Prostate Brachytherapy: The Last (and Next) 25 Years

Prostate Brachytherapy: The Last (and Next) 25 Years

First I think to predict the future, that was the hardest part, where we are going in 25 years. I know where we’ve been because I was there for most of it, so I’m going to talk a little bit from a business and an economic standpoint basically because of where I think things are going to go from a payor perspective.

I was fortunate enough to get to know Willet Whitmore, whom you’ve all spoken so highly of. He represented the early generation of open implants and then obviously Ragda and the Seattle group came along with the transperineal. This is when I was a resident. An actual implant with a Mick Applicator. I’m honored to give this talk in front of Nelson and Michael, very accomplished brachytherapists. Some of you may remember doing this. It was a bloody mess.

Then the transperineal technology came along and it was open to much criticism. Typically these are the seeds. A lot of work has been done over the years comparing iodine to cesium to palladium. Basically, the results are all very similar so we’re just going to keep evolving.

One of the things we learned early on in the early 90s was toxicity. This is an implant that was far too heavy, where all the seeds were loaded equally across the prostate. These patients had awful complications to the urethra and the rectum. We learned to get over that, much of the work done by John Blasko, Nelson Stone, Michael Zelefsky, and a lot of the pioneers sequentially working through toxicity. John did a lot.

We worked through the problem of seed migration in the late 90s where the seeds would get to the lung. We actually had one in a coronary. How that happened was through a patent ductus. Then obviously industry helped us out by linking seeds together. Again, I’m just working through the evolution of brachytherapy to try to prepare you for where I think we’re going to go.

We abandoned fluoroscopy, which was commonly used in almost all implants. I think it’s pretty much been abandoned in our practice almost 10 years. Why? Because of biaxial and sagittal imaging and a biplanar probe. When we first started, we only had one plane to work in. That was the X and Y coordinates. We now have sagittal. Not only can we protect the rectum, we can see where the needles are, where the seeds are. These have been big advances, again, to minimize toxicity.
John Blasko was very instrumental, among many others. A better understanding of how the implants could maintain control of tumor and yet not increase complications to the urethra and the rectum. The one great thing about brachytherapy is it is a technology that’s immune to prostate motion. That’s always been in our advantage.

PSA kinetics has been widely study. I know Neil’s written a bunch on it on PSA bounce. Early on in the late 90s people were critical of brachytherapy saying if the guy had low risk disease, his PSA was 6. Now a year and a half later it’s up to 10. I think we’re still working through the pathophysiology of PSA bounce, but it’s real and it doesn’t alarm people that are experienced with the disease.

This is what I’m most excited about. Probably around circa 2005 we tried to get away from this one size fits all. We evolved. We started talking about a spectrum of disease in the implant world. Just breaking down low risk disease, high volume low risk, intermediate low volume, high-risk low volume, where they fit on the spectrum. We started paying more attention. I think Larry pointed out very nicely about patient toxicity and really looking at all of these things on the patient side of things and then matching them.

American Brachytherapy Society came out and established guidelines to try to help people in their practice and show them what they felt was appropriate based on the literature. This kind of summarizes it. Just working through. It really comes down to these significant cancers Michael pointed out about dose escalation trials in the external beam world, but in our world it’s dose, dose, dose.

This is some data that we just are working on now. We presented at looking at combined modality for T3 lesions, 7-year follow up. There’s no question with these bulky tumors trimodality therapy is better than any monotherapy. This is new data. There’s quite a bit of this emerging in the literature and you’re going to see it.

Quality of life has become a big issue in I guess all our practices. We’re all striving if you’re going to treat somebody to maintain quality of life.

Now we get into the business side of things. Looking at this, this is the government. This is what the government’s looking at and this is what the government’s probably going to do. I would not be surprised that we’re going to have bundled care. For the diagnosis of prostate cancer you’re going to be given a value amount, whether it’s 10,000. It’s going to be the same thing that happened with anti-androgens, LHRH agonists with Lupron and all that. They call it the LCA, least costly alternative. That’s the way the politicians talk.

In Chicago, our numbers since 2007 have declined dramatically. I work at a big center where everybody comes to do their cases. In 2014 this year we’re down to about half of what we were, more than half. The reason for it is that we have four big urology groups. I’m not making an editorial on it in Chicago, but the have their own radiation machines. They no longer do implants.

Brachytherapy I think is hurting around the country just because of the competition with IMRT. I’m concerned about the training programs, but it still is a good treatment. We also looked at patient populations, the effect the baby boomers might be having on this treatment. There were 1,500 patients treated in this era, 1,500 patients treated in the later era. Three things that came out were age, the younger patients, earlier disease, higher body mass index, and then more primary treatment with implants. Less use of hormone therapy.

This was published in 2010, kind of now looking at the costs of things and where brachy is lining up, and it does have value. This is a slide. These are called spidergrams. This is work being done by Dr. Kaplan at the Harvard Business School–he’s an economics professor–Steven Frank, and me. This is the MD Anderson data comparing proton, IMRT, and brachytherapy in each axis. They’re very difficult to read, but one would be cost, urinary symptoms, GI.

The whole goal here is the farther you plot away from the central axis in each ordinate means the greater value. The more area that’s covered, here’s proton with cost. Proton’s very costly, so it doesn’t score well in the cost ordinate. The whole goal here is this and that is why we think brachy’s going to have a high value in the end.

Innovation. We’ve got to just touch on this. Dominant index lesion. We’re able to do more sophisticated implants based on actually what Neil showed you with mapping biopsies. We do all this in Chicago. I’m impressed to see Neil’s new software. The bottom line is we’re able to do a better implant, avoid more toxicity. That’s our style, but I like Neil’s style where one needle gets the whole length of the gland.

Focal therapy. I’m a believer that that is going to have a place in the future.

Where are we going? This is the question Alan asked. I think we have to look at what the business world is doing. It’s smart technology. It’s not unheard of. This was in the Wall Street Journal just 10 days ago. Smartphones. What do I mean by that? There’s all of this microfluid that’s being done with nanoparticles so it’s not unusual that your phone could pick up your GPS, your genomic prostate score. It’s crazy. You’re just identifying a bad gene. This stuff is going to happen.

Future innovations. Nanobots, telurdides treatment, unique illness. I mean all these talks are talking about this, but it’s going to be that synthesis of all this data to make sense on your Smartphone. It wouldn’t be uncommon for a patient to say, “I’ve got prostate cancer; what do I do,” and the Smartphone dictates your future.

I really believe we’re going to be into this microfluid technology and I believe brachytherapy’s going to be the delivery system. I really believe the future, when I think back to 1990. I mean what more? These guys would be just amazed today at the things that we’re doing from a genetics standpoint.

Davis BJ, Horwitz EM, Lee WR et al. American Brachytherapy Society consensus guidelines for transrectal ultrasound-guided permanent prostatebrachytherapy. Brachytherapy. 2012 Jan-Feb;11(1):6-19.
http://www.ncbi.nlm.nih.gov/pubmed/22265434

Moradi M, Salcudean SE, Chang SD, et al. Multiparametric MRI maps for detection and grading of dominant prostate tumors. J Magn Reson Imaging. 2012 Jun;35(6):1403-13.
http://www.ncbi.nlm.nih.gov/pubmed/22267089