Low dose-rate prostate brachytherapy

1. Low dose-rate prostate brachytherapy Self-learning tutorial

2. What is it? • A self-learning slide tutorial, including detailed slide notes, to work through at your own pace • Part of the Prostate Brachytherapy Advisory Group (PBAG) online nurse education programme Why is it being provided? • To help you understand more about prostate brachytherapy, an increasingly popular alternative to prostatectomy and external beam radiotherapy (EBRT), for patients with localised prostate cancer About this slide tutorial

3. To view the detailed notes, select either ‘View Normal’ or ‘View Notes Pages’ • To view slides on full screen (no notes visible) select ‘View Slide Show’ • To print the notes and the slides, select ‘Print notes pages’ About this slide tutorial

4. 2008 NICE guideline on prostate cancer identified prostate brachytherapy, along with prostatectomy and EBRT, as one of the three proven radical treatment options for men with low- or intermediate-risk localised prostate cancer NICE prostate cancer guideline 2008 NICE guideline on the diagnosis and treatment of prostate cancer

5. Prostate brachytherapy involves the transperineal placement of radioactive seeds directly into the prostate • This treatment delivers a high dose of radiation directly into the prostate • During the procedure, rectal ultrasound is used to assess the size and shape of the prostate What is prostate brachytherapy? (1)

6. The seeds are placed into the prostate through fine hollow needles inserted into the perineum • A grid-like device is used to guide the needles into the correct position • A computer program ensures that the right dose of radiation is delivered to the prostate and that other organs are unaffected • The seeds stay in the prostate permanently and remain radioactive for 3-9 months What is prostate brachytherapy? (2)

7. Treatment selector chart from the Prostate Cancer Centre, Guildford • Many patients with localised prostate cancer are potential candidates for prostate brachytherapy • Patient characteristics including cancer risk, age and prostate size, help to determine which treatment is most appropriate Which patients are candidatesfor brachytherapy?

8. Prostate brachytherapy is associated with fewer complications and side-effects than other radical treatments Treatment selector chart from the Prostate Cancer Centre, Guildford What are the side-effects?

9. Numerous clinical studies have shown that prostate brachytherapy is highly effective at curing cancer and prolonging survival in patients with localised prostate cancer Clinical efficacy of prostate brachytherapy (1)

10. Prostate brachytherapy, prostatectomy and EBRT are equally effective at curing cancer and prolonging survival in patients with localised prostate cancer Clinical efficacy of prostate brachytherapy (2) 1 0.8 EB≥72Gy COMB PI 0.6 bRFS RP 0.4 RP = radical prostatectomyEBRT = external beam radiotherapyPI = permanent seed implantation(LDR brachytherapy)COMB = combined seeds and EBRT 0.2 p=0.18 0 36 84 0 12 24 48 60 72 Months Kupelian et al. Int J Radiat Oncol Biol Phys 2004

11. Prostate brachytherapy, prostatectomy and EBRT have different effects on patients’ quality of life • Treatment decisions should take into account the effects of treatment on quality of life, as well as survival EPIC: Urinary Function EPIC: Urinary Bother Quality of life following prostate brachytherapy 100 100 90 90 80 80 70 70 60 60 50 50 40 40 30 30 20 20 10 10 0 0 Pre-treatment Month 1*† Month 3*† Month 6*†‡ Month 12*† Month 24*† Pre-treatment Month 1* Month 3*‡ Month 6*‡ Month 12 Month 24 EPIC: Sexual Bother EPIC: Sexual Function 100 100 90 90 80 80 70 70 60 60 50 50 40 40 30 30 20 20 10 10 0 0 Pre-treatment*† Month 1*† Month 3*† Month 6*† Month 12†‡ Month 24†‡ Pre-treatment Month 1*† Month 3*† Month 6*† Month 12*† Month 24*† Radical prostatectomy Brachytherapy Three-dimensional (3D) external beam radiotherapy Adapted from Ferrer et al. Int J Radiat Oncol Biol Phys 2008 (Fig 4) Higher score = better function Ferrer M et al. Int J Radiat Oncol Biol Phys 2008; 72: 421–32.

