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Dennis R. Hill, MD to be a Panelist at the Third Annual Prostate Cancer Symposium

Oakland, CA August 17, 2013.  Dennis R. Hill, MD has confirmed today that he will be a panelist at the Third Annual Prostate Cancer Symposium titled “The Changing Paradigm of Prostate Cancer: Selective screening, Personalized Treatment and Survivorship in a Period of Rapid Progress.” The event will be Tuesday, September 17 from 5:30 to 8:30pm and is sponsored by the Alta Bates Summit Health Education Center. At this year’s symposium an expert panel of physicians and professionals address the newest treatment options for prostate cancer, and how to pro-actively address quality of life and health issues during and after treatment. Discussions will cover screening, watchful waiting, treatment technology, nutrition, physical fitness as well as possible side effects like incontinence and urinary issues.

Dr. Hill’s presentation will be on High Dose Rate Brachytherapy for prostate cancer treatment vs Surveillance. Dr. Hill comments, “There is a changing paradigm in prostate cancer on several fronts, including screening, diagnosis and treatment. It can be confusing. Hopefully, this panel will not only bring the latest information out, but also some common sense on how to approach this important cancer.” The other physician panelists will present “Rational Approach to Screening and Treatment Decisions in the Era of Genetic Assessment” and “The Urologist’s Perspective on Surveillance vs Treatment” and “The March towards Controlling Recurrent and Aggressive Prostate Cancer.” There will also be panelist presentations on enhancing survivorship quality by a nutritionist and a physical therapist.

Following the presentations there will be a question and answer session with the panelists. The event is open to the public and will be held at Alta Bates Summit Health Education Center, 400 Hawthorne Avenue, Oakland, CA 94609. Reservations are required. To reserve a seat call (510) 204-5804 or send an email to slaveni(at)sutterhealth(dot)org.

About Dennis R. Hill MD

Dr. Hill has been doing High Dose Rate Brachytherapy for prostate cancer treatment exclusively since 2004 and has published scholarly articles on the subject. His office is located at: Dennis R. Hill MD 3012 Summit Street Suite 2675 Oakland, CA 94609 510-869-8875 drh(at)dennisrhillmd(dot)com and his website is hdrprostatebrachytherapy.com, which includes a quiz to determine if a patient is a candidate for HDR Prostate Brachytherapy.

Active Surveillance of Prostate Cancer in African American Men

Oakland, CA July 18, 2013.  Dennis R. Hill M.D. Radiation Oncologist at the Alta Bates Summit Medical Center in Oakland, CA reports that although active surveillance of biopsy proven low risk prostate cancer is an alternative to immediate treatment it is a long term commitment. Active surveillance programs typically require PSA and digital rectal exams every three months and potential re-biopsy annually. Although the cancer will not go away, the rationale is that the pace of disease can be determined and treatment may not be required for the man’s remaining natural life. More men are choosing this option rather than proceeding to surgery, radiation therapy, permanent seed implant or high dose rate brachytherapy. Dr. Hill has always recommended active surveillance in elderly patients or patients with other serious illness which may overtake them before the prostate cancer. However there is new evidence that active surveillance may be more risky for African American men. The study was published online June 17 in the Journal of Clinical Oncology. http://jco.ascopubs.org/content/early/2013/06/17/JCO.2012.47.0302

Dr. Hill notes that the study authors report that black men with very-low-risk disease are more likely than their white counterparts to actually have more aggressive disease. They retrospectively looked at 256 black and 1473 white very-low-risk patients who nonetheless underwent radical prostatectomy at Johns Hopkins University in Baltimore, Maryland. It is the largest cohort to date of black men who qualify for active surveillance, according to senior author Edward Schaeffer, MD, and colleagues from Hopkins. They found that the black men had significantly higher rates of upgrading at surgery than their white counterparts (27.3% vs 14.4%), and more adverse pathology (i.e., high-risk disease) (14.1% vs 7.7%). The men in the study were culled from a group of 19,142 men who underwent radical prostatectomy at The Johns Hopkins Hospital from 1992 and 2012. The 1801 men selected for study inclusion had very-low-risk disease, according to National Comprehensive Cancer Network criteria. They had a clinical-stage disease of T1c or less, a biopsy Gleason score of 6 or less, no more than 2 positive biopsy cores, core involvement of 50% or less, a prostate-specific antigen (PSA) level below 10 ng/mL, and a PSA density of 0.15 ng/mL per cm³ or less. In previous studies of men managed with active surveillance, results for cancer-related outcome by race have been mixed but this is by far the largest study.

