A Message From the President
Dr. Peter Rossi and Dr. Brett Cox have assembled a distinguished list of faculty for the Denver HDR LDR prostate workshop on November 1-2.  We are offering 30 teams of practicing Radiation Oncologists/Physicists/
Dosimetrists/Urologists the chance to learn from ABS international experts in HDR and LDR prostate brachytherapy in a small group workshop setting. This is a very practical workshop that will enable teams to refine or implement a modern prostate brachytherapy practice. Each team will have the tools for rapid implementation of a high quality brachytherapy practice. This will be a 2-Day Education and Simulator Training Workshop in HDR and LDR Brachytherapy. Topics include “The Rationale for Brachytherapy in the Treatment of Prostate Cancer, Practical LDR AND HDR Brachytherapy, A Successful Brachytherapy Practice, Review of Treatment Planning Solutions: The Technology and Tools for a Successful Brachytherapy Practice”, with the Keynote Address by urologist, Dr. David Crawford, “Disruptive Technologies in Prostate Cancer: The Use of Genomic Markers and Prostate Biopsy Decisions”. 

We have the following outstanding faculty:  Mira Keyes, Thomas Pugh, Brian J. Moran, John E. Sylvester, Sushil Beriwal, Brett W. Cox, Marissa A. Kollmeier, Louis Potters, Dan Cail, Martin King, Peter F. Orio, Ron DiGiaimo, Brian J. Davis, Steven J. Frank, Mahta McKee, Gerard C. Morton, Daniel J. Krauss, Matt Giles, Alvaro Martinez, Firas Mourtada, Christopher Deufel, Juanita M. Crook, Bruce Libby, Bradley Prestidge, Timothy Showalter, Arsalan Siddique, and Peter J. Rossi.
 
The scholarship includes registration, meals and a $300 stipend ($1,300 value per scholarship awardee). The hotel rate is economical at $150 per night. A very high value workshop for those who attend. Don't delay, the deadline is August 31, 2019.

A key mission of the ABS is to promote the highest possible standards of brachytherapy practice. These schools are an integral part of our mission and align with the 300 in 10 initiatives. So, please consider applying for a team scholarship. It will be well worth your time as we continue our new mission to train 30 competent brachytherapy per year over the next 10 years.

Congratulations to Dr. Ahmed Awad who is our first recipient of the 3 month LDR prostate brachytherapy fellowship under Dr. Brian Moran at the Chicago Prostate Center. Dr. Awad recently begin his 3 month training. A special thank you to Theragenics for sponsoring our first ABS fellowship, and a special thank to Dr. Moran for sharing your expertise in LDR brachytherapy.  I have reached out to several industry partners and other high volume academic and community sites to implement additional 3 month fellowships for HDR prostate, GYN, breast and skin. There is a high level of interest. These 3 month brachytherapy fellowships are one of the critical 6 phases for radiation oncologists to develop brachytherapy competency.

Finally, for the upcoming ABS summer newsletter, we will give you updates on brachytherapy implications for the new APM – Dr. Peter Orio and others have been working feverishly on this – and a detailed 300 in 10 update. 

Thank you,  
Daniel G. Petereit, MD, FASTRO
President  

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Chairman's Corner
Peter F. Orio, III, DO, MS
Thank you for the honor and privilege of serving as your President from June 2018 through June 2019. We were able to accomplish so much because we came together as a unified society.

Looking Back

In 2019 we achieved new records for the American Brachytherapy Society. We had record membership accrual, as well as record attendance at the 2019 Annual Meeting. The ABS now has more followers on social media than ever before, and as such we are reaching an unprecedented number of practitioners, patients and families with our message.

We kicked off our Know Your Options campaign, the slogan on which my presidency was based. Last year during prostate cancer awareness month, and since then, many of us have worked diligently with our partners across industry and academics to take part in awareness campaigns that build the demand for brachytherapy as an equally offered treatment option by practitioners and an equally demanded treatment option requested directly by our patients. In doing our part, Dr. Daniel Petereit, Dr. Brian Moran and myself teamed up with On Demand Hosted by Rob Lowe to shoot an informational piece on prostate brachytherapy. The segment was picked up by Fox Business Network and reached 51.6 million households, airing during primetime, and the piece will continue to be available to all our patients via web link on our website.

