Sexual potency following interactive ultrasound-guided brachytherapy for prostate cancer

Favorable preservation of erectile function after prostate brachytherapy for localized prostate cancer

PURPOSE

We analyzed the rate of preserved potency after prostate brachytherapy (PB) with radioactive seeds and the impact of patient comorbidities on post-PB erectile dysfunction (ED).

METHODS

We included 627 patients who were assessed for pre- and postimplant potency between 2005 and 2017. Assessment was based on the Common Terminology Criteria for Adverse Events Scale (CTCAEs). Logistic regression models were used to assess clinical predictors of preserved potency after PB defined as having sufficient erections for sexual activity with or without the need of oral pharmacologic assistance. Covariates included age, diabetes (DM), hypertension (HTN), dyslipidemia (DLP), coronary artery disease (CAD), International Prostate Symptom Score (IPSS), prostate volume, and Cancer of the Prostate Risk Assessments (CAPRA) score. Patients on androgen deprivation therapy or using five alpha reductase inhibitors were excluded from analyses.

RESULTS

Post-PB potency was assessed at an average of 6 months (n = 627), 1 year (n = 538), 2 years (=440), 4 years (n = 272), and 5 years (n = 124). At 2 and 5 years, post-PB potency was preserved in 87% and 84% of patients, respectively. When adjusting for all available covariates, advanced age, pre-PB potency, and the presence of vascular comorbidities (HTN, DM, and DLP) were all predictors of potency at 2 years after PB (all p < 0.01). When performing a sensitivity analysis for vascular comorbidities, the presence of DM had the strongest impact on ED than either HTN or DLP (p < 0.01).

CONCLUSION

More than 84% of patients had preserved potency 5 years after PB. Advanced age, pre-PB potency, and vascular comorbidities had a statistically significant impact on potency after PB.

Brachytherapy for the urologist: A multidisciplinary team update for 2019

Brachytherapy is a well-established treatment for localised prostate cancer. Urologists are often tasked with discussing all available treatment options with the newly diagnosed patient. Unlike radical prostatectomy and external beam radiotherapy, knowledge of brachytherapy may be limited. The aim of this article is to provide an up-to-date guide on patient selection, modern brachytherapy techniques and the management of side effects, such that the core urologist can be more confident in both discussing initial treatment options and the long-term management of brachytherapy patients.

Level of Evidence: Level 5 - review article

Penile Rehabilitation Strategies Among Prostate Cancer Survivors

Despite advances in technical and surgical approaches, erectile dysfunction (ED) remains the most common complication among prostate cancer survivors, adversely impacting quality of life. This article analyzes the concept and rationale of ED rehabilitation programs in prostate cancer patients. Emphasis is placed on the pathophysiology of ED after diagnosis and treatment of prostate cancer to understand the efficacy of rehabilitation programs in clinical practice. Available evidence shows that ED is a transient complication following prostate biopsy and cancer diagnosis, with no evidence to support rehabilitation programs in these patients. A small increase in ED and in the use of phosphodiesterase type 5 (PDE5) inhibitors was reported in patients under active surveillance. Patients should be advised that active surveillance is unlikely to severely affect erectile function, but clinically significant changes in sexual function are possible. Focal therapy could be an intermediate option for patients demanding treatment/refusing active surveillance and invested in maintaining sexual activity. Unlike radical prostatectomy, there is no support for PDE5 inhibitor use to prevent ED after highly conformal external radiotherapy or low-dose rate brachytherapy. Despite progress in the understanding of the pathophysiologic mechanisms responsible for ED in prostate cancer patients, the success rates of rehabilitation programs remain low in clinical practice. Alternative strategies to prevent ED appear warranted, with attention toward neuromodulation, nerve grafting, nerve preservation, stem cell therapy, investigation of neuroprotective interventions, and further refinements of radiotherapy dosing and delivery methods.

Acute urinary morbidity after a permanent 125I implantation for localized prostate cancer

We evaluated the predictive factors of acute urinary morbidity (AUM) after prostate brachytherapy. From November 2005 to January 2007, 62 patients with localized prostate cancer were treated using brachytherapy. The (125)Iodine ((125)I) seed-delivering method was a modified peripheral pattern. The prescribed dose was 144 Gy. Urinary morbidity was scored at 3 months after implantation. The clinical and treatment parameters were analysed for correlation with AUM. In particular, in this study, Du90 (the minimal dose received by 90% of the urethra), Dup90 (the minimal dose received by 90% of the proximal half of the urethra on the bladder side) and Dud90 (the minimal dose received by 90% of the distal half of the urethra on the penile side) were analysed. We found that 43 patients (69.4%) experienced acute urinary symptoms at 3 months after implantation. Of them, 40 patients had Grade 1 AUM, one patient had Grade 2 pain, and two patients had Grade 2 urinary frequency. None of the patients had ≥Grade 3. Univariate and multivariate analysis revealed that Du90 and Dup90 were significantly correlated with AUM. In this study, Du90 and Dup90 were the most significant predictors of AUM after prostate brachytherapy.

Phase I trial of weekly docetaxel, total androgen blockade, and image-guided intensity-modulated radiotherapy for localized high-risk prostate adenocarcinoma

BACKGROUND

This was a phase I study to find the maximum tolerable dose (MTD) of weekly docetaxel combined with high-dose intensity-modulated radiotherapy (IMRT) and androgen deprivation therapy (ADT).

PATIENTS AND METHODS

Men with localized high-risk prostate cancer (HRPC) were treated with weekly docetaxel at 10 to 30 mg/m(2) concurrent with IMRT of 77.4 Gy to the prostate and 45 Gy to the seminal vesicles. ADT consisted of a gonadotropin-releasing hormone agonist (GnRHa) and bicalutamide beginning 2 months before and during chemoradiation. GnRHa was continued for 24 months.

RESULTS

Nineteen patients were enrolled. No dose-limiting toxicity (DLT) was seen with docetaxel doses up to 25 mg/m(2). At the 30 mg/m(2) level, 2 of 4 patients experienced DLTs of both grade 3 fatigue and dyspepsia. At 41 months' median follow-up, 2 patients had died--1 from metastatic prostate cancer and the other from heart failure. Two other patients experienced biochemical failure. One patient with bladder invasion at diagnosis experienced late grade 2 urinary hesitancy 9 months after completion of radiotherapy, requiring short-term intermittent catheterization. All patients had erectile dysfunction, but no late toxicities worse than grade 2 were identified.

