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DR ZELEFSKY: Although this 55-year-old man refused to receive hormonal therapy
or undergo surgery, I discussed with him that our standard approach is based on
available studies and includes hormonal therapy. I explained the standard options
because I felt he needed to hear them, even though he claimed to be well informed.
The patient had no evidence of metastatic disease. However, some bowel was
located over his seminal vesicles, or in close proximity, that would make it difficult
to deliver a tumoricidal dose of external beam radiation. So we treated him
with a combination of brachytherapy and IMRT external beam radiation.
He completed radiation therapy about three years ago and his PSA level is
approximately 0.3 ng/mL. He’s faring well, but he still has a high risk of
failure and needs to be followed carefully.
DR GOMELLA: Was the combination of brachytherapy and IMRT external beam
radiation part of a study protocol, or are you offering that as standard care?
DR ZELEFSKY: We offer the combination for locally advanced disease as
standard care, not necessarily on a protocol. We have emerging protocols
evaluating high-dose rate brachytherapy as monotherapy for some patients
with locally advanced disease.
For a patient like this, it would have been standard to incorporate hormonal
therapy, but the combination of brachytherapy and IMRT external beam
radiation is a reasonable option (Zaider 2005).
DR GOMELLA: I would like to warn that this combination should be considered
cautiously. Clinicians need to recognize that Dr Zelefsky is an artist in
administering external beam radiation therapy and brachytherapy. I know
of some disastrous cases that are the result of patients receiving combination
therapy from clinicians who do not have the skill of Dr Zelefsky.
DR ZELEFSKY: The published literature does show more morbidity with these
combination therapies, so clinicians and patients have to be cautious about this
approach. If it’s done well, it’s an effective way of delivering a high dose.
Currently, the patient is doing well and has no incontinence. He does have
a little more nocturia than before and remains on an alpha blocker, but his
erectile function is normal and he is sexually active.
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