Utilization of brachytherapy in Quebec, Canada

  • Magali Lecavalier-Barsoum
    Corresponding Author. Department of Oncology, Faculty of Medicine, McGill University, Montreal, Quebec, Canada, Tel.: 43-88-881927
    Department of Oncology, Faculty of Medicine, McGill University, Montreal, Quebec, Canada

    Department of Radiation Oncology, Jewish General Hospital, McGill, University, Montreal, Quebec, Canada
    Search for articles by this author
  • Farzin Khosrow-Khavar
    Department of Oncology, Faculty of Medicine, McGill University, Montreal, Quebec, Canada
    Search for articles by this author
  • Krum Asiev
    Department of Oncology, Faculty of Medicine, McGill University, Montreal, Quebec, Canada

    Department of Medical Physics, Jewish General Hospital, McGill University, Montreal, Québec, Canada.
    Search for articles by this author
  • Marija Popovic
    Department of Oncology, Faculty of Medicine, McGill University, Montreal, Quebec, Canada
    Search for articles by this author
  • Te Vuong
    Department of Oncology, Faculty of Medicine, McGill University, Montreal, Quebec, Canada

    Department of Radiation Oncology, Jewish General Hospital, McGill, University, Montreal, Quebec, Canada
    Search for articles by this author
  • Shirin A. Enger
    Department of Oncology, Faculty of Medicine, McGill University, Montreal, Quebec, Canada

    Department of Medical Physics, Jewish General Hospital, McGill University, Montreal, Québec, Canada.

    Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Quebec, Canada
    Search for articles by this author



      Despite the excellent clinical outcomes from brachytherapy treatments compared with other modalities and the low associated costs, there have been reports of a decline in utilization of brachytherapy. The aim of this study was to investigate in detail the trend in utilization of brachytherapy in the province of Québec, Canada, from 2011 to 2019.


      All radiotherapy clinics in the province of Quebec, and among these the clinics that provide brachytherapy treatments, were identified. This observational retrospective cohort study involved analysis of data compiled by the Ministère de la Santé et des Services Sociaux du Québec for the period of 2011 to end of 2019 on all brachytherapy procedures performed in the province of Quebec. Time series graphs were used to describe the number of high dose rate (HDR) and low dose rate (LDR) brachytherapy treatments during the studied time period. Statistical analysis was conducted using R statistical software.


      Between 2011 and 2019, 12 hospitals in the province of Québec provided radiotherapy treatments, and all of them offered brachytherapy services. The median annual number of brachytherapy sessions was 4413 (range 3930-4829). HDR brachytherapy represented over 90% of all brachytherapy treatments throughout the study period. Significant changes over time were observed in the number of treatments: at least 5% change was seen only for the two most common subtypes of brachytherapy, HDR interstitial and HDR intracavitary, with an increase of 9.6% and a decrease of 9.2%, respectively. The use of other subtypes of brachytherapy (HDR-plesiotherapy, LDR-interstitial, LDR-intracavitary, LDR-eye plaque) was stable between 2011 and 2019, with ≤ 2.5% variation.


      This study demonstrates an overall steady use of brachytherapy between 2011 and 2019 in Quebec. Brachytherapy offers numerous advantages for the treatment of diverse cancer sites. Although more sophisticated external beam radiotherapy treatments have emerged in the last decades, the precision and cost-effectiveness of brachytherapy remain unbeaten. To ensure the continued use and availability of brachytherapy, governments must put in place policies and regulations to that effect. Training and exposure of future health care professionals to brachytherapy within Quebec and Canada is essential to provide all patients the same access to this life saving modality.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Brachytherapy
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Committee C.C.S.A.
        Canadian Cancer Statistics.
        Canadian Cancer Society, 2019: 2019
      1. Foundation, Q.C.Quebec Cancer Statistics. Available from:

        • Vu C.C.
        • Blas K.G.
        • Lanni T.B.
        • et al.
        Cost-effectiveness of prostate boost with high-dose-rate brachytherapy versus intensity-modulated radiation therapy in the treatment of intermediate-high risk prostate cancer.
        Brachytherapy. 2018; 17: 852-857
        • Vu C.C.
        • Jawad M.S.
        • Krauss D.J.
        The cost-effectiveness and value proposition of brachytherapy.
        Semin Radiat Oncol. 2020; 30: 87-93
        • Rose J.
        • McLaughlin P.Y.
        • Falkson C.B.
        Brachytherapy practice across Canada: a survey of workforce and barriers.
        Brachytherapy. 2013; 12: 615-621
        • Phan T.
        • Mula-Hussain L.
        • Pavamani S.
        • et al.
        The changing landscape of brachytherapy for cervical cancer: a Canadian practice survey.
        Curr Oncol. 2015; 22: 356-360
        • Keyes M.
        • Crook J.
        • Morris W.J.
        • et al.
        Canadian prostate brachytherapy in 2012.
        Can Urol Assoc J. 2013; 7: 51-58
        • Pla C.
        • Evans M.D.
        • Podgorsak E.B.
        Dose distributions around selectron applicators.
        Int J Radiat Oncol Biol Phys. 1987; 13: 1761-1766
      2. IAEA. DIRAC DIrectory of RAdiotherapy Centres. Available from:

        • Safdieh J.
        • Wong A.
        • Weiner J.P.
        • et al.
        Utilization of prostate brachytherapy for low risk prostate cancer: Is the decline overstated?.
        J Contemp Brachytherapy. 2016; 8: 289-293
        • Han K.
        • Milosevic M.
        • Fyles A.
        • et al.
        Trends in the utilization of brachytherapy in cervical cancer in the United States.
        Int J Radiat Oncol Biol Phys. 2013; 87: 111-119
        • Guedea F.
        • Ellison T.
        • Venselaar J.
        • et al.
        Overview of brachytherapy resources in Europe: a survey of patterns of care study for brachytherapy in Europe.
        Radiother Oncol. 2007; 82: 50-54
        • Guedea F.
        • Venselaar J.
        • Hoskin P.
        • et al.
        Patterns of care for brachytherapy in Europe: updated results.
        Radiother Oncol. 2010; 97: 514-520
        • Corkum M.T.
        • Morton G.
        • Louie A.V.
        • et al.
        Is prostate brachytherapy a dying art? Trends and variation in the definitive management of prostate cancer in ontario, canada.
        Radiotherap Oncol. 2020; 152: 42-48
        • Wickham H.
        ggplot2: elegant graphics for data analysis.
        Springer, New York2009
        • Tanderup K.
        • Fokdal L.U.
        • Sturdza A.
        • et al.
        Effect of tumor dose, volume and overall treatment time on local control after radiochemotherapy including MRI guided brachytherapy of locally advanced cervical cancer.
        Radiother Oncol. 2016; 120: 441-446
        • Followill D.
        • Geis P.
        • Boyer A.
        Estimates of whole-body dose equivalent produced by beam intensity modulated conformal therapy.
        Int J Radiat Oncol Biol Phys. 1997; 38: 667-672
        • Petti P.L.
        • Chuang C.F.
        • Smith V.
        • et al.
        Peripheral doses in CyberKnife radiosurgery.
        Med Phys. 2006; 33: 1770-1779
        • Hall E.J.
        • Wuu C.S.
        Radiation-induced second cancers: the impact of 3D-CRT and IMRT.
        Int J Radiat Oncol Biol Phys. 2003; 56: 83-88
        • Kry S.F.
        • Bednarz B.
        • Howell R.M.
        • et al.
        AAPM TG 158: Measurement and calculation of doses outside the treated volume from external-beam radiation therapy.
        Med Phys. 2017; 44: e391-e429
        • Vuolukka K.
        • Auvinen P.
        • Palmgren J.E.
        • et al.
        Incidence of subsequent primary cancers and radiation-induced subsequent primary cancers after low dose-rate brachytherapy monotherapy for prostate cancer in long-term follow-up.
        BMC Cancer. 2020; 20: 453
        • Hoskin P.J.
        • Rojas A.M.
        • Ostler P.J.
        • et al.
        Randomised trial of external-beam radiotherapy alone or with high-dose-rate brachytherapy for prostate cancer: Mature 12-year results.
        Radiother Oncol. 2020; 154: 214-219
        • Morton G.C.
        • Alrashidi S.M.
        High dose rate brachytherapy in high-risk localised disease - why do anything else?.
        Clin Oncol (R Coll Radiol). 2020; 32: 163-169
        • Morton G.C.
        High-dose-rate brachytherapy boost for prostate cancer: rationale and technique.
        J Contemp Brachytherapy. 2014; 6: 323-330
        • Mendez L.C.
        • Morton G.C.
        High dose-rate brachytherapy in the treatment of prostate cancer.
        Transl Androl Urol. 2018; 7: 357-370
        • Wojcieszek P.
        • Białas B.
        Prostate cancer brachytherapy: guidelines overview.
        J Contemp Brachytherapy. 2012; 4: 116-120
        • Chin J.
        • Rumble R.B.
        • Kollmeier M.
        • et al.
        Brachytherapy for patients with prostate cancer: american society of clinical oncology/cancer care ontario joint guideline update.
        J Clin Oncol. 2017; 35: 1737-1743
        • Spratt D.E.
        • Zumsteg Z.S.
        • Ghadjar P.
        • et al.
        Comparison of high-dose (86.4 Gy) IMRT vs combined brachytherapy plus IMRT for intermediate-risk prostate cancer.
        BJU Int. 2014; 114: 360-367
        • Ágoston P.
        • Major T.
        • Fröhlich G.
        • et al.
        Moderate dose escalation with single-fraction high-dose-rate brachytherapy boost for clinically localized intermediate- and high-risk prostate cancer: 5-year outcome of the first 100 consecutively treated patients.
        Brachytherapy. 2011; 10: 376-384
        • Aluwini S.
        • van Rooij P.H.
        • Kirkels W.J.
        • et al.
        High-dose-rate brachytherapy and external-beam radiotherapy for hormone-naïve low- and intermediate-risk prostate cancer: a 7-year experience.
        Int J Radiat Oncol Biol Phys. 2012; 83: 1480-1485
        • Kaprealian T.
        • Weinberg V.
        • Speight J.L.
        • et al.
        High-dose-rate brachytherapy boost for prostate cancer: comparison of two different fractionation schemes.
        Int J Radiat Oncol Biol Phys. 2012; 82: 222-227
        • Neviani C.B.
        • Miziara M.A.
        • de Andrade Carvalho H.
        Results of high dose-rate brachytherapy boost before 2D or 3D external beam irradiation for prostate cancer.
        Radiother Oncol. 2011; 98: 169-174
        • Zwahlen D.R.
        • Andrianopoulos N.
        • Matheson B.
        • et al.
        High-dose-rate brachytherapy in combination with conformal external beam radiotherapy in the treatment of prostate cancer.
        Brachytherapy. 2010; 9: 27-35
        • Corkum M.
        • Loblaw A.
        • Hasan Y.
        • et al.
        Prostate high dose-rate brachytherapy as monotherapy for prostate cancer: late toxicity and patient reported outcomes from a randomized phase II clinical trial.