CONCLUSION

Weekly docetaxel may be combined with high-dose IMRT and long-term ADT up to a MTD of 25 mg/m(2). Acute toxicities and long-term side effects of this regimen were acceptable. Future studies evaluating the efficacy of docetaxel, ADT, and IMRT for localized HRPC should use a weekly dose of 25 mg/m(2) when limiting the irradiated volume to the prostate and seminal vesicles.

[Sexual function after permanent seed implant prostate brachytherapy]

PURPOSE

The aim of this study was to evaluate the long-term effects of permanent seed implant prostate brachytherapy (BT) on sexual function (SF).

MATERIALS AND METHODS

From September 2003 to July 2005, 56 patients underwent radical retropubic prostatectomy (RRP) without any hormone therapy, while 353 patients had undergone BT without any adjuvant hormone therapy in a single institute. Out of these 353 patients in the BT group, 305 patients received neoadjuvant hormone therapy (BT NHT + group), while 48 did not (BT NHT - group). SF was prospectively evaluated using the UCLA Prostate Cancer Index (UCLA-PCI). Potency was defined as the UCLA-PCI Q26 point of > or = 3.

RESULT

The preimplant UCLA-PCI scores of SF for BT NHT - and BT NHT + groups were 50.9 and 13.4, respectively. The SF score of the NHT - group post operatively decreased to 38.9 within 6 months, but was maintained at the same level after that. With the recovery of the androgen, SF score of the NHT + group improved after BT: however, it did not reach up to that of the NHT - group. In the univariate analysis, patient's age was the only predictive factor for SF after BT. Thirty-four out of 48 patients in the BT NHT - group and 23 out of 56 patients in the RRP group showed adequate potency before surgery. Their 5-year potency preservation rate was 73.6% in the BT NHT - group and 4.3% in the RRP group.

CONCLUSION

SF slightly decreased immediately after BT but was usually maintained during the course observation for 5 years. The 5-year SF preservation rate after BT was 73.6%.

Does brachytherapy of the prostate affect sperm quality and/or fertility in younger men?

OBJECTIVE

Sperm banking prior to surgical procedures which may affect fertility, such as retroperitoneal lymph node dissection, has been well documented. However, such procedures are usually performed in young men. With older men marrying later in life, or remarrying, we wanted to investigate the effects of radiation on prostate cancer patients who wanted to have children afterwards.

MATERIAL AND METHODS

We encountered several patients with prostate cancer who decided to undergo brachytherapy and were planning to have more children. We performed a search using PubMed and Ovid for the period 1966-2001 using the key words "fertility", "sperm banking", "radiation effects", "prostate cancer" and "brachytherapy".

RESULTS

Of the four young patients we encountered who underwent brachytherapy, we found no significant change in semen parameters post-therapy, and three of them were able to father a child subsequently without any deleterious side-effects. It has been demonstrated in several reports that external-beam radiation therapy is associated with decreased spermatogenesis due to Leydig cell dysfunction and decreased serum testosterone, as well as having a direct effect on spermatogonia. However, there is a scarcity of literature discussing the effects of prostate brachytherapy on spermatogenesis as the patients involved are usually older and usually do not desire to father any more children. As I has a half-life of 60 days, we used an exposure of 10 mR/h at the symphysis pubis and used integration to find the total dose exposed to the testis as follows: Limits 14 400 to 0, S 10e (-In2/1440.Tdt) where T = 14 400 and 20.75 R = 20.75 cGy. Therefore, the total dose was 20.75 cGy x 0.91 = 18.88 cGy. This value is considered too low to have any significant effect on testicular tissues.

CONCLUSIONS

We speculate that the effects of prostate brachytherapy on spermatogenesis in prostate cancer patients are minimal. However, due to the half-life of I, we recommend that these patients should wait for at least 3-4 months before trying to conceive. Furthermore, younger men with prostate cancer may want to consider sperm banking prior to brachytherapy if they want to have children in the future.

Association of single nucleotide polymorphisms in SOD2, XRCC1 and XRCC3 with susceptibility for the development of adverse effects resulting from radiotherapy for prostate cancer

The objective of this study was to determine whether an association exists between certain single nucleotide polymorphisms (SNPs), which have previously been linked with adverse normal tissue effects resulting from radiotherapy, and the development of radiation injury resulting from radiotherapy for prostate cancer. A total of 135 consecutive patients with clinically localized prostate cancer and a minimum of 1 year of follow-up who had been treated with radiation therapy, either brachytherapy alone or in combination with external-beam radiotherapy, with or without hormone therapy, were genotyped for SNPs in SOD2, XRCC1 and XRCC3. Three common late tissue toxicities were investigated: late rectal bleeding, urinary morbidity, and erectile dysfunction. Patients with the XRCC1 rs25489 G/A (Arg280His) genotype were more likely to develop erectile dysfunction after irradiation than patients who had the G/G genotype (67% compared to 24%; P=0.048). In addition, patients who had the SOD2 rs4880 T/C (Val16Ala) genotype exhibited a significant increase in grade 2 late rectal bleeding compared to patients who had either the C/C or T/T genotype for this SNP (8% compared to 0%; P=0.02). Finally, patients with the combination of the SOD2 rs4880 C/T genotype and XRCC3 rs861539 T/C (Thr241Met) genotype experienced a significant increase in grade 2 late rectal bleeding compared to patients without this particular genotypic arrangement (14% compared to 1%; P=0.002). These results suggest that SNPs in the SOD2, XRCC1 and XRCC3 genes are associated with the development of late radiation injury in patients treated with radiation therapy for prostate adenocarcinoma.

TGFB1 Single Nucleotide Polymorphisms Are Associated With Adverse Quality of Life in Prostate Cancer Patients Treated With Radiotherapy

PURPOSE

To investigate whether the presence of single nucleotide polymorphisms (SNPs) located within TGFB1 might be predictive for the development of adverse quality-of-life outcomes in prostate cancer patients treated with radiotherapy.

METHODS AND MATERIALS

A total of 141 prostate cancer patients treated with radiotherapy were screened for SNPs in TGFB1 using DNA sequencing. Three quality-of-life outcomes were investigated: (1) prospective decline in erectile function, (2) urinary quality of life, and (3) rectal bleeding. Median follow-up was 51.3 months (range, 12-138 months; SD, 24.4 months).

