Advancing Veteran Care: Richmond VA Becomes First VA Medical Center to Introduce HDR Brachytherapy

A new chapter in prostate cancer care

Prostate cancer is the most common cancer treated by the Radiation Oncology team at Richmond VAMC, and it remains one of the leading causes of cancer death in men. For years, Veterans here have had two main options: surgery through Urology or radiation therapy, most often in the form of external beam radiation given over several weeks. For nearly three decades, the medical center also offered traditional low‑dose‑rate (LDR) brachytherapy, in which radioactive “seeds” are permanently implanted into the prostate to slowly deliver radiation over several months.

“We were doing the seed implant, which is a commonly done procedure,” said Dr. Matthew Schutzer, radiation oncologist at the Richmond VA. “Needles are used to implant radioactive sources into the prostate, and they stay there permanently.”

Now, the team has launched a high‑dose‑rate (HDR) prostate brachytherapy program that replaces permanent seeds with a single, precisely controlled radiation source. The updated technique is still a form of prostate brachytherapy, but instead of leaving seeds in place, needles are inserted into the prostate and a machine guides one radiation source through them.

How HDR brachytherapy works

HDR brachytherapy still relies on needles placed into the prostate in the operating room, but what happens next is very different. The radiation source sits at the tip of a thin wire and is driven by a computer‑controlled machine into each needle, moving through multiple positions inside the gland and “dwelling” at programmed points until the entire prescribed dose is delivered from within the prostate over about 20 minutes.

“The primary advantage is control,” Schutzer said. “Being able to make sure we treat the target effectively while avoiding too much radiation to the bladder, rectum, and urethra.

The planning is done in real time with ultrasound guidance, the team can account for the true size and shape of the prostate on the day of the procedure, rather than relying on older scans. 

Bruce Curran, chief therapeutic medical physicist at Richmond VAMC explains that with HDR, if needles are not in ideal positions, the team can adjust how long the source stays in specific spots to compensate. In a typical case, they place about 15 needles and optimize the dose to create an implant that matches the Veteran’s anatomy.

Therapeutic medical physicist Robert Hawranko sums it up: “We’re not guessing; we know precisely what dose we’ll give to the prostate and surrounding structures before we treat. We deliver treatment to that exact geometry. There’s no need to bring the patient back later to add more seeds, as can sometimes happen with LDR.”

Modern MRI and other imaging tools are helping the team go even further. “Because we now understand more about where disease is inside the prostate, we can boost the dose to the areas that need it most,” Curran added. For Veterans, that means treatment can be tailored more closely to their particular cancer.

Safer for Veterans and staff

When Veterans received permanent seeds, they left the operating room with tiny radioactive sources inside their bodies. Those seeds delivered treatment safely, but they also meant months of low‑level radiation and, in some cases, temporary limits on close contact with young children.

HDR changes that equation. “With HDR, the exposure to staff and the risk to staff is essentially nil,” Curran said. During the 20 minutes of active radiation, the patient remains in the room with the implanted needles while the team monitors from just outside using cameras and physiologic monitors. If anything is needed, staff can be back at the bedside in seconds.

The new technique also improves safety by eliminating loose radioactive seeds in the operating room. “There’s no loose source that could accidentally drop on the floor,” Curran said. Rigorous quality assurance checks ensure that the afterloading machine is functioning correctly and that the dose delivered matches the dose prescribed.

The role of the team

Behind this advanced procedure is a tightly coordinated, multidisciplinary team. A radiation oncologist leads the clinical decision‑making and performs the needle placement, determining a course of radiation treatment for each patient based on the specifics of their disease.

Two medical physicists specialize in the science of radiation and treatment planning. “Medical physicists make sure that whatever the doctor prescribes, we can deliver safely and accurately,” Curran said. They create the plan, optimize the dose in real time in the operating room, and verify that the technology performs as expected.

Nursing staff from the minor procedures area, along with the anesthesia team, round out the group, keeping Veterans safe and comfortable throughout the procedure. Typically, six to eight people are present in the room for most of the case, working together from start to finish.

Although brachytherapy has been used to treat cancer for more than a century, the Richmond VA team stresses that today’s HDR program is anything but old‑fashioned. “HDR brachytherapy is really quite an advanced technology,” Hawranko said. “We have to be accurate to sub‑millimeter distances and sub‑second timing, and the treatment is delivered robotically with no staff in the room during radiation.”

Why HDR matters for Veterans

For some Veterans, HDR and LDR may both be viable options, but HDR offers several important advantages. Its precision and adaptability make it especially valuable when cancer extends outside the prostate capsule or into the seminal vesicles, where permanent seeds can be difficult to place reliably.

“If the cancer extends outside the prostate, I really wouldn’t be comfortable doing LDR because you don’t have the same level of control over where the radiation dose goes,” Schutzer explained.

HDR is also an important tool when prostate cancer returns after prior radiation. Instead of treating the entire gland again, the team can focus just on the portion where the recurrence is located. “For patients whose cancer has come back after previous radiation, HDR allows us to treat just part of the prostate with the extra precision that retreatment requires,” Schutzer said.

From a physics standpoint, HDR brachytherapy offers some of the most conformal dose distributions available. “Compared with external beam radiation, brachytherapy delivers a highly conformal dose from inside the target, so much less normal tissue receives radiation,” Hawranko said. This steep dose fall‑off helps protect nearby organs such as the bladder and rectum.

First in the VA—and looking ahead

Dr. Michael Chang, Chief of Radiation Oncology at the Richmond VA Medical Center, said Richmond is the first facility in the VA system to launch an HDR prostate brachytherapy program. “We are the first site in the VA to do this and currently hold the only active HDR brachytherapy license in the VA,” he said.

Before the Mission Act, Richmond served as a national referral center for permanent seed implants, with Veterans flying in from as far away as Puerto Rico, Washington, D.C., and Los Angeles. Today, demand for HDR is already strong locally. “We have only done one of these. Right now, we are booked until June,” Schutzer noted. “We are excited about this. Once we get our stride, get our process down, we’re hopeful we can scale up and maybe take regional patients.”

For now, the focus is squarely on prostate cancer, which will keep the team busy, but they see broader possibilities on the horizon. “Although we’re only doing prostate right now, there are other diseases for which HDR is a desired treatment, particularly in gynecologic cancers,” Curran said. The team also sees future potential in skin, breast, and certain head and neck cancers as the VA’s expertise evolves in this field.

What has not changed is the mission: to provide Veterans with safe, effective, and state‑of‑the‑art cancer care as close to home as possible. HDR brachytherapy at Richmond VA is the latest example of that commitment—combining advanced technology, careful teamwork, and a deep understanding of Veterans’ needs to offer more precise options in the fight against prostate cancer.