HDR brachy monotherapy for high risk

HDR brachy has a lot of radiological advantages - it can treat areas outside of the prostate (including the seminal vesicles and prostate bed), it is infinitely adjustable in the doses it can deliver, it can be adjusted to deliver only very low doses to other organs. It's results have been concomitantly impressive - very high rates of cancer control, and very low rates of urinary and rectal toxicity, with especially impressive preservation of erectile function. As a monotherapy, it has been used for favorable risk patients, but has usually been combined with external beam radiation for unfavorable risk patients. Some recent studies suggest it can be used effectively even for high risk patients with improvement in toxicity over the combination therapy.

HDRBT monotherapy in treatment of high-risk prostate cancer

These studies, and my own results, continue to bolster my long term confidence in this treatment method. Wish more urologists were following this to provide better options for their patients.

I admittedly stumbled into HDR brachy. I didn't even realize there were two flavors of brachy before I went to UCLA for my consult. I'm just one data point, but it's sure working out in the early innings...

This is a subject of great personal interest to me. With suspected SV involvement and possible ECE detected on MRI, my choice of HDR mono-therapy (versus combination HDR brachy treatment with external radiation and possibly ADT) was, in the words of my doctor, "pushing the envelope". He did however express confidence that it was an appropriate method of treatment for my situation. I spent a full day in the UCLA medical library examining all of the HDR mono-therapy studies that I could find before I made my decision. It seems to me that in Japan and Europe, HDR mono-therapy is a more common treatment method for higher risk cases. In Japan, ADT is also frequently used with HDR, but one study explained that the reason has more to do with insurance requirements than with medical necessity.

In the Japanese study, 94% received ADT, and in the UK study, 92%. The German study used less at 60%, but they didn't randomize the ADT vs non-ADT, so it would be hard to draw conclusions even if they did break them out separately. They Germans also gave the highest amount of radiation, and had the highest control rate. Until there is a randomized clinical trial at modern dose rates, the use of ADT with it remains controversial. The ones that use it use it short-term for the most part.

This is not common in Japan, Europe or anywhere else. There are only 3 published studies worldwide, and they are relatively small. Its use for this is still very much considered experimental. I doubt it will gain traction in the future because of the poor economics, and because it has no advantage, and a few disadvantages, over SBRT for high risk. SBRT is equally experimental for high risk, but is cheaper, much less bother, and can additionally treat pelvic LNs, if required. There are also more doctors who could potentially administer it.