Our campaign to bring awareness on brachytherapy’s efficacy for all disease sites through Press Releases directly to the media have also been very successful. Our first release in September, Know Your Options , was picked up by 196 outlets nationwide. Our second release for Breast Cancer Awareness Month was picked up by 183 outlets nationwide and our third release of 2018, Cure is Possible if Patients Receive Brachytherapy for cervical cancer was picked up by 192 outlets nationwide. Our most recent press release, Skin Cancer Diagnosis - Do You Really Know "All" Your Treatment Options? , was released in conjunction with the Annual Meeting and Skin Cancer Awareness month in June, and was picked up by 131 outlets nationwide.

Building on our Knowledge is Power campaign, under the direction of current President Dr. Dan Petereit, the ABS has worked for the last year to implement a 10-year strategy called 300 in 10 . The goal is to ensure the training of 30 competent brachytherapists every year for the next 10 years through a multi-faceted approach that includes increasing public awareness, brachytherapy mini-fellowships, updating residency training guidelines, simulator/didactic training and proctorship opportunities. In the spring of 2019 we selected our first fellow to be trained under the direction of Dr. Brian Moran and industry colleagues continue to support our mini-fellowship opportunities, providing ample opportunities for more success into the future.

The 2019 ABS Annual Meeting held in Miami from June 13-15 th was one for the record books! This is tangible proof that we are winning the battle to keep brachytherapy in the hearts and minds of patients and practitioners. This meeting was truly unprecedented. We saw new and innovative techniques, embraced new technologies and banded together as a society to show the world how serious we are in our fight. Our Scientific Program Chairs, Brett Cox and Kristin Bradley, will recap for you in this edition of the BrachyNews all the successes of our meeting. You can see all the highlights on #ABSBRACHY19 thanks to all of you who showcased the meeting on social media!

Looking Forward
As I discussed during my Presidential Address at the Annual Meeting “Live by the Pixel, Die by the Pixel: Brachytherapy Joins the Battle” I am focused on the future of brachytherapy. Artificial intelligence will be a major influencer on our lives as physicians and these disruptive technologies will change the way healthcare is delivered. If we do not adapt to how medicine is delivered as practitioners and as a specialty we run the danger of losing our specialty to those who do. As brachytherapists, we can provide full spectrum cancer care, navigate in-patient hospital wards and operating rooms while using our hands to effect cure. We may be the blueprint and key to saving the specialty as we have skills that will not soon be replaced by AI, especially if we maintain our empathy as we guide patients though their course of cancer care.

Remember united we stand, divided we fall. This applies to the entire specialty of radiation oncology, as well as to brachytherapy. Together we must be vigilant to keep brachytherapy at the forefront of radiation oncology. Through combined efforts and unified messages, we can fend off attacks that are not scientifically grounded but are simply sound bites and half-truths that can easily be put on non-peer reviewed social media platforms by provocateurs. We must all take the time to counter these mis-truths with the whole truth as we bring knowledge and power to our patients and practitioners. Other specialties are encroaching on what is rightfully ours, and worse, we are causing confusion internally within the specialty as we forget that having more tools in the radiation oncology toolbox is a good thing as we strive to personalize medicine for our patients. To remove any effective, efficient and well-established treatment is foolish simply because it may not reimburse as much or might require more time to provide. To survive, we must stop the in-fighting.

Now and into the future, we must band together, and adapt together... because if we do not, we may find ourselves in a place we did not intend.

Thank you
I want to thank each and every one of you that has provided service to the organization during my tenure as president. Because of each of you we have made great strides forward in 2018 and the first half of 2019. I look forward to continuing to advocate unapologetically for all things brachytherapy, and working with all of you. To continue our success, I encourage you to stay vigilant and do your part!
 
