Radiotherapy and Oncology 198 (2024) 110381

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Radiotherapy and Oncology

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Original Article

Prostate high dose-rate brachytherapy as monotherapy for low and

intermediate-risk prostate cancer: Efficacy results from a randomized phase
II clinical trial of one fraction of 19 Gy or two fractions of 13.5 Gy: A
9-year update
John M. Hudson, Andrew Loblaw , Merrylee McGuffin , Hans T. Chung , Chia-Lin Tseng ,
Joelle Helou , Patrick Cheung , Ewa Szumacher , Stanley Liu , Liying Zhang , Andrea Deabreu ,
Alexandre Mamedov , Gerard Morton *
Sunnybrook Odette Cancer Centre, University of Toronto, Canada

A B S T R A C T

Background and Purpose: High dose-rate (HDR) brachytherapy as a monotherapy is an accepted treatment for localized prostate cancer, but the optimal dose and
fractionation schedule remain unknown. We report on the efficacy of a randomized Phase II trial comparing HDR monotherapy delivered as 27 Gy in 2 fractions vs.
19 Gy in 1 fraction with a median follow-up of 9 years.
Materials and Methods: Enrolled patients had low or intermediate-risk disease, <60 cc prostate volume and no androgen deprivation use. Patients were randomized to
27 Gy in 2 fractions delivered one week apart vs a single fraction of 19 Gy.
Results: 170 patients were randomized: median age 65 years, median follow-up 107 months and median baseline PSA 6.35 ng/ml. NCCN risk categories comprised
low (19 %), favourable (51 %), and unfavourable intermediate risk (30 %). The median PSA at 8 years was 0.08 ng/ml in the 2-fraction arm vs. 0.89 ng/ml in the
single-fraction arm. The cumulative incidence of local failure at 8 years was 11.2 % in the 2-fraction arm vs. 35.9 % in the single-fraction arm (p < 0.001). The
incidence of distant failure at 8 years was 3.8 % in the 2-fraction arm and 2.5 % in the single-fraction arm (p = 0.6).
Conclusions: HDR monotherapy delivered in two fractions of 13.5 Gy demonstrated a persistent cancer control rate at 8 years and was well-tolerated. Single-fraction
monotherapy yielded poor oncologic control and is not recommended. These findings contribute to the ongoing discourse on optimal HDR monotherapy strategies for
low and intermediate-risk prostate cancer.

Introduction decreased healthcare resource utilization [3,4]. Assuming an alpha/beta

ratio of 1.5 for prostate cancer, a single fraction of 19 Gy would have a
Multi-fraction high dose-rate brachytherapy (HDR) has emerged as a biological efficacy equivalent to fractionated protocols of 13.5 Gy in 2
safe and effective monotherapy for patients with intermediate-risk fractions, 11.5 Gy in 3 fractions, or 9.5 Gy in 4 fractions. Based on this
prostate cancer and those with low-risk disease who decline active radiobiological premise, several single institutional series investigated
surveillance [1]. Over the past three decades, numerous single- 19 Gy in 1 fraction HDR monotherapy with promising short-term clin­
institutional studies have consistently reported high cancer control ical outcomes [5–8].
rates for HDR monotherapy delivered over 2 to 6 fractions [2], with Motivated by the potential advantages of ultra-hypofractionated
limited follow-up on 2-fraction regimens. Notably, the National HDR monotherapy, a prospective randomized phase II clinical trial
Comprehensive Cancer Network® (NCCN®) endorses 13.5 Gy in 2 was initiated in 2013 to compare two-fraction (27 Gy in 2) and single-
fractions and 9.5 Gy BID over two implants as acceptable treatment fraction (19 Gy in 1) regimens. Early toxicity and health-related qual­
regimens. ity of life outcomes have previously been reported and were well
Compressing the number of treatment fractions to as few as possible tolerated for both treatment arms [9]. At the 5-year mark, the two-
has several logistical and radiobiological advantages, including fraction regimen demonstrated excellent tolerability and a higher can­
increased patient convenience, reduced anesthesia exposure, and cer control rate than the single-fraction strategy [10,11]. Our purpose is

