Prostate Cancer Update
Brachytherapy for Prostate Cancer: Proven or Just Popular?
(September 2000, Cancer Care in Canada)
Brachytherapy, a new technique for operating on tumours of the prostate gland is making waves in Canada. In April 2000, the Globe and Mail proclaimed it will be the treatment of choice within five years. Prostate cancer support groups in several provinces are also demanding broader access to it. However, brachytherapy remains an option for only a very few Canadian men with prostate cancer. Is the enthusiasm of Canadian physicians being tempered by scientific skepticism? Are tight budgets to blame?
In brachytherapy, tiny radioactive seeds are implanted by needle directly into the prostate in an attempt to limit the irradiation of healthy tissue while delivering a powerful dose to the tumour itself. The goal is to avoid the impotence and incontinence that so often results from prostate surgery or external beam radiation. Reports coming from the U.S. suggest that brachytherapy is about as effective as prostatectomy in preventing cancer recurrence.
In Canada, the treatment is offered in Quebec, Ontario, Alberta and British Columbia. All four programmes are budget-limited, and select their patients according to rigid criteria. PSA count, and tumour size and grade must be fairly low. The prostate gland itself must be within certain size limits, and the patient must have a minimum ten-year life expectancy. 'Using our own criteria, 400 to 500 people are eligible here annually,' says Dr Jim Morris, who heads B.C.'s brachytherapy program. 'But the most procedures we can hope to perform is 200 a year because of budget limitations.' He anticipates the criteria being loosened up to include perhaps twice as many people in the future.
Balancing scientific proof and popular demand
Dr. Morris stresses that brachytherapy does have major side effects, and that there's not enough evidence yet to prove that it's safer than prostatectomy or external beam radiation. Dr. Eric Vigneault, who heads Canada's oldest brachytherapy programme in Quebec City, echoes these sentiments. 'Brachytherapy has major side-effects which are often understated in the literature.' Dr. Vigneault's experience with 275 patients to date is beginning to provide a picture of side-effects. Like the US studies, he is seeing very low rates of permanent gross incontinence, and impotence rates of 40% compared to the 80% seen in radical prostatectomy. 'But we don't know the long-term effects,' he says. 'There's reason to believe that healing from radiation involves more scarring than healing from surgery. This could lead to a rigid, incompetent sphincter and incontinence developing years after the treatment.'
Despite the skepticism among doctors, there's no question patients want this treatment, and the demand is likely to grow. 'Among our patients who are offered the treatment,' says Dr. Morris, 'over 90% take it, basically because of a perception that it's as effective as prostatectomy but with less chance of resulting in incontinence and impotence.' Dr. Morris estimates that brachytherapy is probably slightly more expensive than surgery, but considerably cheaper than external beam radiation. 'It's only more expensive than surgery because surgeon's fees are so low in Canada,' he says.
Both Dr. Vigneault and Dr. Morris are hoping to increase the number of patients they treat by 50% in the next 12 months. Dr. Morris now finds himself treating patients from other provinces. 'They believe the treatment is equally effective against the cancer, with lesser side effects. That's just an opinion, but it's beginning to look like a fairly sound one. We're planning to publish some results once our database reaches a respectable size, and they will probably lend support to that belief.'
Murray Brennan, of the Alberta Prostate Cancer Support Network, is waiting to undergo brachytherapy and has been petitioning his Health Department for more funding. 'They won't say it outright, but it's the dollar factor that makes them reluctant.' Nevertheless, he believes we'll be hearing a lot more about the treatment. 'No politician would dare to come out and say he's prepared to accept high rates of impotence and incontinence to save a few dollars.'