Joseph Chin, MD
D. Andrew Loblaw, MD
AS REPORTED by Joseph Chin, MD, of London Health Sciences Centre, London, Ontario, and colleagues in the Journal of Clinical Oncology, ASCO and Clinical Care Ontario (CCO) have issued a joint update to the prior CCO guideline on use of brachytherapy in patients with prostate cancer.1,2 The update was informed by a targeted literature review performed by an update committee that identified recent randomized trials comparing dose-escalated external-beam radiation therapy with brachytherapy; five trials provided the evidentiary support for the update. The update panel was co-chaired by Dr. Chin (CCO) and D. Andrew Loblaw, MD (ASCO), of Sunnybrook Health Sciences Centre, Toronto, Ontario.
The guideline questions for the update, key recommendations, and qualifying statements are summarized/reproduced here.
Guideline Questions
IN PATIENTS with newly diagnosed prostate cancer, what is the efficacy of brachytherapy alone for clinical outcomes compared with external-beam radiation therapy alone or radical prostatectomy alone?
In patients with newly diagnosed prostate cancer, what is the efficacy of brachytherapy combined with external-beam radiation therapy for clinical outcomes compared with brachytherapy alone, external-beam radiation therapy alone, or radical prostatectomy alone?
Among the isotopes used for low-dose–rate brachytherapy (eg, iodine-125 [125I], palladium-103 [103Pd], and cesium-131 [131Cs]), which isotope maximizes clinical outcomes when used in patients with newly diagnosed prostate cancer?
Updated Recommendations
FOR PATIENTS with low-risk prostate cancer who require or choose active treatment, low-dose–rate brachytherapy alone, external-beam radiation therapy alone, or radical prostatectomy should be offered to eligible patients.
For patients with intermediate-risk prostate cancer, choosing external-beam radiation therapy with or without androgen-deprivation therapy, brachytherapy boost (low-dose rate or high-dose rate) should be offered to eligible patients. For low-risk to intermediate-risk prostate cancer (Gleason 7, prostate-specific antigen [PSA] = 10 ng/ mL or Gleason 6, PSA = 10–20 ng/mL), low-dose–rate brachytherapy alone may be offered as monotherapy. For patients with high-risk prostate cancer receiving external-beam radiation therapy and androgen-deprivation therapy, brachytherapy boost (low-dose rate or high-dose rate) should be offered to eligible patients.
“Recommendations for low-risk patients are unchanged from the initial CCO guideline, because no new randomized data informing this question have been presented or published since its release.”— Joseph Chin, MD, and colleagues
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125I and 103Pd are each reasonable isotope options for patients receiving low-dose–rate brachytherapy; no recommendation can be made for or against using 131Cs or high-dose–rate monotherapy.
Patients should be encouraged to participate in clinical trials to test novel or targeted approaches to this disease.
Qualifying Statements
PATIENTS SHOULD be counseled about all management options (surgery, external-beam radiation therapy, active surveillance, as applicable) in a balanced, objective manner, preferably from multiple disciplines.
Recommendations for low-risk patients are unchanged from the initial CCO guideline, because no new randomized data informing this question have been presented or published since its release.
Factors rendering patients ineligible for brachytherapy may include moderate to severe baseline urinary symptoms, large prostate volume, medical unfitness, prior transurethral resection of the prostate, and contraindications to radiation treatment.
Androgen-deprivation therapy may be given in neoadjuvant, concurrent, and/or adjuvant settings at physician discretion. It is noted that neoadjuvant androgen-deprivation therapy may cytoreduce the prostate volume sufficiently to allow brachytherapy.
There may be increased genitourinary toxicity compared with external-beam radiation therapy alone.
Brachytherapy should be performed at a center following strict quality-assurance standards.
It cannot be determined whether there is an overall or cause-specific survival advantage for brachytherapy compared with external-beam radiation therapy alone, because none of the reviewed trials was designed or powered to detect a meaningful difference in survival outcomes.
Additional information is available at www.asco.org/Brachytherapy-guideline and www.asco.org/guidelineswiki. ■
DISCLOSURE: For full disclosures of the panelists, visit www.jco.ascopubs.org.
REFERENCES
1. Chin J, Rumble RB, Kollmeier M, et al: Brachytherapy for patients with prostate cancer: American Society of Clinical Oncology/Cancer Care Ontario joint guideline update. J Clin Oncol 35:1737-1743, 2017.
2. Rodrigues G, Yao X, Loblaw DA, et al: Evidence-based guideline recommendations on low-dose rate brachytherapy in patients with low- or intermediate-risk prostate cancer. Can Urol Assoc J 7:E411-E416, 2013.
