Impotence, incontinence, rectal
bleeding and penile shrinkage � these are just a few of
the side effects of the treatment options available to
64-year-old Ibrahim Khan. These are the reasons why the
minimum of treatment is often the best approach for prostate
cancer patients who may end up dying of something else
long before the tumour becomes life threatening. Unfortunately,
Mr Khan is part of a subset of patients whose tumours
are aggressive or already spreading. For these men, watching
and waiting is not an option, yet doctors treating them
have to make tough choices. The August issue of the International
Journal of Radiation Oncology, Biology, Physics simplifies
the choices by detailing a novel and apparently successful
three-pronged approach that combines permanent radioactive
seed brachytherapy with hormonal and external beam radiation
therapies � treatments frequently used on their own.
The full
course of treatment was tried on 132 high-risk patients,
who took nine months of hormonal therapy. In the third
month, the brachytherapy implants were inserted, and
in the fifth month, external beam treatment began. There
was some variation in both the internal and external
radiation doses but this had no statistically significant
impact on outcomes.
Patients were followed at six-month
intervals with prostate specific antigen (PSA) monitoring
and, in 63 cases, with testosterone measurements. Two
years after treatment, 47 patients underwent transrectal
biopsy. Overall, the PSA failure rate, as defined by
the American Society for Therapeutic Radiology and Oncology
criteria, was 14% over five years, a remarkable achievement
in this group.
Among patients measured for testosterone
one year after hormone treatment completion, 82% had
normal levels. An impressive 100% of the 47 patients
biopsied two years after treatment completion tested
negative, even though half of those who had suffered
PSA failure were included in this group.
These results compare favourably
to a study of radical prostatectomy in similar high-risk
patients published last year in the Journal of Urology,
which saw a five-year PSA failure rate of 32%. Another
large trial, published last year in the Journal of
Radiation Oncology, tried various combinations of
hormonal treatments with external beam radiation and
achieved a PSA failure rate of 36% in the best-treatment
arm. With fewer than half as many patients experiencing
PSA failure in this trial, the addition of brachytherapy
to the treatment regimen seems very worthwhile.
Lead author Dr Richard Stock, Chairman
of the Department of Radiation Oncology at New York's
Mount Sinai School of Medicine, certainly thinks so:
"This is a very exciting study because it shows that
this new approach of combining brachytherapy, external
beam irradiation and hormonal therapy to cure prostate
cancer can be very effective for men with aggressive
forms of the disease."
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