January 13, 2005

Bay Area’s CET provides new generation of cancer treatment

By Jeanne Carbone Lewis
Staff Writer

You have cancer. These three words uttered by a physician create terror in the hearts of anyone who hears them.
Surgery cuts through the body to remove malignant growths. Chemotherapy and radiation then attack the body’s healthy tissues and organs to thwart any missed microscopic cells with the guidelines: Treat enough to destroy the cancer but allow the patient live.

Dr. Jeffrey Demanes in his office at Oakland-based CET.

After the patient endures surgery, radiation and chemotherapy, there are other problems to face. Nausea, tiredness and hair loss are recognized acute side effects but there are other long-term consequences. Each type of cancer and treatment leaves a trail of afflictions not well known to the general public.

Prostate surgery may cause incontinence and impotence. Memory problems, premature meno-pause and nerve damage are not uncommon after treatment for breast cancer. Not to mention the disfigurement associated with certain surgeries. After external beam radiation treatment, the patients may have side effects in or near the treated organs. Prostate cancers patients can have permanent bowel or bladder injury. Then there are the emotional problems of feeling ill and wondering…did the treatment destroy all the malignant cells and will the cancer return?

“I hear about people undergoing surgeries and radiation for all kinds of cancer who never even hear about HDR brachytherapy,” said Gillian Altieri, a New Almaden resident and a certified medical dosimetrist at California Endocurietherapy Cancer Center [CET]. “I wish they would have heard about our treatment methods. The other form of brachytherapy called permanent seed implants are limited to prostate cancer. They leave the patient radioactive, offer less control of the radiation delivery and permanent seeds can travel—to the lungs or other organs after being inserted. HDR is a real technological advancement that helps patients by using virtual computer images and robotic precision to deliver radiation directly into the tumor so that it cures cancer and protects normal tissue at the same time.”

HDR less invasive, tumor-specific treatment
The Oakland-based CET center is taking brachytherapy cancer treatment to the next level by using high dose rate [HDR] brachytherapy. HDR is used to treat prostate, gynecological, breast, head and neck, lung, esophageal and bile duct cancers along with soft tissue sarcomas and recurrent cancers of many types when other treatments have failed. CET is only one of a handful of clinics in the United States to offer this less invasive, tumor-specific cancer therapy.

Brachytherapy isn’t new. Low-dose-rate [LDR] brachytherapy has been practiced for almost a century. LDR radiation sources require days or months to deliver the prescribed radiation dose. The radiation sources may not stay in the position or location the physician initially placed them, resulting in uncertain doses to the cancer and the nearby organs. The patient receiving LDR is radioactive until either the source is removed or it decays to a level where it no longer poses a radiation exposure risk to others.

HDR brachytherapy solves those problems. The radiation dose is delivered in minutes, so there is no opportunity for the radiation source to shift from where the doctor intended. HDR is temporary brachytherapy. After the treatment, nothing is left behind in the patient so radiation exposure to others is eliminated.

“The biggest plus of HDR over LDR is that we know what the doses will be to the cancer and the nearby tissues BEFORE any radiation is given to the patient,” explains Altieri.

A dosimetrist’s job is to shape the radiation to cover the cancer while sparing the normal tissue from the radiation as much as possible. With over 20 years experience in the field, Gillian says HDR is the most accurate way to treat small, localized cancers in the prostate, breast, cervix, head and neck and other organs.

Basically, HDR brachytherapy treatment involves four steps:
The first step is the placement of the applicator by the brachytherapy specialist. This step may be done under sedation, local, spinal or general anesthesia according to the tumor site and the type of applicator required to best fit the situation.

Dosimetrist Gillian Altieri evaluating a prostate implant. Photos by Jeanne Carbone Lewis

Second, a CT scan or x-rays are taken by radiation therapists to determine the exact location of the implant in the body and its relationship to adjacent organs with review by the physician.

Third, the images are downloaded by the dosimetrist to enter into the image and data into the treatment-planning computer. The computer does the initial calculation but it is the dosimetrist who “fine tunes,” or customizes the radiation dose to conform to the target tumor area while minimizing the doses to nearby normal tissues. The completed treatment plan is then approved by the physician; the computer transfers the instructions to the HDR remote afterloader.

Fourth, the treatment begins when the catheters are connected to the tubes of the afterloader, a sophisticated apparatus that houses the radiation. Programmed instructions tell the afterloader where to direct the radiation and for how long [usually about 10 to 15 minutes] while therapists and nurses monitor the patient. The entire treatment process takes 30 to 60 minutes depending on each particular patient’s cancer diagnosis. When the treatment is completed, the radiation source is retracted back into the HDR afterloader with no radiation left behind the patient. After the treatment, the implant is removed and the patient goes home soon afterward.

