Dr. Bradley Prestidge is the Medical Director of the Bon Secours Cancer Institute at DePaul Medical Center in Norfolk, Virginia. He has a deep and extensive background with brachytherapy, using the treatment to overcome prostate, breast, gynecologic and head and neck cancers. “I developed an interest in brachytherapy during my residency, so it’s a career-long interest of mine,” he explained. “I really believe in the modality of brachytherapy.”
To support this belief, the physician cited three studies that demonstrate the power of brachytherapy in treating prostate cancer. Recent data shows the effectiveness of this treatment beyond low-risk to include both intermediate- and high-risk categories of this disease. The ASCENDE-RT Trial demonstrated a strong statistical improvement in outcomes for intermediate- and high-risk patients when external beam radiation (EBRT) and hormone therapy is combined with brachytherapy versus EBRT and hormone treatment alone. This improvement is validated by a 5-yr follow-up in the study.
Dr. Prestidge reinforced these results with his own study, where he presented his initial findings to the 58th Annual Meeting the American Society for Radiation Oncology (ASTRO) in the Plenary session. This randomized trial looked at procedures performed on 600 patients across 68 cancer centers in North America, focusing on intermediate-risk patients. The goal was to assess whether adding EBRT to transperineal interstitial permanent brachytherapy conveyed an additional benefit in progression free survival (PFS), or control of the cancer growth, at five years following treatment. The original hypothesis was that the combination treatment would result in a 10% improvement in cancer control, but this turned out not to be true. The survival rates for men who received brachytherapy alone were comparable to those who underwent the more aggressive combination radiation treatment.
“These findings suggest that many men with intermediate-risk prostate cancer can be well managed with seed implant alone and do not require the addition of external beam radiation,” said Dr. Prestidge. “Contrary to expectations, the more aggressive, combined treatment did not result in superior cancer control rates at five years follow-up, indicating that men can achieve a similar survival benefit with fewer late side effects through brachytherapy alone.”
The benefits of brachytherapy are not limited to prostate cancer. When a national epidemiological study examined the national trends for cervix cancer, it was also found that the combination of brachytherapy and EBRT delivered a significant survival advantage compared to EBRT alone.
Brachytherapy and urethral re-strictures
Dr. Prestidge addressed one of the concerns raised by the ASCENDE-RT study: the possibility of urethral re-strictures occurring as a result of brachytherapy. “What the authors of the ASCENDE-RT study believe, and I agree with this conclusion, is that these complications are a factor of technique and experience of the provider. You have to be careful not to place too many seeds past of the apex of the prostate, as that is what most likely causes these strictures.”
Comparing the isotopes used in brachytherapy
Dr. Prestidge believes that the half-life of each of the different isotopes available for brachytherapy can make a real impact on toxicity for the patient. “For my patients, I use Cesium-131 instead of Iodine because most of the effective isotope life is spent in 4-5 wks, compared to the 60-day half-life of Iodine,” he said. “Iodine will still be putting out a pretty good dose of radiation 8 or 9 months later. My patients have a shorter duration of acute uropathic complaints because of that.”
“Also, while not yet firmly proven, if you look at most of the accepted radiological parameters and theories on how cancer dies from radiation exposure, a shorter half-life gives you a more effective cancer-kill,” Dr. Prestidge continued. “There’s a theoretical benefit in outcomes from a shorter half-life isotope like Cesium.”
Defining the future of brachytherapy
Dr. Prestidge highlighted the current and future challenges for brachytherapy, as he noted that utilization of the treatment has been dropping steadily. “Brachytherapy has suffered in recent years, as reimbursements are not favorable towards it compared to other modalities of treatment,” he stated. “It’s unfortunate, as the efficacy of this treatment is proven out in the literature. As data in reputable studies such as the ASCEND-RT trial get out in the general consciousness, hopefully adoption of this treatment will increase. It doesn’t make sense to use other modalities when brachytherapy is not only effective, but importantly, cost-effective.”
To further this goal, Dr. Prestidge trains other radiation oncologists on brachytherapy and also travels to other cancer centers to learn new techniques. “I consider myself both a student and a teacher of brachytherapy,” he explained. He was named only the second Thom Shanahan Brachytherapy Educator of the Year at the most recent ABS annual meeting
Dr. Prestidge works on the socio-economic committee for the American Brachytherapy Society (ABS) to help promote the specialty. He’s helped to develop educational programs, worked to establish a national protocol, and is the Director of the Annual ABS Scholarship Program. The scholarship program sends interested young physicians to centers of excellence, where 400-500 have been trained in brachytherapy over the 7-8 years the program has been operational. This program is expanding globally to promote the treatment worldwide.
“Despite the challenges, I think that brachytherapy is on the verge of great things,” declared Dr. Prestidge, “On the near horizon, there’s the very real possibility that we’re going into different payment models that I believe that will be a good thing for brachytherapy. I think the time will soon come when payers will provide a lump sum to treat certain diagnoses, but the specific treatment option will be left to the provider, facility and patient. Based on the outcomes and cost-effectiveness, I think brachytherapy will stack up quite well in those models.”
“If radiation oncologists want to treat a lot of prostate cancer in the future, they need to become proficient in brachytherapy,” he continued. “Just because physicians are not getting the training during residency does not mean it will be any less important in their career. It’s true that no one’s mind will be changed overnight, but we need to keep making the arguments for this effective treatment one hospital and cancer conference at a time.”
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