Since the calculated gamble of using active surveillance to manage very-low-risk prostate cancer appears to be more uncertain for black men, Dr Hill agrees with the authors that “African American men with very-low-risk prostate cancer should be counseled about increased oncologic risk when deciding among their disease management options.”

About Dennis R. Hill MD

Dr. Hill has been doing High Dose Rate Brachytherapy exclusively since 2004. He has done over five hundred High Dose Rate Prostate Brachytherapy implants and has published scholarly articles on the subject. His office is located at: Dennis R. Hill MD, 3012 Summit Street, Suite 2675, Oakland, CA 94609 510-869-8875. His email is drh(at)dennisrhillmd(dot)com and his website is hdrprostatebrachytherapy.com, which includes a quiz to determine if a patient is a candidate for HDR Prostate Brachytherapy.

Routine PSA Screening for Prostate Cancer

PR image PSA 7-6-13Oakland, CA July 13, 2013.  Dennis R. Hill M.D. Radiation Oncologist at the Alta Bates Summit Medical Center in Oakland, CA reports that although the United States Preventative Services Task Force (USPSTF) has recommended that PSA screening for prostate cancer NOT be done on any man of any age this recommendation is not without controversy. The USPSTF shook up the status quo last July when it advised against PSA testing with averagerisk men of any age who had no prostate cancer symptoms.(1) In May 2013, the American Urological Association (AUA) released new clinical guidance on the early detection of prostate cancer.(2) The USPSTF panel that developed the 2012 recommendations did not include representation from the urology community. The American Urological Association (AUA) feels that as the physicians most experienced in the diagnosis and treatment of prostate cancer, urologists should be involved in the development of prostate cancer screening recommendations to ensure that the guidance is evidence-based and also targets the preferences of individual patients. The AUA strongly supports the inclusion of specialists on the USPSTF (as outlined in the USPSTF Transparency and Accountability Act) that develop recommendations that impact patient care. The AUA remains in disagreement with the USPSTF in its general statements against the use of PSA testing in all men. They support a man’s right to be tested for prostate cancer – and to have his insurance pay for it, if medically necessary – if, in fact, he decides to do so following a detailed conversation with his physician about the benefits and harms of screening. The AUA continues to support the use of the PSA test. However, PSA-based screening without clearly targeting those who are most likely to benefit from testing does result in harms, including over diagnosis and overtreatment. All involved professionals have to take a more targeted approach to minimize these harms. The AUA feel that men ages 55 to 69 who are in good health and have more than a 10- to 15-year life expectancy should have the choice to be tested and not discouraged from doing so.

There is general agreement that early detection, including PSA screening, has played a key part in decreasing prostate cancer mortality. My own experience goes back to before PSA screening was widely available (PSA testing became widely available in the late 1980’s).  During this time before PSA testing I was practicing external beam radiation and the majority of prostate cancer patients we saw had locally advanced disease and were difficult to cure. Symptoms are rarely a first sign of prostate cancer. Most are asymptomatic even if they have advanced local disease. Even if the patients that do have symptoms they are often related to the benign enlargement of the prostate not the cancer. I know for a fact that I have been seeing prostate cancer in a much earlier stage since the advent of PSA testing. It may be that we are a victim of our own success. The prostate cancer mortality dropped very noticeably in the 1990s after the advent of PSA testing.

The cure rates with early stage low risk disease are high and essentially the same (over 90%) whether the treatment is radical surgery, external beam radiation, permanent seed implant or high dose rate brachytherapy. The USPSTF says there are harms from overtreatment but that depends on the type of treatment given. High Dose Rate Brachytherapy has a very low complication rate compared to the other modalities.  There are essentially no rectal complications, no incontinence and a low percentage of erectile dysfunction.

