In the recent years, advances in brachytherapy technology has resulted in a renewed interest in this treatment option. The current indications for brachytherapy as a monotherapy for PC as recommended by Ragde etal.34 are presented in Table 26.3. Proponents of seed implantation argue that the 5- and 10-year follow-up data in low-risk patients demonstrate PSA levels that were comparable to reported RP series, and better than some ERBT published data.34 Since brachytherapy is indicated for a highly favorable population, an argument can be made that this select group of patients have influenced these results. When the Johns Hopkins group applied the stringent criteria of Ragde's series to their RP series, a bioTable 26.3. Brachytherapy optimum inclusion criteria.
Clinical stage (T1 a-T2a) Gleason sum (2-6) PSA (<10 ng/ml) Prostate volume <60 cm3 Urine flow rate >15 cm3/second AUA symptom score <10-12
chemical no evidence of disease (NED) rate of almost 98% at 7 years was achieved versus only 79% for brachytherapy.35 In addition, progression curves showed a plateau with long-term follow-up for men with Gleason 5-6 tumors who underwent surgery, whereas a progressive downward trend was observed in the data of Ragde et al. Moreover, when used to treat tumors of Gleason scores of 7 or higher, brachytherapy was proven to be inadequate.36 Since needle biopsy specimens have a 35% potential chance of being undergraded,37 a question may be raised about the effectiveness of brachytherapy in such a setting.
Again, there is a widespread perception that there is no impairment in sexual function with brachytherapy. After reviewing 66 references published over the last 10 years, Peneau observed an impotence rate of 25% associated with brachytherapy and progressive decrease in sexual potency with time.38 In a study comparing general and disease-specific health-related quality of life in men undergoing brachytherapy to those undergoing radical prostatectomy and age-matched healthy controls, sexual function and bother were equivalent in RP and brachytherapy groups, and both were worse than in healthy controls.39 The same study has shown that general health-related quality of life did not differ greatly among the three groups. Urinary leakage was better in the brachytherapy group than in the prostatectomy group; however, both were worse than controls. The brachytherapy group had significantly worse AUA symptom index scores and worse bowel function than RP group. Patients who underwent combined brachytherapy and ERBT performed worse in all general and disease-specific health-related quality of life domains compared to those who had brachytherapy as a monotherapy. In contrast to common beliefs, brachytherapy may not offer a better quality of life over other treatments.
Lastly, although early literature suggested a benefit for brachytherapy over RP in terms of cost effectiveness,40 more recent studies demonstrated that the costs of brachytherapy are substantially higher than RP.41'42 Although treatment expense should not be the primary consideration in management strategies, its role may become more important in choosing the proper treatment modality in the face of doubt. Although we believe that brachytherapy is an acceptable approach, in the young and healthy patient, surgery offers a more reliable treatment option.
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