12. Advantages Disadvantages Patients can experience transient urinary irritative symptoms Close contact with small children and pregnant women should be avoided in first 2 months after treatment • Avoids physical trauma of a major surgical procedure • One-off minimally invasive procedure requiring minimal hospitalilsation • Procedure causes minimal bleeding • Precise placement of the seeds offers more tailored treatment • Relatively few long-term side-effects • Quick recovery and return to normal activity • More likely to retain quality of life compared with other treatments • Maintains sexual potency in many patients • Produces good long-term clinical outcomes • Cost-effective treatment option Advantages and disadvantages of prostate brachytherapy

13. Efficacy • Equivalent efficacy to prostatectomy and EBRT • Quality of life • Quality of life is more likely to be retained than after prostatectomy or EBRT • Side effects are generally not as serious; sexual side-effects are less common than after prostatectomy • Hospital stay • Prostate brachytherapy: 1 or 2 day visits • EBRT: many day visits(5 days-a-week for 4–7 weeks) • Prostatectomy: prolonged hospital stay (up to 1 week) How does prostate brachytherapy compare with other radical treatments?

14. If I have prostate brachytherapy do I become radioactive? Is prostate brachytherapy a new procedure? Questions your patients may ask (1) What about my sex-life after prostate brachytherapy?

15. Where can I getprostate brachytherapy? How long will it take toreturn to my normaldaily activities? Questions your patients may ask (2) Will the NHS pay for my treatment?

16. An increasingly popular alternative to other recommended radical treatments for localised prostate cancer • Involves the transperineal placement of radioactive seeds directly into the prostate • As effective as other recommended radical treatments at curing cancer and prolonging patient survival • More likely to retain quality of life than other radical treatments Summary: prostate brachytherapy

17. LDR prostate brachytherapy centres in England

18. The number of NHS and private hospitals and centres in the UK currently providing LDR prostate brachytherapy are: England: 29 Scotland: 2 (Glasgow and Edinburgh) Wales: 1 (Cardiff) Ireland 2 (Dublin and Galway) For a detailed list, download the separate file entitled ‘LDR brachytherapy centres’ available from the website of the Prostate Brachytherapy Advisory Group: www.prostatebrachytherapyinfo.net (See section: Information for healthcare professionals) The website also contains additional detailed information about each centre in the section ‘UK brachytherapy centres’. UK brachytherapy centres

19. NICE • Prostate cancer: diagnosis and treatment clinical guideline CG58 • nice.org.uk/guidance/CG58 • For patients • Understanding NICE guidance • For healthcare professionals • The guideline in full • Implementation advice • Slide set Prostate brachytherapy • See the following websites for further information: • prostatebrachytherapyinfo.net • prostatebrachytherapycentre.com Further information

20. Stephen Langley (Chair) • Professor of Urology, Prostate Brachytherapy Centre, Guildford • Niki Baier • NHS Commissioning Advisor, Surrey • David Bottomley • Consultant Clinical Oncologist, St James’s Institute of Oncology, Leeds • Richard Gledhill • Prostate Cancer Charity Specialist Nurse, Queen Elizabeth Hospital, Birmingham • Philip Marazzi • General Practitioner, East Horsley, Surrey • Rick Popert • Consultant Urological Surgeon, Guy’s and St Thomas’ NHS Foundation Trust, London • Graham Robson • Patient Representative, Aberdeen The Prostate Brachytherapy Advisory Group (PBAG) Learn more about PBAG at: www.prostatebrachytherapyinfo.net Email the PBAG at: admin@prostatebrachytherapyinfo.net The activities of the PBAG are supported by an unrestricted educational grant from Oncura