Interview Brachytherapy, the method that targets the tumor and protects healthy cells

Brachytherapy, an advanced form of internal radiotherapy, acts directly on the malignant tumor, from its immediate vicinity, considerably reducing the radiation exposure of the surrounding healthy tissues. This precise therapeutic method manages to provide shorter, more effective treatments with minimal side effects, redefining the way modern medicine fights cancer.

Brachytherapy is a form of internal radiation therapy that involves placing radioactive sources inside or in close proximity to a tumor to deliver a high dose of radiation to the cancerous tissue while minimizing exposure to surrounding healthy tissue. This method is often used in the treatment of several types of cancer, such as cervical, endometrial, prostate, and can be used alone or, more frequently, in combination with other oncological therapies.

Dr. Beatrice Anghel, primary radiotherapy physician, coordinator of the Brachytherapy Department at the SANADOR Oncological Center, explains in an interview for “Weekend Adevărul” when this procedure is recommended, how it differs from classical radiotherapy and, above all, how it protects healthy cells. The doctor emphasizes the fact that it is a modern treatment, which offers the patient the possibility of returning to a normal life immediately after the operation.

“Weekend Adevărul”: What is brachytherapy and how does it differ from classical external radiotherapy?

Dr. Beatrice Anghel: Brachytherapy is a modern, complex treatment, a cancer treatment by which we manage to place radiation sources inside the tumor or near it. The tumor volume of interest is targeted very well and with millimeter precision, and the surrounding healthy tissues are protected. The difference is, in fact, in the placement of the radioactive source in the tumor, while in classical external radiotherapy, the source is outside the body, controlled and manipulated with the help of a device. So brachytherapy works directly in or near the tumor. The radioactive source is placed in the tumor, and in external radiotherapy the radiation beam is guided by a device.

A useful treatment

Why is brachytherapy so important for gynecological cancers, especially cervical?

Gynecological cancers – cervical, endometrial and vaginal – are common among women in Romania. But there are cancers that can be cured with brachytherapy. Brachytherapy actually increases the survival rate by achieving local control and reducing the risk of vaginal recurrence in cervical or endometrial cancer. Therefore, brachytherapy is a useful treatment, it can be used as a unique treatment modality or complementary to the surgical act.

What is the role of brachytherapy in lower rectal and anal canal cancers?

In these two types of cancer, brachytherapy finds its utility when we want to preserve sphincter function. Through a less invasive method, we manage to avoid wearing a permanent colostomy. Therefore, brachytherapy can be used to supplement the dose of radiation administered by placing sources in the anal canal through intracavitary devices, so as to protect the sphincter complex as best as possible and ensure an effective dose with appropriate control.

Protecting healthy cells

How does brachytherapy help protect healthy organ cells in the bladder, bowel, rectum, vagina?

Because the placement of the radiation source is performed only in the volume of interest, the decrease in doses is steep and the protection of the surrounding organs is significant. So, through physical and radio-biological concepts, we follow the parameters related to the immediate vicinity of the volume of interest. We manage to effectively protect the bladder and rectum by controlling and visualizing the volume of interest through imaging-guided techniques. Thus, we perform an imaging-guided brachytherapy, based on precise information.

What are the main benefits for the patient in terms of healing, reduction of adverse effects and quality of life?

The patient manages to lead a normal life after the treatment. Most of the time, the treatment is unique, effective and allows rapid social reintegration. There are some steps to follow after treatment, however gradual resumption of usual activities is encouraged, perhaps even physical exertion encouraged to be progressive. Periodic checks are important, therefore, continue the collaboration with the doctors participating in the act of treatment. Oncological treatment is to be taken into account and patients are also advised to follow certain recommendations.

Advantages and risks

What are the advantages of brachytherapy compared to external beam radiation therapy and surgery?

If we talk about external radiotherapy, it is carried out in a general way, respecting certain parameters and covering a wider spectrum of conditions. In contrast, in brachytherapy, where the tumor can be accessed and a radiation source can be placed, either intraoperatively or in the treatment of some skin cancers, the efficiency is superior. I’ll give you an example of skin cancer. If we had a tumor formation on the hand, it is much easier to place a radiation source on the skin than to do external radiotherapy and not be able to control the dose that can penetrate more towards the phalanges, for example.

What risks or side effects can occur with brachytherapy and how are they managed?