Thank you,  
Peter F. Orio III, DO, MS 
Chairman of the Board
 
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Patient Safety Corner
Ra diation Safety Aspects for 177-Lu Dotate Administration
Susan L. Richardson, PhD
Neil Taunk, MD
177 Lu labeled radiopharmaceuticals have been FDA approved for use in targeted radionuclide therapy since January of 2018. Lutetium-177 is primarily a beta emitter with Eβ MAX of 0.497MeV with low-energy gamma components of 113 keV and 208 keV and a physical half-life of 6.65 days. 177-Lu DOTATATE (Lutathera) has been used in the treatment of some gastric neuroendocrine tumors (NETs). 177 Lu-PSMA (prostate-specific membrane antigen) is also used in the treatment of metastatic castration resistant prostate cancer. With the increasing use of these radionuclides in the radiation oncology setting, this Patient Safety Corner will discuss some administrative and radiation safety issues encountered in dose administration, primarily focusing on Lutathera.

Infusion method:
The prescribed dose for Lutathera is 200 mCi (7.4GBq) administered every 8 weeks for a total of 4 doses. Lutathera is administered by slow intravenous infusion over approximately 30 minutes concomitantly with an amino acid solution to protect the kidneys and an antiemetic. Immediately following infusion, the patient will receive a short-acting octreotide over the next few hours. The recommended method of drug infusion is the gravity method. 

Preparation:
The room must be prepared for the patient prior to their arrival. Since the drug administration takes several hours, the patient should be comfortable and in a position such that they can reach the bathroom easily. Since they will be flushed with amino acids, they will need to void multiple times over the course of administration. The patient chair, recliner, or bed should be lined with disposable underpads (or “Chux”) to contain any patient fluids. The patient should be in comfortable, accessible clothing such as a t-shirt and sweat pants. Any clothing items that could potentially be contaminated by toilet water (such as gown ties and strings) should be avoided.

The drug is mainly excreted through the urine of the patient. Therefore, careful preparation of the bathroom is important for containment of radioactive waste. Figure 1 shows the private bathroom for a Lutathera patient. The toilet seat itself is wrapped in pads and the basin and behind the toilet is wrapped with saran wrap. Depending on the water pressure, the water droplets produced from the toilet flushing may spray contaminated water in the area immediately surrounding the toilet. The handrails, door knobs, and sink faucet handles are also wrapped in saran wrap. Individuals should consult their local and state regulations to make sure that disposal of radioactive patient waste (urine) through public sewage is permitted.

Prior to infusion beginning, the patient will receive a radiation safety consult from the physicist describing the requirements for safe release. A precaution list is given to the patient outlining good practices such as sleeping in a separate bed for a few days, and flushing twice after using the restroom. The patient and family should all understand the precautions prior to continuing. Radiation can be detected in the urine up to 30 days after administration.

Administration:
The written directive should be completed and signed per institutional and regulatory rules. After appropriate dose receipt and assay, the vial and lead pig are placed in a plexiglass box or other administration container. Due to the non-negligible gamma component of the radiation, it is recommended to position a leaded glass barrier between the dose and the staff (see Figure 2A) for ALARA purposes. Conventional nuclear medicine practices suggest lining the administration boxes and draping between the dose and the patient to contain drips or spills (see Figure 2B). The entire system may be placed on a stable cart or other device to allow easy removal of the needles and waste after administration. 

The radiation oncologist and physicists should wear protective gowns and gloves during treatment. The dose is prepared through 2 needles – the short needle is usee to provide positive pressue to the system and should be positioned above the fluid surface. The long needle is driven to the bottom of the dose vial (see Figure 3). It is important to check the position of these needles over the course of treatment as a medical event has been reported due to loss of integrity of the seal. The IV and infusion line should be checked for correct orientation and connection. If necessary, air can be added to the system via an empty syringe to regain positive pressure. The dose is infused at variable rates per the manufacturer. During the approximate 30 minute delivery, the activity may be monitored through leaded glass shield with a survey meter or Geiger counter similar to a Y-90 sphere administration. Once the observed exposure rate remains stable, the dose has been delivered.