RESULTS

Those patients who possessed either the T/T genotype at position -509, the C/C genotype at position 869 (pro/pro, codon 10) or the G/C genotype at position 915 (arg/pro, codon 25) were significantly associated with the development of a decline in erectile function compared with those who did not have these genotypes: 56% (9 of 16) vs. 24% (11 of 45) (p = 0.02). In addition, patients with the -509 T/T genotype had a significantly increased risk of developing late rectal bleeding compared with those who had either the C/T or C/C genotype at this position: 55% (6 of 11) vs. 26% (34 of 130) (p = 0.05).

CONCLUSIONS

Possession of certain TGFB1 genotypes is associated with the development of both erectile dysfunction and late rectal bleeding in patients treated with radiotherapy for prostate cancer. Therefore, identification of patients harboring these genotypes may represent a means to predict which men are most likely to suffer from poor quality-of-life outcomes after radiotherapy for prostate cancer.

[Brachyterapy in localized prostate cancer]

INTRODUCTION AND OBJECTIVES

Considering the high frequency of localized prostate cancer in stages, at the moment there are minimally invasive techniques that compete with the classic surgery. One of them is the Low Dose Rate (LDR) Brachytherapy with permanent implants of 1125 seeds. The objective of the present study is to expose our experience from the year 1998, when we made the first treatment, until today. The results and the morbidity of the patients over a 7 and a half years period are analyzed.

MATERIAL AND METHODS

A total of 800 patients were treated with LDR brachytherapy, with average age of 68 years and range between 48 and 83 years. In all patients the 1125 seeds were used with Rapid-Strand and peripheral load by means of intraoperative planning.

RESULTS

The urinary rate of complications was of 3% of AUR, and 0.2% of urinary incontinence. The morbidity on the digestive apparatus was of a 12% intermittent bleeding, 2% of proctitis, and a 0.3% of rectal fistulas.

Effect of low dose-rate prostate brachytherapy on the sexual health of men with optimal sexual function before treatment: analysis at ≥ 7 years of follow-up

OBJECTIVE

To evaluate the effect of low-dose rate prostate brachytherapy on the sexual health of men with > or = 7 years of prospective evaluation and optimum sexual function before treatment.

PATIENTS AND METHODS

In all, 223 patients with T1b to T3a prostate cancer and a median (range) age of 66 (50-82) years were treated with permanent seed implantation from November 1990 to March 1998. They were followed for a median (range) of 8.2 (7-14.1) years using prospective quality-of-life measures. Erectile function (EF) was assessed using a physician-assigned score and beginning in June 2000; the validated International Index of EF (IIEF-5) was used as a complementary method to quantify late EF. No adjustment was made to differentiate sexual function with or with no pharmacological intervention for EF. Pearson's chi-square test and Student's t-test were used to compare the groups.

RESULTS

Of the 223 men, 131 (59%) had optimal EF before their brachytherapy; of these, 51 (40%) at the last follow-up evaluation were using either a phosphodiesterase type 5 inhibitor (44, 86%), yohimbine (two, 4%) or alprostadil (five, 10%). The age at implantation was highly predictive of current EF; 23 of 25 (92%) men aged 50-59 years had a current EF of > or = 2; those aged 60-69 and 70-78 years had an EF of > or =2 in 48/75 (64%) and 18/31 (58%) (P = 0.01). A current IIEF-5 score of > or = 16 also correlated highly with age at implant, i.e. 50-59, 16/25 (64%); 60-69, 20/75 (27%) and 70-78 years, 6/31 (19%) (P < 0.001).

CONCLUSION

Patients aged <60 years and with optimal EF before low-dose rate prostate brachytherapy have a very high probability of long-term EF.

Quality of Life for Men With Prostate Cancer

The aim of this article is to selectively review the current research findings related to quality of life and prostate cancer. English-language journals indexed in MEDLINE, PubMed, and CINAHL published between 1999 and 2005 were searched for relevant articles using the following keywords: "quality of life and prostate cancer," "prostatectomy," "radiation therapy," "brachytherapy," "cryotherapy," or "androgen deprivation therapy." References in selected articles were reviewed for potentially relevant articles not identified through database searches. All treatment modalities have a significant impact on quality of life for men with local or advanced prostate cancer. Alterations in sexual functioning cause the most significant impact on quality of life for men. Quality of life is decreased in both the short and long term for men with prostate cancer. Oncology nurses must be cognizant of the challenges that a diagnosis of prostate cancer presents to the man with prostate cancer and his partner. Patients should be fully informed of the potential for impact on quality of life with all treatment modalities, and the oncology nurse can play an important role in both providing this information and supporting the patient when quality of life is impacted.

A genetically determined dose-volume histogram predicts for rectal bleeding among patients treated with prostate brachytherapy

PURPOSE

To examine whether possession of genetic alterations in the ATM (ataxia telangiectasia) gene is associated with rectal bleeding in a dose-dependent and volume-dependent manner.

METHODS AND MATERIALS

One hundred eight prostate cancer patients who underwent brachytherapy using either an (125)I implant, a (103)Pd implant, or the combination of external beam radiotherapy with a (103)Pd implant and had a minimum of 1 year follow-up were screened for DNA sequence variations in the 62 coding exons of the ATM gene using denaturing high-performance liquid chromatography. Rectal dose was reported as the volume (in cubic centimeters) of rectum receiving the brachytherapy prescription dose. The two-sided Fisher exact test was used to compare differences in proportions.

RESULTS

A significant correlation between the presence of any ATM sequence alteration and Grade 1 to 2 proctitis was obtained when the radiation dose to rectal tissue was quantified. Rectal bleeding occurred in 4 of 13 patients (31%) with a variant versus 1 of 23 (4%) without a genetic alteration for patients who had <0.7 cm(3) of rectal tissue receiving the implant prescription dose (p = 0.05). Of patients in whom 0.7-1.4 cm(3) of the rectum received the implant prescription, 4 of 11 (36%) with an ATM alteration exhibited Grade 1 to 2 proctitis, whereas 1 of 21 (5%) without a variant (p = 0.04) developed this radiation-induced late effect.

CONCLUSIONS

The possession of genetic variants in the ATM gene is associated with the development of radiation-induced proctitis after prostate cancer radiotherapy for patients who receive the full prescription dose to either a low or a moderate volume of rectal tissue.

