Quality Assurance in Prostate Brachytherapy Treatment - Case Study Example

Report by ashok kaul Quality Assurance in Pro Brachytherapy treatment Introduction Brachytherapy is a type of radiotherapy or radiation treatment given to the cancer patients. There can be mainly two types of this treatment. One treatment involves high dose of radiation, called HDR and the other that has low dose of radiation called LDR. Lower dose radiation treatment is the best suited plan for early stage prostrate cancer patients.. This can also be called ‘pin hole surgery” or “seed implementation” treatment.. According to AAPM, this treatment procedure was introduced in mid 1980s and it has now become an effective treatment option for the patients with early and localized cancer only. Starting with USA, the treatment option has spread fo other countries of the world where such techniques are being effectively used to treat number of early cancer stage patients. AS per the findings and reports of Kupelian PA, Potters L, Khuntia D, published in International Journal of Radiation Oncology Biology Physics 2004; LDR prostrate therapy gives the best results when it is the case of a localized prostrate cancer, meaning that the cancer is limited to the prostrate gland only. This treatment is given under the general anesthesia conditions, as radioactive seeds are injected directly into the prostrate through fine needles. This way the radiotherapy can destroy the cancer and seeds remain there on a permanent basis. AS found by Potters L, Morgenstern C, Calugaru E, after the study of localized cancer patients for 12 years, and reported in The Journal of Urology 2005;173:1562–1566; the seeds can remain inside since they gradually become inactive as radioactivity slows time over the period and decays safely in a natural manner. LDR brachytherapy is different from the traditional surgery as it requires no incision being as a dry case procedure.. Most of such patients return to work within a few days as the hospital stay is limited to one to two nights only. AS per Ash D, Flynn A, Batterman J et al. ESTRO/EAU/EORTC recommendations on permanent seed implantation for localized prostate cancer, published in Radiotherapy and Oncology 2000;57:315–321, the patients of early stage (T1, T2) prostrate cancer limited to local area only can safely go for LDR brachytherapy or seed implantation treatment. Doctors take the help of certain factors and tests like the cancer stage and grade, PSA level, Gleason score etc. .to decide this treatment of LDR brachytherapy. While the above findings have helped the doctors to have a better outlook of this treatment, patients are also encouraged to enquire from the doctor about the results of these tests and the type of treatment offered in relation to such test results. These findings as reported in the above publication” Radiotherapy and Oncology”, suggest that those patients having higher PSA level and Gleason score should be given LDR brachytherapy in combination with external beam radio therapy. The risks involved and the benefits achieved from LDR brachytherapy treatment are discussed later in this report. However, it is that this type of treatment is highly effective for the early prostrate cancer patients. Description of Prostrate Brachytherapy During the seed implementation process as involved in LDR brachytherapy, an ultrasound probe sends the images of the prostrate gland, when it is inserted through the rectum. The size and the shape of the gland, given by these images, helps the doctor to decide about the correct radiation doses needed for implementation. The locations for insertion of seeds are already identified in the beginning of this procedure, and as such the seeds are inserted. According to the findings of Salembier C, Lavagnini P, Nickers P as reported in Tumour and target volumes in permanent prostate brachytherapy:, which is a supplement to the ESTRO/EAU/EORTC recommendations on prostate brachytherapy. Radiotherapy and Oncology 2007;83:3–10; this procedure usually takes one to two hours. In the whole procedure there is no need for any surgical incision. The needles are used to insert radioactive seeds into the gland. While these needles pass through the skin between scrotum and perineum, the ultrasound probe guides these needles to reach their final position. Around 125 seeds (ranging from 70 to 150) are inserted through these needles, which are guided to their target positions, into the prostrate gland. The study further shows that the ultra sound images help the needles to reach their target positions accurately. Once the seeds are implanted, the needles are removed, while the seeds are in place to target the cancerous tumour. Computer software available to decide on the right doses of radiation helps in the seed implementation procedure to target and fully treat all cancer cells present in the prostrate area. While the seeds are actively releasing their radiation, the patient has to take some basic precautions. The contact or travel with adults may be fine, but contacts for extended periods with small children and pregnant women should be avoided, for the first two months after the seed implementation. As per Ash D, Flynn A, Batterman J et al. ESTRO/EAU/EORTC recommendations on permanent seed implantation for localized prostate cancer, published in Radiotherapy and Oncology 2000;57:315–321, the guidelines for a sexual intercourse include the use of condom during this activity, after a LDR brachytherapy, as sometimes a seed may be expelled during the first few ejaculations. These guidelines also advise that patients should ensure that the first follow-up is within four to six weeks and then every three months for a year, followed by six monthly visits for five years. Thereafter the patient can get a check up annually Quality Assurance systems for effective prostrate bracytherapy . While there are induced radio resistance (IRR) and IRMER guidelines, for the proper and effective quality assurance treatment plan for the radiology deptt., various independent societies and colleges have set their own standards for meeting the legislative requirements in this regard. The Royal College of Radiologists, London have set the following parameters fo the effective quality assurance of radiation therapy., while emphasizing the patient care to remain as the first preference. As per the ARR guidelines chapter 1,.Coordination between the patients and the staff of oncology department. Same guidelines mention that any skills mix initiative should not underestimate the safety of the patient, as the same is always the first requirement. Arr guidelines state that medical responsibility will be borne only by a registered medical practitioner, whereas a medical practitioner or a certified clinical practitioner will conduct the clinical task. The patient should have the full knowledge of the staff attending him or her for performing these tasks. Arr standards further state that while planning