Their guidelines suggesting which therapies are suitable are stratified by patient risk level:
- Low dose rate brachytherapy (LDR-BT) alone
- External Beam Radiation Therapy (EBRT) alone, or
- Radical prostatectomy (RP)
For favorable intermediate risk patients (no Gleason score> 3+4, no more than half the cores positive, PSA<10, and stage<T2b):
- LDR-BT alone
- EBRT with or without androgen deprivation therapy (ADT) and a brachy boost (LDR-BT or HDR-BT) to the prostate.
- EBRT and ADT and a brachy boost (LDR-BT or HDR-BT)
They make the following qualifying statements:
- Patients should be counseled about all their management options (surgery, EBRT, active surveillance, as applicable) in a balanced, objective manner, preferably from multiple disciplines.
- Recommendation for low-risk patients is unchanged from initial guideline, because no new randomized data informing this question have been presented or published since.
- Patients ineligible for brachytherapy may include: moderate to severe baseline urinary symptoms, large prostate volume, medically unfit, prior transurethral resection of the prostate, and contraindications to radiation treatment.
- ADT may be given in neoadjuvant, concurrent, and/or adjuvant settings at physician discretion. It is noted that neoadjuvant ADT may cytoreduce the prostate volume sufficiently to allow brachytherapy
- There may be increased genitourinary toxicity compared with EBRT alone.
- Brachytherapy should be performed at a center following strict quality-assurance standards.
- It cannot be determined whether there is an overall or cause-specific survival advantage for brachytherapy compared with EBRT alone, because none of the trials were designed or powered to detect a meaningful difference in survival outcomes.