Brachytherapy or conformal external radiotherapy for prostate cancer: a single-institution matched-pair analysis

Brachytherapy or conformal external radiotherapy for prostate cancer: a single-institution matched-pair analysis - Cure of localized prostate cancer requires adequate local treatment. This study shows that brachytherapy achieves cure in 95% by delivering very high radiation doses with acceptable toxicity. The results obtained with 'conventional dose' 3-dimensional conformal radiation were significantly worse, likely due to the lower radiation dose used.

Recently, a meta-analysis of dose-escalation randomized trials1 has been published. This paper suggests that 90Gy is required to cure intermediate risk prostate cancer and high risk, 96Gy. Such doses are not obtainable with any current external beam technique.

Emerging data supports the use of brachytherapy (low dose rate or high dose rate) as the most effective way of safely escalating radiation dose with acceptable toxicity. For low and selected intermediate risk cancers, brachytherapy alone suffices. For higher risk cancers a component of external beam radiation with or without adjuvant androgen ablation is added in. Such approaches have been shown in small randomized trials to be effective, and are now being explored in larger multi-institution phase 2 (RTOG 0019 and RTOG 0321) and phase 3 trials. (Canadian ASCENDE-RT).

The current utilization of brachytherapy is falling2 which is surprising, given that our results are typical of those from other large centers. Competition from other forms of external radiation, such as IMRT and stereotactic body radiation, plus the explosion in use of robotically-assisted radical prostatectomy are the reason. None of these techniques achieve the very high cure rates demonstrated with brachytherapy, and may be inferior. 3

In the absence of randomized data, uro-oncologists should disclose to their patients these results during the shared decision-making process. A multidisciplinary assessment (MDA) prior to a decision is required in some countries, such as the UK. Similar MDA are used in most other forms of cancer management and its adoption in those with prostate cancer would serve our patients better.

1. Viani, G.A., E.J. Stefano, and S.L. Afonso, Higher-than-conventional radiation doses in localized prostate cancer treatment: a meta-analysis of randomized, controlled trials. Int J Radiat Oncol Biol Phys, 2009. 74(5): p. 1405-18.

2. Cooperberg, M.R., et al., Contemporary Trends in Low Risk Prostate Cancer: Risk Assessment and Treatment. J Urol, 2007. 178(3S): p. S14-S19.

3. Eastham, J.A., Robotic-assisted prostatectomy: is there truth in advertising? Eur Urol, 2008. 54(4): p. 720-2.

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