FROG - FLORIDA RADIATION ONCOLOGY GROUP is the premier Radiation Oncology practice in America. It has grown from a single physician over 50 years ago, to our current group of 25 board certified Radiation Oncologists practicing in clinics throughout Florida.		Prostate Cancer Treatment Options Approximately 240,000 men will be diagnosed with prostate cancer each year, making it the most common cancer in the United States. Fortunately, with improvements in early detection and recent advances in non-surgical treatment, men can be cured of this disease and still maintain an excellent quality of life. SURGERY - PROSTATECTOMY PROSTATE SEED IMPLANTS IGRT AND IMRT COMBINED TREATMENT PROTON BEAM Surgery - Prostatectomy The only other treatment besides seed implants and radiation therapy proven to cure prostate cancer is a prostatectomy. This is considered a major operation that typically takes several hours. It involves making at least a 4” incision in the lower abdomen to surgically remove the prostate gland. Hospitalization is required for a few days, and a catheter in the bladder needs to be used in all patients for a few weeks following the procedure. Robotic prostatectomy can be done at select institutions. Here, the surgeon guides robotic arms to perform the operation. Smaller incisions are used resulting in somewhat shorter recovery times. Some studies have questioned whether there is a higher risk of positive margins (leaving cancer behind) following robotic surgery. Long-term side effects are similar to open prostatectomy in most studies. Loss of urinary control (incontinence) and loss of sexual function (impotence) can occur with this procedure. The likelihood of these complications varies greatly with the skill and experience of the surgeon. A prostatectomy can only cure men when the cancer is completely removed. If surgery leaves behind even a few microscopic cancer cells, these can later grow and ultimately spread. Robotic prostatectomy can be done at select institutions. The surgeon guides robotic arms to help perform the operation. Smaller incisions are used, which may result in slightly shorter recovery times. Some studies have shown a higher risk of positive margins (leaving cancer behind) following robotic surgery requiring supplemental treatment afterwards. (JCO 2008)  A recent major study from Harvard showed that men who underwent robotic surgery actually had higher rates of incontinence (loss of urinary control) and loss of sexual function (impotence) than men treated with an open prostatectomy (JAMA 2009) (Eur Urol 2010).  The likelihood of these complications, as well as success rates, varies greatly with the skill and experience of the surgeon. Several recent studies have shown that outcomes following surgery are significantly worse if the surgeon has performed less than 250 of these procedures. (JNCI 2007) (NEJM 2002)

Prostate Seed Implants
Prostate Seed Implant (also known as Brachytherapy)

Most men are choosing a radioactive seed implant for treatment of their prostate cancer due to its superior long-term results and lack of long-term side effects. Recently published studies have shown that with 15 years of follow-up, a seed implant is a very effective treatment for prostate cancer. If found early, more than nine out of ten men will be cured of their cancer after seed implants.

Prostate seed implantation is based upon the use of tiny radioactive seeds, each smaller than a grain of rice. The seeds are made of titanium and contain a small amount of palladium or iodine. After placement, the seeds emit an intense amount of radiation to the cancer in the prostate, and only minimal radiation outside the prostate to other areas, such as the bladder and rectum. The seeds give off radiation for a few months and then are permanently inactive. Because cancer cells are much more sensitive to radiation than normal cells, they can be selectively killed.

Prostate implantation is a simple outpatient procedure that takes less than one hour. Men typically report to the hospital in the morning, and return home a few hours later. The entire procedure is done through very thin needles while under a light general or spinal anesthetic. There is no cutting involved and no stitches are required. With an ultrasound in the rectum, a live picture of the prostate is obtained. The Urologist then precisely places the needles in the prostate, through the perineum (the area of skin between the scrotum and rectum). The Radiation Oncologist then inserts the seeds through the needles. Once the procedure is completed and the anesthesia has worn off, you can go home. Most men do not complain of any pain and most do not need a catheter after the procedure. Unlike surgery, the risk of incontinence is less than 1%. Most men return to their normal activities that next morning, and can return to work, playing golf, etc.

For more information about the seed implant procedure, please click here

IGRT and IMRT

Patients with more aggressive or advanced stages of cancer have a higher than ideal risk of cancer outside the prostate. This is an area beyond the surgeon’s reach. External radiation delivered from a high-energy X-ray machine called a linear accelerator can help treat just outside the prostate, where the prostate cancer cells may reside. Using the latest computer technology, the prostate can be precisely targeted within the body, and radiation can be safely delivered.

Image Guided Radiation Therapy (IGRT) takes IMRT one step further. To accomplish this, we use various technologies such as BAT ® ultrasound imaging, Acculoc ® tracking of implanted fiducials, or Cone-beam ® CT scans before each daily treatment, to acquire an image of the prostate and surrounding anatomy. The goal is to detect any slight change in position of the prostate gland that may result from movement or variations in filling of the bladder or rectum. Using this information, the computer adjusts the radiation beam accordingly in order to precisely target the treatment to your prostate’s position that day. It is the latest and most advanced system for the delivery of radiation, allowing much greater precision than proton therapy. This allows us to further maximize the radiation does to the prostate and minimize the dose to the surrounding normal organs.