the radiotherapy treatment along with its delivery and verification, the requirements of Ionizing Radiation(Medical Exposure) regulations, IRMER and other guidelines with reference to the definition of medical experts and other operating staff are met. These standards are very strict that only competent and trained staff should be involved in the pretreatment planning, to undertake such tasks. It further states that those involved with the treatment planning should work under the overall supervision and responsibility of the medical doctor.. As per the ARR guidelines 12.4.2, the clinical oncologist is responsible for the definition of target volume, gross tumor volume and the corresponding organs at risk The American College of radiology (ACR) is a premier organization in this field and they have setup their standards, which are being redefined, periodically. As per the ACR standards radical prostatectomy and external beam radiotherapy have been effective alternative treatment for this type off malignancy. However, the seed implantation treatment has been growing wide acceptance since 1985, everywhere. Hence, the following guidelines are set by ACR for this purpose. Although ACR set of rules cannot be taken as legislative instruments, these guidelines are accepted worldwide. As per the ACR standards, the American board of radiology should certify a radiation oncologist. According to the ACR standards for brachytherapy of prostrated cancer, dosimetric planning is required before or during the seed implantation. It further says in its chapter four that CT scan or MRI should be conducted to determine the volume study before the implantation procedure is started. According to the ACR standards, chapter six each patient should necessarily undergo post-implantation dosimetry. This treatment can give .the data on the actual seed radiation dose delivered and the variation from the planned treatment dose, if any. While discussing on the radiation safety and physics quality control, the ACR standard, chapter seven states that physicians should pay attention to spatial resolution , geometric accuracy and gray scale contrast, while analyzing the data from TRUS imaging system along with report of ultrasound task force. Same guidelines also insist that the concerned medical doctor while starting clinical procedure should commission computerized planning system. It further suggests that dose rate values from the planning system should be compared to the AAPM report. The ACR standards further specify that the recommendations of AAPM TG-40, TG-56 and TG -64 should be followed. The preplan template coordinates should be verified in relation to the position of the prostrate gland, as per the ACR standards, before the implantation procedure is started. The standards further require that the medical doctor and the physicist should verify the total number of seeds implanted and those remaining, independently. Conclusion Low dose radiation prostrate brachytherapy, called seed implantation procedure has proved to be effective in the treatment of early cancer diseases. As it is said to be a dry case procedure, it does not involve a major surgery. Hence very few side effects are observed in this treatment. As per the report published by Langley SE, Laing R. Prostate brachytherapy has come of age: a review of the technique and results. BJU International 2002;89:241–249,the LDR treatment being very effective for the patents of early stage cancer, there could be side effects, like the patients experiencing difficulty while urinating, during the first six months after the treatment. International Journal of Radiation Oncology Biology Physics 2007;67:812–822 reports on the results of a French multi center prospective medico-economic study. In localized cancer--- Brachytherapy versus prostatectomy, by Buron C, Le Vu B, Cosset JM et al says that there could be the problems relating to the erectile dysfunction. While the LDR treatment may be the most effective one in majority of early stage cancer diseases, ts effectiveness is directly related to the successful implementation ofquality assurance plan. The legislations like IRR99and IEMER along with AAMP standards and other standards as described above do help to improve the efficacy of the treatment. However, the safety of the patient is the paramount factor in the whole procedure. Patients need to be given the written description of the radiation procedure guidelines including the side effects and the precautions that patients need to take during the post treatment period. BIBLIOGRAPHY References (some of these have been cited in the above report) Kupelian PA, Potters L, Khuntia D et al. Radical prostatectomy, external beam radiotherapy less than 72 Gy, external beam radiotherapy ≥72 Gy, permanent seed implantation, or combined seeds/external beam radiotherapy for stage T1-T2 prostate cancer. International Journal of Radiation Oncology Biology Physics 2004;58:25–33 Salembier C, Lavagnini P, Nickers P et al. Tumour and target volumes in permanent prostate brachytherapy: a supplement to the ESTRO/EAU/EORTC recommendations on prostate brachytherapy. Radiotherapy and Oncology 2007;83:3–10 Ash D, Flynn A, Batterman J et al. ESTRO/EAU/EORTC recommendations on permanent seed implantation for localized prostate cancer. Radiotherapy and Oncology 2000;57:315–321 National Institute for Clinical Excellence. Prostate cancer diagnosis and treatment (2008). NICE clinical guidelines 58. London: National Institute for Clinical Excellence The Prostate Brachytherapy Advisory Group: www.prostatebrachytherapyinfo.net Crook J, Fleshner N, Roberts C, Pond G. Long-term urinary sequelae following 125Iodine prostate brachytherapy. The Journal of Urology 2008;179:141–146 Buron C, Le Vu B, Cosset JM et al. Brachytherapy versus prostatectomy in localized prostate cancer: Results of a French multicenter prospective medico-economic study. International Journal of Radiation Oncology Biology Physics 2007;67:812–8 The Royal College of Radiologists and the College of Radiographers (1999) Inter-Professional Roles and Responsibilities in a Clinical Oncology Service. London: The Royal College of Radiologists Institute of Physics and Engineering in Medicine (2002) Guidelines for the Provision of a Physics Service to Radiotherapy. York: Institute of Physics and Engineering in Medicine. www.ipem.org.uk/sigs/rtsig/role_doc.pdf Department of Health (2000) NHS Cancer Plan. London: Department of Health. www.doh.gov.uk/cancer American Association of Physicists in Medicine. AAPM Report No. 64. Med Phys 1999; 26. American Society of Therapeutic Radiology and Oncology Consensus Panel: consensus statement: guidelines for prostrate specific antigen following radiation therapy. Int J Radiat Oncol Biol Phys 1997; 37:1035-1041. SOURCES Board of Faculty of Clinical Oncology The Royal College of Radiologists 38 Portland Place London W1B 1JQ The American College of Radiology, American Brachytherapy Society (USA) Read More