Young Age Not a Deterrent for Prostate Brachytherapy, Study Shows

November 2, 2007 (Los Angeles) — Generally reserved for older patients, researchers are now suggesting that prostate brachytherapy can be a valuable alternative to surgery for younger men as well. Presenting here at the American Society for Therapeutic Radiology and Oncology (ASTRO) 49th Annual Meeting, investigators showed excellent 5-year biochemical control in young men who had radiation seed implants.
"The more aggressive approach is surgery," Anthony Zietman, MD, from Harvard Medical School, in Boston, Massachusetts, and the education council chair for ASTRO, told reporters attending a news conference. "But patients like to have a choice and their options have often been artificially narrowed because seed implants have not always been offered to younger patients. Men are about 30 years behind women, who have been offered more options when it comes to breast cancer therapy," he said.
"This is a very good study coming out of the Mount Sinai Medical Center," Phillip Devlin, MD, from the Brigham and Women's Hospital, in Boston, and the editor of ASTRO News, said during an interview. On board for the study are Drs. Richard Stock and Nelson Stone, whom Dr. Devlin called "pioneers and intellectual power houses."
The debate over prostatectomy vs brachytherapy has been a long and often passionate deliberation, with clinicians generally divided by specialty and sometimes professional bias.
Just last month, Swiss researchers from the Geneva Cancer Registry published a study in the Archives of Internal Medicine promoting the benefits of surgery (2007;167:1944-1950). The group criticized the lack of conclusive evidence in the field and concluded that "surgery offers the best chance of long-term prostate-cancer-specific survival, in particular for younger patients and patients with poorly differentiated tumors."
Avoiding Surgery Affords Benefits and Risks
Dr. Devlin agreed there has been a lack of data in this area. But despite the absence of evidence, he was among the first, 20 years ago, to offer patients — including younger men — the option of radiation seed implants. "There was a number of us pursuing this and we were widely seen as reckless," Dr. Devlin said. But the surgical recovery time for patients undergoing prostatectomy is weeks and can result in a number of negative effects.
"To be blunt," Dr. Devlin said, "I had patients who wanted to be able to play golf after treatment and they wanted to be able to have sex after that. It wasn't going to happen with surgery."
Dr. Devlin says he is reassured by this latest study presented at the meeting. "This shows it was okay for us to have done what we did."
But what about the potential increased risk for secondary cancers? During the question period after the presentation of the study, Anthony D'Amico, MD, PhD, from Brigham and Women's Hospital, said that 1 of the reasons urologists in particular tend to err on the side of surgery is because many are concerned about this risk.
He cited a poster from the meeting that looked at the risk for secondary cancers after radiation alone and after brachytherapy (with no surgery). He said the risk for secondary cancers in these patients was just 1 in 300. He asked lead author and presenter Alice Ho, MD, from Mount Sinai in New York, to comment on this risk.
Dr. Ho responded that diligent follow-up of these patients is key and that, when assessing risk, determining whether it will be possible to closely observe a patient should be taken into account.
The investigators looked at more than 1700 patients treated with prostate brachytherapy and hormone therapy. Patients had clinically localized prostate cancer T1 or T2. The end point for the trial was biochemical freedom from failure, and follow-up ranged from 2 to 16 years (median, 5 years).
The researchers found that young men had biochemical outcomes equivalent to older men after radiation seed implants.
On univariate analysis, the researchers found that the young men had better 5-year biochemical freedom from failure than older men, but they caution that this might be due to the greater percentage of young men who presented with low-risk disease and who were treated more recently with higher doses of radiation.
Despite these potential limitations, Dr. Ho pointed out that this study questions the traditional view that age is a negative prognostic factor in prostate cancer. "A greater percentage of younger men in our study presented with low-risk disease," she told reporters attending a news conference. "And we saw no difference in prostate-specific antigen control rates [between] younger men [and] older men treated with seed implant."
The investigators concluded that younger men diagnosed with localized prostate cancer should be presented with all treatment options, including brachytherapy.
The researchers have disclosed no relevant financial relationships.
American Society for Therapeutic Radiology and Oncology (ASTRO) 49th Annual Meeting: Abstract 160. Presented October 31, 2007.