Patient and physician reporting of symptoms and health-related quality of life in trials of treatment for early prostate cancer: considerations for future studies

AIMS

Clinical trials in early prostate cancer (EPC) have used a variety of outcome measures, including patient-reported outcomes (PROs) and physician-reported data. We review published studies and suggest a set of outcome measures and a portfolio of more detailed questionnaire options to produce a more homologous data set for future clinical trials.

MATERIALS AND METHODS

A literature search combining the terms 'quality of life' or 'symptoms' and 'prostate cancer' or 'prostate adenocarcinoma' was carried out. Relevant papers were reviewed to assess key areas of toxicity and quality of life (QoL). These were discussed by a panel with a special interest in the assessment of QoL measures and PROs.

RESULTS

Twenty-one validated candidate questionnaires were identified. The Short Form 12 was recommended due to its combination of brevity and assessment of pain, general and mental health, physical, social and emotional function. Specific questionnaires should assess localised symptoms after treatment, including sexual function, erectile dysfunction, bowel function and lower urinary tract symptoms (LUTS). The modular use of separate symptom indices was recommended. For sexual function, the International Index of Erectile Function and the International Continence Society questionnaire were considered the best available. The International Continence Society Male Short Form questionnaire best addressed LUTS. Incontinence of stool (solid, liquid or gas) and its effect on function should be assessed. The Vaizey questionnaire is recommended. The Radiation Therapy Oncology Group scale, which is physician administered, remains helpful in studies including radiotherapy, as it places current trials within appropriate historical context. Rates of procedures to treat complications and pharmaceutical interventions for treatment-related symptoms should be recorded at the time of each questionnaire follow-up.

CONCLUSION

Although novel therapies may produce different toxicities, the current recommendations should help to produce trial protocols that will allow comparable data to be generated within clinical trials comparing outcome from surgery, radiotherapy and other targeted ablative therapies for EPC.

Assessment of postbrachytherapy sexual function: a comparison of the IIEF-5 and the MSEFS

PURPOSE

This study is to compare the Mount Sinai Erectile Function Score (MSEFS), our brachytherapy program's physician-assigned scale, with patients' independently completed International Index of Erectile Function-5 (IIEF-5).

METHODS AND MATERIALS

A total of 1202 patients with T1-T3 prostate cancer were treated with ultrasound-guided radioactive seed implantation +/- EBRT with at least one visit where both MSEFS and IIEF-5 were completed. Spearman rho correlations were performed.

RESULTS

The MSEFS significantly correlated with the total IIEF-5 scores on all comparisons. The coefficient was 0.65 for comparisons at initial consultation and 0.76 for all visits. The correlations remained strong, averaging to 0.76 for visits 1 through 10.

CONCLUSIONS

In assessing erectile dysfunction after radiation, the MSEFS correlates well with, but cannot be replaced by, the IIEF-5, which is weighted toward one's degree of sexual desire. More insight into patients' erectile function after brachytherapy may be gotten if the IIEF-15 is used instead of the IIEF-5 with our MSEFS.

Five-year outcome of intraoperative conformal permanent I-125 interstitial implantation for patients with clinically localized prostate cancer

PURPOSE

To report the 5-year tumor control and toxicity outcomes for patients with localized prostate treated with I-125 permanent implantation using an intraoperative real-time conformal planning technique.

METHODS AND MATERIALS

Between January 1998 and June 2002, 367 patients with prostate cancer were treated with I-125 permanent interstitial implantation using a transrectal ultrasound-guided approach. Real-time intraoperative treatment planning which incorporated inverse planning optimization was used. The median follow-up time was 63 months.

RESULTS

The median V100 and D90 were 96% and 173 Gy, respectively. In 96% of cases a D90 of >140 Gy was achieved. The median urethral and rectal doses were 100% and 33% of the prescription doses, respectively. The 5-year PSA relapse-free survival outcomes for favorable and intermediate risk patients according to the ASTRO definition were 96% and 89%, respectively. In these patients no dosimetric parameter was identified which influenced the biochemical outcome. Of 38% who developed acute Grade 2 urinary symptoms, 63% had resolution of their symptoms within a median time of 6 months. The incidence of late rectal and urinary Grade 3 or higher toxicities were 1% and 4%, respectively. Seven percent (n = 27) developed late rectal bleeding (Grade 2) and 19% experienced late Grade 2 urinary symptoms.

CONCLUSION

Real-time intraoperative planning consistently achieved optimal coverage of the prostate with the prescription dose with concomitant low doses delivered to the urethra and rectum. Biochemical control outcomes were excellent at 5 years and late toxicity was unusual. These data demonstrate that real-time planning methods can consistently and reliably deliver the intended dose distribution to achieve an optimal therapeutic ratio between the target and normal tissue structures.

Do vardenafil and tadalafil have advantages over sildenafil in the treatment of erectile dysfunction?

Erectile dysfunction (ED) affects up to 50% of men between the ages of 40 and 70 years of age. Sildenafil, vardenafil and tadalafil have all been shown to be similarly effective in the treatment of men with ED of vary etiologies, to have similar adverse effects profiles, and to improve quality-of-life by similar amounts. As these phosphodiesterase 5 (PDE5) inhibitors all increase the hypotensive effects of nitrates, they are not suitable for use in patients taking nitrates for the treatment of ischaemic heart disease. All three inhibitors must be used with caution in patients taking alpha(1)-adrenoceptors antagonists for benign prostatic hyperplasia. Although nonarteritic anterior ischaemic neuropathy has been reported in some users of the PDE5 inhibitors, there is no conclusive evidence that PDE5 inhibitors cause this rare effect. Tadalafil has a longer half-life than sildenafil or vardenafil, and a longer duration of action than sildenafil and vardenafil. Most preference studies have shown tadalafil to be preferred, but there are serious limitations to some of these studies. One approach to treatment is to give each patient a short- and long-acting agent, and for individuals to decide their preference.

Early use of a phosphodiesterase inhibitor after brachytherapy restores and preserves erectile function

OBJECTIVE

To investigate whether the early use of phosphodiesterase inhibitors (PDEIs) after brachytherapy (BT) is associated with better erectile function, as of men potent before BT 38-70% have erectile dysfunction afterward.

