What is the role of conventional external beam radiotherapy (EBRT) in the treatment of prostate cancer?

Updated: Nov 29, 2018
  • Author: Isamettin Andrew Aral, MD, MS; Chief Editor: Edward David Kim, MD, FACS  more...
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Answer

Answer

As biochemical endpoints of therapy replace clinical endpoints, the role of conventional external beam radiation therapy (EBRT) in the management of localized prostate cancer is likely to diminish. The reasons include an appreciation of the importance of dose escalation, the ability to offer patients more precise target localization, and the use of combined treatment strategies (ie, addition of hormonal manipulation or brachytherapy to the primary treatment).

The current literature supports the role of conventional EBRT in the management of localized prostate carcinoma. Countering this view is historical information reported by Paulson et al, [9]  along with a meta-analysis by Wallis et al, [10] which showed that in early-stage disease, surgery offered better results than EBRT. However, the randomization schema and statistical analysis associated with these data make definitive conclusions difficult.

Although the Paulson study was a prospective trial, it was conducted before the routine use of prostate-specific antigen (PSA) testing and pelvic imaging. No similar study has been conducted in the PSA era. In fact, a trial at the US National Cancer Institutes (NCI), the Prostate Intervention versus Observation Trial (PIVOT), failed to include radiotherapy as a treatment arm.

The 2 forms of therapy are unlikely to be directly compared in the future. Retrospective comparisons, using PSA-based outcomes, suggest no significant difference between them. The results for patients with T1/T2 disease treated with conventional EBRT are similar to results achieved after radical prostatectomy. The 2 treatments offer comparable rates of disease control, and 10-year survival rates are similar (> 60%) in studies by both Bagshaw [11] and Perez [12] .

Despite the decreasing frequency of conventional EBRT in the management of prostate carcinoma, there is no significant body of data to indicate that this treatment should be abandoned. In fact, Radiation Therapy Oncology Group (RTOG) trial 94-13 suggests that whole-pelvis radiotherapy (ie, conventional treatment) may improve the local regional control of disease in patients with increased risk of non–organ-confined cancer (ie, high Gleason score and high prostate-specific antigen [PSA] level). [13]

Regardless of the current status of conventional EBRT in prostate cancer, a clear understanding of the former standard treatments will, at the least, allow a greater appreciation of more current techniques.


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