Debate 2: Primary Localized Prostate Cancer: The Case for Whole-Gland Brachytherapy Boost

Amani A Chowdhury ¹, Peter J Hoskin ²

⁰Mount Vernon Cancer Centre, Northwood, UK; Division of Cancer Sciences, University of Manchester, Manchester, UK.

Seminars in Radiation Oncology +

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June 14, 2025

View abstract on PubMed

Summary

Whole gland brachytherapy (BT) combined with external beam radiotherapy (EBRT) significantly improves outcomes for intermediate- and high-risk prostate cancer (PCa). This optimal radical radiotherapy regime offers superior tumor control with manageable late toxicities.

Area Of Science

Oncology
Radiation Oncology
Urology

Background

Whole gland brachytherapy (BT) boost combined with external beam radiotherapy (EBRT) is a proven treatment for intermediate- and high-risk prostate cancer (PCa).
Randomized controlled trials (RCTs) and meta-analyses confirm its superiority over EBRT alone, demonstrating long-term benefits in biochemical relapse-free survival (bRFS).
Concerns exist regarding potential late genitourinary (GU) and gastrointestinal (GI) toxicities associated with this combined approach.

Purpose Of The Study

To evaluate the efficacy and toxicity of whole gland BT boost in combination with EBRT for locally advanced prostate cancer.
To compare the benefits of whole gland BT boost versus focal boost or EBRT alone.
To reinforce the role of whole gland BT boost as an optimal radical radiotherapy strategy.

Main Methods

Review of three randomized control studies (RCTs) and meta-analysis data.
Analysis of long-term outcomes and toxicity profiles.
Consideration of prostate cancer's multifocal nature and challenges in delineating dominant intraprostatic lesions (DIL).

Main Results

Whole gland BT boost with EBRT significantly improves bRFS for intermediate- and high-risk PCa.
Evidence supports the superiority of this combination over EBRT alone.
While focal boost shows promise, whole gland boost is favored due to PCa's complexity and lack of head-to-head trials.

Conclusions

Whole gland BT boost combined with EBRT is the optimal radical radiotherapy regime for locally advanced prostate cancer.
The radiobiological advantages and robust evidence base for BT support its use over various EBRT boost techniques.
Despite potential toxicities, the oncological benefits of whole gland BT boost outweigh concerns, especially given challenges with focal boost justification and DIL delineation.