My feeling is more consistent with the AUA position. If the man is healthy, between 55 to 70 years old, I think he should have a screening PSA test every two years. Men at high risk for disease, such as a positive family history, should be encouraged to discuss their individual case with their doctor, regardless of age.

About Dennis R. Hill MD

Dr. Hill has been doing High Dose Rate Brachytherapy exclusively since 2004. He has done over five hundred High Dose Rate Prostate Brachytherapy implants and has published scholarly articles on the subject. His office is located at: Dennis R. Hill MD 3012 Summit Street Suite 2675 Oakland, CA 94609 510-869-8875 drh@dennisrhillmd.com and his website is hdrprostatebrachytherapy.com, which includes a quiz to determine if a patient is a candidate for HDR Prostate Brachytherapy.

(1) http://www.uspreventiveservicestaskforce.org/prostatecancerscreening/prostatefinalrs.htm#consider

(2) http://www.auanet.org/common/pdf/advocacy/grassroots-toolkits/DPCToolkitFAQs.PDF

PSA Testing Following Brachytherapy Treatment

Oakland, CA June 22, 2013.  Dennis R. Hill M.D. Radiation Oncologist at the Alta Bates Summit Medical Center in Oakland, CA reports that several patients of his have questioned the value of prostate specific antigen (PSA) testing following high dose rate brachytherapy since they have read or heard about the recent change in the guidelines established by The U.S. Preventative Services Task Force (USPSTF) that shook up the status quo last July when it advised against PSA testing with average-risk men of any age who had no prostate cancer symptoms. This publication was followed this year by similar guideline from the America Urological Association (AUA) which was released last month. The AUA committee noted that the greatest benefit appears to be for those 55 to 69 but urged that men in that age group discuss the pros and cons with their doctor before deciding whether to proceed. An elevated PSA level doesn’t necessarily signify prostate cancer, but it can trigger a cascade of tests and treatments that could be riskier than the disease itself, potentially causing impotence, incontinence or even death from prostate cancer surgery.

Dr. Hill pointed out that those guidelines are addressing the use of PSA screening of normal healthy patients on a routine basis and are designed to prevent unnecessary testing and treatment. This is totally different than PSA testing of patients with established prostate cancer. After treatment for prostate cancer the most reliable method of follow-up is digital rectal exam and a PSA test. No elaborate imaging or scanning is necessary. Although the entire gland is treated with high dose rate brachytherapy, the gland is not completely ablated and some normal functioning gland remains which can continue to make some measurable PSA. It is not expected to drop to undetectable levels, rather it should drop down into a “new normal” range following treatment. For example, maybe the pretreatment PSA value was 8.4 then three months following high dose rate brachytherapy it dropped to 1.7 then at six months it was 0.7 at nine months 0.2. Over the next months and years it would vary between 1.1 and 0.1. Keeping in mind that the pretreatment PSA was 8.4 this would be an acceptable variation within the new normal range for that patient and would not raise a red flag provided the prostate exam was negative. Generally speaking, if the digital rectal exam and PSA are stable for five years or more there is very little chance that there would be a recurrence. Dr. Hill recommends PSA and digital rectal exam every three months for the first two years following treatment, then every six months out to five years, then annually after five years. Dr. Hill mentioned that on occasion there is a phenomenon called a “PSA bounce” which can occur within the first two years or more following high dose rate brachytherapy http://hdrprostatebrachytherapy.com/hdr-method/. This is a spike in a one time reading of the PSA which drops back to into the normal range on repeat testing three to six months later. Although the cause is unknown it does not raise a suspicion of recurrence. Only if there is a steady rise on three consecutive readings or a measurement of 2.0 over the lowest PSA following treatment (nadir) would Dr. Hill order other tests to rule out a recurrence.

Dr. Hill stressed that PSA testing is a vital part of the follow up program following high dose rate brachytherapy.

About Dennis R. Hill MD

Dr. Hill has been doing High Dose Rate Brachytherapy exclusively since 2004. He has done over five hundred High Dose Rate Prostate Brachytherapy implants and has published scholarly articles on the subject. His office is located at: Dennis R. Hill MD 3012 Summit Street Suite 2675 Oakland, CA 94609 510-869-8875 drh(at)dennisrhillmd(dot)com and his website is hdrprostatebrachytherapy.com, which includes a quiz to determine if a patient is a candidate for HDR Prostate Brachytherapy.

