best cure rates for intermediate and high-risk prostate cancer.”

Dr. John Sylvester

• Performed over 5,500 prostate brachytherapy procedures
• Developed multiple technical improvements in the brachytherapy procedure
• Co-authored and edited The Prostate Cancer Treatment Book.
• Published numerous articles and medical textbook chapters on prostate brachytherapy
• Lead investigator in a multi-institutional protocol evaluating the quality of life outcomes of patients treated with EBRT plus a Cesium-131 seed implant boost
• Lead Seattle investigator in a Palladium-103 dose de-escalation protocol for men with low risk prostate cancer
• Lead Seattle investigator in a gene therapy protocol for salvage of external beam radiation therapy failures
• Lead investigator in a randomized trial evaluating the new Thin Strand™ versus standard size seeds
• American Cancer Society Fellowship during his year as Chief Resident at UCLA
• 2016 – Top Doctors Radiation Oncology, Sarasota Magazine
• 2015 – Top Doctors Radiation Oncology, Sarasota Magazine
• 2014 – Innovation/Research Award, Manatee County
• 2014 – Top Doctors Radiation Oncology, Sarasota Magazine
• 2013 – Top Doctors Radiation Oncology, Sarasota Magazine
• 2012 – Top Doctors Radiation Oncology, Sarasota Magazine
• 1988 – American Cancer Society Fellowship

ADV-125 R0