How can men decrease risk of developing prostate cancer?

There’s no way to decrease risk because till today the cause of prostate cancer is not known. Most important is early diagnosis that can be achieved by annual prostate screening. This is the key to a radical cure of the disease.

In which age should prostate screening begin?

It should start at the age of 40. Men with a familial history of the disease or African Americans should begin annual checkup earlier.

Which is the most effective method to diagnose prostate cancer?

Diagnosis of prostate cancer is based on measurement of PSA level, on digital rectal examination of the prostate and on the transrectal ultrasound (TRUS). These two examinations will lead to an early diagnosis, thus to high possibility of radical treatment.

Which are the indications of prostate brachytherapy?

All low risk patients that are candidates for radical prostatectomy or external beam irradiation can be candidates for prostate brachytherapy. In high risk patients (see Table 1) combination therapy is applied giving superior results (85-90%) to any monotherapy treatment option. The decision about monotherapy or combination form of treatment will be taken after consulting your urologist, but combination form should include all patients with high possibility of disease spread outside the prostate.

What are the cure rates after prostate brachytherapy?

90-95% in 15-years follow up.

How can early diagnosis be achieved?

Early diagnosis is based on proper informing of men and on annual checkup of the prostate. There is no prevention of the disease and only early diagnosis gives hope for definite treatment. It is important to know that patients previously been submitted to prostatectomy (open or transurethral) for prostate hyperplasia, possess the same risk for developing prostate cancer as the rest of the population. So, annual prostate screening should include this group of men too.

Do radioactive seeds harm the patient in any way?

No. The seeds remain permanently in the prostate and in few months become totally inactive causing no discomfort at all.

What does annual prostate screening consists of?

i) clinical examination, including digital rectal examination (DRE)
ii) laboratory screening, such as measurement of PSA level
After the above two screening tests, urologist will decide to recommend or not further screening (transrectal ultrasound or prostate biopsy).

What are the symptoms of the Prostate Cancer?

At the onset of the disease (prostate cancer and prostate hyperplasia), symptoms may not be present because the lesion is small. At later stages of the disease the followings symptoms might appear:
Frequency (frequent urination), nycturia (patient gets up frequently at night to urinate), decreased urine flow, straining (difficulty in starting urination), urinary retention (inability to urinate), blood in sperm or urine, skeletal or back pain.

What is the importance of digital rectal examination?

It is the simplest examination for assessing any disease of the prostate gland (inflammation, hyperplasia or cancer).

Where is diagnosis of prostate cancer based?

It is based on prostate specific antigen level measurement and on transrectal ultrasound. PSA level should be measured every 6 months or annually. Transrectal ultrasound is the best tool for visualization all the anatomy of prostate gland and results of the above mentioned will lead the patient to a prostate biopsy or not.

Why patients are combining hormonal therapy (complete androgen blockage) with brachytherapy?

It is proven that combination of hormonal therapy and radiation gives better results than radiation alone. Also, complete androgen blockage decreases prostate volume and this facilitates seed implantation. Hormonal administration starts 2-3 months prior to implantation and depending on the stage of the disease it may continue for 3-6 months after. The decision concerning the length of hormonal treatment should be taken by your urologist performing the implant.

How is the disease confirmed?

The disease is confirmed by a prostate biopsy under transrectal ultrasound guidance. Several small prostatic tissue samples will be obtained, that then are sent to the pathologist for examination under the microscope (presence of cancerous cells).

What different types of prostate biopsy exist?

There are two types of prostate biopsy, the conventional transrectal one and the new, advanced transperineal (or mapping) biopsy. The first is performed through rectum and usually 12 cores are obtained, 6 from each lobe, from sites elected by the physician performing the ultrasound. The second is performed through a part of intact skin, called perineum that is located between scrotum and anus. Behind this part of skin, prostate can be found. The main difference of this type of biopsy is that it allows obtaining numerous cores (40-80, depending on prostate size) from constant puncture sites guided from a template, similar to that used for prostate brachytherapy or cryotherapy. This new technique maximizes diagnostic accuracy and side effect profile is kept at the same level of that of transrectal biopsy. «Hygeia» hospital was the first institution in Greece that performed the mapping biopsy in 2008 (Prostate Brachytherapy center and Ultrasound Department).