PATIENTS AND METHODS

We evaluated a prospectively created database of 2500 patients who had had BT at our institution since 1992. We measured baseline age, cancer stage, Gleason grade, prostate specific antigen (PSA) level at diagnosis, implant type, use of neoadjuvant and adjuvant hormonal suppression therapy, use of external beam radiotherapy in conjunction with interstitial therapy, and follow-up PSA levels. Men were stratified by their use of PDEIs at <1 year (early group) or >1 year after implantation (late group). We excluded all men who did not have baseline Sexual Health Inventory for Men (SHIM) scores and at least one follow-up SHIM score; the latter were obtained at 6-month intervals after BT. Data were analysed using the Mann-Whitney U-test.

RESULTS

In all, 210 men met the inclusion criteria; 85 began using PDEIs within a year of BT, and 125 started after a year. The mean time to PDEI use was 191 days in the early and 595 days in the late group. The median age was 62 years in the early and 63 years in the late group (P = 0.02). Baseline Gleason scores did not differ, nor did PSA levels between the groups. Of men in the early group, 48% received neoadjuvant and/or adjuvant hormonal suppression therapy, vs half of men in the late group. Baseline SHIM scores were not significantly different, nor were scores at the first two follow-up assessments, but the scores at 18-36 months after BT were significantly different.

CONCLUSION

The early use of PDEIs after BT is associated with a significant improvement in and maintenance of erectile function compared with late use. Men undergoing BT should be encouraged to use PDEIs early after implantation, to preserve erectile function.

Prospective evaluation of quality of life after interstitial brachytherapy for localized prostate cancer

PURPOSE

Permanent interstitial brachytherapy (IB) has become an increasingly appealing therapeutic option for localized prostate cancer (LPC) among physicians and patients because it involves short hospitalization and treatment and its postulated low degree of toxicity may reduce its impact on the patients' quality of life (QoL). The aim of this prospective study was to assess the impact of IB on the QoL of patients with LPC.

METHODS AND MATERIALS

A validated self-completed questionnaire was administered to the patients before and after IB and then at yearly intervals. The items allowed the identification of seven subscales exploring physical well-being (PHY), physical autonomy (POW), psychological well-being (PSY), relational life (REL), urinary function (URI), rectal function (REC), and sexual function (SEX).

RESULTS

The assessment of the QoL of 147 patients treated between May 2000 and February 2005 revealed no relevant differences in the PHY scale scores 1 month after IB or later, and the same was true of the POW, PSY, and REL scales. Urinary function significantly worsened after IB and returned to pretreatment levels only after 3 years; the impact of the treatment on the URI scale was greater in the patients with good baseline urinary function than in those presenting more urinary symptoms before IB. Rectal and sexual functions were significantly worse only at the post-IB evaluation.

CONCLUSIONS

The results of the present study confirm that the impact of IB on the patients' QoL is low despite its transient negative effects on some function, and extend existing knowledge concerning QoL after IB.

ATM sequence variants are predictive of adverse radiotherapy response among patients treated for prostate cancer

PURPOSE

To examine whether the presence of sequence variants in the ATM (mutated in ataxia-telangiectasia) gene is predictive for the development of radiation-induced adverse responses resulting from (125)I prostate brachytherapy for early-stage prostate cancer.

MATERIALS AND METHODS

Thirty-seven patients with a minimum of 1-year follow-up who underwent (125)I prostate brachytherapy of early-stage prostate cancer were screened for DNA sequence variations in all 62 coding exons of the ATM gene using denaturing high-performance liquid chromatography. The clinical course and postimplant dosimetry for each genetically characterized patient were obtained from a database of 2,020 patients implanted at Mount Sinai Hospital after 1990.

RESULTS

Twenty-one ATM sequence alterations located within exons, or in short intronic regions flanking each exon, were found in 16 of the 37 patients screened. For this group, 10 of 16 (63%) exhibited at least one form of adverse response. In contrast, of the 21 patients who did not harbor an ATM sequence variation, only 3 of 21 (14%) manifested radiation-induced adverse responses (p = 0.005). Nine of the patients with sequence alterations specifically possessed missense mutations, which encode for amino acid substitutions and are therefore more likely to possess functional importance. For this group, 7 of 9 (78%) exhibited at least one form of adverse response. In contrast, of the 28 patients who did not have a missense alteration, only 6 of 28 (21%) manifested any form of adverse response to the radiotherapy (p = 0.004). Of the patients with missense variants, 5 of 9 (56%) exhibited late rectal bleeding vs. 1 of 28 (4%) without such alterations (p = 0.002). Of those patients who were at risk for developing erectile dysfunction, 5 of 8 (63%) patients with missense mutations developed prospectively evaluated erectile dysfunction as opposed to 2 of 20 (10%) without these sequence alterations (p = 0.009).

CONCLUSIONS

Possession of sequence variants in the ATM gene, particularly those that encode for an amino acid substitution, is predictive for the development of adverse radiotherapy responses among patients treated with (125)I prostate brachytherapy.

Facing erectile dysfunction due to prostate cancer treatment: perspectives of men and their partners

A well-known side effect of prostate cancer treatment is erectile dysfunction. However, little is known about how men and their sexual partners think about the threat of erectile dysfunction prior to prostate cancer treatment. Twenty-one patients who had been diagnosed with early prostate cancer, but not yet treated, and 13 female partners of these men were recruited from two urologists' offices. In separate, semistructured individual interviews with men and their partners, thoughts about the threat of erectile dysfunction were solicited. Men's reactions to the possibility of losing their sexual capacity due to prostate cancer-related treatment were linked to their current level of sexual function. Women reacted to erectile dysfunction by stressing the existence of other relationship dimensions, whereas they were aware about the gravity of their male partners' feelings about potency. Finally, both men and women alike had concerns about the implications of erectile dysfunction on their relationship. Physicians advising men about treatment options should consider exploring men's current sexual function, thoughts about identity, and especially men's relationship situation. Physicians addressing these issues with men and their partners should provide resources for counseling.

Vessel-sparing prostate radiotherapy: Dose limitation to critical erectile vascular structures (internal pudendal artery and corpus cavernosum) defined by MRI

PURPOSE

Most evidence suggests that impotence after prostate radiation therapy has a vascular etiology. The corpus cavernosum (CC) and the internal pudendal artery (IPA) are the critical vascular structures related to erectile function. This study suggests that it is feasible to markedly decrease radiation dose to the CC and the IPA and directly determine the impact of dose limitation on potency.