Several treatments may be necessary depending on the severity or location of the cancer.

Benefits of HDR
HDR treatment is noninvasive. Patients do not undergo major surgery with the therapy done on an outpatient basis except for head and neck. The cancer is irradiated from the inside the body so that it does not pass through healthy tissues and organs. Patients walk out from HDR treatments with temporary minor soreness and swelling.

Catheter insertion sites heal and appear unnoticeable in CET’s case studies. And the patient is not radioactive to others. CET conducts thorough patient follow-up and has 5 and 10-year outcome studies on the effectiveness of HDR prostate and other cancer treatments.

“I chose HDR brachytherapy,” Chuck Weber, a Los Gatos resident who went to CET for a second recurrence of prostate cancer [the first was treated with external beam radiation over an eight-week period in 1992] in 2000, said. “I interviewed more that 20 physicians and visited at least 10. I chose Dr. Demanes based on the number of cases he had, the convenience to home and the feeling I got from the facility and staff. The advantage of HDR over other types of treatment is the radiation is guided precisely, sparing surrounding tissues. I check my PSA every three months and it is the lowest it has been since I was diagnosed in 1989.” [To read more of Weber’s experience at CET, go to www.prostatepointers.org/seedpods/weber.html].

Promising 5- and 10-year studies
CET’s study, “High Dose Rate Intensity Modulated Brachytherapy with External Beam Irradiation for Prostate Cancer: California Endocurietherapy’s [CET] 5- and 10-Year Results” has been accepted for publication in the International Journal of Radiation Oncology Biology and Physics, considered the leading recorder of clinical data in the field of radiation oncology. The results of the 10-year follow up study showed that 90 percent of the patients remained free of disease progression and the complication rates were very low. To see results, go to www.cetmc.com/publications.html.

Equally impressive are CET’s studies on breast cancer. Following lumpectomy for early-stage breast cancer, women no longer need to have six to seven weeks of daily external beam radiation therapy [EBRT]. With HDR, the treatment is finished in five days with no skin reactions, no dose to the underlying structures like lung, while receiving a conformal treatment with a high chance of local control because HDR can deliver a much higher dose to the tissues at the risk of recurrence than EBRT can. To date, none of CET’s breast cancer patients have had a recurrence.

Head and neck cancers are also a specialty of CET. In treating tongue cancer, HDR brachytherapy allows precise delivery of high doses of radiation eliminating the potential surgical disfigurement and preserving the function of the tongue.

Founder of CET
Dr. Jeffrey Demanes founded CET in 1982 and is board certified in three medical specialties: internal medicine, radiation and medical oncology. He has performed hundreds of LDR implants before adding the HDR system in 1991. With HDR, he realized the “convergence of disciplines.” and is a proponent of the technologically advanced system. CET has safely delivered over 15,000 HDR treatments and received a commendation from the state for its safety record.

Dr. Demanes believes that HDR isn’t more widely used because not enough doctors have been trained in HDR and that this treatment is a new area of discovery. Most physicians who treat cancer patients are surgeons, oncologists or radiation oncology specialists who concentrate on EBRT. Patients understandably receive the treatments familiar to their doctor and public awareness. HDR is becoming better known because of its effectiveness. Because of the complexity of the HDR treatment, a center must consist of board certified radiation oncologists, brachytherapy nurse specialists, radiation therapists and dosimetrists and medical physicist. CET staffs 20 professionals.

“Once I realized the capabilities of HDR technology, I made a commitment to offer this sophisticated treatment to all my patients,” Dr. Demanes said from his third story office overlooking Summit Medical Center in Oakland. “The accuracy is better; we are certain of the dose, there’s more control and you know what the doses are before the treatment actually begins. And there are relatively few side effects. For me, someone who has been a specialist in brachytherapy for more than 20 years, it is the renaissance of brachytherapy.”

Dr. Demanes specialized in radiation oncology at University of California [UC] Los Angeles and did a fellowship in medical oncology at the UC, San Francisco and special training in brachytherapy at Memorial Hospital, Long Beach.

CET is an affiliated institution with Stanford University Medical Center and trains their residents in HDR brachytherapy. Demanes was presented with the Henry S. Kaplan Award from Stanford University in 2004 and is president-elect of the American College of Radiation Oncology.

For more information on California Endocurietherapy Cancer Center call (510) 986-0690 or (877) 238-1437 or go to www.cetmc.com. CET is located at 3012 Summit St., Suite 2675, Oakland, Calif., 94609.