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Prostate brachytherapy: Guidelines assure procedural success and safeguard patients

Prostate brachytherapy: Guidelines assure procedural success and safeguard patients

ABSTRACT: Mismanaged therapy at one institution has dealt a blow to the field, but practitioners explain why the technique remains worthwhile.

An image from a 3D prostate cancer treatment plan created using Varian's BrachyVision treatment planning software. Image courtesy of Varian Medical Systems.

The New York Times last year uncovered a scandal about prostate brachytherapy procedures at the Veterans Affairs Medical Center in Philadelphia: A single radiation oncologist had allegedly botched more than three-fourths of the prostate brachytherapy procedures performed at the hospital during a six-year period.

Treatment problems ranged from brachytherapy seeds placed in healthy organs to inadequate radiation dose levels in patients. The article also claimed that lack of quality control and peer review at the Philadelphia VAMC allowed the errors to go undetected for six years (The New York Times, June 21, 2009).

The situation prompted a flurry of government activity: Both houses of Congress called veterans affairs committee meetings, while the Nuclear Regulatory Commission (NRC) launched its own investigation and found that the hospital had committed multiple safety violations in its prostate brachytherapy program. The NRC also looked at other prostate brachytherapy programs in the VA systems, but reported that, while the agency did identify some problems, these issues did not reach what it called "widespread programmatic breakdown that afflicted [the] VA Philadelphia."

Just last month, the NRC proposed a $227,500 fine against the U.S. Department of Veterans Affairs (VA) for violations of NRC regulations associated with errors at the Philadelphia facility.

For those who perform prostate brachytherapy, the Philadelphia VAMC case was a shocker; even the most minimal standards for performing the procedure seemed to have been ignored, such as using follow-up CT scans to view and evaluate seed placement after the procedures and calculate radiation dosages.

Still, physician-experts who testified before Congress in July 2009 were quick to point out that the Philadelphia story was the exception and not the rule. "Each year, there are approximately 50,000 brachytherapy treatments performed in the U.S." said W. Robert Lee, MD, a professor of radiation oncology at Duke University in Durham, N.C., who testified before Congress on behalf of ASTRO.

"Even with [the events that occurred within the VA], only about 0.22% of the procedures nationwide resulted in a reportable event in 2008. Brachytherapy is an extremely safe and effective procedure," Dr Lee said.

It's a point that proponents are keen to drive home: This state-of-the art, and often highly successful, treatment option should not be judged by the mistakes made at one institution. In fact, the American Brachytherapy Society (ABS) is in the process of updating its 10-year-old guidelines to reflect advances in the field.

"There is an enormous body of literature and data on thousands of patients over the last 20 years showing that patients have been successfully treated with brachytherapy in the United States and Europe," said Eric Horwitz, MD, ABS president. "The case of the Philadelphia VA highlights the need for consensus and strict guidelines."

Oncology News International spoke with Dr. Horwitz and other experts about the current state of prostate brachytherapy. They offered advice to referring physicians and their patients on how to determine if the treatment—and the physician performing the treatment—is their best bet.

"We know that our outcomes, our control of PSA, and our disease-free survival are tied to adherence to guidelines," said Nathan Bittner, MD, an ABS board member. The cases at the Philadelphia VAMC were "unfortunate, and set the field of brachytherapy back a great deal. It underscores the importance of standards in our field."

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