Which are the indications of transperineal (or mapping) prostate biopsy?

Transperineal prostate biopsy can be performed: 1. As an initial biopsy, since has high diagnostic accuracy, 2. After a previous negative transrectal biopsy and 3. In cases were focal treatment is considered, were mapping of the prostate is essential for proper selection of candidates. Focal treatment is a new type of minimal invasive treatment that is gaining more and more acceptance in Europe and US due to fewer side effects that possesses, compared to all other form of treatments that attend to cure the whole gland.

What refers to prostate cancer staging?

After disease confirmation by biopsy next step is to stage the disease, as done with all types of cancers, and this will determine treatment options in order to achieve the highest cure rates. Prostate cancer stages (low, intermediate and high) are determined from PSA level at time of diagnosis, Gleason score and clinical stage (see Table 1). Low risk patients are those that have all 3 characteristics of that group. Intermediate group is formed from patients that possess only 1 characteristic of that group. High risk patients are those having two intermediate risk features or at least 1 high risk one.

 Low riskIntermediate riskHigh Risk
PSA < 10 10-20 > 20
Gleason score ≤ 6 7 8-10
Clinical stage ≤ T2a T2b ≥ T2c

Table 1: Prostate cancer patients risk groups

What are the current treatment options?

Prostate cancer treatment options depend on the stage of the disease at time of diagnosis. Low risk patients have the following options: radical prostatectomy (open, laparoscopic or robotic), brachytherapy, external beam irradiation or watchful waiting. Intermediate and high risk groups of patients should elect combination of the above mentioned treatments in order to achieve the highest cure rates.

What is exactly prostate brachytherapy?

It refers to the placing of permanent radioactive pellets or “seeds” inside the prostate, also called internal radiation. It can be applied as a single therapy (monotherapy) in low risk patients or combined with hormonal therapy and/or external beam irradiation in intermediate and high risk patients. This minimal invasive method is performed in USA since 1985 and in Europe since 1996. The material used has the size of less than half grain of rice, composed of Iodine-125 and is totally harmless for humans.

How implantation of seeds is achieved?

Patient enters hospital and is submitted to routine examinations (blood screening, ECG and chest X-ray) and το fleet enema for emptying the last part of bowel. After, he is brought to operating room where spinal or general anesthesia is applied. Brachytherapy team will then perform the implant with the aid of high technology equipment and will last around 60 minutes. Patient exits the hospital the same or next day and returns to his normal life activities. Seeds remain permanently inside the prostate and in few months they become totally inactive causing no discomfort.

Which are the criteria to choose prostate brachytherapy?

Every patient that is candidate for radical prostatectomy or external beam irradiation is also candidate for brachytherapy. Especially is indicated for patients that want to avoid the risks of a major operation (surgical removal of gland or radical prostatectomy), or its side effects (incontinence and impotence). The final decision concerns only the patient and should be taken after careful counseling from his urologist, who should carefully analyze all treatment options and their side effects.

Which are the advantages of prostate brachytherapy?

-It offers highest cure rates (95%)
-It avoids risks of a major operation
-Normal anatomy is preserved, so no incontinence or impotence are caused
-Patient exits the hospital the day of implantation or next day, when he returns to his normal life activities
-The procedure is highly accepted by patients and no special precautious measures should be taken for him or his environment.

My physician told me that stage of my disease can be treated by radical prostatectomy or radioactive seed implantation. Are the two treatment options equally effective?

The cure rates of two treatment options in low risk patients (see table 1) are the same in 20 year follow up. In intermediate and high risk patients combination of treatments should be applied.

In which cases should combination treatments be applied?

In intermediate and high risk patients (see Table 1) combination of treatments should be applied in order to achieve the highest cure rates.

Is it true that prostate seed implantation has been used in the past but without satisfactory results?

