Jaime Lewis (Host): While prostate cancer affects one in eight men in America, advanced treatment options are significantly changing outcomes. Today I am sitting down with Dr. Shana Coplowitz, Medical Director of the Radiation Oncology Center at the Litman Cancer Center at Montefiore St. Luke's Cornwall. She's going to talk about stereotactic body radiation therapy for prostate cancer and why it's becoming an important treatment option. 

This is Doc Talk presented by Montefiore St. Luke's Cornwall. I'm Jaime Lewis. Hello, Dr. Coplowitz. Thank you for joining us.

Shana Coplowitz, MD: Hi. Thank you for having me.

Host: Well, let's start with the basics. What exactly is stereotactic body radiation therapy or SBRT and how does it work for prostate cancer patients?

Shana Coplowitz, MD: So SBRT is a technique that we use for radiation, which essentially is allowing us to very precisely target areas, essentially giving a much smaller margin, and therefore treating much less normal tissue than we do with other techniques. It's also typically using higher doses of radiation, so we're able to complete treatments in much less time than standard treatments are done.

Host: So much more focused and a smaller real estate.

Shana Coplowitz, MD: Yes.

Host: And who best qualifies for this kind of treatment when it comes to prostate cancer?

Shana Coplowitz, MD: Most patients do. Typically the ones that we are treating are patients who have what's called intermediate risk disease. Arguably patients with low risk prostate cancer probably don't need to be treated, but if they opt for treatment, it is certainly an option for them. The only patients that I really would not recommend getting treated with SBRT, are patients who have high risk prostate cancer.

Or patients who have lymph nodes involved. Typically I would not recommend SBRT for those patients, but otherwise, for the intermediate and low risk cancer patients, I think it's a great option.

Host: What are the advantages of doing this kind of treatment compared to something else say?

Shana Coplowitz, MD: Honestly, it's the time factor. Standardly, prostate cancer treatments are done in either 45 or 28 treatments. So you're talking about nine weeks of radiation, five and a half weeks of radiation, which is really a lot, especially, you know, for men who are working, who you know, have other things that they want to do with their time, really don't want to be coming in for that many treatments. Able to be finished in five treatments, which is typically done every other day. So the whole process takes about two weeks. So it's really just so much more appealing for patients, rather than having to come in for so many times. 

Host: Are there any downsides to SBRT treatment?

Shana Coplowitz, MD: So because it's a bit of a higher dose of radiation, theoretically some of the urinary side effects could be a little bit more intense, could be a little bit more acute. So patients who have significant urinary issues at baseline, so often patients with prostate cancer, you know, are typically older men, generally will have urinary symptoms. So they're waking up at night to urinate, going frequently during the day to urinate. So patients who really have significant urinary complaints at baseline may not be the best candidates for this because it really kind of may make it a little bit worse, although, you know, maybe not.

You know, that's probably one of the biggest downsides is maybe those urinary complaints could be a little bit more acute. But honestly, I think that when the treatments are done appropriately, when you're really cognizant of how you're planning the radiation, I think that you can avoid a lot of those issues.

When we do it here, we actually will prophylactically give patients who are not already on medication for urination, we'll prophylactically put it on, or give it to them just because this will kind of potentially help mitigate any of these urinary side effects that they might otherwise start to notice with the treatments.

Host: What about long-term effectiveness with a more focused treatment like this? Does it tend to be as effective as other methods?

Shana Coplowitz, MD: So the studies really do so far suggest that it is equally effective as other options for radiation, as the longer options for radiation. One of really kind of cool things about SBRT that studies have been looking into is actually doing focal boosts with the radiation treatment. So in other words, you get a an MRI for a patient with prostate cancer, you see a small prostate cancer lesion in the prostate.

So typically when we treat, we're treating the entirety of the prostate, and we do that with all the treatments. But there's studies looking with SBRT, that actually kind of while you're treating the entire prostate, giving a focal SBRT boost, meaning giving a higher dose to that area of prostate cancer.

And studies are, are really kind of intriguing and, showing that potentially that actually controls it better than patients who are just getting standard treatments. And so that's another kind of cool up and coming thing that, that is potential advantage of SBRT.

Jaime Lewis (Host): Well, what should patients expect when they're getting ready or when they're undergoing the actual treatment process?

Shana Coplowitz, MD: One of the things that's really important with prostate SBRT, because we are using higher doses of radiation, is to really make sure that we are protecting the rectum because the rectum sits directly behind the prostate and you really want to make sure that you're not giving a high dose of radiation to the rectum. Because that could potentially lead to complications in the future, something called radiation proctitis.

And so anybody who is getting SBRT will need a couple of things to prepare. So one of those things is something called a rectal spacer, which is a gel that our urologists will put in for us, and it's a gel that gets put in, in between the prostate and the rectum, and that gel stays in place long enough to get you through the treatments, and then over time actually gets reabsorbed back into the body, but creates this kind of artificial space there where you're able to minimize the dose of the rectum.

So that's one thing that patients are going to need to do. It is a procedure, you know, in a way similar to a biopsy. But it's a very quick procedure. So urologists do that at the same time as they put the spacer in, they will also put a few tiny little markers into the prostate. And the cool thing about what we do here at St. Luke's, which is really very specific to our radiation machine, something called a Radixact, which we just installed last year, is that the machine will actually track those markers during the actual treatment because prostates move, you know, with breathing, with gas in the rectum, they'll move a little bit. So our machine can actually track the motion of the prostate and will follow it and really allows us to be very precise in how we're delivering the treatment because we're actually following the prostate movement and treating it as it moves.

So that's why they put those markers in. So those are two things that get put in. That's by the urologist in preparation for the treatment. In terms of what we do here in the radiation department, is we will do a planning session, which is a CAT scan. We will also send the patients for an MRI, a special MRI that's done at the hospital.

And we use both the CAT scan and the MRI to plan out the radiation treatment. And finally, the last thing is on a day-to-day basis in terms of preparing, we're going to ask that the patients fill their bladder to some degree. So typically we'll have them drink a bottle of water about an hour before, and they're also going to try to clear out their bowels.

So we have them do an enema every day prior to the treatment. So it is a little bit more involved in terms of what we do to prepare for the treatments. But I think at the end of the day, because it's such a shorter course of treatment, you know, even though it's a little bit more involved, I think at the end of the day a better option for a lot of people.

Host: Yeah, it sounds like it could be worth it for the right person. Well, for those interested in SBRT, what is the first step they should take?

Shana Coplowitz, MD: The first step would be to come talk to me. So anybody who has prostate cancer, typically diagnosed by the urologist will get referred to me and they'll come and they'll have a consultation and we'll talk about all the different options. We'll go through all the preparations, all the side effects, you know, what to expect, make sure that it truly is appropriate for them.

And then if they say, okay, I'm on board, let's do it; we talk to the urologist. We get them set up for the spacer, for the fiducials, which are the markers, and then we get them set up for the planning and we go from there. So the first step would be to come talk to me.

Host: Well, Dr. Coplowitz, thanks so much for joining us.

Shana Coplowitz, MD: My pleasure. Thanks for having me. 

Host: That was Dr. Shana Coplowitz, Medical Director of the Radiation Oncology Center at Montefiore St. Luke's Cornwall's Litman Cancer Center. To learn more about the cancer treatment options available, visit montefioreslc.org and thanks for listening to Doc Talk presented by Montefiore St. Luke's Cornwall. And please remember to subscribe, rate, and review this podcast and all the other Montefiore St. Luke's Cornwall podcasts.