The Operating Theatre journal April 2021

WHY MEN MUST RESEARCH THEIR PROSTATE CANCER TREATMENT OPTIONS
Growing clinical evidence-base highlights long-term side effects and
risks associated with the most popular prostate cancer treatments
There is currently no consensus as to the optimal treatment for localised
prostate cancer, and urologists and radiation oncologists continue to
debate the relative merits of therapies. Most men and their partners
ultimately choose a therapy based on how well informed they are about
the various options, their respective side effect profiles and personal
lifestyle choices, and recommendation from their consultant.
Yet, for many men, this is a confusing and worrying time. Men diagnosed
with localised prostate cancer have numerous management options,
including active surveillance, androgen-deprivation (hormone) therapy,
and definitive therapy with the intent to eradicate or cure the cancer.
Among patients who are offered these curative-intent treatments,
the vast majority are offered either radical prostatectomy (surgery
to remove the prostate) or radiation therapy. Radiation therapy,
however, includes a range of treatments and dosing including externalbeam
based therapies, high-dose-rate (HDR) or low-dose- rate (LDR)
brachytherapy, and combinations of beam and brachytherapy, with or
without hormone therapy. Choosing amongst these can be a daunting
task.
However, there is a growing clinical evidence-base which suggests
certain standard-practice treatment options and doses may not be as
effective, and / or have significant long-term clinical side effects that
clinicians and patients alike should be aware of.
Urinary Adverse Events after High- versus Low-Dose-Rate Brachytherapy
with or without Radical (External-beam) Radiotherapy
A 2016 study comparing the incidence of severe urinary adverse
events (UAEs) after low-dose-rate (LDR) and high-dose-rate (HDR)
brachytherapy, as well as after LDR plus external beam radiation
therapy (EBRT) and HDR plus EBRT, found no statistically significant
toxicity differences were observed between LDR and HDR. However,
combination radiation therapy (either HDR plus EBRT or LDR plus EBRT)
increases the risk of severe UAEs compared with HDR alone or LDR
alone.
Single-dose High-Dose-Rate Brachytherapy
Most recently, a 2021 study by Shreya Armstrong et al of the Mount
Vernon Cancer Centre, Northwood, UK, undertook a retrospective
review of treatment records of patients who received single-dose
(fraction) HDR-B, concluding that long-term follow up of single dose
HDR-B for localised prostate cancer has revealed higher than expected
rates of biochemical and local failure and should therefore not be used
as a monotherapy for intermediate- and high-risk cancer patients.
This is further backed up by a 2019 study from Leeds Teaching Hospitals
NHS Trust comparing men with intermediate and high risk prostate
cancer treated using LDR–EBRT and HDR–EBRT, which concluded that
patients treated with HDR–EBRT were more than twice as likely to
experience biochemical progression compared with LDR–EBRT.
Moreover, recent advances in the development of LDR Brachytherapy,
such as 4D Brachytherapy, mean that the treatment is now available as
a one-stage implant technique that can normally be performed within
45 minutes. Improved dosimetry and clinical outcomes together with
reduced side effects have been demonstrated over traditional twostage
approaches.
Saheed Rashid, Managing Director, BXTAccelyon, comments: “While the
importance of men and their families researching all the treatment
options available to them and discussing these with their consultant
must be emphasised, there is an increasing body of evidence to
suggest that, of the curative-intent treatment options, Low-Dose-Rate
Brachytherapy as a mono- or combination therapy, has favourable
outcomes and fewer adverse side effects.
“As a treatment, this option has been proven for over 25 years, and
advancements such as 4D brachytherapy and NHS England supported
toxicity barriers have further improved the patient experience.”
Augmented reality could change the way we carry
out minimally invasive surgery
Over the last few decades, minimally invasive surgery (MIS) has replaced open surgery as the preferred method across many medical fields.
However, the relatively restricted field of view in MIS poses challenges when performing procedures that require three-dimensional visualization,
such as correct device placement or removal of sensitive tissues.
Previous technological attempts at expanding the view during MIS have involved adopting surgical scene reconstruction techniques. However,
most existing techniques have yet to demonstrate consistent performance capabilities. Consequently, greater emphasis has recently been directed
towards developing the pre-existing technology of augmented reality (AR).
AR allows the user to see the real world overlaid with a layer of digital content. It can address the visual shortcomings of MIS by expanding the field
of view for surgeons. Furthermore, as healthcare systems globally are still overburdened with the additional pressures of the COVID-19 outbreak,
new hospital measures of limiting viral transmissions between physicians and patients are highly sought after. Surgeons opting for MIS could
strongly benefit from AR when performing procedures that would normally have been an open surgery. Advancements and wide-spread adoption
of AR in MIS can thus limit patient exposure to aerosolized viral particles.
AR will improve the planning and mapping of MIS
AR could be one of many approaches to reducing this burden on hospitals by indirectly controlling the spread of the coronavirus. MIS reduces
surgeons’ exposure to aerosolized coronavirus particles. Open surgery also typically involves a longer hospital stay, which may increase nosocomial
virus transmission and increase pressure on resources and hospital bed capacity.
Research from the University of Alberta and the University of Salento found AR could be particularly useful in laparoscopic surgery and surgical
planning. The integration of AR into MIS means surgeons would not solely rely on endoscopes. Instead, AR projections of scans can be superimposed
on patients in real-time to aid planning and increase accuracy when placing devices. For patients, this could reduce the chances of trauma and
scarring while also accelerating postoperative recovery.
AR may not be embraced across all surgical procedures, as its use is strongly dependent on the rigidity of the organs or tissues involved in the
operation. For example, AR has found relative success in neurosurgery for both the brain and spine as the structures are rigid, which helps the
surgeon differentiate between the augmentation and the actual scene. On the other hand, AR and other types of image-guided surgery are unlikely
to be used for abdominal MIS as organs and tissues are less rigid. Instead, traditional endoscopic views will continue to be relied upon for these
procedures.
The future of MIS
AR has the potential to improve the accuracy of minimally invasive procedures, and in turn, reduce surgical errors. Worth nearly $4bn in 2018, the
global AR market will reach $76bn by 2030, growing at a compound annual growth rate (CAGR) of 24%, according to GlobalData estimates. AR in MIS
is currently still being researched. ProjectDR is one of the software platforms exploring how AR can improve visualization in the operating theatre.
ProjectDR projects medical scans directly onto a patient body and can even provide segmented images if the surgeon selects this function. AR’s
use for MIS is still in the early stages, but GlobalData expects this technology to significantly impact the healthcare industry over the next few
years.
Source: Medical Device Network
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