Our next question is actually, "Today, as of 2020, should a patient consider traveling
potentially a long distance to a center of excellence for beam radiation treatment
or has radiation technology and, I guess, personnel development
of who is doing this radiation for local centers and local options, would that seem adequate?"
Yeah, my thinking is evolving on this. When IMRT first came out at the Cleveland Clinic in 2004, we
would send people back to Cleveland and it was certainly worth it. The
patients did extremely well. IMRT was a giant breakthrough back in 2004, 2005,
and then as the people in Los Angeles learned how to do it, we started referring locally. We have,
in our experience because we refer a lot of radiation therapy out of our practice every year,
have seen a difference with centers of excellence that do a lot of volume compared to some of
the private centers that are out in the small community areas, and it's just a sense that the,
you know, the chances for side effects is less if you go to a large-volume center. There's no doubt
some excellent doctors out in the community that do equally good work, it's just hard to know who
they are, and since radiation is a one-time thing and if it isn't done properly it can leave you
with life-long issues, we're still pretty picky about where we send out patients for radiation.
Yeah, I think talking about the volume in any treatment,
it's something that we are always pounding the drum about at PCRI, so that makes a lot of sense.
Our next question is in regard to
possibly radiation causing new cancers. So is it possible to know how often radiation treatment
causes new cancers and is there any particular form of radiation that is more likely to cause it?
This is one of the attractions of brachytherapy, of course, is that the radiation doesn't have to
be beamed through the body to hit the prostate, and it appears that the incidence of secondary
cancers is very tiny with brachytherapy, almost immeasurable. There is a difference with
older radiation where the beam radiation wasn't very accurate and there was a larger area around
the prostate that was exposed, and there were, over a 10-20 period after the radiation, there was
a very small incidence—well less than 1%—of people that could get secondary bladder or rectal tumors.
There's a sense that this is being further reduced now because IMRT and SBRT are becoming so precise
and there's very little overflow of radiation around the edge now,
but there is still—we monitor patients and we've had patients getting IMRT, as
I mentioned now for over 15 years. I've seen one patient who developed a secondary—appears to be
a secondary—bladder tumor. Who knows how many thousands of patients we've referred.
So, it's a very tiny risk, but we generally recommend that people get a urine analysis
once a year to look for blood and then if that is present, we order something called
a Cxbladder which looks for bladder tumors, and after 10 years or so, 5-10 years, we'll start
doing an ultrasound of the bladder wall—make sure that there's nothing suspicious there.
So, our next question is in regard to radioligand therapy. So, first of all,
before I ask the question, can you explain what Xofigo and Lutetium are?
So, these are types of radiation that are given by injection. It's like a smart bomb that circulates
through the blood stream and then radiation coalesces around the tumors in the bone or the
lymph nodes, and the Xofigo is exclusively for bones which is a derivative of radium,
and then the lutetium—which is not FDA approved yet—is a monoclonal antibody and it will clip onto
prostate cancer patient's cancers just like PSMA PET scans do. So, if they're in the lymph nodes,
bones, or other sites, it brings the radiation right to the cancer.
Well, in regard to that, so our question is, "Is radioligand therapy,
like you just mentioned (like Xofigo and lutetium), a reasonable option
for a patient who has already gotten the maximum amount of radiation that they can?
Yeah, there's people who have had radiation to their prostate or lymph nodes or even to
their bones. As long as they don't have a depleted immune system, which you measure with a CBC—look
at the white count, look at the platelet count, make sure there's no excessive anemia.
Those things are extremely rare after people have had standard radiation for prostate cancer. It
actually doesn't occur at all. But sometimes men with very advanced cancers where their
bone marrow has been weakened or they've had a lot of previous chemotherapy, they may not
be able to get Xofigo or lutetium-177, but for most people, it's not an issue at all.
My next question kind of goes into the cost. I know we've talked about, you know, the different
types of side effects of radiation and all. So, you know, traveling and the convenience of it,
but is there any form of radiation that is more cost-effective than another?
Permanant brachytherapy seeds are the most cost-effective if it's a single treatment,
and so, I think economically, I'm not an expert in the economics of radiation, but shorter courses of
radiation because the radiation therapists do bill by the visit. So, people that only get 5 visits,
it's going to be less expensive than people that get 20 or 30 visits. So, I think that the
economics of seed implants are very attractive and this is why seed
implants are becoming more popular around the world as time goes on.
I know in a previous video, we talked about brachytherapy and one of the reasons why it's
not as popular is not many doctors do it due to the reimbursement issues. So, you had
mentioned that there's a possible change coming in medicare coverage. Is there any update on that?
No, it's the people that work for medicare that make these decisions that say that it's coming.
I don't know if we'll see that in 2021. We certainly look forward to it.
Doctors are incentivized by profits and the doctors that give IMRT are paid so much better
than the doctors that do seed implants. If they could bring those on a more even basis,
then we'll be seeing a lot more seed implants because the literature—the scientific support
showing cure rates and side effects—show that it's an excellent way to treat people.
So, talking about seed implants. "It has been said that temporary seed implants are preferable for
disease that may have spread beyond the gland since it can be placed around the prostate.
But would that still matter if the patient has already received beam radiation?
I think it would be a matter of degree. The permanent seeds are ideally placed in
the prostate. So, if there's, for example, clear cut spread into the seminal vesicles,
the temporary seed implants where they use the radiation through a catheter,
they can even be put up into the seminal vesicles that's a better approach.
So, when we're talking about disease outside the prostate, sometimes it's just theoretical—high
PSA or maybe there's an MRI that says maybe the edge of the prostate looks a little bit ragged.
Permanent seeds are fine with that because they put the seeds up near the edge of the
prostate and they emit radiation for about half a centimeter outside around the gland,
but when you have a situation that shows up maybe on a digital rectal or an MRI that there are
obvious large amounts of cancer that are growing outside the prostate,
I think that's where the temporary seeds are more appropriate than the permanent seeds.
Is there a preferred form of radiation for salvage therapy after radical prostatectomy?
Almost all of the data is with IMRT, so
that would probably be the safest more traditional approach. There are preliminary data with SBRT and
the proton doctors have their protocols as well. So, I don't know that there's a preferred form,
but when you look at the literature and the data, it's almost all IMRT.
Thanks for watching. If you would like more information,
you can visit our website at PCRI.ORG.
Also, subscribe to our YouTube channel. We come out with new prostate cancer videos every week.