The influential role of GPs – and brachytherapy – in prostate cancer care

New guidelines around PSA testing promise to transform prostate cancer outcomes in Australia. The guidelines, which recommend that asymptomatic men between the ages of 50-69 are offered PSA testing every two years1, replace US Preventative Services Task Force guidelines and previous differing guidelines in Australia that some urologists blame for an increase in presentations with metastatic prostate cancer2. Certainly, when screening was discouraged, adverse consequences followed, with evidence showing that mortality from prostate cancer is lower when men are screened for it3. With prostate cancer the third most common cause of male cancer deaths in Australia, policies that improve early diagnosis can only help reduce mortality.

Yet efforts to improve outcomes require a similar focus on treatment. With choice now a key component of patient-centred care, we’re fortunate to have multiple treatment options for prostate cancer – but we could arguably do more to ensure newly-diagnosed patients understand the full range. For many, these options will include brachytherapy – an efficacious equivalent to traditional treatments4 that can yield important advantages in quality of life, convenience and patient experience. Despite these advantages, awareness and use of brachytherapy remains low. It’s a missed opportunity. However, with the new guidelines giving GPs a more active role in early diagnosis, physicians have the chance to harness their trusted relationship with patients and help them make fully-informed decisions about their care.

Complex choice

The choice of treatment for localised prostate cancer can certainly be complex, influenced by factors like age and co-morbidity, cancer characteristics, treatment availability and personal preferences. A fundamental principle is for patients to be given comprehensive information, access to multi- disciplinary input and psycho-social support during the decision-making process. Whilst there are various models whereby this may be achieved, the GP plays an integral role in all of them.

The USANZ recommends giving patients the opportunity to see a radiation oncologist for an opinion on all available treatment options5. The RANZCR’s Target Cancer campaign cites GPs as the best means of facilitating this at the referral stage. In addition, Optimal Care Pathways guidelines provide detailed information on the holistic approach to cancer care6, whilst PCFA Prostate Cancer Support Nurses provide further resources to support patients’ decision-making. We must maximise all these resources to help patients make informed choices.

Brachytherapy: underused

Active Surveillance is now an option for patients with early stage prostate cancer but if he desires radical treatment or has more aggressive disease, surgery (radical prostatectomy (RP) or robotic radical prostatectomy), remains the most common primary treatment for prostate cancer. Alongside it, external beam radiation (EBRT) and brachytherapy complete the range of options. However, despite brachytherapy being an alternative for many patients – it’s an unsung option that often goes under the radar.

Brachytherapy achieves high precision, targeted radiotherapy, using computerised treatment planning and image-guided delivery systems to deliver a tailored ablative tumour dose to the prostate whilst sparing surrounding organs. There are two techniques; low-dose rate (LDR), where radioactive seeds are permanently implanted into prostate tissue, and high-dose rate (HDR), where the radioactive source is temporarily placed into the prostate via implanted needles. Brachytherapy can be used as a monotherapy or in combination with EBRT.

LDR monotherapy

Established and emerging evidence supports a wider use of monotherapy brachytherapy. A 2012 comparative effectiveness study by the Prostate Cancer Study Group evaluated more than 50,000 patients with low, intermediate and high-risk disease treated with all available primary treatment options4,7. It found LDR monotherapy brachytherapy an excellent alternative to surgery in patients with low-risk and favourable intermediate-risk prostate cancer. Low-risk patients treated with LDR monotherapy demonstrated PSA recurrence-free survival (RFS) rates similar to those for EBRT and RP; long-term biochemical RFS reported at 89% at 12 years8. LDR monotherapy brachytherapy has also proven to be a good option in patients with selected favourable intermediate-risk disease, once again indicating durable PSA RFS; long-term biochemical RFS reported at 78% at 12 years8.