Is low-dose brachytherapy really “better” than other treatment options (redux)?

An article just published by Grimm et al. in a supplement to BJU International argues (quite persuasively) that low-dose brachytherapy is the best form of treatment for men with low-risk prostate cancer.

Because of the apparent persuasiveness of this article, we feel it is important to make some very clear observations about it, as follows:

  • There is absolutely nothing “wrong” about using low-dose brachytherapy to treat low-risk prostate cancer.
  • This article is not based on a prospective, randomized clinical trial; it is just another restrospective data analysis.
  • Like all retrospective data analyses, it suffers from multiple inherent problems, starting with those of patient selection bias.
  • It has been published in a supplement to BJU International devoted exclusively to brachytherapy, and not in a fully peer-reviewed issue of the journal.

For those who want to read the full details that are included in this paper, they are basically the same as those included in a document available on the web site of the Prostate Cancer Treatment Center, and they have been available on this web site since at least May 2011, so they are not exactly “new” data. The Prostate Cancer Treatment Center is a private practice, brachytherapy-focused treatment center in Seattle, Washington. Dr. Grimm (the lead author of the current paper) is its executive director. In addition, the paper just published in the supplement to BJU International was sufficiently important to the Prostate Cancer Treatment Center that they issued a media release about it earlier today too. Dr. Grimm believes as passionately about the merits of brachytherapy as Dr. Walsh and Dr. Catalona do about the merits of radical surgery.

The “New” Prostate Cancer InfoLink has observed regularly that there are data strongly supportive of the role of brachytherapy alone and in combination with external beam radiation therapy and androgen deprivation therapy for the treatment of low-, intermediate-, and high-risk patients with localized forms of prostate cancer. In particular, it has separately been demonstrated, in a prospective clinical trial reported by Sanda et al. in 2008, that brachytherapy was, at that time and in the patients under study, associated with a lower overall risk for complications and side effects during the follow-up period than radical surgery, external beam radiation therapy, or first-line hormone therapy.

There are no data from a randomized trial (or even from a highly structured, prospective registry study) to demonstrate that first-line, low-dose brachytherapy really is any better than any other form of management as a treatment for low-risk prostate cancer. Indeed, it may well be no better than active surveillance at up to 10 years of follow-up in men of 65 years or older — and it does come with risk for a significant range of side effects!

The “New” Prostate Cancer InfoLink considers this paper to be yet another interesting but relatively inconsequential attempt to “position” one form of therapy as “better” than others, based on statistical analysis of data that can not, in fact, be used to prove the claims that are being made.

Based on the data available today (and from about the past 7 or 8 years), we would not criticize any patient with low-risk prostate cancer if he chose to be treated with low-dose, permanent-seed brachytherapy. We would also not criticize him for deciding to fly to Seattle for his treatment. It is a very reasonable choice. Dr. Grimm and his colleagues are arguably among the morst experienced and technically skilled brachytherapists in the world. However, the idea that low-dose brachytherapy is some form of new “gold standard” for the treatment of low-risk prostate cancer is neither justified nor substantiated by these data. It is just one of a number of very reasonable options based on the personal perspectives of the patient.

One Response

  1. Neither the article, nor the include 5+ year data on erectile function for all men or men disaggregated by age. If brachytherapy were genuinely producing significantly different outcomes in regard to quality of life measures, billboards would be plastered and radiologists would have ponied up for a Super Bowl ad. Just more marketing bologna.

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