Our literature review shows that the long-term results following low-dose-rate brachytherapy are equivalent to the results following radical surgery and external radiotherapy. At the NICE Institute, low-dose-rate brachytherapy is regarded as an established treatment, with results in line with those of the other two treatments for low-risk prostate cancer.
In 2011, the European Society of Radiation Oncologists (ESTRO), the European Organisation for Research and Treatment of Cancer (EORTC) and the European Association of Urology (EAU) issued clinical guidelines for low-dose-rate brachytherapy for prostate cancer patients with a low-risk profile, where extra-prostatic tumour extension was excluded (27). In the EAU guidelines for 2012, low-dose-rate brachytherapy is recommended for prostate cancer patients in the low-risk group (3). This is regarded as standard treatment in the countries where the method is used (28). The EAU judges the underlying data as evidence level 2b (knowledge based on at least one well-designed study without randomisation). In Norway, low-dose-rate brachytherapy is regarded as equivalent to radical surgery in the national action programme for treatment of prostate cancer (17).
The goals of low-dose-rate brachytherapy are local disease control, reduction in the risk of metastases and maintaining a good quality of life. Because of the good prognosis, the adverse effects and quality of life of the patients and their preferences are key aspects of the method (27, 28). Patients must be carefully selected to maintain a low morbidity profile.
In order to prevent overtreatment, there should be guidelines for the commencement of treatment, both at the time of diagnosis and in connection with progression during active surveillance. However, the criteria for selecting and monitoring these patients are not clear. We have therefore concentrated on those wanting targeted primary treatment. There is also a risk of a primary tumour being underestimated and undertreated, as was demonstrated in a randomised study where patients under active survillance had significantly reduced cause-specific survival compared with those who had had radical surgery (21).
In our literature search, we found that there were limited adverse effects after low-dose-rate brachytherapy. The treatment is not suitable for patients with obstructive urination problems – their symptoms will be exacerbated. They should be offered other curative treatment. The risk of secondary cancer of the rectum or urinary bladder is not higher than the risk in the normal population, so treatment of young patients does not appear to be contraindicated (8).
International randomised studies of low-dose-rate brachytherapy have not been conducted, and it is improbable that any will be (29, 30). This is due to the biology of prostate cancer. The frequency of recurrence in low-risk patients is low, and the probability of significant differences developing after 15 – 20 years of follow-up is limited. The patients’ other treatment preferences may also make randomisation difficult (31).
Low-dose-rate brachytherapy is an attractive curative therapeutic option because of the few adverse effects. The method is standard treatment in Europe and the USA for organ-confined low-risk prostate cancer.
Cost-benefit assessments indicate that low-dose brachytherapy is comparable with radical surgery and external radiotherapy (9, 26), but sickness absence and the costs of patient transport do not appear to have been included in the calculations. The treatment takes about half an hour, average time spent in hospital is 12 hours, and the patient can usually start working again after 3 – 4 days. With external radiotherapy, patients receive outpatient treatment every day for about eight weeks, usually followed by eight weeks of sick leave. According to a recently published study, half of the patients are on sick leave for more than six weeks after radical surgery (32).
A number of uro-oncologists in Norway master the high-dose brachytherapy technique (33, 34). The implantation technique for high-dose-rate and low-dose-rate brachytherapy is virtually identical. In 2005, the treatment requirement for low-dose-rate brachytherapy in Norway was estimated at about 60 – 70 patients (internal report from expert group at the Radium Hospital). Because of increased attention to prostate cancer and increasing «wild» screening, the incidence of low-grade disease will also increase among younger men. This will probably lead to an increase in the future need for low-dose-rate brachytherapy.
From a medical point of view, the introduction of the method will be future-oriented. If sickness absence and patient transport are taken into account, we believe that low-dose-rate brachytherapy will yield socioeconomic savings compared with other treatment.