        Radiother Oncol. 2020; 156: 160-165
        • Thomas M.A.
        • Ochoa L.L.
        • Zygmunt T.M.
        • et al.
        Accelerated partial breast irradiation: a safe, effective, and convenient early breast cancer treatment option.
        Mo Med. 2015; 112: 379-384
        • Bennion N.R.
        • Baine M.
        • Granatowicz A.
        • et al.
        Accelerated partial breast radiotherapy: a review of the literature and future directions.
        Gland Surg. 2018; 7: 596-610
        • Cho L.P.
        • Manuel M.
        • Catalano P.
        • et al.
        Outcomes with volume-based dose specification in CT-planned high-dose-rate brachytherapy for stage I-II cervical carcinoma: A 10-year institutional experience.
        Gynecol Oncol. 2016; 143: 545-551
        • Kang H.C.
        • Shin K.H.
        • Park S.Y.
        • et al.
        3D CT-based high-dose-rate brachytherapy for cervical cancer: clinical impact on late rectal bleeding and local control.
        Radiother Oncol. 2010; 97: 507-513
        • Karlsson J.
        • Dreifaldt A.C.
        • Mordhorst L.
        • et al.
        Differences in outcome for cervical cancer patients treated with or without brachytherapy.
        Brachytherapy. 2017; 16: 133-140
        • Gill B.S.
        • Lin J.F.
        • Krivak T.C.
        • et al.
        National Cancer Data Base analysis of radiation therapy consolidation modality for cervical cancer: the impact of new technological advancements.
        Int J Radiat Oncol Biol Phys. 2014; 90: 1083-1090
        • Beveridge R.D.
        • Akhoundova D.
        • Bruixola G.
        • et al.
        Controversies in the multimodality management of locally advanced rectal cancer.
        Med Oncol. 2017; 34: 102
        • Onaitis M.W.
        • Noone R.B.
        • Hartwig M.
        • et al.
        Neoadjuvant chemoradiation for rectal cancer: analysis of clinical outcomes from a 13-year institutional experience.
        Ann Surg. 2001; 233: 778-785
        • Kalyan A.
        • Rozelle S.
        • Benson A.
        3rd, Neoadjuvant treatment of rectal cancer: where are we now?.
        Gastroenterol Rep (Oxf). 4. 2016: 206-209
        • Gani C.
        • Bonomo P.
        • Zwirner K.
        • et al.
        Organ preservation in rectal cancer - Challenges and future strategies.
        Clin Transl Radiat Oncol. 2017; 3: 9-15
        • O'Gorman C.
        • Denieffe S.
        • Gooney M.
        Literature review: preoperative radiotherapy and rectal cancer - impact on acute symptom presentation and quality of life.
        J Clin Nurs. 2014; 23: 333-351
        • Vuong T.
        • Devic S.
        • Moftah B.
        • et al.
        High-dose-rate endorectal brachytherapy in the treatment of locally advanced rectal carcinoma: technical aspects.
        Brachytherapy. 2005; 4: 230-235
        • Vuong T.
        • Devic S.
        High-dose-rate pre-operative endorectal brachytherapy for patients with rectal cancer.
        J Contemp Brachytherapy. 2015; 7: 183-188
        • Hesselager C.
        • Vuong T.
        • Påhlman L.
        • et al.
        Short-term outcome after neoadjuvant high-dose-rate endorectal brachytherapy or short-course external beam radiotherapy in resectable rectal cancer.
        Colorectal Dis. 2013; 15: 662-666
        • Nout R.A.
        • Devic S.
        • Niazi T.
        • et al.
        CT-based adaptive high-dose-rate endorectal brachytherapy in the preoperative treatment of locally advanced rectal cancer: Technical and practical aspects.
        Brachytherapy. 2016; 15: 477-484
        • Yau I.
        • Vuong T.
        • Garant A.
        • et al.
        Risk of hypogonadism from scatter radiation during pelvic radiation in male patients with rectal cancer.
        Int J Radiat Oncol Biol Phys. 2009; 74: 1481-1486
        • Rijkmans E.C.
        • Cats A.
        • Nout R.A.
        • et al.
        Endorectal brachytherapy boost after external beam radiation therapy in elderly or medically inoperable patients with rectal cancer: primary outcomes of the phase 1 HERBERT study.
        Int J Radiat Oncol Biol Phys. 2017; 98: 908-917
        • Corner C.
        • Bryant L.
        • Chapman C.
        • et al.
        High-dose-rate afterloading intraluminal brachytherapy for advanced inoperable rectal carcinoma.
        Brachytherapy. 2010; 9: 66-70
        • Glaser S.M.
        • Dohopolski M.J.
        • Balasubramani G.K.
        • et al.
        Brachytherapy boost for prostate cancer: trends in care and survival outcomes.
        Brachytherapy. 2017; 16: 330-341
        • Orio III P.F.
        • Nguyen P.L.
        • Buzurovic I.
        • et al.
        The decreased use of brachytherapy boost for intermediate and high-risk prostate cancer despite evidence supporting its effectiveness.
        Brachytherapy. 2016; 15: 701-706
        • Mitchell J.M.
        Urologists' use of intensity-modulated radiation therapy for prostate cancer.
        New England Journal of Medicine. 2013; 369: 1629-1637
        • Li R.
        • Yashar C.
        • Thaker N.
        • et al.
        Radiation oncology alternative payment model (APM): an introduction and primer for the proposed rule for practices and providers.
        Practical radiation oncology. 2021; 11: e22-e29
        • Boyce-Fappiano D.
        • Ning M.S.
        • Gjyshi O.
        • et al.
        Payment Methodology for the Radiation Oncology Alternative Payment Model: Implications for Practices and Suggestions for Improvement.
        • Morton G.
        • Taggar A.
        • Keyes M.
        • et al.
        Brachytherapy education and certification—A Canadian approach.
        Brachytherapy. 2020; 19: 857-860