* Corresponding author at: Sunnybrook Odette Cancer Centre, 2075 Bayview Ave, Toronto, ON, M4N 3M5, Canada.
E-mail address: [email protected] (G. Morton).

https://doi.org/10.1016/j.radonc.2024.110381
Received 4 April 2024; Received in revised form 5 June 2024; Accepted 8 June 2024
Available online 13 June 2024
0167-8140/© 2024 The Authors. Published by Elsevier B.V. This is an open access article under the CC BY-NC license (http://creativecommons.org/licenses/by-
nc/4.0/).
J.M. Hudson et al. Radiotherapy and Oncology 198 (2024) 110381

to report long-term PSA and oncologic outcomes to help inform current test as appropriate. PSA changes over time were evaluated using General
practice. Linear Mixed modelling with a natural log transformation of baseline
and post-treatment PSA values. Biochemical disease-free survival
Materials and methods (bDFS) was defined as the time from treatment to failure date (if a pa­
tient had the event), to the death date (if a patient died), or to the last
Patient and clinical characteristics follow-up (if a patient completed the study or withdrew earlier). It was
estimated using Kaplan-Meier curves with log-rank testing used to
The clinical trial was registered on ClinicalTrials.gov (NCT0189009) compare curves. Univariate and multivariable Cox proportional hazard
and approved by the Sunnybrook Health Sciences Centre Research models were used to search for significant covariates related to bDFS.
Ethics Board. As previously outlined, eligible patients had histologically Cumulative incidences were calculated using Nelson-Aalen curves.
confirmed adenocarcinoma of the prostate, clinical stage T1c or T2a, Analysis was conducted using Statistical Analysis Software (SAS version
with an ISUP Grade Group of 1, 2, or 3, a serum prostate-specific antigen 9.6, Cary, NC) and R package (version 4.3.0) [13]. A two-sided p-value
(PSA) level of less than 20 ng/ml and were deemed fit for general of < 0.05 was considered significant.
anesthesia. Prostate volume was restricted to 60 cc. No androgen
deprivation was allowed, and patients were clear of distant or nodal Results
metastases determined by conventional staging. Block randomization
randomly assigned subjects to one of the two treatment arms. The One hundred eighty patients were accrued to the clinical trial be­
sample size was calculated as previously described [9]. tween June 2013 and April 2015. Ten were excluded from treatment and
analysis (4 ineligible after staging and pathology review, 3 were tech­
Treatment protocol nically unsuitable for brachytherapy due to pubic arch interference, 2
withdrew consent and chose alternative treatments, and 1 was excluded
Treatment comprised HDR brachytherapy delivered as either a single due to an unrelated medical event). Of the remaining 170, 87 were
fraction of 19 Gy or two fractions of 13.5 Gy administered one week randomized to receive 19 Gy × 1 vs. 83 to receive 13.5 Gy × 2. Patient
apart (allowable range 5–14 days). Implants were guided and planned demographics and baseline clinical factors are summarized in Table 1,
using intra-operative trans-rectal ultrasound (TRUS), with dwell time with no significant differences between treatment arms. Median follow-
optimization performed using Oncentra Prostate v 4.1.6 (SP1) (Elekta, up was 107 months (range 24–131 months). Median age was 65 years
Sweden) [12]. (range 46–80 years), and median baseline PSA was 6.35 ng/ml (range
Treatment implants, planning and delivery were performed 1.12–16.01 ng/ml). Overall, 19 % had NCCN low risk, 51 % favourable
sequentially under general anesthesia with the patient positioned in intermediate risk and 30 % unfavourable intermediate-risk prostate
dorsal lithotomy. A median of 16 flexible ProGuide catheters (Elekta, cancer.
Sweden) were advanced to the base of the prostate under TRUS guidance As previously reported [10], the median PSA decreased over 5 years
using a 5 mm template grid. The Clinical Target Volume (CTV) was in both treatment arms, reaching a value of 0.18 (IQR 0.08–0.63) ng/ml
defined as the prostate with a 0–2 mm expansion based on disease pa­ in the 2-fraction arm compared to 0.57 (IQR 0.32–1.50) ng/ml in the
rameters (i.e., patients with palpable or visible disease had a CTV single-fraction arm (p < 0.0001). Beyond 5 years, the median PSA in the
expansion around the nodule). No additional margin was added for the 2-fraction arm continued to decrease to a value of 0.08 ng/ml (IQR
Planning Target Volume (PTV). Organs-at-Risk (OARs) were the rectal 0.04–1.00) at 8 years, in contrast to a rise in PSA within the single-
wall and catheterized urethra (with a 1 mm radial expansion), both fraction arm to 0.89 ng/ml (IQR 0.32–2.10) in the same time frame
along the length of the prostate. (Fig. 1). As seen in Table 2., 38.4 % of patients in the 2-fraction arm
The prescription dose (19 Gy or 13.5 Gy) was prescribed to the PTV achieved a PSA value of ≤ 0.2 ng/ml at 4 years (increased to 51.4 % at 5
with the following planning objectives: PTV V100 > 95 %, PTV V150 < years). In contrast, 11.5 % of patients treated with a single 19 Gy ach­
35 %, PTV V200 < 12 %; urethra maximum dose < 120 % and urethra ieved a PSA of ≤ 0.2 ng/ml at 4 years (increased to 16.9 % at 5 years).
D10 < 115 %; rectal maximal dose 90 % and V80 < 0.2 cc (where Vx is After adjusting for baseline PSA, a significant interaction between time
the volume of that structure receiving x% of the prescribed dose and Dx and treatment arms was observed, with the 2-fraction arm demon­
is the dose to x% of the structure). Dwell times were determined using strating a faster and greater PSA response compared to the single-
inverse dose-volume histogram-based optimization (DVHO). After
treatment completion, all catheters were removed, and the patient was
Table 1
awakened and discharged home once recovered from the anesthesia. Baseline clinical factors in patients randomized between 19 Gy in a single
Subjects randomized to the 2-fraction arm returned a week later for their fraction and 27 Gy in 2 fractions. Data are represented as median (interquartile
second fraction. range).
19Gy1f (n = 87) 27Gy2f (n = 83) p-
Follow-up and statistical considerations value

