Five-year potency preservation after iodine-125 prostate brachytherapy

Acute and late side-effects after low dose-rate brachytherapy for prostate cancer; incidence, management and technical considerations

PURPOSE

To review common reported side effects and complications after primary LDR-BT (monotherapy) and discuss some of the technical aspects that could impact the treatment outcomes.

METHODS AND MATERIALS

A literature search was undertaken using medical subject headings (MeSH) complemented by the authors' personal and institutional expertise.

RESULTS

The reported incidence of acute and late grade 2 or above urinary, bowel and sexual side effects is very variable across the literature. The learning curve and the implant quality have a clear impact on the toxicity outcomes. Being aware of some of the technical challenges encountered during the procedure and ways to mitigate them could decrease the incidence of side effects. Careful planning of seed placement and seed deposition allow sparing of the organs at risk and a lower incidence of urinary and gastro-intestinal toxicity.

CONCLUSIONS

Low dose-rate brachytherapy remains a standard monotherapy treatment in the setting of favorable-risk prostate cancer. High disease control and low long-term toxicities are achievable in expert hands with a good technique.

Brachytherapy Combined With or Without Hormone Therapy for Localized Prostate Cancer: A Meta-Analysis and Systematic Review

Purpose: The purpose of this study was to evaluate the efficacy of brachytherapy combined with or without hormone therapy in patients with localized prostate cancer.

Methods and Materials: We systemically searched the Medline, Web of Science, Cochrane Library and Embase databases for studies published between the databases' dates of inception and February 2019. The primary endpoints were the 5-year overall survival (OS) rates, 5-year biochemical progression-free survival (bPFS) rates and 10-year bPFS rates. The results were expressed as the relative risk (RR) and 95% confidence interval (CI). Based on the heterogeneity evaluated with the I² statistic, a meta-analysis was performed using either a random- or fixed-effects model.

Results: A total of 16 cohort studies including 9,359 patients met all the criteria for inclusion in the analysis. Our data showed that brachytherapy (BT) combined with hormone therapy (HT) increased the patients' 5-year bPFS rates (RR = 1.04, 95% CI: 1.01–1.08, P = 0.005) and 10-year bPFS rates (RR = 1.12, 95% CI: 1.02–1.23, P = 0.001) compared with BT monotherapy. However, BT combined with HT did not increase the patients' 5-year OS rates (RR = 1.02, 95% CI: 0.99–1.095, P = 0.1) compared with BT monotherapy.

Conclusions: BT combined with HT can increase the bPFS rates of patients with localized prostate cancer, but it does not improve patients' OS rates.

Prospective four years of evaluation of erectile function after low-dose-rate prostate brachytherapy using baseline IIEF-5 > 16

Purpose

Prostate brachytherapy (BT) is a validated treatment for localized prostate cancer (CaP) and an attractive therapy option for patients seeking to preserve erectile function (EF). The aim of this paper is to prospectively assess EF evolution during 4 years after BT.

Material and methods

Between February 2007 and July 2012, 179 patients underwent an exclusive Iodine-125 BT, for low-intermediate favorable risk CaP of whom, 102 had an initial international index of erectile function 5 score (IIEF-5) > 16 and were included in the study. Of those, 12.7% received neo-adjuvant hormonotherapy (HT) to decrease the prostate volume. Post-BT intake of phosphodiesterase inhibitors (PDE5i) was not an exclusion criterion. Erectile function was prospectively assessed using a validated questionnaire IIEF-5 before treatment and annually for 4 years.

Results

At 1-year follow-up, 54% of patients preserved an IIEF-5 > 16 and only 8% suffered from severe ED. During the next 3 years, the results were not statistically different. The mean IIEF-5 lost 4 points during the first year, 17 vs. 21, and remained stable during the following 3 years. We did not find any significant differences in the proportion of patients treated by PDE5i (18-20%). As for patients with a normal preoperative IIEF-5 (> 21) (n = 52), 35-42% preserved a normal EF and 71-77% maintained an IIEF-5 > 16, including 13-19% of patients who needed PDE5i. Those results were stable for over 4 years.

Conclusions

During the first 4 years after BT, more than half of patients maintained an IIEF-5 > 16, and EF results remained stable. Severe erectile dysfunction (ED) was very rare.

Reporting Erectile Function Outcomes After Radiation Therapy for Prostate Cancer: Challenges in Data Interpretation

BACKGROUND

Choice of prostate cancer treatment is frequently influenced by the expected chance of treatment-induced side effects such as erectile dysfunction (ED). However, great discrepancy in cited ED rates exists in the contemporary radiation therapy literature.

