Low-dose rate brachytherapy for men with localized prostate cancer

Localized prostate cancer has not spread outside the prostate gland. LDR-BT is short-distance internal radiotherapy. Low-energy radioactive sources with a short half-life are implanted permanently into the prostate. We reviewed the published research on this treatment to investigate how effective and safe it is. Unfortunately, we identified only one randomized controlled trial comparing LDR-BT versus RP. The results were considerably prone to bias. Important survival outcomes were not reported. Due to lack of research studies, it has not been proven whether patients treated with this procedure live longer than patients treated with treatment alternatives. In this single study, after the intervention, a rise in prostate-specific antigen (PSA) was similarly likely to occur after LDR-BT and RP, but this finding does not resolve the question of whether cancer was truly present again in both groups. Urinary incontinence was less frequent after LDR-BT and urinary irritation was less frequent after RP at a short-term follow up at 6 months. No results were reported at 12 and 60 months. Significant differences after long-term follow up were not identified for patient-reported outcomes. At present, the question whether LDR-BT is a favorable treatment compared to other treatment alternatives in patients with localized prostate cancer remains unanswered.

Authors' conclusions: 

Low-dose rate brachytherapy did not reduce biochemical recurrence-free survival versus radical prostatectomy at 5 years. For short-term severe adverse events, low-dose rate brachytherapy was significantly more favorable for urinary incontinence, but radical prostatectomy was significantly more favorable for urinary irritation. Evidence is based on one RCT with high risk of bias.

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Background: 

Localized prostate cancer is a slow growing tumor for many years for the majority of affected men. Low-dose rate brachytherapy (LDR-BT) is short-distance radiotherapy using low-energy radioactive sources. LDR-BT has been recommended for men with low risk localized prostate cancer.

Objectives: 

To assess the benefit and harm of LDR-BT compared to radical prostatectomy (RP), external beam radiotherapy (EBRT), and no primary therapy (NPT) in men with localized prostatic cancer.

Search strategy: 

The Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (from 1950), and EMBASE (from 1980) were searched in June 2010 as well as online trials registers and reference lists of reviews.

Selection criteria: 

Randomized, controlled trials comparing LDR-BT versus RP, EBRT, and NPT in men with clinically localized prostate cancer.

Data collection and analysis: 

Data on study methods, participants, treatment regimens, observation period and outcomes were recorded by two reviewers independently.

Main results: 

We identified only one RCT (N = 200; mean follow up 68 months). This trial compared LDR-BT and RP. The risk of bias was deemed high. Primary outcomes (overall survival, cause-specific mortality, or metastatic-free survival) were not reported. Biochemical recurrence-free survival at 5 years follow up was not significantly different between LDR-BT (78/85 (91.8%)) and RP (81/89 (91.0%)); P = 0.875; relative risk 0.92 (95% CI: 0.35 to 2.42).

For severe adverse events reported at 6 months follow up, results favored LDR-BT for urinary incontinence (LDR-BT 0/85 (0.0%) versus RP 16/89 (18.0%); P < 0.001; relative risk 0) and favored RP for urinary irritation (LDR-BT 68/85 (80.0%) versus RP 4/89 (4.5%); P < 0.001; relative risk 17.80, 95% CI 6.79 to 46.66). The occurrence of urinary stricture did not significantly differ between the treatment groups (LDR-BT 2/85 (2.4%) versus RP 6/89 (6.7%); P = 0.221; relative risk 0.35, 95% CI: 0.07 to 1.68). Long-term information was not available.

We did not identify significant differences of mean scores between treatment groups for patient-reported outcomes function and bother as well as generic health-related quality of life.

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