Prostate cancer - is anyone around to talk about brachytherapy please?

[MoonandSixpence]

DH has recently been diagnosed with prostate cancer and has to choose between surgery to remove the prostate or brachytherapy (seed implant radiotherapy). Having read all the info we've been given, he's veering towards brachytherapy but his PSA level is 11.6 which is slightly above the recommended range for this treatment.

Does anyone have any wisdom they can share about either brachytherapy or prostate removal please? The long-term success rates for both options are fairly equal, and also fairly positive, but the possible side effects for both are quite daunting.

Any advice/experience much appreciated.

Shameless bump!

Hi Moon, what is your dh's gleason score? Its that, combined with his PSA that will determine his risk group.

You can look at the outcomes for men in the different risk groups here which might help.

The side effect list is daunting, but they are well understood, and certainly in brachy (which is what I know a lot about), the specialist nurses and radiographers will make sure that he can manage them.

Hi, thanks for responding - will have a good read through that link.

His gleason score is 7 (3 plus 4, with one area reading as 4 plus 3). He's 50, no symptoms at all at the moment. His father had prostate cancer about 15 years ago, which is why DH's PSA levels have been monitored.

Looking at that link, I can't quite work out if DH is in the low-risk or intermediate risk category, but that's probably a question for his oncologist.

I think DH's main concern if he chooses brachy is what happens if the cancer has spread beyond the prostate, as further radiotherapy wouldn't then be an option. Sorry for all the questions, just trying to get my head round it all.

He's at the bottom of the intermediate risk group.

If his cancer had spread locally, then depending on where, and when it was found, then radiotherapy can sometimes be given. However brachy tends to treat further out than tissue would be removed surgically, so theres a balance there too.

Has anyone mentioned HDR brachytherapy? Some UK centres offer this as monotherapy to men with intermediate risk.

Thanks for clarifying that, CMOT. I was really hoping you'd post on here as I'd seen your name on other prostate cancer threads and you're clearly very knowledgeable :)

No one has mentioned HDR brachytherapy at this stage. We're in the south east, not sure if that makes a difference. Is it something he should be asking about?

Its worth having a look at - the monotherapy (as in the only treatment) approach is newish and not many people in the UK offer it as yet.

Thank you - will ask about it at the next appointment, but I can't see it listed in the treatments offered at the hospital so maybe it's not available here.

Is it common to have no symptoms at this stage? It's a bit worrying to think he could have gone on for months/years not knowing anything was wrong.

Yes, you don't get symptoms till the tumour gets big enough to compress the urethra - which gives the same symptoms as normal prostate enlargement with age.

Ah, that makes sense. I think the lack of symptoms is what makes it seem a bit unreal at the moment, and also makes the possible side effects from treatment (incontinence, ED etc) seem more daunting. But obviously not as daunting as not getting on with treatment as soon as possible.

What some men do is to decide on what side effect would be a deal breaker for them if all the options have pretty much equal cancer control outcomes.
So some would choose surgery if bowel issues were a total no go for them.
Others feel ED is the biggest concern, and choose a radiation treatment where any resulting ED is normally treatable with Viagra (as its blood vessel damage related, wheras surgery is nerve related) - and so on

I feel for men in this position. It is a really difficult decision to make. It is rare in medicine that you have to decide between such different treatments without the option to fall back on the other if one fails.

As CMOT said many men are guided by their fear of side effects or even gut instinct. Some can't bear the idea of brachytherapy, others just want the tumour out ASAP.

Surgeons will often promote surgery by saying that the patient can have radiotherapy afterwards if the tumour is not completely removed. Whilst this is true, having both treatments considerably increases the risk of side effects such as incontinence or erectile dysfunction. Oncologists would argue that it is surely better to have one treatment alone.

I think the most important thing to do is to ensure that he is a good candidate for whatever treatment he receives.

As for HDR brachytherapy I am not hugely up to speed with this but I do have contacts in oncology centres in the South East and so could easily find out for you.

Agreed, Twodogs - it's the fear of making the wrong choice that's the difficult part, daft as it sounds.

I think his gut feeling now is that he doesn't want to go through surgery - he's self employed and concerned about taking time off work - so it's looking like brachytherapy is the way to go. We've got a bit more research to do on HDR, but if you do have any insight that'd be wonderful.

I really appreciate you and CMOT taking the time to answer, thank you.

Hi , my dad had HDR brachytherapy back in February, This was the only treatment he could have due to him having lymphoma a few years back and doctor saying his body wouldn't be able to cope with surgery or regular radiotherapy.

They told him one in seven would have complications. He was the one in seven. He couldn't urinate properly after treatment and 5 months later still has a cathether.

His PSA has gone from 8 to 0.something, and apart from the cathether issue he is fine

Hi ibelieveinangels, so sorry to hear that your dad has had complications following his treatment - it sounds like he's had a rough few years. Hopefully the fact that his PSA reading is back to normal is some compensation.

Can I ask how old your father is, and if it's not too personal, if he was having any urinary problems prior to the HDR brachytherapy?

Can someone explain why brachytherapy means other treatment options are subsequently unavailable. Pc seems to run in our family, dbro being the latest having to make a similar decision.

Hi Liz,

It is very difficult to perform surgery to remove the prostate after either standard radiotherapy or brachytherapy, because of all the scar tissue.

Having said this, it is quite rare for the cancer to return in the prostate after either radiotherapy or brachytherapy, if the cancer returns it is usually elsewhere in the body, and the likelihood is that the cells were already there at the time of initial treatment.

You can given radiotherapy after surgery (not brachytherapy but conventional radiotherapy) and this is usually recommended if the tumour is not fully removed at the time of operation. The other situation in which this is done is if PSA starts to rise after surgery.

Thank you that is very helpful. DF had radiotherapy and uncle had surgery and radiotherapy but with dbro it is a bit more tricky as he is 20 years younger than when they were diagnosed so weighing up the potential side effects and longer term implications seems more important . His last PSA test suggested levels slightly above the threshold so he has options to have radiotherapy, brachytherapy or surgery or just wait and see.

In some cases you can have brachytherapy, especially HDR after surgery, but really all cases where a man has PSA progression after primary treatment are different. It all depends on where there is tumour, how long ago their first treatment was, whether they have other issues and so on.

Lizs, has your brother had a template biopsy or standard transrectal?

Not sure tbh , he's had more than one in last year or so.

I'm not an expert in brachy (I'm in imaging) but I work somewhere that is a leading UK centre and I know people who are experts (global in a couple of cases) so can ask them any questions that you have. However CMOTDibbler seems to be nailing all the relevant questions!

One thing that strikes me: LIZS, have your brothers had a test for the BRCA genes? For that matter, have you? If Ca prostate runs in the family, it can be a factor (just as it is in breast cancer). Young age of diagnosis is another indicator...