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Brachytherapy monotherapy for favorable and select unfavorable intermediate risk prostate cancer

Prostate Cancer and Prostatic Diseases (2025)Cite this article

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Abstract

Background

Current National Comprehensive Cancer Network guidelines define brachytherapy monotherapy as a suitable treatment for favorable intermediate risk (FIR) and unfavorable intermediate risk (UIR) prostate cancer. Our objective is to define the subgroup of patients suitable for brachytherapy monotherapy.

Methods

We conducted a single-institutional retrospective analysis of intermediate risk prostate cancer, treated with brachytherapy with or without androgen deprivation therapy (ADT) and/or external beam radiation therapy (EBRT). The primary endpoint was biochemical failure (BF), defined as prostate specific antigen (PSA) > 0.4 ng/mL. For monotherapy, multivariate Fine-Gray analysis was used to identify risk factors associated with BF. Univariate analysis was performed to evaluate whether ADT and/or EBRT were associated with BF for patients without and with such factors.

Results

Among 1622 patients, the median follow-up was 10.4 years. For monotherapy, PSA ≥ 10 ng/mL (adjusted sHR 3.01; 95% CI: 1.10–8.27; p = 0.032) and cT2b-c disease (adjusted sHR 4.52; 95% CI: 1.85–11.07; p = 0.001) were associated with BF. The 10-year incidences of BF after monotherapy for patients without and with these risk factors were 5.8% (3.8% FIR, 8.8% UIR) versus 17.2% (9.3% FIR, 23.9% UIR), respectively. For the cT1-T2a/PSA < 10 risk group, neither the addition of ADT (sHR 0.90; 95% CI: 0.38–2.1; p = 0.82) nor EBRT (sHR 0.65; 95% CI: 0.36-1.18; p = 0.16) was associated with biochemical failure. For the cT2b-T2c and/or PSA ≥ 10 subgroup, ADT (sHR: 0.33; 95% CI: 0.14–0.74; p = 0.007) but not EBRT (sHR 0.66; 95% CI: 0.34–1.31; p = 0.24) was associated with BF.

Conclusions

Brachytherapy monotherapy is suitable for all FIR, and UIR disease meeting cT1-T2a/PSA < 10 criteria.

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Fig. 1: Cumulative incidence curves of biochemical failure, stratified by number of unfavorable intermediate risk factors.
Fig. 2: Cumulative incidence curves of biochemical failure for entire group, stratified by brachytherapy monotherapy treatment (yes versus no) and cT1-T2a/PSA < 10 versus cT2b-T2c and/or PSA ≥ 10 groups.
Fig. 3: Cumulative incidence curves of biochemical failure, stratified by presence or absence of ADT or EBRT.

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Data availability

The datasets generated during and/or analysed during the current study are not publicly available due to patient privacy concerns but reasonable data requests can be made to Dr. Grgur Mirić.

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Author information

Authors and Affiliations

  1. Department of Radiation Oncology, Dana-Farber Cancer Institute and Brigham and Women’s Hospital, Boston, MA, USA

    Martin King, Shalini Moningi & Peter Orio

  2. Urologic Research Institute, Sarasota, FL, USA

    Grgur Mirić, Robert Galbreath & Ryan Fiano

  3. Bethany College, Bethany, WV, USA

    Grgur Mirić

  4. Ohio University Eastern, St. Clairsville, OH, USA

    Robert Galbreath

  5. Department of Radiation Oncology, University of Washington, Seattle, WA, USA

    Kent Wallner

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  1. Martin King
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  5. Shalini Moningi
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Contributions

MK, GM, and PO conceived and designed the study. GM, RF, RG, and KW acquired data. MK, GM, and PO wrote the manuscript. MK, GM, PO, RF, RG, KW, and SM reviewed the manuscript for intellectual content.

Corresponding author

Correspondence to Martin King.

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Competing interests

Martin King has received research funding from Palette Life Sciences, Bayer Healthcare, and AstraZeneca, outside of the submitted work. Grgur Mirić has served as a consultant for Theragenics, outside of the submitted work. Robert Galbreath has received a grant from Theragenics for statistical analysis of the submitted work. Peter Orio has received research funding, consulting fees, and stock for Palette Life Sciences, outside of the submitted work.

Ethics approval and consent to participate

All methods were performed in accordance with the relevant guidelines and regulations. Institutional-board approval has been obtained from the Bethany Ethical Research and Animal Care Committee (reference number S24-16). In addition, all patients signed an IRB-approved informed consent form at the time of treatment, which included consent for their clinical data to be used in future research.

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King, M., Mirić, G., Galbreath, R. et al. Brachytherapy monotherapy for favorable and select unfavorable intermediate risk prostate cancer. Prostate Cancer Prostatic Dis (2025). https://doi.org/10.1038/s41391-025-01021-3

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