John C. Blasko, MD

In the realm of general oncology, patients who present with aggressive, poorly differentiated malignancies are usually at high risk for disseminated disease, and systemic therapy often supersedes local therapy in importance. It is not surprising, then, that a similar systemic approach to therapy is often considered for patients who present with high-risk prostate cancer. This recommendation is often supported by much of the surgical literature that cites discouraging outcomes in these patients when treated by radical prostatectomy alone.

Permanent prostate brachytherapy with or without supplemental therapies is a highly effective treatment for clinically localized prostate cancer, with biochemical outcomes and morbidity profiles comparing favorably with competing local modalities. However, the absence of prospective randomized brachytherapy trials evaluating the role of supplemental external-beam radiation therapy (XRT) has precluded the development of evidence-based treatment algorithms for the appropriate inclusion of such treatment. Some groups advocate supplemental XRT for all patients, but the usefulness of this technology remains largely unproven and has been questioned by recent reports of favorable biochemical outcomes following brachytherapy used alone in patients at higher risk. Given that brachytherapy can be used at high intraprostatic doses and can obtain generous periprostatic treatment margins, the use of supplemental XRT may be relegated to patients with a high risk of seminal vesicle and/or pelvic lymph node involvement. Although morbidity following brachytherapy has been acceptable, supplemental XRT has shown an adverse impact on long-term quality of life. The completion of ongoing prospective randomized trials will help define the role of XRT as a supplement to permanent prostate brachytherapy.

The role of prostate brachytherapyin the treatment of prostatecancer continues to expand andevolve. The increasing clinical use andwider acceptance of this treatmentmodality can be attributed to published10-year data demonstrating cure ratesequivalent to those of radical prostatectomyand to quality-of-life studiesthat demonstrate relatively lowermorbidity from brachytherapy comparedto surgery.[1-4] It is the easeand convenience of treatment, the apparentequivalent cure rates, and theperception of lower morbidity thatmakes this treatment so appealing topatients. However, like all treatments,prostate brachytherapy does have sideeffects, and some patients will suffersignificant complications or severemorbidity.