Brachytherapy: is it really “better” as a first-line treatment for low- and intermediate-risk prostate cancer?


An analysis of data on treatment of nearly 137,500 men treated for prostate cancer between 1991 and 2007 has suggested that permanent seed brachytherapy may be safer, less costly, and at least as effective as any other widely available form of first-line therapy for men with low- and intermediate-risk prostate cancer.

These data will be presented by Ciezki et al. at the Genitourinary Cancers Symposium in San Francisco later today, but the abstract is already available on line, the American Society for Clinical Oncology (ASCO) has already announced data at a press conference; a full news report is available on the WebMD web site; and another commentary can be found on the Medscape web site.

Ciezki et al. used the linked SEER-Medicare database to examine data from patients with prostate cancer who were treated with prostatectomy (RP), external beam radiotherapy (EBRT), or brachytherapy (BT) between 1991 and 2007 (which allowed the possibility of data on patients with as much as 16 years of follow-up).

In particular, the authors looked for procedural billing codes that were associated with treatments for toxic side effects and complications of RP, EBRT, and BT and the costs of such treatments.

Here is what they found:

  • The database contained 137,427 patients who were ≥ 65 years of age at diagnosis and had prostate cancer as their only cancer diagnosis.
    • 59,559 (43.3 percent) were treated with RP.
    • 60,806 (44.2 percent) were treated with EBRT.
    • 17,062 (12.4 percent) were treated with BT.
    • No patient received combined therapy.
  • The average (median) follow-up was 71 months (just under 6 years).
  • 10,585 patients (7.3 percent) had some form of toxicity or complication requiring treatment.
    • 6.9 percent of men receiving RP needed treatment.
    • 8.8 percent ofmen receiving EBRT needed treatment.
    • 3.7 percent of men receiving BT needed treatment.
  • Dilation of a urethral stricture was the most common treatment for a genitourinary complication (3.6 percent of all patients).
  • Cauterization of rectal bleeding was the most common treatment for a gastrointestinal complication (0.8 percent of all patients).
  • The annualized costs of therapy were
    • $2,557.36 per patient-year for BT
    • $3,205.71 per patient-year for RP
    • $6,412.29 per patient-year for EBRT

Czieki and his colleagues conclude that — over this 16-year period — the long-term toxicity and the cost per patient-year of the three major, first-line treatment modalities differ within the Medicare-eligible community, and that EBRT is the most toxic and the most costly.

Now it needs to be said that aspects of this conclusion should be treated with caution, and for a variety of reasons.

In the first place, it seems highly likely that during much of this time period, the patients most likely to receive EBRT as first-line therapy for prostate cancer would have been older and had more advanced forms of prostate cancer than the men being treated with RP and BT. This would, on its own, make it likely that such patients were at greater risk for complications of treatment.

Secondly, over the time period being discussed, there have been massive changes in the quality of care. In 1991, very few physicians even offered BT; most surgeons were still learning how to do nerve-sparing prostatectomies; there were no surgical robots; and almost all EBRT was carried out using three-dimensional, conformal beam radiation therapy. Compare that to the situation in 2007, by which time most surgery was done with da Vinci robots; most radiation therapy was done by IMRT; and there was significant set of brachytherapy specialists.

Thirdly, the use of active surveillance as a first-line management strategy is not explored in this study.

There is probably little doubt that, amortized over time, EBRT is the most expensive form of first-line treatment for prostate cancer. However, whether the complications and toxicities associated with EBRT are really much higher today than those associated with BT and RP is probably open to question.

3 Responses

  1. But what about comparative mortality?

  2. Are there studies underway to address the precautions presented in this paper related to IMRT and/or CyberKnife treatments?

    Currently my Gleason number is 7 (3 + 4) and my PSA is between 9 and 10 ng/ml. I am scheduled for CyberKnife treatment in 3 weeks. Research I have read about indicates that current toxicity rates are about the same as BT and RP! Should I rethink my decision? (I’m 76 and have some heart issues … pacemaker and atrial fibrillation. In spite of this, I am physically quite active.)

  3. Dear Greg:

    (1) I am not aware of any data that is likely to be available in the near future that directly compares the toxicities associated with SBRT (CyberKnife radiation) to those associated with other forms of therapy.

    (2) Currently available data would suggest that levels of toxicity associated with CyberKnife radiation may be somewhat lower than those associated with IMRT, but it is almost impossible to know the accuracy of such data because there has been no form of comparison that takes account of all the appropriate criteria (patient age, disease stage, etc.).

    SBRT (CyberKnife radiation) is really just one particular and sophisticated type of external beam radiation therapy. It is highly targeted and (for many men) its major appeal is in the convenience factor because it requires far fewer visits to the radiotherapy suite. There is no good reason (yet) to believe that SBRT is noticeably more effective or significantly safer than other forms of radiation therapy. Equally, as explained above, it is hard to be able to say with accuracy whether current forms of radiation therapy like IMRT are in fact any less safe than brachytherapy or surgery. Only one head to head study on this topic has ever been done … and it preceded the availability of SBRT.

    I understand that you are nervous about what might “go wrong” with your treatment, regardless of what type of treatment you have. However, I have no reason to believe that, for a man like you, SBRT would be a poor choice compared to any other option … and it certainly does have the benefit of relative convenience. Brachytherapy may not be appropriate for you in any case because it does require a surgical procedure to implant the radioactive seeds.

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