Testosterone Supplements After Treatment for Prostate Cancer: Is It Safe?

Dennis R. Hill M.D. Radiation Oncologist at the Alta Bates Summit Medical Center in Oakland, CA discusses the use of testosterone supplements after prostate cancer treatment and reviews recommended safety precautions. When Dr. Hill saw one of his patients recently in follow up who was treated four years ago with High Dose Rate Brachytherapy, the question came up whether or not the use of testosterone supplements is safe. As discussed in a recent article in News Max Health, entitled: “Testosterone Supplements: Fountain of Youth for Men?” (1) Dr. David Samadi, vice chairman of the Department of Urology and Chief of Robotics and Minimally Invasive Surgery at the Mount Sinai School of Medicine in New York City states that testosterone supplements are not always safe.

Dr. Hill’s patient is now sixty four years old and he had what we call low risk disease (2) originally. His examination, including a digital rectal exam and PSA were normal. There was no evidence of disease recurrence. During this visit he revealed to Dr. Hill that four months earlier he had his testosterone level checked. Since it was low his primary doctor started him on testosterone supplementation and his mood and energy have improved and his sex drive is strong again. He did not ask for Dr. Hill’s opinion about it, but he weighed in nonetheless. He explained that prostate cancer thrives in male “soil” and one of the methods used to improve results in more high risk disease is to add androgen deprivation therapy to surgery or radiation.

Dr Hill notes that androgen deprivation therapy or ADT nearly stops the normal production of testosterone. The improved cure rates have been shown in several randomized clinical trials of radiation treatment or surgery for prostate cancer. That being the case it would be reasonable to assume that testosterone addition in a previously treated prostate cancer could make things worse by adding “fertilizer to soil.” Dr. HIl also pointed out that men normally produce less testosterone as they age. It is not a medical condition requiring treatment unless it is so low that it can be diagnosed as hypogonadism. Even then the threshold blood level varies widely from one lab to the next and an endocrinologist, a specialist in hormonal diseases, should be the one making that diagnosis. It is also know that estrogen supplementation for menopausal women was thought to be safe years ago and now it is known there are increased incidences of cancer of the uterus and breast with that practice and it is no longer recommended. He understood that in his opinion he should stop the testosterone supplements. He countered that his suicidal tendencies have now gone, he has a better attitude, his energy is better and so is his sex drive. Dr. Hill could not convince him to stop the supplements. He understood that he was putting himself at risk for a recurrence but was not willing to quit. He did agree however to being followed more closely in follow up. Normally Dr. Hill recommends follow up every six months after three years have passed since high dose rate brachytherapy treatment for prostate cancer. He agreed to be seen in follow up every three months. Dr. Hill agreed that they disagree, but they will be able to detect a recurrence earlier if it occurs.

About Dennis R. Hill MD

Dr. Hill has been performing High Dose Rate Brachytherapy procedures exclusively since 2004. He has done over five hundred High Dose Rate Prostate Brachytherapy implants and has published scholarly articles on the subject. His office is located at: Dennis R. Hill MD 3012 Summit Street Suite 2675 Oakland, CA 94609 510-869-8875 drh@dennisrhillmd.com and his website is hdrprostatebrachytherapy.com, which includes a quiz to determine if a patient is a candidate for HDR Prostate Brachytherapy.

(1) http://www.newsmaxhealth.com/Headline/low-testosterone-mens-health-libido-energy/2013/04/19/id/500323#ixzz2V9woGoE5
(2) *PSA less than ten, Gleason score 3 + 3, and no palpable disease and negative endorectal coil MRI scan of the pelvis.