Following completion of the dose administration, the IV line is removed from the patient and wrapped in the absorbent pads and placed in the plexiglass box. All staff are surveyed outside the room for potential contamination. The cart is then removed from the room and the residual dose can be measured [ZO1]  . The survey may be done with needles in tact in the bottle or they may be removed depending on the well counter configuration (figure 4). The patient remains in their private room for their octreotide dose over the next several hours. Publications indicate that dose to staff during the procedure are well below occupational limits and pose no concern.

Patient release
Appropriate guidelines must be followed to ensure safe release of the patient. NUREG 1556 Vol 9, 10 CFR 35.75(b), the IAEA, and the NCRP all have various guidelines to provide information about patient release requirements. Most published sources indicate that Lutathera patients may be released the same day, but must be given instructions in the United States. It may be easiest for institutions to establish their their patient release criteria based upon administered activity rather than on measured dose rate. It is estimated in the literature that approximately 40-50% of the activity is excreted over the 4 hours post-administration. The patient will remain radioactive for approximately 30 days. Patient release information should include language and information about contacting the department should the patient set off any radiation detectors (airports, ferries, etc).

Post administration
After the patient has been released, a radiation survey must be performed to establish no contamination remains in the room. The absorbent pads, saran wrap, and all other barriers are removed and placed in the trash as long as they have no detectable radiation. The pads and saran wrap near the toilet are typically highly contaminated. Due to space constraints this trash is stored and decayed separately. The toilet itself may be radioactive and require cleaning to get to background dose rates. Disposable toilet brushes may be useful.

Lu-177 waste may be decayed in storage under 10 CFR 35.92, “Decay-in-storage.” Small quantities of metastable Lu-177 (Lu-177m), with a half-life of 161 days, may be present as a contaminant generated from the production of Lu-177. In this case the trash must be stored until at background levels.
Figure 1 : Private bathroom prepared for a Lutathera patient. Saran wrap is used on metal surfaces such as handrails and faucets. Absorbent pads are used on the floor and on the toilet seat. The toilet basin is also wrapped in saran wrap.
Figure 2A: Radiation dose in green pig placed in a plexiglass box for administration. A leaded glass shield is placed between the dose and the staff for ALARA purposes. Figure 2B: disposable draping between the patient and the dose.
Figure 3: Drug needle positioning
Figure 4: Assay after administration
Join us in Denver for the 2019 HDR LDR Prostate Workshop.
Knowledge is Power, Increase Patient Access to High Quality Prostate Brachytherapy.
Goals:
  • To improve education and training of HDR/LDR Brachytherapy
  • To facilitate a more rapid transition from education to practice implementation
  • To ensure high quality brachytherapy delivery
  • To communicate the value of brachytherapy
The Program:
  • 2-Day Education and Simulator Training Workshop in HDR and LDR Brachytherapy
  • Scholarship includes, registration, meals and a $300.00 stipend ($1,300 value per scholarship awardee)
  • 30 teams of practicing Radiation Oncologists/Physicists/Dosimetrists/Urologists will learn from up to 20 ABS international experts in HDR and LDR prostate brachytherapy in a small group workshop setting
  • Each team consists of one Radiation Oncologist, one Medical Physicist and/or Dosimetrist, and Urologist (optional)
Deadline extended to August 31, 2019!
Click here for more information
For more information, please email bradleyl@theragenics.com

REGISTRATION OPENING SOON
2019-2020 ABS Board of Directors

Daniel G. Petereit, MD , President
Firas Mourtada, PhD, President Elect
Ann Klopp, MD, PhD, Vice President
Brett W. Cox, MD, Treasurer
Christopher L. Deufel, Secretary
Peter F. Orio, III, DO, MS , Chairman of the Board
Catheryn Yashar, MD, Past Chairwoman of the Board

Directors-at-Large
  
Sushil Beriwal, MD
Kristin Bradley, MD
Peter J. Rossi, MD
Timothy Showalter, MD

Meetings and Workshops of Interest