Brachytherapy: What to expect for short and longterm effects?

@bob1955
Someone just asked me about this and I pulled up something. Someone said about VMAT previously.

Someone wrote this in a previous message unfortunately I didn’t capture the actual message. Maybe the writer will recognize it.

I was 3+4 with a high Decipher score. Underwent 39 sessions of VMAT with the TrueBeam after having fiducials and SpaceOAR inserted. That was 2 years ago and I am now in remission. I had a single day a few months ago with some blood accompanying a bowel movement, but nothing since. No other side effects (I had ED before the treatment and still have it, though treatments suggested here have helped greatly with that).

On the other hand, I have a friend who was also treated using a TrueBeam linac at a different location. He had fewer sessions and did not have the SpaceOAR. He has suffered greatly from radiation proctitis and has undergone numerous procedures to stop his rectal bleeding.
If you choose the TrueBeam option, I would strongly encourage you to have a spacer implanted. Good luck.

@jeffmarc Thanks. I have SpaceOAR and fiducials. Appreciate the concern.

just a simple anecdotal
apparently there is considerable prostate cancer in my family (genes)
I had RARP, my brother radiation.
However, our 96-year-old uncle had brachytherapy maybe 30-40 years ago
He recently reported to me that he and my aunt are still living in the same house since the early 60s (independently) and bumping into each other's walkers
I was diagnosed too late for this option and am certainly not believing it is the best however, I will take 96

@edinmaryland
Not sure if this has been mentioned before. With all the cancer in your family, you should definitely get hereditary, genetic test testing to see if you have a genetic problem that could make the cancer more aggressive.

When evaluating brachytherapy treatments be sure that you understand the difference between low dose (LDR-B) and high dose brachytherapy (HDR-B). LDR-B is done with permanently placed radioactive seeds that decay over time. LDR-B is done much less in current times than HDR-B. I think there are several reasons for this. One is that LDR-B causes more urinary irritation since the seeds are active 24/7 for quite a period of time. Second is that radiation applied in higher doses over shorter periods has proven more effective in killing cancer cells and less damaging to healthy nearby tissue. As such, I think that if you are considering brachytherapy you should focus on HDR-B since it allows a short term high dose of radiation applied internally through 16 catheters inserted into the prostate. Since HDR-B radiates from inside out, it is a very safe form of radiation.

HDR-B can be used as a monotherapy, but it is most often applied in conjunction with external beam radiation like IMRT. I am almost two years out from 26 sessions of IMRT and one session of HDR-B. I have no side effects at all and my PSA is at 0.13. See my bio for more info.

Just saw this article https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2845485 that compared HDR Brachytherapy (HDR-B) when used as a monotherapy to 5 sessions of SBRT. HDR-B is generally considered a very safe and effective form of radiation because it radiates from inside out through catheters placed in the prostate. In current times, HDR-B is most often not used as a monotherapy. It is most often used in one session as a radiation boost to the prostate in conjunction with multiple IMRT sessions for the greater pelvic region.

When HDR-B is used as a monotherapy, typically multiple sessions are needed and this may be the cause for why greater side effects in the future were noted as compared to SBRT. The greater number of recurrences of cancer after HDR-B used as a monotherapy as compared to SBRT is probably related to the fact that HDR-B can't reach much past the immediate prostate gland whereas SBRT can. Using only HDR-B radiation as a monotherapy, lymph nodes and the greater pelvic region cannot be treated and this is likely what caused a greater number of recurrences of cancer as compared to SBRT.

Overall, my take on this article is that SBRT becomes an even more attractive option for those considering radiation and that HDR-B as a monotherapy should be avoided.

Interesting subject and pertains to treatment options that were suggested to me and have discussed with two centers of excellence. Have to make a decision soon. One option is a trial with one HDR- Boost, 5 proton sessions to whole pelvic region and ADT.
The other is HDR-Boost, 23 IMRT sessions over 4.5 weeks and short course ADT. I was told by both centers they are no longer do LDR brachytherapy, only HDR. Of course both would include rectal spacers.

I was going to start a new post with my stats and get opinions from the knowledgeable members on this forum about these options.

Dr. Nelson Stone gave a talk on BT at the 2024 Prostate Cancer Symposium

The American Brachytherapy Society (ABS) set up a task force to do a comprehensive literature review of EBRT with HDR boost therapy and make statements, published in 2025.
https://www.sciencedirect.com/science/article/abs/pii/S1538472125001175
"This current consensus provides recommendations and accompanying support for the use of HDR brachytherapy in combination with EBRT for patients with unfavorable intermediate- and high-risk prostate cancer."

Keep in mind that the ABS noted that they had previously published recommendations for LDR boost in 2021. This review of HDR boost was not intended to downgrade what they said about LDR boost. "Both LDR and HDR brachytherapy boost are supported by professional guidelines, and the choice between the 2 is often determined by physician, patient, and/or treatment facility resources"

Conclusions, after their literature review of HDR boost: "For men with intermediate- and high-risk prostate cancer, HDR brachytherapy boost is a safe and effective technique for dose-escalation that can achieve superior biochemical control compared with EBRT alone, possibly with an improved GU and GI side effect profile compared with an LDR brachytherapy technique."

They published a series of questions that their expert panel gave answers to, summed up as an assessment of the strength of their recommendation, i.e. "strong" or "weak", and an assessment of the existing evidence they considered, i.e. "low", "moderate", "high", or "expert opinion".

So, as to the efficacy of LDR boost vrs HDR boost, they "strongly" concluded efficacy was similar, based on "high" quality evidence.

As to the toxicity of LDR boost vrs HDR boost:

Their conclusion was "strong" that "Acute urinary toxicity may be lower with HDR compared with LDR; long-term urinary toxicity is expected to be similar", but they said they believed their evidence was "moderate" for this conclusion.

On bowel toxicity: "Strong" conclusion: "Acute and long-term bowel toxicity may be lower with HDR compared with LDR" based on "moderate" evidence.

The whole paper is behind a paywall on Science Direct, but if you click on the patient access link and jump through the appropriate hoop, they email you the paper for free.

@copyman

My diagnosis is cT3b. My RO has prescribed one session of HDR, with 20 or so sessions of EBRT. Although he has said "protons or photons" in the past, I believe this prescription is photons. He has access to both types of EBRT. He's been critical of protons for PCa in the past, saying his whole prostate department at the NCI designated cancer center where he works is skeptical that protons are superior when used to treat PCa. He is the chief of the BT program there.

My RO was only going to prescribe HDR boost, as opposed to LDR, if his evaluation indicated I would be a good candidate for BT, he said, because my seminal vesicles are involved. I have no idea what his stance on LDR is.

I presented my case to Western Radiation Oncology in S.F. for a 2nd opinion They claim to be the highest volume LDR center in the US. The doc there said they would not accept me as a patient because their recommendation was HDR boost and they are not tooled up to do HDR there. He pointed to the seminal vesicle involvement.

I asked my RO about his 5 session EBRT clinical study, as he had mentioned he might offer this in the past. He was definite that my best course was the longer 20 session EBRT, because of the BT HDR boost.