<p><strong> </strong><strong>In patients with unfavorable intermediate- or high-risk prostate cancer electing radiation therapy, clinicians should offer dose-escalated hypofractionated EBRT or combined EBRT + brachytherapy (LDR, HDR) along with a risk-appropriate course of ADT. <em>(Strong Recommendation; Evidence Level: Grade A/B)</em></strong></p>
Discussion
Discussion
<p>Trials have demonstrated a benefit in clinical control for unfavorable intermediate- or high-risk prostate cancer patients who receive either dose-escalated moderately hypofractionated IMRT or EBRT plus a brachytherapy boost (HDR temporary prostate implant or LDR permanent prostate implant).<sup>300-305</sup> Combining EBRT and brachytherapy has demonstrated improved biochemical control over EBRT plus ADT alone in randomized trials.<sup>300-302, 305</sup></p>
<p>Interestingly, the phase III randomized ASCENDE-RT trial compared two methods of dose escalation in 398 patients with intermediate- or high-risk prostate cancer: DE-EBRT boost to 78 Gy or LDR brachytherapy boost.<sup>302-304</sup> All patients were initially treated with 12 months of ADT and pelvic EBRT to 46 Gy. The primary endpoint of control (biochemical, no evidence of disease) was 89% versus 84% at 5 years; 86% versus 75% at 7 years; and 83% versus 62% at 9 years for the LDR versus EBRT boost arms (log-rank P < .001). However, toxicity was higher in the brachytherapy arm, with a cumulative incidence of grade 3 genitourinary events at 5 years of 18.4% for brachytherapy boost and 5.2% for EBRT boost (P < .001). In addition, increased gastrointestinal toxicity among patients treated with a brachytherapy boost was also seen (cumulative incidence of grade 3 events at 5 years, 8.1% versus 3.2%; P = .12).</p>