Has the recent SBRT vs HDR monotherapy analysis changed your use of HDR monotherapy for intermediate-risk prostate cancer?

With excellent outcomes with SBRT in this group (PACE-B), the additional advantage of brachy is limited. The predominant use of HDR brachy is either as a boost for high-risk or as salvage after previous EBRT.

My short answer is that I continue to consider both SBRT and HDR as acceptable standards of care for localized, intermediate-risk prostate cancer. Although this study does present a provocative conclusion, I ultimately ran into some trouble understanding the methodology easily from the paper, which provided a barrier for me to using these findings to adjust my patient counseling.

In summary, the SHERBET study was a post hoc analysis of 5 prospective trials to compare SBRT and HDR brachytherapy. These trials included 3 non-randomized trials (NCT01146340 [pHART6], NCT03588819 [2SMART], and NCT02031328 [2STAR]) and two randomized trials (NCT0189009, NCT01423474 [PATRIOT]), although, of relevance to interpretation, neither of the included rando...

Unfortunately, there will probably never be a head-to-head randomized comparison of SBRT vs HDR monotherapy, given the non-invasive nature of the former vs the latter, so we are left with post-hoc comparisons of prospective trials of the 2 modalities separately and retrospective data. The Udovicich paper reports a post-hoc patient-level data analysis of 4 SBRT trials and 1 HDR brachytherapy trial from a single high-volume institution. These are all prospectively conducted trials. Despite the inclusion of 5 trials, the overall patient numbers are small. There were only 67 HDR brachytherapy patients and 180 SBRT patients. The groups were not balanced for prognostic factors, with fewer HDR brachytherapy patients having unfavorable features. De...