Case study: a new approach to prostate cancer treatment

How Maidstone and Tunbridge Wells NHS Trust is working with BXTAccelyon to offer 4D brachytherapy to patients, reducing the need for anesthesia

The technology

4D Brachytherapy is a hybrid approach to LDR brachytherapy for prostate cancer.

It combines the benefits of both a two-stage and one-stage implant technique to create a new real-time and dynamic approach to seed brachytherapy.

It not only eliminates some of the disadvantages aligned with each approach, but also introduces a host of added benefits.

The benefits:

  • An effective and highly-targeted treatment option
  • A time-efficient procedure for both patients and clinicians
  • Reduced cost for the hospital – Maidstone Hospital has shortened the duration of the operating list by almost 30%
  • Side effects are significantly reduced for patients

The impact

Maidstone and Tunbridge Wells NHS Trust has identified 4D brachytherapy as one of the most-effective and time-efficient means of treating prostate cancer.

We have seen many advantages to using this treatment compared to the standard two-step procedure

This revolutionary new technique has become preferable to the standard two-stage Low Dose Rate (LDR) brachytherapy implant technique due to its speed, highly-targeted approach, and the reduced risk of side effects.

Alastair Henderson, consultant urological surgeon at the trust, said: “I have been providing 4D brachytherapy since 2015.

“In 2015 we undertook 48 procedures using the new 4D technique and we have seen this increase to 83 procedures throughout 2016.

“We have seen many advantages to using this treatment compared to the standard two-step procedure.

“One main advantage is in relation to the comfort and convenience of our patients.

“Using the 4D brachytherapy treatment we are able to undertake a volume study without a catheter; this is a welcome change as the use of a catheter has always been the main area of discomfort and distress for patients.

“Furthermore, the volume study is able to be performed by our consultant brachytherapy radiographer and therefore does not need to take place in an operating theatre. Any clinical room can be used, which has created time and process efficiencies for the centre, as well as convenience of appointments for patients.

“As the oncology or urology consultant is not required to be present at this stage, we have seen them gain back much-needed and precious time.

“Our records show that on average consultants at Maidstone have shortened the duration of the operating list by almost 30% by sharing the workload for volume studies with a radiographer colleague.

“Our intra-op planning is robust and reproducible therefore we have seen our dosimetry improve by 16% compared to using the standard two-step brachytherapy without additional dose to critical structures or increased toxicity.”

The standard two-step LDR brachytherapy technique required more than one theatre visit and anaesthetic, while the traditional single-stage technique meant patients would remain in theatre under anaesthetic for the full scanning, dose planning and procedure – a lengthy time of around two hours.

Our records show that on average consultants at Maidstone have shortened the duration of the operating list by almost 30% by sharing the workload for volume studies with a radiographer colleague

This was not advantageous to the patient, and also limited the number of treatments possible in a theatre schedule.

Contrary to the above, the 4D technique means that patients no longer require two anaesthetics and the pre-planning scan can take place alongside the clinical visit all within the space of 15-20 mins.

This development has been made possible thanks to the scientific approach to treatment planning reflecting that the size of the prostate predicts the number of seeds required during treatment. This means a simple and unobtrusive ultrasound scan carried out in outpatients is all that is required to accurately predict the right amount of radioactive seeds required for implantation.

With this information – produced via a proprietary nomogram - clinicians can now pre-order and pre-load the seeds in advance of theatre ready for implantation, removing a number of the steps normally carried out under anaesthetic in traditional two stage implant. It is a very quick process of identifying not only how many seeds to use, but also finding out where to position them in the prostate.

Henderson said: “4D brachytherapy also offers flexibility with our implant technique.

“We use a combination of pre-loaded strands and the Isoloader, which allows us to build real-time strands as required. This enables us to deliver a very-robust, wholly-stranded implant.

“The 4D technique can be used with the philosophy of either using central loose seeds or wholly-stranded seeds therefore providing flexibility and allowing consultants to adapt the technique as they choose.”

As the oncology or urology consultant is not required to be present at this stage, we have seen them gain back much-needed and precious time

4D Brachytherapy not only improves efficiency; this hybrid approach also minimises side effects. A more-targeted and precise coverage of radiation around the prostate gland means reduction in potential complications. For example, it reduces the risk of urinary symptoms and erectile dysfunction, both common side effects of prostate vancer treatment.

Henderson said: “In our experience the 4D brachytherapy approach that we use here has improved dosimetry, which we know is associated with improvements in cancer control.

“It also allows us to treat patients without seeing any worsening in the degree of post-treatment symptoms compared with the standard technique.”

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