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Home » EU Health, Health, Prostate Cancer

Improve access to brachytherapy for all patients across Europe

Submitted by on 14 Jul 2017 – 09:35

Despite brachytherapy being highly effective among prostate cancer patients, availability of facilities differs across Europe and several countries are still under-equipped. Dr Bradley Pieters, Head – Brachytherapy Department, University of Amsterdam, calls for a uniform spread of brachytherapy facilities among all European countries and reiterates the need for raising awareness about its applications in treating prostate cancer

Prostate cancer is by now the most common cancer among males in Europe. For localised low-risk prostate cancer, an active surveillance policy can be followed. However, patients at aggressive stages of the disease are commonly treated by surgery or radiation therapy. When radiation treatment is considered, several options are available including brachytherapy, intensity modulated radiotherapy (IMRT), and proton therapy. Based on the stage of the disease, radiation therapy may be combined with hormonal therapy.

Choice of treatment should be according to patient preference and based on expected outcome, considering both cancer control and side effects. However, the choice of therapy for individual patients, particularly the choice for brachytherapy, can be influenced by the availability of resources.

Brachytherapy

The techniques of brachytherapy can be divided in permanent and temporary implants. For permanent implants a low-dose rate (LDR) isotope (iodine-125) is used. The sources are placed directly in the prostate gland using needles passed through the skin of the perineum under anesthetic guided by ultrasound. This treatment can be delivered as a daytime admission or at most one-night hospital admittance. Because of the low source activity used, the sources remain for a lifetime in the human body and decay over several months to negligible radiation activity.

Temporary implants are performed by placing needle or catheters in the prostate using the same ultrasound guided technique. In this case a high-dose rate (HDR) source (iridium-192) is used that is passed through the needles or catheters by a brachytherapy afterloader. This is a machine that enables safe application of high dose rate radiation using remotely controlled transmission and withdrawal of the source along guide tubes into the patient. For HDR brachytherapy, several radiation exposures (fractions) may be necessary; although there are several promising studies showing that a single dose will result in a satisfactory outcome.

Advantages

The major advantage of brachytherapy is that the radiation dose distribution can be planned and delivered in a very conformal way, adapted to the prostate shape of the individual patient. In this way, the dose is concentrated in the prostate gland, where the tumor is, and the neighbouring organs receive only a very small dose, an important consideration in minimising side effects.

Another not unimportant aspect of brachytherapy is the cost of treatment. Brachytherapy equipment is the least expensive of all available radiation therapy equipment and because treatment is performed in one or two days the total cost of treatment is limited particularly when compared to surgery or a prolonged course of external beam radiotherapy. The cost of installation of a brachytherapy unit is in the order of €400-600K, whereas for an IMRT linear accelerator is €2-3M and a proton center €100-300M. Labour costs are another expense that determines the overall cost of treatment. When comparing a 1-2 day brachytherapy treatment to a 4-7 weeks EBRT treatment the cost differences can be by a factor 2 to 4.

As an example, published data from the United States, facing the same issues as in Europe, shows the large differences in cost of prostate cancer treatment estimated to be $2395, $5467, and $23,665 for LDR, HDR and IMRT, respectively. (1)

Efficacy

Brachytherapy has been shown to be an efficient treatment modality to treat prostate cancer. In a comprehensive literature review tumor a control probability of 82-96% at 10-12 years was found. (2) As expected by the favourable dose distribution the toxicity rates were low. (3) In the recent randomized ASCENDE-RT trial a better disease-free survival was found for patients for who brachytherapy was given compared to IMRT alone. (4)

Image showing an LDR prostate implant with sparing of the urethra (indicated by an arrow) and rectum (bottom of the picture). Circles are the positions of the radioactive sources. Coloured lines indicate the dose distribution within and around the prostate, which is outlined in red.

Threats

Despite the favourable treatment outcome with brachytherapy and the lower costs, not all patients in Europe can be offered this treatment modality because of restricted availability. About 52% of all radiotherapy departments in Europe have brachytherapy facilities. The availability of brachytherapy facilities differs among European countries.  40% of all radiotherapy departments in France, Spain, and Italy availability offer brachytherapy. Whereas 60% of radiotherapy departments in northern, eastern and southeastern European countries have such facilities. (5)

Where brachytherapy cannot be offered to patients, they will be offered surgery or radiation treatment provided by IMRT and in certain cases even by the more expensive proton therapy.

The reason why brachytherapy is not offered or not discussed with patients is often because of the restricted availability of brachytherapy and a lack of education and training in brachytherapy to develop new teams comprising brachytherapists (medical doctors), clinical physicists and radiation technologists.

Urgent measures

In order to maintain and increase the use of brachytherapy for the treatment of prostate cancer some measures need to be taken by policymakers, governments, stakeholders, national cancer societies, oncology and radiotherapy departments, and professionals in the field.

1. There is a need for the uniform spread of brachytherapy facilities among all European countries so that all potential patients can have access.

2. Education of residents and young specialists needs to be developed to include knowledge of brachytherapy and its applications in prostate cancer.

3. The option for brachytherapy needs to be discussed with every single candidate patient in order that they are able to choose among all potential treatments.

4. Expansion of brachytherapy facilities should be planned to enable access and delivery of treatment without unacceptable waiting lists developing.

5. There is a need for a more balanced look at the cost of the different treatments for prostate cancer and consideration of cost-effectiveness in comparing the available modalities.

References:

1. Shah C, Lanni TB, Jr., Ghilezan MI, Gustafson GS, Marvin KS, Ye H, et al. Brachytherapy provides comparable outcomes and improved cost-effectiveness in the treatment of low/intermediate prostate cancer. Brachytherapy. 2012;11:441-5.

2. Crook J. Long-term oncologic outcomes of radical prostatectomy compared with brachytherapy-based approaches for intermediate- and high-risk prostate cancer. Brachytherapy. 2015;14:142-7.

3. Budaus L, Bolla M, Bossi A, Cozzarini C, Crook J, Widmark A, et al. Functional outcomes and complications following radiation therapy for prostate cancer: a critical analysis of the literature. Eur Urol. 2012;61:112-27.

4. Morris WJ, Spandinger I, Halperin R. Low-Dose-Rate Brachytherapy for Low- and Intermediate-Risk Prostate Cancer: A Dose-Response Analysis for 3392 Consecutive 125-Iodine Monotherapy Patients. Radiother Oncol. 2015;115:S239.

5. Rosenblatt E, Izewska J, Anacak Y, Pynda Y, Scalliet P, Boniol M, et al. Radiotherapy capacity in European countries: an analysis of the Directory of Radiotherapy Centres (DIRAC) database. The Lancet Oncology. 2013;14:e79-e86.