Dr. med. Stefan Carl recently published a long-term evaluation of low-dose-rate (LDR) brachytherapy as a treatment option for localized prostate cancer.
We spoke to Dr. Carl about this publication and his professional experience.
We sat down with Dr. med. Stefan Carl to talk about his recent publication “Long-term evaluation of low-dose-rate (LDR) brachytherapy in localized prostate cancer”. He and his colleagues conducted a retrospective multicenter analysis of LDR brachytherapy treatment in Germany.
Dr. med. Stefan Carl
Dr. Carl was trained at the Department of Urology at Heidelberg University and is an accomplished urologist with almost 25 years of experience in the field. He is one of the resident urologists at the “Urologie Emmendingen” treating patients at the “Kreiskrankenhaus Emmendingen” hospital, where up to 100 patients a year are being treated with LDR brachytherapy.
The study and findings paint a clear picture of the potential that LDR brachytherapy has in treating patients with prostate cancer. The results could possibly even influence German guidelines for treating prostate cancer. To better understand the thought process behind the study and to fully grasp what the results could entail, we wanted to talk to Dr. Carl himself.
Eckert & Ziegler: Dr. Carl, thank you so much for your time. We were intrigued by your recent publication about LDR brachytherapy (LDR-BT). In it, you have presented the oncological results of LDR-BT using exemplary studies. So, summarize for us, how does LDR-BT present itself as a treatment option overall.
Dr. Stefan Carl: Currently, LDR-BT is a curative treatment option for patients with localized prostate cancer. The European guidelines recommend LDR-BT for patients from low to intermediate risk P-Ca. The advantage of LDR-BT compared to other treatment options like prostatectomy and external radiation is the short length of hospital stay and reduced side effect while having equal chance to be healed.
Low-Dose-Rate Brachytherapy (LDR-BT)
In this treatment, small radioactive sources (seeds) are placed inside the prostate. Each seed has a length of 4.5 mm and a diameter of 0.8 mm and emits a specific low dose of radiation to its surrounding tissue inside the prostate. By placing the seeds homogeneously throughout the organ, the prostate is covered with the designated dose required to destroy the cancerous cells. Since irradiation is mainly localized around the radioactive source, neighboring tissues are spared.
E&Z: You also mention the current study situation regarding the comparison of LDR-BT with the treatment alternatives. How effective is it in comparison to radical prostatectomy (RP)?
SC: The two randomized controlled trials (RCT) published by Giberti et al. showed no significant differences in P-Ca Patients treated with either radical prostatectomy or LDR-BT. To our knowledge, these are currently the only existing RCTs comparing Px and LDR-BT.
E&Z: This applies to low-risk prostate cancer. What about the treatment of intermediate- and high-risk patients?
SC: Most recently, a large prospective multicenter study published by Viktorin-Baier (2021) showed equally good oncological results for patients with intermediate risk P-Ca treated with LDR-BT. Actually, we were able to reproduce these results in our own study.
A lately published RCT by Morris et al. 2017 (ASCENDE Trial) compared external beam radiation (EBRT) and LDR-BT + EBRT Boost. The study showed significant advantages for high-risk P-Ca patients treated with LDR + EBRT Boost compared to EBRT Alone.
E&Z: Are there any completed randomized control trials (RCT) that compared LDR-BT with the other established treatment options?
SC: Aside from the three mentioned studies by Giberti and Morris, there are no further RCTs comparing curative treatment options for localized P-Ca. Sadly multiple big anticipated RCT-Studies with the aim to compare all four established primary treatment options ergo AS (active surveillance), Px, EBRT and LDR-BT failed because of insufficient patient recruitment. The infamous german example would be the PREFERE-Trial, which suffered from recruitment problems and to our opinion a too complex study design.
E&Z: Can you give us a quick description of your study’s specifics? What parameters were considered, what methods were used, and, above all, what results were obtained.
SC: We analyzed 618 patients with localized P-Ca treated with LDR-BT. The majority of our cohort were patients with low and intermediate risk prostate cancer. The primary endpoint of our study was biochemical relapse free survival (bRFS). Simply explained, bRFS means that patients stay under their respective PSA-Nadir after their procedure.
The main results would be that almost 90% of our patients had no PSA-relapse after an estimated follow-up of 10 years. Especially when comparing low and intermediate risk patients in monovariate and multiple regression models, there we no significant differences between intermediate and low risk patients in bRFS. However, our study is limited by the retrospective study-design.
E&Z: What motivated you to this study-design? What were you aiming for?
SC: At the moment, there are dichotomous recommendations between German and European guidelines for prostate cancer concerning LDR-BT. German recommendations are limited to low-risk P-Ca patients, but the current literature suggests a safe use for patients with intermediate risk as well. This circumstance motivated us to report our promising results from a German point of view.
E&Z: What do you think, what kind of impact will these findings have?
SC: Hopefully we will have a larger understanding and a better acceptance for LDR-Brachytherapy as a treatment option compared to radical surgery and external beam radiation therapy. Patients like a safe treatment with a short hospital stay while having a comparable healing rate. Concerning the international guidelines Germany is far behind the EAU guidelines and the ABS guidelines So we hope that in the near future the German guidelines, will be adapted with a recommendation of LDR-BT for Gleason Score 7a.
E&Z: Dr. Carl, thank you very much for your insights!
If you want to find out more about LDR-Brachytherapy for prostate cancer, watch the following YouTube-Video or contact us for additional informational material!