Median Age (years) 65 (59, 70) 65 (60, 70) 0.7317

Follow-up occurred at six weeks and three months, every three Clinical Stage 0.8648
months for the first year, every six months from year 1 to 5, and then T1c 67 (77 %) 63 (76 %)
annually. Each visit included a digital rectal examination and serum PSA T2a 20 (23 %) 20 (24 %)
measurement. The PSA nadir was defined as the lowest PSA value at any Median PSA (ng/ml) 6.43 (4.71, 6.27 (4.64, 0.9366
8.90) 8.68)
point after treatment. Biochemical failure was a rise of 2 ng/mL above Grade Groups 0.0694
the PSA nadir. Patients with biochemical failure or clinical suspicion of 1 28 (32 %) 19 (23 %)
recurrence were re-staged with a CT scan of the chest, abdomen, and 2 45 (52 %) 57 (69 %)
pelvis, bone scan, multiparametric MRI of the prostate, and PSMA PET 3 14 (16 %) 7 (8 %)
NCCN Risk Group 0.2449
scan when available. Any radiographic suspicion of local recurrence
Low risk 21 (24 %) 12 (14 %)
(within the prostate) was confirmed through biopsy. Favourable intermediate risk 40 (46 %) 46 (55 %)
Demographic, tumour, and treatment characteristics were summa­ Unfavourable intermediate 26 (30 %) 25 (30 %)
rized using the median and interquartile range (IQR) for continuous risk
variables and proportions for categorical variables. Comparisons be­ Cores Positive (%) 31 (18, 42) 30 (17, 46) 0.9875
Gleason 4 or 5 (%) 5 (0, 25) 10 (1, 20) 0.4320
tween the arms were made using the Wilcoxon rank-sum or Fisher exact