 

Prior to beginning this treatment, our patients undergo a CT scan of the pelvis in the Radiation Oncology department. This scan is used to create a customized plan, tailored to fit each patient’s anatomy precisely. The IGRT is typically given for only a few minutes a day, five days a week. When combined with a seed implant, this part of the treatment is approximately five weeks long. If given alone, without a seed implant, the treatment is typically for eight weeks.

Radiation treatment is completely painless and non-invasive. During treatment, the most commonly reported side effects are slight fatigue and having to go to the bathroom more frequently. You will NOT develop any nausea, abdominal pain, hair loss, or skin burning. You will NOT lose your ability to control your bowels or bladder. You will be able to continue working full-time and should enjoy all of your regular activities.

Case for Combined Treatment

For treatment to be effective in patients who have more aggressive or advanced stages of prostate cancer, it must be directed at both the prostate and the surrounding areas where cancer cells may have spread. To accomplish this, a prostate seed implant is typically combined with a few weeks of external radiation and/or a temporary hormone blocking medicine to actually give cure rates similar to those seen in patients seen with early stages of cancer.

The seed implant delivers a high dose of radiation to the prostate, where most or all of the cancer cells reside. It gives minimal radiation to the surrounding areas. The hormone therapy and IGRT (external radiation) not only treat the cancer in the prostate, they also attack cancer cells that may have spread outside the prostate.

IGRT (or intensity modulated radiation therapy) delivered from a high-energy linear accelerator can help treat just outside the prostate, where the prostate cancer cells may reside. IGRT is the latest and most advanced system for the delivery of external radiation. This technique allows for maximum radiation to be delivered to the prostate and the surrounding areas at risk for harboring cancer cells, while minimizing radiation to the normal areas, such as the bladder and rectum. When combined with a seed implant, this part of the treatment is typically a few minutes a day, five days a week, for five weeks.

The radiation treatment is completely painless and non-invasive. During treatment, the most commonly reported side effects are slight fatigue and having to go to the bathroom more frequently. You should NOT develop any nausea, abdominal pain or loss of hair on your head. You will NOT lose your ability to control your bowels or bladder. You will be able to continue working full-time and should enjoy all of your regular activities.

Hormone blocking therapy

Prostate cancer typically feeds on testosterone, the male hormone. A combination of a shot (Lupron or Zoladex) that you receive every few months from your Urologist, and pills (Flutamide or Casodex) that you take daily can temporarily block all of the testosterone in your body. By cutting off the “food supply” to the cancer, several helpful things happen:

• After a few months, your prostate will shrink 30-40% in size. In men with large prostate glands, it becomes easier to distribute the seeds for the implant and fewer seeds are required. An added bonus is that you will probably notice that it is easier to urinate because your prostate is smaller.
  
• Some cancer cells outside the prostate may actually die, or “starve to death.”
  
• The remaining cancer cells can be made more sensitive or vulnerable to the upcoming radiation and thus more likely to be killed.

While hormone-blocking treatment alone will not permanently rid the body of the cancer, it has been shown to improve cure rates with radiation in men with more advanced stage cancer. It also has the ability to make the seed implant procedure possible in men with very large prostates that would have otherwise been technically too difficult to implant. When administered, men typically take the hormone blocking treatment for two to three months before beginning radiation, and continue the treatment until after the seed implant. Common side effects from the hormone blockers include temporary hot flashes, fatigue, and loss of libido.

Proton Beam Cancer Treatment

Proton beam radiation is an older technology that has actually been in use since the 1950s. Rather than treating cancer with photons, as occurs with IGRT, men are simply treated with a different type of radioactive particle, called protons. Because it is new to north Florida, some men have been interested in comparing proton beam to newer and more precise forms of treatment, such as prostate Seed Implants and IGRT.

The safety and effectiveness of seed implants and IGRT has been thoroughly studied in hundreds of scientific papers, with superb long-term 15 year outcomes. In contrast, after 50 years of proton use, there is still remarkably very little published data on its cure rates and complications. There are no studies reporting outcomes beyond 5 years after treatment with proton beam. There are no studies showing long-term potency and incontinence rates. This data is critical for men with a long life expectancy. A review of every published study on proton beam radiation shows that patients suffer 20-40% higher cancer recurrence rates, are more likely to develop long term complications, and are at a greater risk of developing new cancers than those treated with seed implants. In addition, proton beam therapy is very time consuming (9 weeks of daily treatment are required), costly (more than $100,000), and not covered by many insurance plans.

For these reasons, most major cancer centers throughout the world have decided not to pursue the less effective proton beam technology and instead have focused their attentions on more innovative and successful seed implant and IGRT programs for the optimal treatment of prostate cancer.

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