Prostate Brachytherapy

The Seeds of Healing

Jack Crawford brachytherapy patientWhen 68-year-old John “Jack” Crawford of Whitinsville was told he had prostate cancer on December 10, 2010, the newly-retired former state police officer used his investigative skills to better understand his diagnosis. He read credible medical journals, talked with friends and researched the topic thoroughly. Armed with a page and a half of questions for his doctor, Jack made a conscious decision to become as informed as possible—a process with which he had been familiar during his 32 years working in law enforcement. Still, despite all of his best efforts to research treatment options, Jack admits that nothing could have prepared him for the initial diagnosis. “I didn’t expect it,” he says, solemnly.

Jack had always taken a proactive approach to his health and monitored his prostate-specific antigen (PSA) levels annually. He hadn’t had any symptoms and, therefore, didn’t think prostate cancer would ever become a reality. However, when his own brother was diagnosed with prostate cancer and subsequently died from it in 2000, he knew he needed to take his own health—and hereditary connection to the disease—even more seriously. To complicate matters, his brother-in-law also died from prostate cancer in 2004. “There was an awareness of the disease,” he recalls.

So, when Jack discovered his PSA level was elevated, he was quick to see Milford Regional urologist Mitchell Bamberger, MD, of Tri-Country Urology in Milford, for a more intensive exam and biopsy. When the diagnosis came back as prostate cancer, he wanted to know his options.

“Prostate cancer is the most common non-skin cancer among men, and some estimates suggest that one in six men will be diagnosed with prostate cancer in their lives,” says Peter F. Orio, DO, radiation oncologist at Dana-Farber/Brigham and Women’s Cancer Center and on the medical staff at Milford Regional. “We are diagnosing many prostate cancers before they become clinically significant. As such, we have many highly effective treatment options to offer these patients.”

The good news was that Jack’s prostate cancer was in the early stages and considered low risk. This meant he had a couple of options for treatment. His first option was to undergo a radical prostatectomy during which his prostate would be entirely removed. The second option was external beam radiation therapy which provides a highly conformal radiation dose to the prostate over several weeks. The third option was brachytherapy—a minimally invasive, outpatient procedure during which small radioactive seeds are implanted into and around the prostate to provide targeted radiation treatment.

“We can give a lot of radiation right to the tumor. We treat the entire prostate with a curative dose, but we’re also putting radiation seeds right up against the tumor itself,” explains Dr. Orio, who performs prostate brachytherapy at Milford Regional. Brachytherapy is extremely effective for low-risk prostate cancers, and it can also be used in conjunction with external beam radiation for intermediate or high-risk prostate cancers, he adds.

In order to make an informed decision about his treatment, Dr. Bamberger referred Jack to Dr. Orio to talk more in-depth about brachytherapy. When Jack first heard about brachytherapy, he admits he was skeptical. “I’d always heard, ‘when in doubt, take it out,’” he says. “It makes sense, but as I started to do more research and get educated about the process, I started to realize that this may not be the right answer for me. Every patient is a little different, and they need to figure out what’s best for their situation.”

During his initial consultation to discuss brachytherapy, Jack was particularly impressed with Dr. Orio’s credentials and the time he spent answering all of his questions. “I could not believe I had a doctor of this caliber ten miles from my house,” he exclaims in awe.

Paula, Jack’s wife, agrees, adding that Dr. Orio’s overall demeanor was comforting. “He met all of the criteria, and he had a nice manner to him. That is not essential, but it certainly does a lot to put you at ease,” she recalls.

Dr. Orio explained that for patients with low-risk prostate cancer, brachytherapy is as effective as external beam radiation therapy or even radical prostatectomy. It also has a faster recovery time than surgery and doesn’t require the repetitive trips needed for external beam radiation therapy. However, several factors must be taken into account to determine whether a patient is a good candidate for the procedure, including the size of the prostate, symptoms, whether the disease is confined to the prostate, the percentage of positive biopsies, and the Gleason score which denotes the aggressiveness of the cancer. Brachytherapy is ideal for those with a relatively normal size prostate whose cancer is considered low-risk to intermediate risk and is organ-confined, says Dr. Orio. Jack met all of these criteria.