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J.M. Hudson et al. Radiotherapy and Oncology 198 (2024) 110381

Fig. 1. Median PSA over time for patients treated with a single fraction of 19 Gy (solid black) vs. 27 Gy in 2 fractions (dashed red). A nadir of 0.57 ng/ml was reached
at 60 months, followed by a slow rise in the 19 Gy x 1 cohort. PSA continues to drop for patients treated with 27 Gy in 2 fractions (median 0.08 ng/ml at 96 months).
(For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)

predictive factors for biochemical failure: patients treated with a single

Table 2
fraction of 19 Gy (vs. 27 Gy in 2 fractions) (HR 2.399, p = 0.0031),
Proportion of patients within different ranges of PSA values at 4 and 5 years.
higher baseline PSA (HR = 3.982, p = 0.0001), and a larger percentage
19gy1f (n = 87) 27gy2f (n = 83) p-value of Gleason pattern 4 or 5 (1.015, p = 0.0166).
4 years 5 years 4 years 5 years Local failure was documented in 8 patients in the 2-fraction arm
PSA values (continuous) 0<.0001 compared to 25 patients in the single fraction arm, with a corresponding
N 78 77 73 72 cumulative incidence of local failure of 11.2 % and 35.9 %, respectively,
Median 0.87 0.57 0.30 0.18 at 8 years (p < 0.001) (Fig. 4a). Multivariable analysis identified two
(Q1, Q3) (0.35, (0.32, (0.12, (0.08, significant predictive factors for local failure: treatment with a single
1.51) 1.50) 0.65) 0.63)
fraction of 19 Gy (vs. 27 Gy in 2 fractions) (HR 3.774, p = 0.0010) and
PSA < 0.4 0<.0001
<0.4 23 (29.5 27 (35.1 46 (63.0) 51 (70.8 higher baseline PSA (HR = 3.570, p = 0.0039). Factors not associated
%) %) %) with bDFS and local failure were Gleason score, primary Gleason grade,
≥0.4 55 (70.5 50 (64.9 27 (37.0 21 (29.2 clinical stage, percentage of cores positive or NCCN risk group.
%) %) %) %)
Distant failure was observed in 5 patients who received 27 Gy in 2
PSA 0<.0001
categories fractions compared to 4 patients in the single 19 Gy arm, with a corre­
≤0.2 9 (11.5 %) 13 (16.9 28 (38.4 37 (51.4 sponding cumulative incidence of 3.8 % and 2.5 % at 8 years (p =
%) %) %) 0.6441) (Fig. 4b). Multivariate analysis identified two significant pre­
>0.2–0.5 17 (21.8 22 (28.6 24 (32.9 15 (20.8 dictive factors for distant failure: baseline PSA over 10 ng/mL (vs. under
%) %) %) %)
10 ng/mL) (HR 6.14, p = 0.017) and presence of perineural invasion
>0.5–1.0 24 (30.8 14 (18.2 9 (12.3 %) 4 (5.6 %)
%) %) (HR = 8.15, p = 0.004).
>1.0 28 (35.9 28 (36.4 12 (16.4 16 (22.2
%) %) %) %) Discussion
PSA values in ng/ml.
In this prospective randomized trial, we present the long-term PSA
fraction arm (slope = -0.006 (27 Gy/2) vs. − 0.004 (19 Gy/1), p < kinetics and failure patterns of two HDR monotherapy regimens (27 Gy
0.0001). in 2 fractions vs. 19 Gy in 1 fraction) for low and intermediate-risk
The 8-year bDFS was 83.2 % (95 % CI 75.2–92.0) in the 2-fraction prostate cancer. Building on the findings at the 5-year mark [10], the
arm and 61.5 % (CI 51.6–73.2) in the single fraction arm, p = 0.001 administration of 27 Gy over 2 implants demonstrated a more durable
(Fig. 2). In the 2-fraction arm, bDFS by risk groupings was 88.9 %, 81.7 PSA response at 8 years, with a median value of 0.08 ng/ml, a bDFS of
% and 78.4 % in the low, favourable intermediate and unfavourable 83.2 %, and a local recurrence rate of 11.1 %. Unsurprisingly, unfav­
intermediate-risk groups respectively (p = 0.772). In the single fraction ourable outcomes persisted in the single-fraction HDR monotherapy
arm, bDFS was 79.7 %, 58.5 % and 51.0 % in the low, favourable in­ arm, marked by a rising median PSA to 0.89 ng/ml, a bDFS of 61.5 %,
termediate and unfavourable intermediate-risk groups (p = 0.0979) and a local recurrence rate of 36 %. No differences were seen in the
(Fig. 3a, 3b). Multivariable analysis identified three significant distant relapse rate between the two groups, likely reflecting the

