A Tale of Two Prostates
Brothers face same diagnosis, but take different treatment paths at Mary Greeley.
By Steve Sullivan
David Winter received his diagnosis in the summer. Two weeks later, his older brother Richard got his.
The news was the same for both men: prostate cancer.
The Winter brothers are retirement age but going strong. They were no strangers to the threat of cancer either, having lost a father to complications related to bladder cancer.
The two men received their respective diagnoses from the same urologist, McFarland Clinic’s Dr. Garrett Korrect, and were treated by the same radiation oncologist, Dr. Shane Hopkins, also with McFarland.
But the Winter brothers took different approaches to treating their prostate cancers at the William R. Bliss Cancer Center, a service of Mary Greeley and McFarland.
“Making the decision about which treatment is right for any individual person is complicated and should be customized based on their particular clinical situation,” says Hopkins. “Usually you should have a conversation with both a surgeon and a radiation oncologist to get all the information you need to make the best decision.”
Prostate Cancer: What Every Man Should Know
One in five men in the U.S. will be diagnosed with prostate cancer. It is the second leading cause of death from cancer in men.
Learn more about prostate cancer.
Richard was referred to Korrect after his primary care physician noted that his screening prostate specific antigen (PSA) had risen from “normal” to “abnormal.” A biopsy was performed, leading to the prostate cancer diagnosis.
Richard was eligible for an internal treatment called high dose rate (HDR) brachytherapy, which provides a shorter course of treatment than external beam treatment. It requires two hospitals stays.
The procedure delivers a radioactive source, sometimes called a “seed,” into the prostate. The source essentially zaps cancerous cells.
“For prostate cancer, we know from clinical trials that the higher the dose that can safely be delivered, the higher the chance that the cancer will be cured. Unfortunately, normal structures will be damaged at higher doses, so we need to balance the chance for cure with the risk of side effects from treatment,” says Hopkins, McFarland Clinic radiation oncology. “HDR lets us take the dose higher than external beam radiation does, while keeping the normal structures’ risk at a similar level.”
Before the source can be delivered, however, delivery paths must be created. This involves the placement of needles into the prostate. While the patient is under general anesthesia, the urologist places the needles using a specially designed template that has a pattern of holes. The template is positioned in the perineum, the area between the anus and scrotum.
The first few needles are inserted along the edge of the prostate to hold it in place. Then other needles are placed. The number of needles used depends on the size of the prostate and can range from 14 to 30.
An ultrasound probe inserted in the rectum provides images that the urologist, radiation oncologist, and medical radiation physicist can observe on a monitor. The images help guide the effective placement of the needles.
Once the needles are placed, the medical radiation physicist attaches and maps numbered transfer tubes to the implanted needles in preparation for treatment planning.
The patient is then taken back to recover from the procedure. A few hours later, they will go through a CT scan to determine if the needle placement is still correct. The CT scan is then used by the medical radiation physicist to determine the location of the source and dwell times to achieve the prescribed dose of radiation.
The patient is then taken back to their room. In the afternoon the patient will go through another CT scan to once again determine if the needle placement is still correct.
Brian MacPhail, medical radiation physicist,
and Dr. Shane Hopkins, radiation oncologist,
review a 3D image of a prostate that
will be used for a treatment plan.
“We want to make sure the geometry of the needles still matches the treatment plan,” says Brian MacPhail, Mary Greeley medical radiation physicist. “If anything is off, it usually requires a minor adjustment of the template by the radiation oncologist.”
When all looks good, the transfer tubes are attached to the machine that will deliver the radioactive source. First, a “dummy” source travels up a tube to make sure there are no obstructions. Then the radioactive source travels up the tube. This happens one tube at a time, with the source traveling the length of the tube and then back again. The process takes about 30 minutes.
The source travels to the end of the needle and then retracts approximately 5 millimeters at a time. How long it stays at each stop, or “dwell position,” determines the level of dose at that spot. For example, at a needle close to other tissue, such as around the urethra which is in the middle of the prostate, the stops will be fewer and shorter to protect the tissue.
