Intro: Welcome to UAB MedCast, a continuing education podcast for medical professionals, providing knowledge that is moving medicine forward. Here's Melanie Cole.

Melanie Cole, MS (Host): Welcome to UAB MedCast. I'm Melanie Cole. And today, we're highlighting brachytherapy at UAB Medicine. Joining me is Dr. Samuel Marcrom. He's a radiation oncologist and the Associate Medical Director of Brachytherapy at UAB Medicine.

Dr. Marcrom, thank you so much for joining us today. I'd like you to start by telling other providers a little bit about brachytherapy when it broke onto the scene. You know, how it differs from traditional external beam radiation that we've known as a standard of therapy for so many years. Tell us a little bit about it.

Dr. Sam Marcrom: Well, thank you so much for having me. It's really an honor to be here and to have the opportunity to speak with you, Melanie, as well as to tell people a little bit about what brachytherapy is.

Brachytherapy is a type of radiation treatment, that today it makes up what I would say is the minority of radiation treatments, but it has some really unique components that are extremely useful to take advantage of. And oftentimes it creates the best treatment possible. And so, it comes from the Greek word, brachos or brachýs, which means short or close. And the idea is that if you can get the radiation source a short distance or very close to where you want to treat, you can use this therapy and take advantage of its properties.

And so, it's a bit more invasive than a lot of our treatments. So, a lot of our treatments that are external-beam based, the patient would, say, lay on a table, a machine would move around you. Nothing would actually touch you. And we would treat the tumor from the outside in. But what brachytherapy is where you take an applicator or some type of device and you put it in the body inside the tumor and you treat it from the inside out. And if you're able to place it precisely, then you can take advantage of the really nice properties of brachytherapy, which is that the dose falls off, or the dose goes down very rapidly with distance. So, you have this exponential fall off. And so, what that translates to is more precise treatments that spare the normal tissues, but deliver very high doses to the tumor. And so, you can understand how there's some scenarios where that's extremely advantageous, and sometimes even offers the very best treatment.

Melanie Cole, MS: Well, thank you for that. It really is a fascinating form of therapy. So, what cancers-- expand a little bit on that-- are you using it mostly for?

Dr. Sam Marcrom: Absolutely. So, the two most common sort of cancer types that this is applied for are gynecologic cancers, with cervical cancer being the sort of flagship cancer that's treated with brachytherapy as well as prostate cancer. These are the two most common applications, both here at UAB as well as really nationally and internationally. But it has been used and can be used for many, many types of cancers depending on the situation, many sarcomas, many skin cancers. Breast cancers can be treated with this. There's a really long history of using it across a lot of different cancer types, because of those properties that are really advantageous. But in my practice and I think nationally based on our latest numbers, really, the gynecologic cancers and prostate cancer are the most common applications.

Melanie Cole, MS: Speak about how it is for the patients, the benefits such as precision, which you've mentioned, the side effects, shorter treatment times. Tell us a little bit about what the patient experience is like.

Dr. Sam Marcrom: So, I think you do have the advantage of typically shorter treatment times. So, most external radiation treatments are every day for multiple weeks. There are some exceptions to that, but oftentimes it can take you many sessions to get through a course of treatment, whether that's 20 or 25, or 30 or 35. And with brachytherapy, most of the time you're talking about a very low number of treatments such as three or four or five. And so, there is that advantage that it's a more condensed treatment time. So, from a patient experience, I think that is oftentimes really nice.

You know, the way that brachytherapy is performed varies across institutions. Here at UAB, we have what's called a brachytherapy suite, which is a dedicated procedural area for us to do these procedures. And It's fully staffed with anesthesia and all of the imaging devices that we would need to confirm positioning. And essentially, the goal is that we can make this treatment as patient-centric as possible. So, we can put you to sleep during the parts that are uncomfortable or might be painful. We can get everything exactly correct, treat you, take everything out, and then wake you up as one way that we might do this.

And so from that standpoint, I think, when you have a setup such as we have you, you create the opportunity to not only deliver this really precise treatment in a convenient, sort of short number of treatments, but you can also do it in a way that is not overly painful or uncomfortable for the patient, but when you have all the resources.

Melanie Cole, MS: Tell us about safety and efficacy. What are you seeing, Doctor, as far as outcomes and side effects, that sort of thing? Are you seeing really great outcomes? And if you are, then why did you say it's in the minority? Why do you feel that is?

Dr. Sam Marcrom: So, one of the principles of the treatment is that because the dose does fall off so quickly, you have to be able to place the applicator safely where you want to treat, and you also can't treat very large targets. And so, because of that, you know, the external beam approach has some advantages in terms of treating all over the body very safely as well as treating larger structures potentially.