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J.M. Hudson et al. Radiotherapy and Oncology 198 (2024) 110381

Fig. 2. Biochemical disease-free survival probability (nadir +2 ng/ml) by treatment arm. At 9 years, bDFS was 58.0 % and 75.4 % in the single 19 Gy vs. 27 Gy in 2
fraction arms, respectively.

baseline risk of occult metastases in low and intermediate-risk prostate Minimizing local failure is clinically meaningful due to its known as­
cancer [14]. Both treatment regimens were well tolerated, with a late sociation with developing metastases and dying from prostate cancer
grade 3 urinary toxicity of 1 % and virtually no rectal toxicity [11]. [14]. Multiple factors have been suggested to explain the poor results of
While abundant literature explores the use of HDR monotherapy for single fraction treatments, including the uncertain validity of the linear-
prostate cancer [1,15,16], the wide heterogeneity in dose-fractionation quadratic model with extreme hypofractionation [22], the intratumour
schemes, limited follow-up time, and lack of prospective randomized heterogeneity of alpha/beta ratios [23], radioresistant cell cycle phase,
data pose challenges to establishing universally accepted guidelines. the local microenvironment and hypoxia [24], and even intrafraction
Most of the mature data supporting the use of HDR as monotherapy treatment time [25]. Whatever the root mechanism, our long-term,
utilizes three or more fractions [17]. While several series report high randomized Phase II data continue to discourage the adoption of
biochemical control at 5-years with 2-fraction protocols, to our knowl­ single-fraction monotherapy.
edge only one series has reported outcomes with a median follow-up of More encouragingly, our results of 27 Gy delivered over 2 fractions
over 5 years, and none without the addition of adjuvant androgen demonstrate a more robust 8-year biochemical response and represent
deprivation therapy [18]. While the NCCN Guidelines suggest 13.5 Gy the most mature follow-up supporting this regimen of HDR mono­
× 2 as a prescription dose, the GEC-ESTRO Guidelines also recognize therapy. The PSA continues to decrease at 9 years, suggesting that this
this as a reasonable dose but acknowledge that no evidence-based treatment provides most patients with an ablative radiation dose.
recommendation for HDR monotherapy dose and fractionation can be Several authors have reported that attaining a low PSA value in the first
made. It is essential to determine the long-term efficacy of this dose 4 or 5 years following treatment is associated with a low recurrence rate.
fractionation, which is increasingly being used. Helou and colleagues found that a PSA < 0.6 ng/ml at 3-years following
Given the high reported relapse rate in several series, the GEC- HDR boost was strongly associated with a favourable long-term disease-
ESTRO Guidelines recommend against the routine use of single frac­ free survival [26]. Alayed and colleagues found that 42 % of patients
tion 19 Gy treatments as monotherapy. Our current series would support treated with stereotactic ablative radiotherapy (SABR) achieved a PSA
that recommendation, with a biochemical disease-free survival rate of < 0.4 ng/ml, none of whom subsequently relapsed as opposed to a
only 61.5 % in a favourable group of patients. Historically, considerable recurrence rate of 20 % in those who failed to achieve that value. They
debate has surrounded the credibility of using biochemical failure as a proposed a 4-year PSA value of < 0.4 ng/ml as an early definition of
primary endpoint in clinical trials. According to a recent meta-analysis “biochemical control”. By that definition, in our series, 63 % of patients
[19], it is strongly recommended to consider more suitable endpoints treated with 2-fractions and 30 % of those treated with a single fraction
such as metastasis-free survival. Our data supports this recommenda­ would be considered to have achieved “biochemical control” [27].
tion, as we found no correlation between biochemical disease-free sur­ Following low-dose rate (LDR) brachytherapy, Crook and colleagues
vival and local or distant failures. However, PSA failure remains reported that 77 % of patients had a PSA value of ≤ 0.2 ng/ml at 4 years,
pertinent as it often prompts further investigations, some of which may with a resultant freedom from recurrence rate at 15 years of 96 % [28].
be invasive, such as biopsies to confirm local recurrence, and frequently In a separate UK study, Noble et al. evaluated 248 patients who received
marks the initiation of salvage therapies. These events can significantly LDR and reported that 64 % of patients attained a PSA < 0.2 ng/ml at 4
impact the patient’s quality of life and further burden the healthcare years, with a subsequent DFS of 97.5 % at 10 years [29]. In our present
system. The predominant pattern of relapse remains local, which does study, only 38 % of the patients that received 27 Gy in 2 fractions
not seem to be improved with further focal dose escalation [20,21]. reached a PSA of < 0.2 ng/ml at 4 years and 51 % at 5 years. It is possible