Yes, that is true. Prostate seed implantation was first performed in 1913 and from 1965 to 1983 in several hospitals. The deposition of seeds was done by an open free-hand technique with no imaging available to determine prostate volume and relationship of needles to the prostate. So, guiding of seed placement was inaccurate and this resulted in cold areas (areas where radiation was not enough to kill cancerous cells). With the introduction of transrectal ultrasound by Holm and by computer software planning development these problems were overcome and that lead team of physicians from Seattle in 1985 to describe first the “pre plan” method of seed implantation that yielded excellent disease control rates. Later, in 1995, Stone and Stock from Mount Sinai Hospital in New York described the latest form of prostate brachytherapy that can deliver the highest radiation doses, offering excellent results, with almost no side effects.

Does radiation possess any danger to my family?

No, because radiation emitted by seeds travels in very short distance causing no harm to surrounding organs or to environment.

Do radioactive seeds cause any problem to prostate gland till their radiation wears off?

No. Their radiation lasts for about 6 months, when they have lost 90% of their activity. They permanently remain inside prostate causing no discomfort.

Do radioactive seeds cause any harm to my partner during sexual intercourse?

No, because the seeds are fixed in the prostate and the possibility of one seed to be expelled during ejaculation is extremely low. If that happens though, it will cause no harm to your partner because the activity each seed carries, is very low.

What patient might experience after implantation?

Patient exits the hospital same day or the day after implantation usually feeling no discomfort at all. In few cases blood can be present at the onset of urination gradually disappears after 1-2 days. A small painless bruise below scrotum can also appear that will also go away after few days without the need of any medical intervention.

Which is the normal PSA level after prostate brachytherapy?

PSA level will gradually fall and remain below 0.2ng/ml, usually after a year from the procedure. Till then, it is possible to fluctuate and this is caused by the presence of healthy prostatic cells that are not so sensitive to radiation. This phenomenon is called PSA bounce and doesn’t constitute a disease relapse. It is more common in young patients, large prostate glands and when high radiation doses are delivered.

Can brachytherapy be performed after transurethral removal of prostate gland (TURP)?

Radioactive seed implantation with the Seattle’s technique was a contraindication after transurethral removal of the prostate because it caused high rates of urinary incontinence. The reason was that this method used to deliver high doses in the center of the gland where urethra is located. The new Real-Time method uses peripheral seed deposition, so small amount is applied to urethra, causing no side effects. If TURP is needed after seed implant, should be performed 4-6 months after, from a urologist that is familiar with the technique of brachytherapy and the effects radiation is causing to prostatic tissue.

What is the “follow up” after brachytherapy?

After prostate seed implantation the patient should be examined by his urologist (clinical examination, ultrasound of prostate and urinary bladder, PSA level measurement) every 3 months for the first 2 years. From 2nd till 5th year, the follow up should be every 6 months and beyond 5th year, annually.

Why during the night urinary symptoms become worse?

It is known that walking facilitates urination. After prostate brachytherapy urinary symptoms during the night might become during 2nd-4th month, caused by prostatic swelling and radiation effect to prostatic tissue. This is only temporary and will be relieved by medication. As the activity of the seeds wears off and due to tissue fibrosis caused by radiation, finally patient’s urination will become even better than before implantation. For helping patient to urinate freely, a-blockers and anti-inflammatory drugs are prescribed. Patients are also advised to walk regularly.

After seed implantation urinary symptoms are temporary worsened. Why do you advise patients to increase fluid intake?

The increased amount of fluid intake will decrease acidity of urine and decrease burning sensation that may appear for 1-2 months after implantation. Fluid intake though should not be excessive and certain fluids that increase acidity of urine, such as alcohol, coffee, spicy food and fruit juices, should be avoided. Usually patient can adjust himself amount and content of fluids that help him in order to achieve a better urination.

Which are the complications of prostate seed implantation?

Due to irritation of bladder, urethra and rectum caused by radiation mild symptoms of these organs may appear, that include frequent and burning sensation during urination and frequent bowel movements. These are only temporary and are relieved after appropriate medication. Symptoms will gradually cease after seeds activity wears off.