Not All Low Dose Rate Brachytherapy Isotopes Are The Same

Oakland, CA May 28 2013.  Recently there has been a promotion of the idea that a newer isotope Cesium 131 has markedly improved the permanent seed, or low dose rate, brachytherapy for prostate cancer. The claim is that this newer isotope has a higher energy, a shorter half life, and gives a higher biologically effective dose to the tumor. It is true that Cesium 131 has a higher average energy than the other commonly used prostate cancer permanent seed isotopes on the market. The more commonly used isotopes used are Palladium 103 and Iodine 125. Cesium 131 delivers 90% of the prescribed dose to the prostate gland in 33 days compared to 58 days for Palladium 103 and 204 days for Iodine 125. Another claimed benefit to the short half-life of Cesium 131 is what is known as the “biological effective dose” against cancers exhibiting different characteristics – for instance, slow versus fast growing tumors. This all sounds good and it is an improvement over conventional low dose rate permanent seed brachytherapy with Palladium 103 or Iodine 125.

So how does Cesium 131 compare to temporary high dose rate brachytherapy? High dose rate brachytherapy delivers the entire dose in two treatments over eight days compared to 33 days with Cesium 131. Prostate cancer unlike some other cancers can have a slower growth rate which can be closer to normal tissue than the more virulent cancers. Research has shown that larger doses of radiation over a shorter period of time as delivered by high dose rate brachytherapy may be radiobiologically superior to the protracted low doses over a long time that permanent seeds delivers, including Cesium 131. Since high dose rate brachytherapy is a temporary implant there is no radioactive source left in the patient. Cesium 131 is still a permanent seed implant with the same limitations compared to high dose rate brachytherapy. The Cesium 131 seeds are all of uniform strength so it is very difficult to get uniformity of dose with proper spacing of the seeds. The seeds are implanted into deformable tissue and once the seed is implanted it can’t be moved. The dose plan is still done as an estimated pre-plan prior to surgery or on the fly with “real time intra-operative planning” at the time of surgery. In either case the doses are calculated AFTER the implant. In contrast, with high dose rate brachytherapy the implant catheters and treatment positions are known and the dose can be designed in advance of the source delivery. The final treatment plan is completed and approved by the physician before rather than during or after the source is administered.

Other disadvantages of a permanent seed implant are unchanged by the type of isotope. There can be anatomic changes or migration of seeds during the time it takes the permanent seeds to emit the dose, the permanent seeds cannot be placed at the capsule because there is no anchoring tissue, there are prostate size limitations, the bony pubic arch may limit the implant, and so on.
Although Cesium 131 appears to have an advantage over other permanent seed isotopes, in my opinion the overall advantage still goes to temporary interstitial high dose rate brachytherapy.

What is Intensity Modulated Radiation Treatment (IMRT) and How Does it Compare to High Dose Rate Brachytherapy?

There are a number of prostate cancer treatment options available including Intensity Modulated Radiation Treatment or IMRT. This is an improvement over standard external beam irradiation in that the beam is dynamically modified during the daily treatment. The daily treatments are given over an eight to nine week period.  The treatment machine, called a linear accelerator, delivers a high powered beam of radiation to the body as in standard external beam radiation, but this newer machine is equipped with a special device called a computerized multileaf collimator that shapes the beam during the radiation in accordance with the treatment plan. The shape and speed of the collimator windows determine the intensity of dose to the target. The equipment is rotated around the patient to send radiation beams from different angles to give the tumor a higher dose than the adjacent bladder and rectum.  This is definitely an improvement over standard conformal external beam radiation but it still is an external beam which must penetrate pelvic tissues to get to the target in the middle of the pelvis.

In contrast, High Dose Rate brachytherapy is delivered from within the prostate and radiates outward a short distance with a rapid falloff. The term brachytherapy is derived from the Greek brachy which means short distance. The intensity of the dose is modulated by adjusting the time the source stays at each position within the implanted catheter matrix. The radiation dose is modulated at the target not as it enters the body. Finally, it does not have the daily patient set up and prostate motion problems associated with external beam intensity modulated treatment (IMRT). My conclusion is that IMRT is an improvement in external beam radiation treatment but the advantage still goes to High Dose Rate brachytherapy.

 

Latest Breakthrough in Prostate Cancer Treatment?