METHODS AND MATERIALS

Twenty-five patients (10 external beam, 15 brachytherapy) underwent MRI/CT-based treatment planning for prostate cancer. In addition, 10 patients entered on the vessel-sparing protocol underwent a time-of-flight MRI angiography sequence to define the IPA. The distance from the MRI-defined prostate apex to the penile bulb (PB), CC, and IPA was measured and compared to the distance from the CT-defined apex. Doses (D5 and D50) to the PB, CC, and IPA were determined for an 80 Gy external beam course. In 5 patients, CT plans were generated and compared to MRI-based plans.

RESULTS

The combination of coronal, sagittal, and axial MRI data sets allowed superior definition of the prostate apex and its relationship to critical vascular structures. The apex to PB distance averaged 1.45 cm (0.36 standard deviation) with a range of 0.7 cm to 2.1 cm. Peak dose (D5) to the proximal CC in the MRI-planned 80 Gy course was 26 (9) Gy (0.36 of CT-planned dose), and peak dose to the IPA was 39 (13) Gy (0.61 of CT-planned dose).

CONCLUSION

The distance between the prostate apex and critical vascular structures is highly variable. Current empiric rules for CT contouring (apex 1.5 cm above PB) overestimate or underestimate the distance between the prostate apex and critical vascular structures. When defined by MRI T2 and MRI angiogram with CT registration, limitation of dose to critical erectile structures is possible, with a more significant gain than has been previously reported using dose limitation by commonly applied intensity modulated radiation therapy studies based on CT imaging. These techniques make "vessel-sparing" prostate radiotherapy feasible.

Clinical and physical determinants for toxicity of 125-I seed prostate brachytherapy

BACKGROUND AND PURPOSE

To assess acute as well as long-term toxicity after permanent prostate seed implantation. To find predictive clinical or dosimetric factors for side effects in order to work out strategies for improvement.

PATIENTS AND METHODS

A group of 174 patients with localised prostate cancer was treated with permanent seed implantation between 1999 and 2001, either alone (140 patients) or in combination with external radiotherapy (34 patients). For the majority (114/174, i.e. 66%) a CT was performed four weeks after implantation and analysed in the planning system VariSeed. In the postimplant analysis, dosimetric descriptors (doses, volumes) were determined for the prostate and rectum and compared with the intraoperative values. In addition, a questionnaire was sent to all patients to assess and quantify acute and chronic toxicity (urinary, rectal, sexual) and the impact on subjective acceptance and quality of life (return rate of questionnaires 83%). The derived score changes were correlated with clinical and dosimetric factors.

RESULTS

In the mono-brachytherapy group 14% (16/140) required a bladder catheter, of them 8% (9/140) with a manifest urinary obstruction. Long-term rectal toxicity (<5%) and impairment of potency (<30%) are moderate and obviously below other treatment options. Urinary toxicity is dominant with an overall long-term dysuria up to 30% (at a mean observation interval of ten months), and a significant trend to decline with follow-up time. Conversely, the erectile function tends to deteriorate with follow-up time. Nevertheless, quality of life is not significantly reduced and acceptance is high. Our analysis suggests that the main factor for urinary toxicity and impaired erectile function is the dose load to larger portions of the prostate (D(50)>240 Gy), which appears to be attributed to unnecessarily high numbers of seeds (for a fixed activity per seed) and needles. The rectal toxicity is correlated with the high dose regions in the rectum (>/=145 Gy). Urinary toxicity is lower for combined-brachytherapy, while rectal toxicity and impairment of potency are slightly higher.

CONCLUSIONS

Toxicity spectrum and quality of life after permanent seed implantation for early prostate cancer are acceptable for nearly all patients (98%). To further improve tolerance we should attempt to achieve a better dose homogeneity, i.e. by reducing D(50). Therefore, special attention should be given to D(50) during the real-time planning process. The necessity of more homogeneous dose distributions might imply a reduction of the activity per seed, e.g. from 0.7 mCi down to 0.6 mCi.

Assessing a Prostate Cancer Brachytherapy Technique Using Early Patient-Reported Symptoms: A Potential Early Indicator for Technology Assessment?

Brachytherapy for early prostate cancer can cause long-term urinary, bowel, and sexual dysfunction. Modifying technique may mitigate complications, but definitive outcome assessment requires long-term follow-up. Although radiation dose plausibly mediates all treatment-related toxicity, short-term symptoms may indicate long-term outcomes. We sought an early indication of whether a modified brachytherapy technique successfully decreased toxicity in the anticipated direction by assessing changes in symptoms and symptom distress 3 months after treatment. In a prospective study of clinically localized prostate cancer using a validated, patient-reported questionnaire, we assessed 85 men, whose primary treatment was brachytherapy alone, prior to treatment and 3 months after the procedure. Twenty-two men received standard ultrasound-guided brachytherapy (SB), and 63 men received magnetic resonance imaging-guided brachytherapy (MB), a technique intended to decrease urinary toxicity by reducing urethral irradiation. Patient age and other sociodemographic variables were similar in the 2 groups. The MB group experienced a greater increase in urinary obstruction/irritation symptoms (P = 0.02) and sexual function distress, but not sexual dysfunction (P = 0.22), whereas the SB group reported a smaller increase in bowel symptoms (P = 0.04) and bowel distress (P = 0.02). We found reduced short-term urinary obstruction/irritation and increased bowel problems after MB consistent with the hypothesized effects of the modified technique, although no obvious mechanism explains the decreased sexual function distress in MB patients. Whether these short-term changes predict long-term outcome differences will require much longer follow-up. However, these results suggest that measuring early symptoms may indicate whether an altered brachytherapy treatment technique has intended favorable consequences, potentially accelerating technology assessment.

Sexual health recovery after prostatectomy, external radiation, or brachytherapy for early stage prostate cancer

Each of the three most common contemporary treatments for localized prostate cancer, radical prostatectomy, external beam radiotherapy, and brachytherapy, can have adverse effects on sexual health. Sexual health outcome can be improved by treatment-specific factors, such as the use of nerve-sparing technique during radical prostatectomy, or worsened by the use of androgen deprivation before external beam radiotherapy or brachytherapy. Contemporary studies that have used validated questionnaires to evaluate multiple components of patient-reported sexuality following prostate cancer treatments provide benchmarks of sexual outcome expectations that are of interest to patients selecting their prostate cancer treatment.

