Having performed more than 1,200 brachytherapy treatments since 1996 and conducting research in this field, urologic oncologist Michael F. Sarosdy, MD, founder of South Texas Urology & Urologic Oncology, in San Antonio, is convinced that this is a far better choice than surgery for most men with prostate cancer, regardless of the patient’s age or tumor characteristics.

(Editor’s note: Dr. Sarosdy has no outside financial interest in any brachytherapy treatment programs, equipment, or services.)

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Brachytherapy is touted as the safest and least expensive of the three main treatments for prostate cancer, which also include radical prostatectomy and external beam radiation therapy (EBRT). Does brachytherapy deserve this reputation?

Dr. Sarosdy: Absolutely. It’s very cost-effective and it has the least impact on day-to-day function in terms of treatment delivery. It’s a one-time outpatient treatment that requires about one hour in the operating room, under anesthesia, to implant the seeds, which are little titanium shells that contain radioactive  material. The patient can quite literally return to work the next day.

Brachytherapy has become more sophisticated and polished in the 25 years since it was first used for prostate cancer. Physics planning software, technique, and ultrasound imaging have improved, and we’ve learned how to do the treatment more effectively and more safely. And now, some physicians are using real-time physics planning, where you do it right in the operating room instead of planning ahead of time and then trying to match up the image in the operating room with the image that was done for the preplan. This does makes the procedure take a little longer.

How often is brachytherapy used relative to other options?

Dr. Sarosdy: Brachytherapy has a very well-defined place in the treatment of prostate cancer. Over the past 10 years or so, there has been less brachytherapy done, because while robotic surgery has not been shown to be superior to open surgery, patients are less reluctant to undergo surgery with a robotic and laparoscopic technique. They feel less threatened by it, even though the fact is that it’s already been  shown to have no higher cure rate. In fact, there  are more frequent urinary complications with the robotic compared to open surgery.

Is there a clearly defined patient for brachytherapy compared with prostatectomy?

Dr. Sarosdy: No. Brachytherapy can be done in any patient with prostate cancer. There’s not one patient that’s better treated with it than another. It’s really suitable for any patient who desires to avoid surgery and external radiation and to undergo a relatively easy-to-deliver treatment that’s going to have less impact, both long-term and short-term, on his lifestyle.

The other reason that we’ve seen a decrease in the number of brachytherapy cases is that physicians—both radiation oncologists and urologists—have made a shift toward IMRT [intensity-modulated radiation therapy], for no other reason than that it’s reimbursed at substantially higher rates than brachytherapy. The cost for IMRT is about three to four times higher than the cost for brachytherapy, with no improvement in outcomes. Also, IMRT treatment delivery is somewhat onerous compared to brachytherapy: You have to go for nine weeks, Monday to Friday, to have the IMRT delivered, as opposed to one day for brachytherapy.

And there’s no data to support the idea that younger men should have surgery over brachytherapy or even IMRT. They actually have longer to live with the complications of surgery than older men—they have a longer time to be incontinent and impotent.