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  This is an original JCO publication from 2017. Please visit the JCO website to access the full article.


Brachytherapy for Patients With Prostate Cancer: American Society of Clinical Oncology/Cancer Care Ontario Joint Guideline Update


 Authors

Joseph Chin, R. Bryan Rumble, Marisa Kollmeier, Elisabeth Heath, Jason Efstathiou, Tanya Dorff, Barry Berman, Andrew Feifer, Arthur Jacques†, and D. Andrew Loblaw

THE BOTTOM LINE

Brachytherapy for Patients With Prostate Cancer: American Society of Clinical Oncology/Cancer Care Ontario Joint Guideline Update

Guideline Questions

1. In patients with newly diagnosed prostate cancer, what is the efficacy of brachytherapy alone for clinical outcomes compared with external beam radiation therapy (EBRT) alone or radical prostatectomy (RP) alone?

2. In patients with newly diagnosed prostate cancer, what is the efficacy of brachytherapy combined with EBRT for clinical outcomes compared with brachytherapy alone, EBRT alone, or RP alone?

3. Among the isotopes used for low–dose rate (LDR) 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?

Target Population

Patients with newly diagnosed prostate cancer who require or choose active treatment and are not considering, or are not suitable for, active surveillance.

Target Audience

Radiation oncologists, urological surgeons, and other clinicians who provide care for patients defined by the target population.

Methods

A systematic review of the literature was performed and relevant evidence was evaluated for inclusion into this updated clinical practice guideline using the signals approach.

Updated Recommendations

  • For patients with low-risk prostate cancer who require or choose active treatment, LDR alone, EBRT alone, or RP should be offered to eligible patients
  • For patients with intermediate-risk prostate cancer choosing EBRTwith or without androgen-deprivation therapy (ADT), brachytherapy boost (LDR or high–dose rate [HDR]) should be offered to eligible patients. For low-intermediate risk prostate cancer (Gleason 7, prostate-specific antigen < 10 ng/mL or Gleason 6, prostate-specific antigen, 10 to 20 ng/mL) LDR brachytherapy alone may be offered as monotherapy. For patients with high-risk prostate cancer receiving EBRT and ADT, brachytherapy boost (LDR or HDR) should be offered to eligible patients.
  • 125I and 103Pd are each reasonable isotope options for patients receiving LDR brachytherapy; no recommendation can be made for or against using 131Cs or HDR 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 their management options (surgery, EBRT, active surveillance, as applicable) in a balanced, objective manner, preferably from multiple disciplines.
  • Recommendation for low-risk patients is unchanged from initial guideline, because no new randomized data informing this question have been presented or published since.
  • Patients ineligible for brachytherapy may include: moderate to severe baseline urinary symptoms, large prostate volume, medically unfit, prior transurethral resection of the prostate, and contraindications to radiation treatment.
  • ADT may be given in neoadjuvant, concurrent, and/or adjuvant settings at physician discretion. It is noted that neoadjuvant ADT may cytoreduce the prostate volume sufficiently to allow brachytherapy
  • There may be increased genitourinary toxicity compared with EBRT 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 EBRT alone, because none of the trials were designed or powered to detect a meaningful difference in survival outcomes.

Additional Resources

Additional information is available at www.asco.org/Brachytherapy-guideline and www.asco.org/guidelineswiki. Patient information is available at www.cancer.net.

ASCO believes that cancer clinical trials are vital to inform medical decisions and improve cancer care, and that all patients should have the opportunity to participate

SUMMARY OF RECOMMENDATIONS

Clinical QuestionRecommendationQualifying Statement
In patients with prostate cancer, what is the efficacy of brachytherapy alone for clinical outcomes compared with external beam radiation therapy (EBRT) alone or radical prostatectomy (RP) alone?For patients with low-risk prostate cancer who require or choose active treatment, LDR alone, EBRT alone, or RP should be offered to eligible patientsPatients should be counseled about all their management options (surgery, EBRT, active surveillance, as applicable) in a balanced, objective manner, preferably from multiple disciplines.
Recommendation for low-risk patients is unchanged from initial guideline, because no new randomized data informing this question have been presented or published since.
In patients with prostate cancer, what is the efficacy of brachytherapy combined with EBRT for clinical outcomes compared with brachytherapy alone, EBRT alone, or RP alone?For patients with intermediate-risk prostate cancer choosing EBRT with or without androgen-deprivation therapy (ADT), brachytherapy boost (LDR or high–dose rate [HDR]) should be offered to eligible patients. For lowintermediate risk prostate cancer (Gleason 7, prostate-specific antigen, 10 ng/mL or Gleason 6, prostate-specific antigen, 10 to 20 ng/mL) LDR brachytherapy alone may be offered as monotherapy. For patients with high-risk prostate cancer receiving EBRT and ADT, brachytherapy boost (LDR or HDR) should be offered to eligible patients.Patients ineligible for brachytherapy may include: moderate to severe baseline urinary symptoms, large prostate volume, medically unfit, prior transurethral resection of the prostate, and contraindications to radiation treatment.
ADT may be given in neoadjuvant, concurrent, and/or adjuvant settings at physician discretion. It is noted that neoadjuvant ADT may cytoreduce the prostate volume sufficiently to allow brachytherapy
There may be increased genitourinary toxicity compared with EBRT alone.
Among the isotopes used for low–dose rate brachytherapy (eg, 125I, 103Pd, and 131Cs), which isotope maximizes clinical outcomes when used in patients with newly diagnosed prostate cancer?125I and 103Pd are each reasonable isotope options for patients receiving LDR brachytherapy; no recommendation can be made for or against using 131Cs or HDR monotherapy.Brachytherapy should be performed at a center following strict quality-assurance standards.
Patients should be encouraged to participate in clinical trials to test novel or targeted approaches to this disease.It cannot be determined whether there is an overall or cause-specific survival advantage for brachytherapy compared with EBRT alone, because none of the trials were designed or powered to detect a meaningful difference in survival outcomes.

ASCO Guideline Disclaimer: The clinical practice guidelines and other guidance published herein are provided by the American Society of Clinical Oncology, Inc. (“ASCO”) to assist practitioners in clinical decision making. The information therein should not be relied upon as being complete or accurate, nor should it be considered as inclusive of all proper treatments or methods of care or as a statement of the standard of care. With the rapid development of scientific knowledge, new evidence may emerge between the time information is developed and when it is published or read. The information is not continually updated and may not reflect the most recent evidence. The information addresses only the topics specifically identified therein and is not applicable to other interventions, diseases, or stages of diseases. This information does not mandate any particular course of medical care. Further, the information is not intended to substitute for the independent professional judgment of the treating physician, as the information does not account for individual variation among patients. Recommendations reflect high, moderate or low confidence that the recommendation reflects the net effect of a given course of action.  The use of words like “must,” “must not,” “should,” and “should not” indicate that a course of action is recommended or not recommended for either most or many patients, but there is latitude for the treating physician to select other courses of action in individual cases. In all cases, the selected course of action should be considered by the treating physician in the context of treating the individual patient. Use of the information is voluntary.  ASCO provides this information on an “as is” basis, and makes no warranty, express or implied, regarding the information. ASCO specifically disclaims any warranties of merchantability or fitness for a particular use or purpose. ASCO assumes no responsibility for any injury or damage to persons or property arising out of or related to any use of this information or for any errors or omissions.


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