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Why Stop at Using High-Dose-Rate Brachytherapy as a Boost for the Prostate?

Montefiore Medical Center The Albert Einstein Cancer Center Bronx, NY

To the Editor:I enjoyed reading the matched-pair analysis of high-dose-rate (HDR) brachytherapy as a boost for locally advanced prostate cancer¹ and salute the authors’ commitment. A 9-year (and counting) dose escalation study certainly requires a great deal of patience (pun intended).

Reviewing the radiobiology arguments the authors make in favor of hypofractionation, as well as the increased precision in delivering the HDR therapy, I wonder whether they might consider HDR alone as treatment for patients who have either a low risk of lymphatic involvement or negative pelvic lymph node dissections. Certainly the iodine-125 experience supports that concept, and if brachytherapy can be done more precisely with an HDR afterloading technique, undergoing the procedure more than once may be acceptable to some.

The study by Kestin et al¹ compares pelvic external radiation plus the HDR boost with prostate-only external radiation therapy. Since the study was offered to the same population (since 1992), I wonder at the rationale for offering pelvic irradiation to the group receiving HDR brachytherapy and making a different choice for those who were only to receive 66.6 Gy to the prostate alone who were not part of any study. If covering the pelvis was not necessary for the 1,109 patients treated at Willam Beaumont Hospital between 1987 and 1997, perhaps the authors might consider HDR therapy alone for some of these patients as well. The study concluded that patients with locally advanced prostate cancer produced lower prostate-specific antigen (PSA) nadirs, longer time intervals until PSA nadir, and improved biochemical control when treated with external radiation plus conformal HDR brachytherapy. My guess is that the improvements just cited were due to the brachytherapy and that the larger external fields used with the brachytherapy were irrelevant, and perhaps unnecessary. We could certainly use someone with both patience and patients to answer these questions and to pioneer definitive HDR brachytherapy without external therapy for management of prostate cancer.

Could the authors also comment further on the 29% to 30%^1,2 rate of impotence? I am particularly interested to know whether the rate of impotence increased with the biologically equivalent dose.

REFERENCES

1. Kestin LL, Martinez AA, Stromberg JS, 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 18: 2869-2880, 2000[Abstract/Free Full Text]

2. Martinez AA, Kestin LL, Stromberg JS, 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 47: 343-352, 2000[Medline]

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This Article Full Text (PDF) Purchase Article View Shopping Cart Alert me when this article is cited Alert me if a correction is posted Services Email this article to a colleague Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Save to my personal folders Download to citation manager Rights & Permissions Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Beitler, J. Search for Related Content PubMed PubMed Citation Articles by Beitler, J. Social Bookmarking                            What's this?