AIM

To analyze the reported ED rates and cause of discrepancies and explore the strengths and limitations in the literature on radiation-induced ED.

METHODS

We performed a PubMed literature search and reviewed the literature on ED rates associated with external-beam radiotherapy and brachytherapy from the past 10 years. Eighteen studies were eligible for inclusion and subsequently reviewed.

OUTCOMES

Variables required for interpretation of erectile function outcomes, including patient demographics, treatment characteristics, and sexual function outcomes.

RESULTS

A large variety in the reported incidence of ED was found among studies. In part, these differences resulted from large variations in (i) study populations, (ii) patient characteristics, (iii) treatment characteristics, (iv) prescription of androgen deprivation therapy, (v) means of data acquisition, (vi) definitions of ED, (vii) temporal considerations, and (viii) erectile aid use. Relevant data required for adequate appraisal of sexual function outcomes were not always reported.

CLINICAL IMPLICATIONS

Based on the present findings, we present general recommendations for reporting of erectile function outcomes after radiotherapy for prostate cancer. These should improve future reports.

STRENGTHS AND LIMITATIONS

This is the first report that presents general requirements on reporting erectile function outcomes in the setting of radiotherapy for prostate cancer. We did not conduct a formal meta-analysis because we focused on concepts of research design; this might be considered a limitation.

CONCLUSION

In this review, we have highlighted the strengths and deficiencies of the current literature on ED after external-beam radiotherapy and brachytherapy for prostate cancer. We have made general recommendations to achieve some degree of standardization among reports and improve clinical interpretability. Wortel RC, Incrocci L, Muhall JP. Reporting Erectile Function Outcomes After Radiation Therapy for Prostate Cancer: Challenges in Data Interpretation. J Sex Med 2017;14:1260-1269.

[Toxicity and quality of life comparison of iodine 125 brachytherapy and stereotactic radiotherapy for prostate cancers]

Quality of life is a major issue for good prognostic prostate cancer, for which brachytherapy is one of the reference treatments. Stereotactic Body Radiotherapy (SBRT) is a recent alternative however not yet validated as a standard treatment. This review of the literature reports and compares the toxicities and the quality of life, either after exclusive brachytherapy with iodine 125 or after SBRT. The comparison is made with the limitations of the absence of randomized trial comparing the two treatment techniques. Acute toxicity appears to be lower after SBRT compared to brachytherapy (from 10 to 40 % versus 30 to 40 %, respectively). Conversely, acute and late gastrointestinal toxicity (from 0 to 21 % and from 0 to 10 % of grade 2, respectively) appears more frequent with SBRT. Late urinary toxicity seems identical between both techniques (from 20 to 30 % of grade 2), with a possible urinary flare syndrome. Both treatments have an impact on erectile dysfunction, although it is not possible to conclude that a technique is superior because of the limited data on SBRT. SBRT has better bowel and urinary (irritation or obstruction) quality of life scores than brachytherapy; while sexual and urinary incontinence remain the same. The absence of randomized trial comparing SBRT with brachytherapy for prostate cancers does not allow to conclude on the superiority of one technique over another, thus justifying a phase III medicoeconomic evaluation.

Erectile function following brachytherapy, external beam radiotherapy, or radical prostatectomy in prostate cancer patients

BACKGROUND AND PURPOSE

For localized prostate cancer, treatment options include external beam radiotherapy (EBRT), radical prostatectomy (RP), and brachytherapy (BT). Erectile dysfunction (ED) is a common side-effect. Our aim was to evaluate penile erectile function (EF) before and after BT, EBRT, or RP using a validated self-administered quality-of-life survey from a prospective registry.

MATERIAL AND METHODS

Analysis included 478 patients undergoing RP (n = 252), EBRT (n = 91), and BT (n = 135) with at least 1 year of follow-up and EF documented using IIEF-5 scores at baseline, 6 weeks, 6 months, 1 year, and annually thereafter.

RESULTS

Differences among treatments were most pronounced among patients with no or mild initial ED (IIEF-5 ≥ 17). Overall, corrected for baseline EF and age, BT was associated with higher IIEF-5 scores than RP (+ 7.8 IIEF-5 score) or EBRT (+ 3.1 IIEF-5 score). EBRT was associated with better IIEF-5 scores than RP (+ 4.7 IIEF-5 score). In patients undergoing EBRT or RP with bilateral nerve sparing (NS), recovery of EF was observed and during follow-up, the differences to BT were not statistically significant. Overall age had a negative impact on EF preservation (corrected for baseline IIEF).

CONCLUSION

In our series, EF was adversely affected by each treatment modality. Considered overall, BT provided the best EF preservation in comparison to EBRT or RP.