Localised prostate cancer: Is brachytherapy better than other options?

It is currently not possible to be sure whether brachytherapy has advantages over other types of therapy in the treatment of early-stage prostate cancer in men. Further research is needed to reliably evaluate how effective brachytherapy is.

Brachytherapy (internal radiotherapy) is one of several treatment options in early-stage prostate cancer (localised prostate carcinoma). It involves implanting radioactive sources in the prostate gland, with the aim of specifically targeting the cancerous cells. This approach is called LDR or “low dose rate” brachytherapy. You can read more about brachytherapy in our fact sheet.

The prostate is a walnut-sized gland. It is part of the male reproductive system, located in front of the rectum (at the end of the bowel) and wraps around the urethra (urinary tube) in men. In prostate cancer, cells of the gland change and become malignant (cancerous). Yet even if cancer cells are found, it does not mean that the illness will definitely cause problems: prostate cancer is not necessarily terminal. Prostate tumours often only grow slowly, or not at all, and do not always spread to other parts of the body and form metastases (secondary tumours).

Nowadays a blood test for “prostate-specific antigens” (PSAs) is carried out in many men to try to detect prostate cancer early on. The PSA test determines whether there is a considerable amount of cells with certain characteristics. The more these tests are used, the more men are diagnosed with early prostate cancer - but the tumour will not pose a danger to most of them. It is estimated that, in 8 out of 10 men with localised prostate cancer, the tumour neither grows nor spreads and it does not become life-threatening. However, it is not possible to predict in which patients the tumour will become a problem.

Treatment approaches in localised prostate cancer

The following options are available for the treatment of cancer that is confined to the prostate gland:

• Careful monitoring (also called “watchful waiting”): This strategy is based on the fact that prostate tumours usually only develop slowly or do not change at all. It is quite common for tumours to stay the same for years after being diagnosed. If the “watchful waiting” approach is chosen, taking the individual risk of the patient into consideration, medical check-ups should be carried out regularly.
• Conventional external radiotherapy (irradiated from outside the body).
• Brachytherapy: In this approach, low-level radioactive capsules (“seeds”) the size of a grain of rice are permanently implanted directly in the prostate using a hollow needle. The aim is to irradiate the tumour in a more targeted way and avoid excessive damage to the surrounding organs (bladder and rectum). This is usually done under a general or local anaesthetic.
• Prostatectomy: Surgical removal of the whole organ including the seminal vesicles.

Comparing brachytherapy with other options

Researchers at the German Institute for Quality and Efficiency in Health Care (IQWiG) compared brachytherapy to the other three treatment options for localised prostate cancer. In order to evaluate the treatments, they looked for randomised controlled trials (RCTs) and other good studies that allowed a direct and fair comparison over relatively long periods of time.

The researchers found 11 studies involving a total of 11,000 participants. There were no randomised clinical trials among these studies. Only four of them were carried out in such a way that it was possible to follow certain changes over time (prospective studies). Because many of the studies had flaws, no reliable conclusions could be drawn based on the available data. For example, various brachytherapy techniques were used so the data could not be compared directly. It was not possible to say how brachytherapy compared with the other treatment options in terms of adverse effects and long-term survival.

None of the studies looked at the differences between the watchful waiting approach and brachytherapy. Some evidence suggests that, compared to brachytherapy, conventional external radiotherapy harms rectal function more. Other research indicates that removing the prostate possibly leads to more sexual dysfunction and urinary incontinence than brachytherapy might.

At the moment it is not possible to draw definite conclusions about the benefits and harms of brachytherapy. This is also true about its effects on long-term survival and nearby organs. The IQWiG researchers therefore urgently recommend that more good-quality clinical trials be carried out in order to make it possible to draw more reliable conclusions about the effects of brachytherapy, particularly in terms of long-term survival.


Author: German Institute for Quality and Efficiency in Health Care (IQWiG)


Note

This health information is a summary of a scientific report published by IQWiG. It is not an assessment of the right to have health care services reimbursed by statutory health insurance funds in Germany. By law, decisions about the reimbursement of diagnostic and therapeutic procedures can only be made by the German Federal Joint Committee (G-BA). The Federal Joint Committee takes IQWiG reports into consideration in its decision-making process. You can find information about the decisions of the German Federal Joint Committee on its English-language website, www.english.g-ba.de.

© IQWiG (Institute for Quality and Efficiency in Health Care)