I don’t think I have previously covered this, but an article in the Journal of Urology is a good reminder of another modality that is not often discussed with patients. High Dose Rate brachytherapy is a method of treating cancer by inserting a highly radioactive seeds into the prostate via catheters and leaving them for a brief time to radiate the tumor. It is different from LDR brachytherapy or “seeds”, which you can read about here. In the LDR procedure, the seeds remain in the body for the rest of your life, while in the HDR methodology, they are inserted, and then removed several times, depending on the way the radiation oncologist wishes to plan the delivery of the radiation dose. As with LDR, HDR can be combined with external beam treatment and/or androgen deprivation. There are several centers with expertise in this technique, including our own, headed up by Dr. David Raben. Whether this is the “best” treatment for any individual, unfortunately, can’t be answered because of the lack of randomized studies. As I have said before,
“there must be 18 ways to destroy your prostate”, and each of them has advantages and disadvantages.
I ran across an article I had archived that may be of interest to some patients contemplating surgery. The USC group, where Dr. Skinner has been a pioneer in working on the proper methodologies for lymph node dissection at the time of radical bladder surgery for cancer, reported excellent outcomes in men whose positive lymph nodes were removed at the time of surgery. To put this in context, in the 1990’s our urology group was holding sessions to teach laproscopic node sampling. The idea was that if you found positive lymph nodes, a patient can’t be cured, so there is no reason to do a prostatectomy with the risks for incontinence, impotence, etc. However, even back in the 1980’s, the Mayo Clinic had reported excellent results for men with positive lymph nodes and diploid cancers who were treated with castration, suggesting that nodal metastases aren’t always fatal.
Another perspective on this comes from testis cancer, where retroperitoneal lymph node dissection reduces the relapse rate by about half after orchiectomy. Or, we can consider the issue that even though finding lymph node involvement in breast cancer is a negative prognostic finding, some patients are cured. In the Southwest Oncology Group, we reported preliminary results on patients with high risk factors like positive nodes who received two years of adjuvant androgen deprivation therapy.
My conclusion from all of this is that if I were to choose surgery to treat my newly diagnosed prostate cancer, I would want ample node sampling, completion of the prostatectomy regardless of whether there is nodal involvement, and would take adjuvant hormonal therapy (probably 2 years minimum, depending on how bad the side effects were in my case) and hope that I was cured. In thinking about this, one wonders about how many patients who have already received surgery, salvage radiation, but have persistence of a rising PSA, might still be curable with drastic surgery to remove all the pelvic contents (pelvic exenteration). This procedure has been done for some gyn cancers, sarcomas and the like but is seldom used in prostate cancer. It is obviously difficult to recommend such a procedure without some confidence that cure is possible. A brief review of the topic is here. The challenge is made more difficult by the fact that the majority of men would have much better quality of life by opting for hormonal therapy, even if it isn’t curative.