Long-term Follow-up and Effectiveness of Brachytherapy
The first follow-up appointment involves a brief office evaluation about 1 week after the prostate brachytherapy procedure to help the patient with his side effects. In our experience, this has been a very good time to review and sometimes adjust the patient’s medical regimen.
The cancer-specific follow-up begins at 3 months, and is then repeated every 6 months thereafter. If his urologist also follows the patient, we will often reduce our own follow-up visit frequency to every 12 months, having the patient alternate visits between the urologist and ourselves. After 5 years, we typically reduce the frequency of the follow-up visits to once per year. The follow-up frequency may be altered in specific cases for various reasons.
Before every visit, a PSA level will be checked, typically about 1 week prior to the appointment, so the radiation oncologist will have that result for discussion with the patient at the time of the appointment.
PSA Response to Brachytherapy
The PSA response to prostate brachytherapy may be more complicated to interpret than after other forms of prostate cancer treatment. The usual PSA response includes a steep drop in the PSA level during the first 3 – 6 months, followed by a more gradual reduction, which may evolve slowly over a number of years. Eventually, most brachytherapy patients see their PSA nadir in the 0.0 – 0.2 ng/ml range, though this may take 5 years or more to fully develop. Too, some patients will never see their PSA drop to a level this low, and yet still be apparently cured of their disease. Rarely, unfortunately, patients will develop a persistently rising PSA after the treatment. If a patient develops a persistently rising PSA after the brachytherapy procedure, this may be diagnosed as “Biochemical failure of their disease.” If this happens, the following tests, care and recommendations will vary, depending upon the exact patient situation.
The PSA “Bounce”
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A fairly common PSA event after prostate brachytherapy is a temporary rise or “bounce” in the PSA level, which then spontaneously returns to a lower level after additional passage of time. The classic “PSA bounce” timing is about 1-2 years after the procedure and may be seen in up to 30% of all brachytherapy patients. Eventually, most of these “bounce” patients become long-term disease-free survivors. If there is a bounce or increasing PSA pattern occurring, more frequent PSA checks may be ordered until the final resolution is observed. Rare cases of double and even triple “bounces” have been reported.
The Prostate Cancer “Cure” Rate
Based upon contemporary literature review, it is reasonable to expect the following long-term (5-10 year) PSA-based disease-free survival probabilities in our brachytherapy patients. (1)(2)(3)
Favorable – 90%
Intermediate – 75-80%
Unfavorable – 30-65%
Most patients with a non-rising PSA at 10 years are likely cured of their disease, though there are no extremely long-term PSA-based data with brachytherapy, or for that matter, with any treatment option. Rare very late relapses will occur and cure is never guaranteed, but the relative lack of PSA-based treatment failures in brachytherapy patients between 5 and 10 years suggests that most of them will be cured.
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3D Conformal Radiotherapy (with IMRT)
High Dose Rate Prostate Brachytherapy
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