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Johns Hopkins Pediatric

New Advanced Multidisciplinary Prostate Cancer Treatments Provide Individualized Care

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In HDR prostate brachytherapy, target dose coverage (the white line) is wrapping tightly around the prostate, limiting high dose into the urethra and minimizing low dose into the rectum.

At the Johns Hopkins Kimmel Cancer Center Prostate Multidisciplinary Clinic at Sibley Memorial Hospital, patients have access to the newest, most advanced treatments, as well as a group of experts who work together to determine the best course of treatment.

HDR Prostate Brachytherapy

Among the latest treatment offerings at Sibley is high dose rate (HDR) prostate brachytherapy, a treatment that is offered at only a few specialized centers across the country and in the Baltimore/Washington region.

HDR brachytherapy offers patients an alternative to low dose rate (LDR) prostate brachytherapy, with less potential for radiation to be absorbed by surrounding tissues compared with other radiation modalities.

It involves depositing high-dose radiation directly into the prostate through a catheter for 15–20 minutes, while LDR brachytherapy involves placing permanent radioactive seeds in the prostate that slowly release radiation over time. Thus, with HDR, the patient does not leave the clinic with implanted radiation or have radiation safety precautions and limitations from being radioactive.

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“Ultimately, what we strive to bring as Johns Hopkins faculty is the clinical and research expertise to look at the whole picture and make sure you’re getting the best care with all of the most advanced and best available tools to treat prostate cancer.” – Curtiland Deville

“Doing this allows us to be very focused with that radiation, and to do so in such a way that minimizes exposure to normal tissues while still providing a really high dose of radiation to the target,” says radiation oncologist Rachit Kumar, who is building the HDR prostate brachytherapy program into a high-volume practice.

HDR brachytherapy can be used to treat early-stage prostate cancer as a solo treatment, or for patients with high-risk or locally advanced disease, it can be given in combination with external beam radiation techniques such as intensity-modulated radiation therapy or proton therapy. It is especially useful as a “salvage” therapy for patients whose cancer has recurred in the prostate after a prior course of radiation.

Outcomes are similar to those in LDR brachytherapy, with disease-free survival rates in the 90%–95% range five years from treatment for patients with early-stage cancer. Ninety percent of patients go home without needing a catheter in their bladder, and of those who do, it is usually removed within two days.

HDR brachytherapy can help treat patients with intermediate-risk and high-risk prostate cancer, who typically receive two rounds of brachytherapy or one round in combination with other treatments, respectively.

Advanced Imaging, Proton Therapy and Radiopharmacology

The Johns Hopkins Kimmel Cancer Center at Sibley offers the latest imaging and image-guided treatments, including multiparametric MRI for advanced diagnostics, MR simulations for radiation treatment planning, and a targeted biopsy system. It also offers molecular imaging such as the prostate-specific membrane antigen (PSMA) PET-CT, which is more sensitive in detecting distant spread than conventional imaging with a CT scan or bone scan.

For eligible patients undergoing radiation, the clinic offers hydrogel spacers, which are injected between the prostate and rectum prior to patients receiving radiation in order to reduce side effect risks to the rectum.

Sibley is home to the Johns Hopkins Proton Therapy Center, which treats a high volume of prostate cancers, says Curtiland Deville, medical director of the proton therapy center and co-director of the multidisciplinary clinic.

Proton therapy can benefit patients with localized or postoperative prostate cancer as well as those with advanced disease. The treatment involves high-energy, precisely targeted particle beams that deposit radiation directly in the targeted tumor, without exit dose beyond the targeted area, limiting collateral exposure to surrounding tissues and organs, such as the bowel, rectum and bladder. The center also uses advanced imaging to ensure the protons are hitting their target, including a new technology known as RGPT (real-time image gated proton therapy) that shuts the beam off if it moves out of a 2-millimeter threshold.

The center has a radiopharmaceutical program that offers Radium-223, also known as liquid radiation. Administered through an IV infusion, Radium-223 is given to patients with metastatic prostate cancer that has spread to the bones and has shown resistance to hormonal therapy (i.e., castrate resistance). Recently, the center began offering lutetium therapy, which is also delivered through an IV and treats prostate cancer that has spread to other parts of the body beyond the bone.

Patients have access to novel treatments through clinical trials that are often not available elsewhere. A study that Deville is currently leading involves a trial for patients with high-risk, locally advanced prostate cancer. He is testing if a PET scan can detect areas where the cancer has spread better than conventional scans such as CT and bone scans, and assessing whether clinicians can see early predictors of treatment response based on imaging before and after hormone therapy.

Multidisciplinary Treatment

In the bimonthly multidisciplinary clinics, a patient meets with a urology or radiation oncology resident or nurse practitioner. The case is then reviewed by a team that includes a urologic oncologist, a medical oncologist, a radiation oncologist, a radiologist and a pathologist. Each physician and the patient meet in one-on-one sessions and discuss the best diagnosis and management options that afternoon.

Research coordinators, research trial specialists and social workers also support patients — from their first appointment in the multidisciplinary clinic through treatment.

“It’s a patient-centered approach where they can get a consultation with everybody who would be involved with their prostate cancer diagnosis and management,” Deville says. “The patient can get everything done in one day.” The team also provides a secondary opinion on workups patients had done at outside providers.

With the variety of prostate cancer treatment options available, Deville says his team’s goal is to present the best treatment options for each patient.

“These are not competing tools,” he says. “Ultimately, what we strive to bring as Johns Hopkins faculty is the clinical and research expertise to look at the whole picture and make sure you’re getting the best care with all of the most advanced and best available tools to treat prostate cancer.”

To refer a patient, call 202-537-4787.

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