A recent study comparing brachytherapy, dose-escalated external beam radiotherapy (EBRT), and stereotactic body radiation therapy (SBRT), argues against the move toward hypofractionation for treating localized, intermediate-risk prostate cancer, suggesting that brachytherapy is the most appropriate management strategy in delivering value-based care (JAMA Netw Open. 2020;3(9):e2017144. doi:10.1001/jamanetworkopen.2020.17144).
“The increase in radiation options and paucity of comparative evidence present challenges in guiding patient-centered care” writes Kevin Nguyen, Department of Radiation Oncology, David Geffen School of Medicine, University of California, Los Angeles, and colleagues. There has been a decline in use of BT over the past decade as radiation trends move toward hypofractionation.
Dr Nguyen and colleagues used the National Cancer Database to compare outcomes between SBRT, brachytherapy, and EBRT for treating intermediate-risk localized prostate cancer.
A total of 30,766 patients were eligible for this study. Patients included in this study had a Gleason score of 6-7, clinical stage T1-T2, and prostate-specific antigen <20 ng/mL, and were diagnosed between January 1, 2004, and December 31, 2014. Only EBRT treatment fractions of ≥75 Gy or ≥42 were included. SBRT was defined as 5 fractions of ≥7 Gy per fraction. The collected data were analyzed from February 1 to March 1, 2020.
In the data used for this study, 41.8% of patients received brachytherapy, 56.1% received EBRT, and 2.1% received SBRT. Between 2004 and 2014, SBRT use increased by 10.57% and EBRT use increased by 13.7%, while brachytherapy use decreased by 20.9%.
The median follow-up was 6.7 years. In the favorable intermediate risk cohort, there was no significant difference in OS between both brachytherapy and SBRT (67.02% vs 64.2%), and SBRT and EBRT (64.2% vs 70.9%) in the favorable intermediate risk group. Patients receiving brachytherapy showed statistically significant improvement in OS when compared to those receiving EBRT (69.8% vs 66.1%).
In the unfavorable intermediate risk cohort, there was no significant difference in OS when comparing brachytherapy vs SBRT (64.9% vs 63.2%), and SBRT vs EBRT (63.2% vs 66.6%). However, patients receiving brachytherapy demonstrated a statistically significant improvement in OS compared to those receiving EBRT (61.2% vs 58.7%).
The results of this study suggest no difference in long-term survival between patients treated with SBRT, EBRT, or brachytherapy.
“Brachytherapy has long been shown to be both clinically effective and cost-effective in the management of localized prostate cancer” wrote Dr Nguyen and colleagues.
“As radiation modalities trend toward hypofractionation with major considerations toward cost-effective treatment, our preliminary evaluation suggests that SBRT and [brachytherapy] remain appropriate management strategies in delivering value-based care,” they concluded.—Marta Rybczynski