After the results of RTOG 0232, would you be comfortable treating unfavorable intermediate risk prostate cancer with brachytherapy monotherapy?

I would not necessarily be comfortable treating every unfavorable intermediate risk (UIR) patient with LDR brachytherapy alone (nor with HDR brachy alone). My reason for this is that 0232 only included about 50 patients in each arm with Grade Group 3 tumors, and no information is available about percent positive biopsies or other indicators of cancer volume. Assignment into Grade Groups (GG) was done post-hoc, since they did not exist when the study began, and it was not a pre-specified stratifi...

We have moved to brachy alone if meets the above criteria as similar outcome and less morbidity.

I concur with the excellent comments by Dr. @Dr. First Last and add the following:

The RTOG 0232 trial included patients with cT1c-T2bN0M0 disease with a Gleason score of 2-6 and PSA of 10-20 or with a Gleason score of 7 with a PSA <10. The majority of patients were T1, Gleason score 7, with PSA <10. Even noting this, RTOG 0232 included unfavorable intermediate-risk. For unfavorable intermediate-risk patients meeting the trial’s criteria, I offer brachytherapy alone as an option provided that PSM...

I typically get a PSMA PET in these patients and urge them to consider short course ADT along with either LDR or HDR with a preference for HDR.