Comparison of dose-escalated, image-guided radiotherapy vs. dose-escalated, high-dose-rate brachytherapy boost in a modern cohort of intermediate-risk prostate cancer patients



      We compared outcomes in intermediate-risk prostate cancer patients treated with dose-escalated adaptive image-guided radiation therapy (IGRT) or dose-escalated high-dose-rate brachytherapy boost (HDR-B).

      Methods and Materials

      Patients with intermediate-risk prostate cancer by National Comprehensive Cancer Network criteria were treated with either CT-based off-line adaptive IGRT (n = 734) or HDR-B (n = 282). IGRT was delivered with 3D-conformal or intensity-modulated radiation therapy with a median dose of 77.4 Gy. For HDR-B, the whole pelvis received a median 46 Gy, and the prostate 2 implants of 9.5 Gy (n = 71), 10.5 Gy (n = 155), or 11.5 Gy (n = 56).


      Median followup was 3.7 years for IGRT and 8.0 years for HDR-B (p < 0.001). Eight-year biochemical control was 86% for IGRT and 91% for HDR-B (p = 0.22), disease-free survival 67% for IGRT and 79% for HDR-B (p = 0.006), and overall survival 75% for IGRT and 86% for HDR-B (p = 0.009). Cause-specific survival (8-year, 100% vs. 99%), freedom from distant metastases (98% vs. 97%), and freedom from local recurrence (98% vs. 98%) did not differ (p > 0.50 each). A worse prognosis group was defined by percent positive prostate biopsy cores >50%, perineural invasion, or stage T2b–c, encompassing 260 (35%) IGRT and 171 (61%) HDR-B patients. These patients evidenced a 5-year biochemical control of 96% for HDR-B and 87% for IGRT (p = 0.002).


      Dose-escalated IGRT and HDR-B both yield excellent clinical outcomes for patients with intermediate-risk prostate cancer. Improved biochemical control with HDR-B for patients with worse pretreatment characteristics suggests that a subgroup of intermediate-risk prostate cancer patients may benefit from dual-modality treatment.