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J.M. Hudson et al. Radiotherapy and Oncology 198 (2024) 110381

Fig. 3. Biochemical disease-free survival by NCCN risk grouping in patients randomized to a single 19 Gy (a) and 27 Gy in 2 fractions (b). Risk grouping was not
associated with local failure in either arm.

that this reflects a different time to ablation of normal prostate tissue SBRT has gained popularity as an ablative treatment for patients
between HDR and LDR and not necessarily a relatively lower long-term with localized prostate cancer. The Phase III HYPORT-PC clinical trial
efficacy. The timeline of the PSA response appears more similar to that compared conventional fractionated EBRT to ultra-hypofractionated
seen with SABR. fractionation (42.7 Gy in 7) without ADT in patients with intermedi­
Although the results of a 2-fraction 27 Gy HDR monotherapy are ate and high-risk disease with a demonstrated 5-year failure-free sur­
promising and undoubtedly superior to the single-fraction experience, vival of 84 % [30]. Similarly, the 5-year outcomes from the PACE-B
one now must question whether they are sufficient to recommend over Phase III randomized trial were recently reported with a biochemical
alternative monotherapies such as HDR given in a greater number of failure-free rate of 94.6 % and a 5.5 % RTOG grade 2 or worse toxicity
fractions, SBRT, LDR brachytherapy, and even radical prostatectomy. Is [31]. These results compare favourably to different clinical endpoints
a bDFS of 83.2 % and a cumulative local failure rate of 11.2 % eight with our earlier reported 5-year bPFS for 27 Gy in 2 fractions HDR
years after 2-fraction HDR monotherapy a result worthy of optimism, or monotherapy at 93.9 %. However, promising, longer-term follow-up
should we remain cautious in its adoption? and ideally randomized clinical trials are needed to validate the

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J.M. Hudson et al. Radiotherapy and Oncology 198 (2024) 110381

Fig. 4. Estimated cumulative incidence of local failures for treatment with a single 19 Gy (black) and 27 Gy in 2 fractions (dashed red). The treatment arm and
baseline PSA were predictors of local failure. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of
this article.)