Mild discomfort and minimal bleeding may occur. Often we also have side effects that can be related to high anxiety and after knowing the protocol, patients are much more relaxed. But when we talk about side effects, they can be immediate or long term. We manage to manage them quite well with drug treatment, and in the long term, if they are cancers with much more advanced locations, with an important loco-regional extension, then we will probably also experience the management of these side effects and we may expect the involvement of colleagues from urology or gastroenterology to help not only with medication, but perhaps also through minimal endoscopic long-term interventions. What are the main side effects? Maybe a little tiredness, apathy, maybe even insomnia. But most of the side effects are reversible.

Success depends on the medical baggage

What are the factors on which the success of brachytherapy depends? The stage of the disease, the age of the patient, associated diseases…

We take into account not only the medical baggage that the patient comes with, but also the entire pre-therapeutic balance – the staging and degree of the tumor, its dimensions, whether or not the patient has comorbidities. So the medical baggage is very important, but mostly the factors actually related to the tumor. The age component is not to be neglected either, because young patients somehow have a much higher metabolic rate and tumors can be, let’s say, small and the results can sometimes be misleading. So we have both advantages and disadvantages, but we consider every criterion, every feature and try to see the big picture.

How does a brachytherapy session actually work? What should patients know?

The brachytherapy session is preceded by a consultation, after which there is a preparation in advance for the best possible success and for an effective treatment with optimal results. Then applying and inserting the brachytherapy devices, scanning them on the patient and the area of ​​interest, then optimizing and making an effective treatment plan with the medical physicist and then the treatment. After treatment, we remove those devices that have been placed, perform immediate symptom control, and formulate recommendations for the next procedure.

Is brachytherapy associated with other treatments or not?

Most of the time, brachytherapy is combined with the other treatments, chemotherapy and surgery. In locally advanced cervical cancer we have all three treatments, more recently also immunotherapy, and in endometrial cancer, if it is operated on and presents risk factors, let’s say with a negative prognosis, brachytherapy helps and reduces the risk of vaginal recurrence.

Is brachytherapy available in us according to European standards?

There is European and international consensus and there are centers in Romania that manage to bring and cover the need for oncological treatment and especially modern, up-to-date brachytherapy. There is less access in areas further from academic centers. This is really an important point, because the higher volume centers are also loaded, but in the end, the European recommendations actually support bringing all the complex cases together to have an expertise and to be able to do a proper audit.

A procedure that makes a difference

Are there any myths or patient fears about brachytherapy?

Yes, there are myths like that the radiation remains in the body, it was probably known, some time ago, in Romania, that there was the implant with prostate seeds and they were afraid of these patients who had implants with radioactive seeds with iodine. Perhaps patients or relatives did not know that the dose decreases with time. After some time, after three months, the radiation is no longer relevant and the patient is effectively no longer a danger to the public or the family. But that was in the case mentioned. Currently, there are more and more HDR devices, controlled by computers, and the source actually reaches the tumor and later withdraws and is automatically manipulated, and the patient does not remain radioactive. Another myth could be that it is painful, but today we can say that we have the facility to integrate anesthesia and intensive care into the procedure, and they manage to help us with the control of pain and discomfort. Or maybe because it’s a long procedure we do a spinal anesthesia, a spinal anesthesia, so that the patient doesn’t feel the pressure not to move, but rather we help him not to mobilize.

What are the benefits of brachytherapy for quality of life? Especially preserving sphincter function and avoiding a permanent stroma?

Just as you numbered them, these are important benefits. The OPERA study, published just last year and presented at the European congress, very clearly specifies the importance of endocavitary brachytherapy, experienced, with an internal irradiation device. We manage to fixate the tumor and irradiate it, monitor it endoscopically afterward and see the changes at that level—from the anal canal or the lower rectum—and somehow control the side effects and get to where we preserve sphincter function.

One disease, several specialists

What comes after brachytherapy? Are there any recommendations related to lifestyle, diet, after the procedure?

We recommend adequate hydration, maintaining a daily stool and increasing daily progressive physical effort, because it is very important for the patient to resume normal activity. After the procedure without anesthesia, patients can resume their activity immediately, maybe even the next day, without any problem and for intense effort. For the procedure with anesthesia, a break between 48 and 72 hours is recommended and then gradually, depending on the patient.

What message do you have for patients and their families about brachytherapy?

It is important to know that there is also this method of treatment, which is not an old one, but is modern, is updated and is integrated into European and international consensuses. It is important to know that a single opinion is not the best approach in oncology treatment. It is good to know more specialists who treat cancer – the surgeon, the oncologist and the radiation therapists, but also the radiologist. So it is very important to know that successful treatment results often come from collaboration, and here there are countless data by which we know and are happy that we can make a difference in a patient’s life.

Article supported by SANADOR