Preferences for sexual information resources in patients treated for early-stage prostate cancer with either radical prostatectomy or brachytherapy

OBJECTIVE

To identify the preferences for sexual information resources of patients before and after definitive treatment for early-stage prostate cancer with either radical prostatectomy (RP) or brachytherapy.

PATIENTS AND METHODS

Two hundred patients (mean age 64 years) treated with either RP or brachytherapy were recruited from radiation oncology (100) and urology (100) outpatient clinics. Patients completed a survey questionnaire to identify the types of information used, preferred sources of information, knowledge of treatments for erectile dysfunction (ED), effect of sexual function on the treatment decision, and the International Index of Erectile Function (IIEF) to assess their current level of sexual function.

RESULTS

Urologists were identified as the main source of sexual information. Written information, Internet access and videos were identified as preferred sources of information before and after treatment. The effects of treatment on sexual function had no apparent significant influence on the men's definitive treatment choice. Compared with patients in the brachytherapy group, patients in the RP group reported having significantly higher levels of sexual desire (P < 0.001) after treatment, but otherwise the erectile domains of the groups were remarkably similar. Two-thirds of patients wanted more information on the effects of treatment on sexual function, and on available treatments for ED.

CONCLUSIONS

These results support the need for physicians to offer patients access to information on the effect of treatment for early-stage prostate cancer on erectile function before and after treatment.

Long-term potency after iodine-125 radiotherapy for prostate cancer and role of sildenafil citrate

OBJECTIVES

To assess the long-term sexual potency and attrition in sexual function after iodine-125 ((125)I) seed radiotherapy and the effect of sildenafil on radiation-induced erectile dysfunction (ED).

METHODS

This prospective study consisted of 86 sexually active patients (mean age 63.5 +/- 7.7 years) who underwent (125)I seed implantation from 1997 to 1999 to treat low-volume prostate cancer (prostate-specific antigen less than 10 ng/mL, Gleason score 6 or less, stage T1-T2). All patients were followed up every 6 to 8 months for 4 years. Patients prescribed sildenafil citrate for ED completed the abridged five-item version of the International Index of Erectile Function (IIEF) and the Erectile Dysfunction Inventory of Treatment Satisfaction (EDITS) questionnaires.

RESULTS

The median follow-up was 49.7 months (range 36 to 66). Of 86 patients, 43 (50%) did not initiate drug therapy; and only 36 (83.7%) of the 43 were interviewed at 4 years. Twenty-three (63.8%) of the 36 patients had erections sufficient for vaginal penetration, with a total mean +/- SD IIEF-5 score of 15.76 +/- 1.13. The other 50% (43 of 86) initiated sildenafil citrate for treatment of ED after seed implantation, with a minimal follow-up of 6 months. At 4 years, 32 (74%) of the 43 were responding positively to sildenafil citrate, with a total IIEF-5 score of 18.3 +/- 1.2. The mean EDITS +/- SD score was 76.5 +/- 3.2, and the spousal satisfaction rate was 72% (31 of 43). The dropout rate was 37% (16 of 43); 10 (63%) of the 16 discontinued because of a lack of efficacy, 3 (19%) because of a return of natural erections sufficient for vaginal penetration, and 3 (19%) discontinued because of side effects (headaches).

CONCLUSIONS

ED is a major long-term issue after (125)I seed radiotherapy, with a long-term potency rate of 29%. Sildenafil citrate improves erections in most patients after (125)I seed implantation.

Brachytherapy for prostate cancer

The use of prostate brachytherapy for the treatment of early-stage, low-grade, low-volume carcinoma of the prostate continues to rise. Given the prolonged natural history of these early lesions, treatment failures may take many years or even a decade or more before becoming clinically evident. It is therefore likely that as the brachytherapy data mature, clinicians will be asked to help manage a potentially large cohort of men who have failed this local therapy--a scenario that will provide a number of unique challenges for the treatment of the disease and the management of the lower urinary tract. This article offers a contemporary review and suggestions with regard to the follow-up of patients who have undergone prostate brachytherapy, including low-dose rate permanent implants and high-dose rate temporary implants for the management of localized prostate cancer. In addition, current controversies in defining biochemical failure following radioactive implantation--including important data regarding the "prostate-specific antigen bounce" phenomenon--are discussed. Finally, a comprehensive review of the management of local recurrence following brachytherapy is offered.

Myths and fallacies in permanent prostate brachytherapy

Because there are competing modalities to treat early-stage prostate cancer, the constraints or deficiencies of one modality may be erroneously applied to others. Some valid concerns arising from surgery and external beam therapy, which have been falsely transferred to brachytherapy, are constraints based on patient age, clinical and pathological parameters, patient weight, and size of prostate. Although the constraints have a valid basis in one modality, knowledge of the origin and mechanism of the constraint has provided a means to circumvent or overcome it in brachytherapy. Failures as measured by biochemical no-evidence of disease (bNED) survival may be attributed to extracapsular disease extension. Such extension often expresses itself in surrogate parameters such as a high percentage of positive biopsies, perineural invasion, or the dominant pattern in Gleason score histology. Failures due to such factors may be prevented by implanting with consistent extracapsular dosimetric margins. Some presumed limitations on prostate brachytherapy originated from data on patients implanted in the first few years the procedure was being developed. Most of the urinary morbidity and a significant part of the decrease in sexual function observed may be avoided by controlling the dosimetry along the prostatic and membranous urethra and at the penile bulb.

Iodine-125 brachytherapy for localized prostate cancer and urinary morbidity: a prospective comparison of two seed implant methods-preplanning and intraoperative planning

OBJECTIVES

To compare morbidity between two currently used iodine-125 seed implantation techniques for the treatment of localized prostate cancer.

METHODS

Iodine-125 brachytherapy was used in 300 consecutive men with localized prostate cancer. Two seed implant techniques were used: preplanning, using preloaded needles, and intraoperative planning, using a Mick applicator. A comparison was made between the groups for urinary morbidity. The International Prostate Symptom Score was assessed prospectively among all patients. Computed tomography-based implant quality parameters were correlated with lower urinary system morbidity.