oncologic safety of SBRT. Investigation. Patrick Cheung: Writing – review & editing, Investiga­
LDR monotherapy is considered one of the first-line monotherapy tion. Ewa Szumacher: Writing – review & editing, Investigation.
techniques for treating patients with favourable intermediate-risk and Stanley Liu: Writing – review & editing, Investigation. Liying Zhang:
those with low-risk disease who decline active surveillance. Multiple Writing – review & editing, Methodology, Formal analysis. Andrea
randomized controlled trials and multi-institutional studies have Deabreu: Writing – review & editing, Project administration. Alex­
consistently shown comparable or improved outcomes for LDR mono­ andre Mamedov: Writing – review & editing, Software, Formal anal­
therapy compared to EBRT [32,33], EBRT+LDR boost [34], SBRT [35] ysis. Gerard Morton: Writing – review & editing, Supervision,
and radical prostatectomy [36]. Biochemical recurrence-free/failure- Methodology, Investigation, Funding acquisition, Conceptualization.
free survival of LDR monotherapy at 10, 15 and 17 years has been re­
ported around 81.5 % [37], 79.9 % [38] and 79 % [39], respectively. An Declaration of competing interest
extensive (N = 3502) retrospective multi-institutional analysis of PSA
kinetics and bRFS demonstrated that men with low and intermediate- The authors declare the following financial interests/personal re­
risk prostate cancer treated with LDR typically reached a lower me­ lationships which may be considered as potential competing interests:
dian PSA nadir (0.01–0.2 ng/ml) compared to SBRT (0.2 ng/ml) and [John M. Hudson – No conflicts of interest relevant to the work pre­
mono-HDR (0.1–0.2 ng/ml), although without difference in biochemical sented. Andrew Loblaw – No conflicts of interest relevant to the work
control at 4 years [40]. In the context of our present research, an presented. Merrylee McGuffin – No conflicts of interest relevant to the
ongoing randomized study led by the CCCTG (PR19, NCT02960087) is work presented. Hans T. Chung – No conflicts of interest relevant to the
evaluating LDR monotherapy (144 Gy) versus HDR monotherapy (27 Gy work presented. Chia-Lin Tseng – Advisor/consultant with Abbvie.
in 2 implants). This trial is expected to clarify whether HDR mono­ Joelle Helou – No conflicts of interest relevant to the work presented.
therapy can be considered a credible alternative to the more established Patrick Cheung – No conflicts of interest relevant to the work presented.
LDR approach. Ewa Szumacher – No conflicts of interest relevant to the work presented.
In conclusion, HDR monotherapy delivered in two fractions of 13.5 Stanley Liu – No conflicts of interest relevant to the work presented.
Gy demonstrated a high cancer control rate at 8 years and was well- Liying Zhang – No conflicts of interest relevant to the work presented.
tolerated. Single-fraction monotherapy yielded inferior results and is Andrea Deabreu – No conflicts of interest relevant to the work presented.
not recommended. Although longer follow-up is needed to confirm the Alexandre Mamedov – No conflicts of interest relevant to the work
durability of the findings, they contribute to the ongoing debate on presented. Gerard Morton reports that financial support was provided by
optimal HDR monotherapy strategies for low–and intermediate-risk Canadian Association of Radiation Oncology].
prostate cancer.
Acknowledgement
Credit authorship contribution statement
This work was funded by an AbbVie-CARO Uro-Oncologic Radiation
John M. Hudson: . Andrew Loblaw: Writing – review & editing, Award (ACURA) from the Canadian Association of Radiation
Investigation, Conceptualization. Merrylee McGuffin: Writing – review Oncologists.
& editing, Project administration. Hans T. Chung: Writing – review &
editing, Investigation, Data curation. Chia-Lin Tseng: Writing – review
& editing, Investigation. Joelle Helou: Writing – review & editing,

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J.M. Hudson et al. Radiotherapy and Oncology 198 (2024) 110381

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