The minimally-invasive nature of brachytherapy, as well as its high success rate, appealed to Jack. “If you’re going to end up with the same result, then why go through all of the radical procedure in terms of removal? It could lead to scarring of the urethra and a longer recovery time,” he concluded. “I felt totally confident after talking with Dr. Orio that he had targeted the area and the prostate was accessible.”

Although Jack considered going into Boston for his procedure, he ultimately chose Milford Regional because of his confidence in Dr. Orio and the medical center’s close proximity to home. He had also accessed Milford Regional’s services several times before and had always been pleased with the care he received. “It’s a very well-respected hospital in this area, and the staff couldn’t have been more helpful,” he recalls.

During the procedure, Dr. Orio worked in conjunction with two physicists and the patients treating urologist. Together, they mapped Jack’s prostate using advanced imaging technologies and input this information into a sophisticated treatment planning computer system. “The computer performs more than 500,000 different iterations of the plan to find the perfect needle-seed combination for Jack’s prostate,” Dr. Orio explains. He and his team then go one step further, refining the plan even more based upon the patient’s specific needs.

The computation is performed during the actual procedure to ensure the most accurate and effective placement of the seeds. According to Dr. Orio, this real-time/intra-operative planning is what sets Milford Regional apart from other hospitals where the planning is done well in advance of the procedure. This delay may or may not reflect the most up-to-date depiction of the patient’s prostate going into surgery.

Using 16-22 fine needles, Dr. Orio deposits approximately 70-100 brachytherapy seeds, each of which is the size of a grain of rice, through the perineum and into the prostate. He also places seeds around the capsule that surrounds the prostate to stop any cancer that is trying to migrate beyond the prostate to other organs. No incisions are made. The seeds are linked together in the most effective pattern for treatment of the patient’s prostate using a plastic material that’s compatible with the body which dissolves over several months. This keeps the seeds locked in place and prevents them from migrating to other areas of the body. Finally, the seeds are exactly placed within the prostate with real time image guidance.

Generally, the seeds provide the highest doses of radiation within the first couple of months, but continue to bath the cancer in radiation for approximately 10 months. “Biologically, we know that prostate cancer is a very slow-growing tumor,” explains Dr. Orio. “Cancer is radio-sensitive in different phases of its cell cycle. By constantly bathing the cancer cells in low-dose radiation, you get them when they’re most vulnerable—when the cancer cells are most likely trying to divide and move into different portions of the cell cycle. Radiation is waiting to kill the cancer cells.”

Brachytherapy’s high precision, targeted approach means radiation is kept a safe distance away from the urethra, which minimizes urinary complications. Radiation doses to the rectum and bladder are also kept to a minimum.

Jack spent approximately six hours in the hospital, which included registration, surgery and recovery from general anesthesia. Aside from some minor tenderness in his perineum as well as some slight burning during urination the day after surgery, Jack says he recovered easily. Dr. Orio prescribes several medications to minimize these side effects, and most patients resume normal activities within a couple of days. Patients undergo a PSA test, CT scan and MRI one month after the procedure and continue to have their PSA levels monitored as well as undergo prostate exams thereafter.

Today, Jack continues to think positively and says he feels great. The former Boston marathoner stays active by running, golfing and volunteering as a track and field coach at Whitinsville Christian School. He attributes his success to the support of his family and the stellar medical care he received at Milford Regional. “We’re fortunate that we have a great medical community here. It was a very positive experience in a negative situation,” he says resolutely.

In addition, Jack—at the advice of Dr. Bamberger—has advocated for other males in his family to monitor their PSA levels. He encourages others diagnosed with prostate cancer to not give up hope.

“This is a very treatable form of cancer, but you have to be proactive,” he emphasizes. “Don’t be afraid to go to the doctor. There are good options. Knowledge is power that will help you make the best decision for yourself.”

Read more about Peter Orio, III, DO

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