And so, I think that inherently is going to limit its use. In terms of some of the outcomes that we are seeing though in appropriately selected patients and good candidates. It's really impressive. The data in cervical cancer is probably the strongest. It's been studied where patients have received either additional external beam treatment or they received brachytherapy. And what the studies consistently show is that the tumor control is improved. The overall survival is improved. And in many cases, the toxicity is actually lower. So, we're seeing better cure, better tumor control with less side effects. And I really just owe that to the fact that it can so precise. Now, it is invasive, you do have to have this applicator placed. But for so many of our patients, our goal is how can we help you move past your cancer, how can we cure the cancer, and not only do that, but help you live well afterwards. And so, having this sort of long-term, long horizon perspective is so critical. And I think that aligns with so many of my patients' goals that that's really a beautiful thing to be able to offer.

Prostate cancer is similar in that there definitely is data of better tumor control with brachytherapy as compared to some other techniques. There's nuances, the details matter. And I think it would be unfair of me to say that you always need to get this treatment because there is nuance, right? But I definitely think it's something that not enough people know about. And it's worth exploring because if you are someone that could have a real benefit, and if those benefits align with your goals, then I think we owe it to our patients to make them aware of that and help them pursue that.

Melanie Cole, MS: That was so well said, Doctor. And for other providers, speak about the multidisciplinary team that work together to deliver this therapy to patients and why that's so comprehensive and important.

Dr. Sam Marcrom: Absolutely. I tell our trainees and our students that come through that radiation is a team sport, but just in the sense that it takes so many people from different training backgrounds to deliver any type of radiation. And brachytherapy may be the pinnacle of that, given the hands-on nature and the involvement required. But, you know, we work within our department with nurses, with radiation therapists, with physicists, with people called dosimetrist that help with planning, as well as students, trainees, and obviously the doctors. Then, we're also, of course, working with the patient. And so, you put all of that together just within our department. It's extremely multidisciplinary. And each of those parts is of vital importance to make the whole machine go, so to speak.

But then if you take a step outside of what we do as radiation oncologists, cancer care is becoming increasingly multidisciplinary. And that is a great thing because the reality is we all have expertise in different areas and our outcomes are getting better because we're all working together to explore new indications, new treatments, new medicines, and understand how do the old or the established medicines integrate in with the new things.

So in my practice, particularly for GYN cancers, I work very closely with our gynecologic oncologists. We have one of the very best departments in the entire country, and they are truly national leaders. And it's a privilege to get to work with them. Their patient ownership is incredible, their partnership in trying to, adhere to standards, but also push the envelope, and what can we do to move things forward is really exciting to be a part of.

Similarly, I have a team of urologists that I work with very closely for prostate cancer patients. And they also are really extraordinary in the way that they approach care, the way that they integrate with our department. And so, I think that that's one of the advantages of our center, and there are others of course similar to this. But we really do work as a team and I think that is where the patients benefit.

Melanie Cole, MS: Well, it certainly is, and what a great center it is, Doctor. And what about new technologies, innovations? What are you seeing on the horizon for brachytherapy and radiation in general? What are you looking for? What are you hoping for?

Dr. Sam Marcrom: This is an exciting time. I mean, it really is. When I think about cancer care and I think about the future, it's really bright. When a patient is faced with the devastating news that they have cancer, that's life-changing. It can be overwhelming at times. And for us to be able to step in at a time of that degree of overwhelm and vulnerability and questioning and uncertainty and say, "We are going to walk this path with you and we have great tools in order to help you reach your goals," and those are getting better literally every week. It seems that there's something new, there's something better. No one ever wants to hear that they have cancer, but it's the best time in the history of the world to have it because our tools, our technology and our advancements are on a tremendous trajectory. And so, because of that, it is exciting to get to watch your patients experience some of these things.

Specifically within radiation oncology, it's a very technology-driven field, and the technology just keeps getting better. In many places, we're seeing tools of automation help to make processes faster, help define the target better, define the normal structures better, develop the plans faster, double check them, and triple check them faster. And so, what that translates to is we're seeing patients go from maybe I meet my doctor and I start my treatment a couple of weeks later to that timeline shrinking tremendously. And I will not be surprised if, in the next five years, we see that timeline go down to same day or next day regularly.

And so, there's tons of data on the amount of delay in care or the time to treatment correlates with your outcomes. And so if we can do high quality things faster, that's better for our patients. We're also seeing an explosion in some of the technologies that we currently use to allow us to be more precise and develop radiation delivery to the tumor more accurately and minimize the dose to the normal tissues.

In terms of brachytherapy, things like having fully staffed dedicated procedure spaces such as we have at UAB allow our patients to get excellent care in a much better way than they used to be able to receive it. We're expanding the indications. We're expanding the things that we can safely treat based on some of the advances that we have both in techniques for placement as well as imaging, incorporating things like a CT scan, incorporating things like an MRI scan, really defining where do we need to treat, where do we not need to treat, and then we're seeing our patients benefit from that.

So, I guess I just this is really exciting and an exciting time. And the future is bright.

Melanie Cole, MS: It certainly is. Thank you so much, Doctor, for joining us and sharing your incredible expertise in this exciting time in brachytherapy and radiation oncology. Thank you again so much. And for more information, please visit our website at uabmedicine.org/physician. That concludes this episode of UAB MedCast. I'm Melanie Cole.