title: Is supplemental external beam radiation therapy essential to maximize brachytherapy outcomes in patients with unfavorable intermediate-risk disease?
abstract: OBJECTIVE
  To evaluate whether supplemental external beam radiotherapy (EBRT) is essential to maximize Pd-103 brachytherapy outcomes in patients with unfavorable intermediate-risk (IR) disease.
  
  
  METHODS
  A total of 630 patients were assessed from two prospective randomized brachytherapy trials evaluating the role of supplemental EBRT in patients with higher risk features. Patients were stratified into unfavorable IR (primary Gleason pattern 4, ≥50% positive biopsies, or ≥2 IR features), favorable IR, and high-risk (HR) cohorts. Median follow-up was 7.5 years. The brachytherapy prescription dose was prescribed to the prostate gland with generous periprostatic margins. Biochemical failure (BF) was defined as a prostate-specific antigen >0.40 ng/mL after nadir. Patients with metastatic prostate cancer or nonmetastatic castrate-resistant disease who died of any cause were classified as dead of prostate cancer. Multiple parameters were evaluated for effect on outcomes.
  
  
  RESULTS
  The 10-year BF for favorable IR, unfavorable IR, and HR was 1.7%, 6.6%, and 15.5% (p < 0.001). At 10 years, prostate cancer-specific mortality (PCSM) and overall mortality (OM) were 0% and 20.4%, 2.1% and 23.2%, and 4.3% and 42.4% for favorable IR, unfavorable IR, and HR. Although unfavorable IR patients had a greater incidence of BF, PCSM, and OM when compared with favorable IR, neither the addition nor dose of supplemental EBRT influenced outcome.
  
  
  CONCLUSIONS
  Outcomes for favorable IR were superior to those with unfavorable IR. Within the confines of this study, neither the addition nor dose of supplemental EBRT influenced BF, PCSM, or OM in patients with IR disease.
authors.affiliation: Department of Radiation Oncology, Schiffler Cancer Center, Wheeling Jesuit University, Wheeling, WV; Department of Urology, Wheeling Hospital, Wheeling, WV. Electronic address: gmerrick@urologicresearchinstitute.org.
authors.forename: Gregory S
authors.initials: GS
authors.lastname: Merrick
authors.affiliation: Department of Radiation Oncology, Puget Sound Healthcare Corporation, Group Health Cooperative, University of Washington, Seattle, WA.
authors.forename: Kent E
authors.initials: KE
authors.lastname: Wallner
authors.affiliation: Department of Radiation Oncology, Schiffler Cancer Center, Wheeling Jesuit University, Wheeling, WV; Ohio Univeristy Eastern, St. Clairsville, OH.
authors.forename: Robert W
authors.initials: RW
authors.lastname: Galbreath
authors.affiliation: Department of Radiation Oncology, Schiffler Cancer Center, Wheeling Jesuit University, Wheeling, WV.
authors.forename: Wayne M
authors.initials: WM
authors.lastname: Butler
authors.affiliation: Department of Pathology, Wheeling Hospital, Wheeling, WV.
authors.forename: Edward
authors.initials: E
authors.lastname: Adamovich
mesh_terms: D000368:Aged; D001918:Brachytherapy; D003131:Combined Modality Therapy / Q000379:methods; D006801:Humans; D008297:Male; D008875:Middle Aged; D060787:Neoplasm Grading; D010165:Palladium / Q000627:therapeutic use; D011446:Prospective Studies; D017430:Prostate-Specific Antigen / Q000097:blood*; D011471:Prostatic Neoplasms / Q000097:blood / Q000473:pathology* / Q000532:radiotherapy*; D011868:Radioisotopes / Q000627:therapeutic use; D020266:Radiotherapy, Conformal; D012307:Risk Factors; D015996:Survival Rate
chemical_list: D011868:Radioisotopes; D010165:Palladium; D017430:Prostate-Specific Antigen
keywords: Biochemical outcome; Brachytherapy; Intermediate risk disease; Prostate cancer; Prostate cancer–specific mortality