The travel itinerary for each tube is determined by the physicist using a complex algorithm, thus the numbered tubes, and 3D images provided by the CT scan.
“The CT scan provides images in slices, like a loaf of bread,” MacPhail explains. “The treatment planning system can see where the needles are going thru each slice and contours of those slices and uses that information to create a 3D model.”
Treatment Goes Smoothly
After the first treatment, the patient will go back to their hospital room. The next morning the process begins again, but with two treatments administered, approximately six hours apart. This gives any normal tissue that has been treated time to repair itself.
In all the patient spends one night in the hospital. Two weeks later, the patient returns to the hospital to repeat the treatment. After that, they are done. Some patients may opt to do one high dose brachytherapy treatment, and then 25 treatments via external beam.
After the first treatment went smoothly, Richard opted to do the second HDR brachytherapy treatment.
“I got along fine with the first one so I stuck with it,” says Richard. “Dr. Korrect and Dr. Hopkins were very good. Both are super nice and very explanatory about the whole procedure. And I can’t say enough about the staff and the care I received on the oncology floor. Everyone was great.”
Richard Winter and David Winter
leave Mary Greeley’s Radiation
Oncology unit after David’s last
treatment for prostate cancer.
David was not surprised when he got his cancer diagnosis as Korrect had been monitoring his prostate health for some time. Because of the size of his prostate, David was not eligible for HDR brachytherapy.
“In order for HDR brachytherapy to successfully treat prostate cancer the HDR catheters placed into the prostate need to evenly and thoroughly cover the entire organ. In men with larger prostates, structures like the pubic bone can prevent placement of HDR catheters in certain parts of the prostate,” says Korrect.
David, instead, had external beam radiation treatment, delivered by a device called a linear accelerator.
“The benefit of external beam radiation is that it can cover areas brachytherapy can't reach. If there is a high risk of disease having spread outside the prostate, into the lymph nodes, or into the fat, external beam radiation is a better option than brachytherapy alone,” says Hopkins. “One of the best treatments combines brachytherapy with external beam radiation so that you get the benefits of both.”
External beam treatment is also guided by 3D mapping done by the radiology physicist. The patient lies on a linear accelerator as the machine delivers the radiation to the designated area. The patient will go through 45 treatments over the course of nine weeks. Each treatment lasts less than 15 minutes. After five weeks, the treatment area will shrink while the dosage will increase.
On a pleasant Tuesday morning in October, David had his last treatment. His brother accompanied him. Afterwards they walked out of Mary Greeley’s Radiation Oncology department together, ready for a new day.
Hydrogel Benefits Prostate Cancer Patients
Mary Greeley is first in state to use the new technology.
Richard Winter made some medical history when he was treated for prostate cancer at Mary Greeley Medical Center.
Winter was the first patient in Iowa injected with SpaceOAR hydrogel, which provides a barrier between the rectum and the prostate.
“Whether a man receives brachytherapy or external beam radiation, the physical limitations of our technology means that nearby structures will get some dose, sometimes a lot of dose,” says Dr. Shane Hopkins, a McFarland Clinic radiation oncologist. “SpaceOAR puts space between the rectum and the prostate, which can make a big difference in how much radiation dose the rectum can avoid. This is a huge breakthrough for treating this cancer because it gives one more tool that decreases the toxicity risk.”
The SpaceOAR System is intended to temporarily position the anterior rectal wall away from the prostate during radiotherapy for prostate cancer, creating space to protect the rectum from radiation exposure. Because of the close proximity of the prostate to the rectum, prostate radiation therapy typically results in some radiation hitting the rectum, which can sometimes cause side effects.
Placed through a small needle, the hydrogel is administered as a liquid, but quickly solidifies into a soft gel that expands the space between the prostate and rectum. The hydrogel spacer maintains this space until radiation therapy is complete. The spacer gradually liquefies and is absorbed and cleared from the body in the patient’s urine.