An internal medicine colleague of mine and I were eating lunch in the hospital cafeteria the other day and our discussion topic came to prostate cancer and high dose rate brachytherapy. He said that he read that a new Calypso System was the latest breakthrough in prostate cancer treatment and what was my take on it. I told him, “During the long course of external beam radiation treatment the prostate naturally moves due to respiration, gas in the rectum, etc. Likewise it is virtually impossible to get a human body in the exact same position every day, five days a week for eight to nine weeks.” This new technology is based on scientific principles very similar to that in global positioning satellite (GPS) devices. Three tiny devices are implanted in the prostate prior to external beam radiation. These devices, each about the size of a grain of rice, are tracking devices called beacon transponders. Then, during external beam radiation, the beacon transponders communicate with the Calypso System constantly so the external beam stays locked on to the target. I told him, “This is an expensive and late refinement to catch up with the inherent virtue of high dose rate brachytherapy for prostate cancer. Of course the prostate moves naturally, but with the high dose rate brachytherapy technique the treatment catheters are implanted in the prostate so they go wherever the prostate goes.” The prostate cancer is always on target. There is no need for a complicated tracking system. Further, the Calypso system still does not address the disadvantage of the external beam going through the normal pelvic structures to get to the walnut sized target. High dose rate brachytherapy treats the prostate cancer from inside out so normal tissue gets a minimal dose. After hearing all this, my colleague agreed that the Calypso system is an improvement but still short of the virtues of high dose rate brachytherapy for prostate cancer.

Every Man Should Know his Options

Mr. F is a patient with prostate cancer that I treated five years ago with high dose rate brachytherapy. I saw him in routine follow up last week and everything was fine with normal PSA and negative prostate examination. There was no evidence of cancer. He is a commercial airline pilot and a member of the Airline Pilots Association, International. In our conversation he mentioned that in the March issue of Air Line Pilot, the official journal of the Airline Pilots Association, International, there is an article under the Health Watch section entitled “Detecting and Treating Prostate Cancer” and it mentioned High Dose Rate brachytherapy. I asked him to send me a copy of the article for my review. He is a delightful guy, and he sent me the entire magazine with a sticky marking the article. Although I was happy to see that High Dose Rate brachytherapy got equal coverage with external beam radiation and permanent seed implantation in the article I was slightly disappointed that the description of the method was so short. Nevertheless, the last two sentences were right on, “…so the individual has no permanent radiation source as with seed implants. Radiation damage to surrounding healthy tissues is minimized.” Overall, I felt it was a fairly accurate description of High Dose Rate brachytherapy for prostate cancer, and I was glad to see that all the treatment methods are mentioned because it is important that every man knows his options.

Dennis R. Hill, MD to Speak at the American Cancer Society Man-to-Man Support Group

March 29 2013, Oakland, CA.  Dennis R. Hill, MD has confirmed today that he will be speaking to the American Cancer Society Man-to-Man support group on High Dose Rate Brachytherapy Tuesday, September 24, from 6:30 to 8:00pm at the Summit Campus of Alta Bates Summit Medical Center in Oakland, CA.

The Man to Man program helps men cope with prostate cancer by offering community-based education and support for patients and their family members. Part of this volunteer organization is outreach and collaboration with health care professionals. Dr. Hill has volunteered to speak for the second time in three years. His previous High Dose Rate Brachytherapy presentation was “a big hit” according to William H. Spurgeon the facilitator of the group. He also said, “We appreciate (Dr. Hill’s) time and energies to help educate our men.”

Dr. Hill explains that High Dose Rate Brachytherapy is an advanced form of treatment for prostate cancer which treats the prostate with radiation from the inside out with temporary implanted catheters. It is less rigorous than surgery, less time consuming than external beam radiation, and more precise than permanent seed implant. The success rate is the same as surgery, external beam radiation and permanent seeds and there are fewer side effects,” according to Dr. Hill.

Dr. Hill has been doing High Dose Rate Brachytherapy exclusively since 2004. He has done over five hundred High Dose Rate Prostate Brachytherapy implants and has published scholarly articles on the subject.  His office is located at: Dennis R. Hill MD 3012 Summit Street Suite 2675 Oakland, CA 94609 510-869-8875 drh(at)dennisrhillmd(dot)com and his website is hdrprostatebrachytherapy.com, which includes a quiz to determine if a patient is a candidate for HDR Prostate Brachytherapy.