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        • Martinez A.A.
        • Kestin L.L.
        • Stromberg J.S.
        • et al.
        Interim report of image-guided conformal high-dose-rate brachytherapy for patients with unfavorable prostate cancer: The William Beaumont phase II dose-escalating trial.
        Int J Radiat Oncol Biol Phys. 2000; 47: 343-352
        • Brenner D.J.
        • Martinez A.A.
        • Edmundson G.K.
        • et al.
        Direct evidence that prostate tumors show high sensitivity to fractionation (low alpha/beta ratio), similar to late-responding normal tissue.
        Int J Radiat Oncol Biol Phys. 2002; 52: 6-13
        • Kestin L.L.
        • Martinez A.A.
        • Stromberg J.S.
        • et al.
        Matched-pair analysis of conformal high-dose-rate brachytherapy boost versus external-beam radiation therapy alone for locally advanced prostate cancer.
        J Clin Oncol. 2000; 18: 2869-2880
        • Sathya J.R.
        • Davis I.R.
        • Julian J.A.
        • et al.
        Randomized trial comparing iridium implant plus external-beam radiation therapy with external-beam radiation therapy alone in node-negative locally advanced cancer of the prostate.
        J Clin Oncol. 2005; 23: 1192-1199
        • Deutsch I.
        • Zelefsky M.J.
        • Zhang Z.
        • et al.
        Comparison of PSA relapse-free survival in patients treated with ultra-high-dose IMRT versus combination HDR brachytherapy and IMRT.
        Brachytherapy. 2010; 9: 313-318
        • Hoskin P.J.
        • Rojas A.M.
        • Bownes P.J.
        • et al.
        Randomised trial of external beam radiotherapy alone or combined with high-dose-rate brachytherapy boost for localised prostate cancer.
        Radiother Oncol. 2012; 103: 217-222
        • Cahlon O.
        • Zelefsky M.J.
        • Shippy A.
        • et al.
        Ultra-high dose (86.4 Gy) IMRT for localized prostate cancer: Toxicity and biochemical outcomes.
        Int J Radiat Oncol Biol Phys. 2008; 71: 330-337
        • Viani G.A.
        • Stefano E.J.
        • Afonso S.L.
        Higher-than-conventional radiation doses in localized prostate cancer treatment: A meta-analysis of randomized, controlled trials.
        Int J Radiat Oncol Biol Phys. 2009; 74: 1405-1418
        • Zelefsky M.J.
        • Yamada Y.
        • Fuks Z.
        • et al.
        Long-term results of conformal radiotherapy for prostate cancer: Impact of dose escalation on biochemical tumor control and distant metastases-free survival outcomes.
        Int J Radiat Oncol Biol Phys. 2008; 71: 1028-1033
        • Peeters S.T.H.
        • Heemsbergen W.D.
        • Koper P.C.M.
        • et al.
        Dose-response in radiotherapy for localized prostate cancer: Results of the Dutch multicenter randomized phase III trial comparing 68 Gy of radiotherapy with 78 Gy.
        J Clin Oncol. 2006; 24: 1990-1996
        • Martinez A.A.
        • Yan D.
        • Lockman D.
        • et al.
        Improvement in dose escalation using the process of adaptive radiotherapy combined with three-dimensional conformal or intensity-modulated beams for prostate cancer.
        Int J Radiat Oncol Biol Phys. 2001; 50: 1226-1234
        • Martinez A.A.
        • Gonzalez J.
        • Ye H.
        • et al.
        Dose escalation improves cancer-related events at 10 years for intermediate- and high-risk prostate cancer patients treated with hypofractionated high-dose-rate boost and external beam radiotherapy.
        Int J Radiat Oncol Biol Phys. 2011; 79: 363-370
        • Yan D.
        • Lockman D.
        • Brabbins D.
        • et al.
        An off-line strategy for constructing a patient-specific planning target volume in adaptive treatment process for prostate cancer.
        Int J Radiat Oncol Biol Phys. 2000; 48: 289-302
        • Roach 3rd, M.
        • Hanks G.
        • Thames Jr., H.
        • et al.
        Defining biochemical failure following radiotherapy with or without hormonal therapy in men with clinically localized prostate cancer: Recommendations of the RTOG-ASTRO Phoenix Consensus Conference.
        Int J Radiat Oncol Biol Phys. 2006; 65: 965-974
        • Bachand F.
        • Martin A.-G.
        • Beaulieu L.
        • et al.
        An eight-year experience of HDR brachytherapy boost for localized prostate cancer: Biopsy and PSA outcome.
        Int J Radiat Oncol Biol Phys. 2009; 73: 679-684
        • Huang J.
        • Vicini F.A.
        • Williams S.G.
        • et al.
        Percentage of positive biopsy cores: A better risk stratification model for prostate cancer?.
        Int J Radiat Oncol Biol Phys. 2012; 83: 1141-1148
        • Scrucca L.
        • Santucci A.
        • Aversa F.
        Regression modeling of competing risk using R: An in depth guide for clinicians.
        Bone Marrow Transplant. 2010; 45: 1388-1395
        • Anderson P.R.
        • Hanlon A.L.
        • Patchefsky A.
        • et al.
        Perineural invasion and Gleason 7-10 tumors predict increased failure in prostate cancer patients with pretreatment PSA <10 ng/ml treated with conformal external beam radiation therapy.
        Int J Radiat Oncol Biol Phys. 1998; 41: 1087-1092
        • Khor R.
        • Duchesne G.
        • Tai K.-H.
        • et al.
        Direct 2-arm comparison shows benefit of high-dose-rate brachytherapy boost vs external beam radiation therapy alone for prostate cancer.
        Int J Radiat Oncol Biol Phys. 2013; 85: 679-685
        • Demanes D.J.
        • Rodriguez R.R.
        • Schour L.
        • et al.
        High-dose-rate intensity-modulated brachytherapy with external beam radiotherapy for prostate cancer: California endocurietherapy’s 10-year results.
        Int J Radiat Oncol Biol Phys. 2005; 61: 1306-1316
        • Kotecha R.
        • Yamada Y.
        • Pei X.
        • et al.
        Clinical outcomes of high-dose-rate brachytherapy and external beam radiotherapy in the management of clinically localized prostate cancer.
        Brachytherapy. 2013; 12: 44-49
        • Chen W.C.
        • Tokita K.M.
        • Ravera J.
        • et al.
        Four-year outcomes of hypofractionated high-dose-rate prostate brachytherapy and external beam radiotherapy.
        Brachytherapy. 2013 Feb 1; ([Epub ahead of print])