Evaluating Factors That Affect HDR Brachytherapy and SBRT Decisions in Radiation Oncology

Asked how he decides between high-dose rate (HDR) brachytherapy and stereotactic body radiation therapy (SBRT) for localized prostate cancer, Adam C. Olson, MD, MSc-GH, associate professor in the Department of Radiation Oncology at the University of Pittsburgh and medical director at Children's Hospital of Pittsburgh of UPMC, gave an answer that reframed the question. “The short answer is I don't,” he said. Olson spoke with CancerNetwork® at the 2026 UPMC Hillman Cancer Center Radiation Oncology Symposium.

The reasoning is evidentiary. Olson described himself as someone who tries to practice with as strong an evidence-based approach as possible, and said the evidence base is quite strong for both brachytherapy and SBRT. Where 2 options are comparably supported, the deciding input is not the radiation oncologist's read of the literature. It is the patient's.

Olson said the consultations can be lengthy because he walks through the pros, the cons, and the logistics of receiving one modality or the other, and he strongly encourages patients to take time to reflect on what fits them. The split he described is not clinical but dispositional: some patients are drawn to radiation going directly into the prostate and are not averse to having a procedure performed, which makes HDR a perfectly reasonable choice, while others want a less invasive approach, for whom SBRT is perfectly appropriate.

The approach traces to a specific paper. Olson cited work from the group at Vanderbilt on treatment-related regret in localized prostate cancer.¹ In that population-based cohort of 2072 men from the Comparative Effectiveness Analysis of Surgery and Radiation registries, regret at 5 years after diagnosis was reported by 16% of patients who underwent surgery, 11% who underwent radiotherapy, and 7% who underwent active surveillance. Treatment modality was not independently associated with regret once patient-reported functional outcomes were accounted for. What was associated with it included whether perceived efficacy and adverse effects matched expectations set before treatment, and participatory decision-making scores, which tracked with lower regret.

Reading those factors, Olson said, the clearest message he received was that his goal was to educate and to provide a space for people to feel they have an opportunity to have input on their decision. On HDR vs SBRT specifically, his aim is to educate and let patients choose what fits them best.

Transcript:

CancerNetwork: Brachytherapy occupies the same space as a lot of other modalities, SBRT among them. How do you decide between them?

Olson: The short answer is I don't. I have thought long and hard about this, and as somebody who tries to practice with as strong an evidence-based approach as possible, the evidence base is quite strong for both brachytherapy and SBRT. These conversations that I have with patients when they're trying to decide what to do can be rather lengthy, because I go through the pros and cons and logistics associated with receiving one or the other. I really strongly encourage patients to take a little bit of time to reflect on what they feel is the best fit for them.

There are some people who really are attracted to the idea of the radiation going directly into the prostate, and they're not averse to having procedures performed, so HDR is a perfectly reasonable choice for them. Alternatively, there are some folks who really want to have a less invasive approach, and SBRT is a perfectly appropriate choice for those patients.

I'm reminded, as we're talking about this, of a study that the group from Vanderbilt did some years ago that looked at treatment-related regret for localized prostate cancer.¹ When I read that paper and looked at some of the factors that are associated with it, one of the clearest messages I received was that my goal was to educate and to provide a space for people to feel like they have an opportunity to have input on their decision. When it comes to the specifics of HDR or SBRT, my goal is to simply educate [the patient] and let them choose what they feel fits them best.

References

Wallis CJD, Zhao Z, Huang LC, et al. Association of treatment modality, functional outcomes, and baseline characteristics with treatment-related regret among men with localized prostate cancer. JAMA Oncol. 2022;8(1):50-59. doi:10.1001/jamaoncol.2021.5160