RESULTS

The median follow-up was 30 months. In both treatment groups, the International Prostate Symptom Score increased significantly for about 9 to 12 months and returned to baseline thereafter. The International Prostate Symptom Scores reached a higher level and remained at a higher level for a longer period in the intraoperative group. Although the differences were statistically significant, they were of mild clinical importance. Overall, the incidence of acute retention and the need for surgery was very low in both groups (2% and 1%, respectively). No differences were noted between the two groups. Significantly better computed tomography-based implant dosimetry parameters were noted with the intraoperative method. A positive correlation (P < 0.001) was found between the dosimetry parameters and symptom severity.

CONCLUSIONS

This prospective study reports the first large-scale comparison of urologic outcomes after two different seed implant techniques. Both were associated with very low urinary retention rates or other grade 3 or greater urologic morbidity. Almost all men had worse urinary symptoms for the first 6 to 9 months, regardless of the seed implant technique used. Patients treated with the intraoperative method demonstrated toxicity for a longer duration. Because of the much better gland isodose coverage and greater doses delivered in the intraoperative seed implantation, we favor this method.

Impact of a novel neoadjuvant and adjuvant hormone-deprivation approach on quality of life, voiding function, and sexual function after prostate brachytherapy

BACKGROUND

Data demonstrate a benefit from neoadjuvant and adjuvant hormone-deprivation therapy with luteinizing hormone-releasing hormone agonists in patients who are treated with radiotherapy for localized prostate carcinoma; however, this approach has detrimental effects on quality of life (QOL). A cross-sectional study was undertaken to evaluate the impact on QOL, voiding function, and sexual function of an alternative hormone-deprivation approach.

METHODS

Three hundred fifty patients with clinical T1c-T2b prostate carcinoma were treated from March 1997 to August 2000 either with palladium 103 brachytherapy (BTM) without hormone therapy or with 8 months of adjuvant and neoadjuvant hormone-deprivation therapy with an antiandrogen and finasteride (BTM+H), were mailed the Functional Assessment of Cancer Therapy (FACT) global well being QOL instrument (FACT-G), the American Urological Association symptom score (AUASS), and specific items addressing urinary control and sexual function from validated instruments. Differences between treatment groups were assessed as a function of time since treatment.

RESULTS

Seventy-two percent of patients responded to the questionnaire. No differences in overall FACT-G scores, AUASS scores, or AUASS subscale scores between the BTM group and the BTM+H group were found. The BTM+H group initially had lower personal well being FACT-G subscale scores, more urinary incontinence, and lower odds of attaining an erection sufficient for intercourse initially, although these differences disappeared with longer follow-up.

CONCLUSIONS

The use of neoadjuvant and adjuvant antiandrogen and finasteride with brachytherapy is associated with QOL equal to that of brachytherapy alone for the treatment of patients with localized prostate carcinoma, allowing the advantages of hormone manipulation in terms of tumor control without its downside.

Predictive factors of acute urinary morbidity after iodine-125 brachytherapy for localised prostate cancer: a phase 2 study

PURPOSE

To analyse predictive factors of acute urinary morbidity after transperineal permanent prostate brachytherapy.

METHODS AND MATERIALS

Sixty patients treated in a phase 2 study with iodine-125 brachytherapy (9/1998 to 2/2000) for localised prostate adenocarcinoma were analysed after at least 1-year follow-up. Prescribed dose was 144 Gy and all patients had a pre-planning and a post-implant dosimetry. Urinary morbidity was evaluated prospectively using the Radiation Therapy Oncology Group (RTOG) scale. We examined the relationship between pre-implant ultrasound prostate volume, post-implant CT-scan prostate volume, neoadjuvant hormonotherapy, total number of needles and seeds, post-implant dosimetry variables, first 30 vs. last 30 treated patients and post-implant urinary morbidity.

RESULTS

All patients experienced some degree of urinary distress symptoms after treatment. Symptoms were generally mild grade 1 in 56% and grade 2 in 10% lasting less than 6 months. Eight patients (13%) required bladder catheter for acute urinary obstruction. At 1-year follow-up, nine patients (15%) complained from persistent dysuria requiring in three cases endoscopic prostate resection. The percentage of urethra volume receiving 216 Gy (cut-off 40%) and the pre-implant prostate volume (cut-off 31 ml) were the only statistically significant predictor of grade 2-3 or persistent urinary morbidity on multivariate analysis.

CONCLUSION

Our short-term data suggest that both pre-implant prostate volume value and post-implant V.U. 150 value might be predictors for urinary morbidity after prostate brachytherapy.

Longitudinal comparison of sexual function after 3-dimensional conformal radiation therapy or prostate brachytherapy

PURPOSE

The risk of erectile dysfunction can influence treatment decisions for localized prostate cancer. To estimate the risk from 2 popular radiotherapies we compared erectile function and overall satisfaction with sexual function after 3-dimensional (D) conformal radiation therapy and transperineal prostate brachytherapy.

MATERIALS AND METHODS

A total of 128 patients with prostate cancer underwent 3-D conformal radiation therapy (median dose 70.2 Gy. to the planning target volume) and 60 underwent palladium transperineal prostate brachytherapy (median dose 90 or 115 Gy. to 80% of the prostate with or without external nonconformal beam radiation therapy. Of the 128 patients 47 (37%) also received a luteinizing hormone releasing hormone (LH-RH) agonist (3 to 4 months), whereas 26 (43%) of the 60 patients received external beam radiation therapy and LH-RH (8 to 9 months). We evaluated erectile function and overall satisfaction with questions from validated, self-administered questionnaires. Patients responded to the questions serially before any prostate cancer therapy and at regular followup visits thereafter. We used the time until a patient returned to baseline erectile function and overall satisfaction to compare treatment modalities.

RESULTS

Median followup was 21 months. Of patients receiving 3-D conformal radiation therapy with or without LH-RH agonists 65% (95% CI 47% to 82%) and 67% (53% to 81%), respectively, returned to baseline overall satisfaction within 12 months after treatment versus 23% (9% to 50%) and 56% (38% to 75%) of the patients treated with transperineal prostate brachytherapy with or without external beam radiation therapy and LH-RH agonists, respectively. Reductions in overall satisfaction appeared to relate to changes in erectile function.

CONCLUSIONS

These data suggest that in the absence of LH-RH agonist use 3-D conformal radiation therapy and transperineal prostate brachytherapy have a similar impact on erectile function and overall satisfaction. Differences observed in erectile function and overall satisfaction in the 2 groups of patients who received adjuvant LH-RH may be due to the different duration of therapy (3 versus 8 months). Longer followup will be needed to evaluate this hypothesis.