Training, Invasiveness, and Workload Behind Falling Prostate Brachytherapy Use

Asked what is driving the decline in prostate brachytherapy use in the United States, Bhanu Prasad Venkatesulu, MBBS, MD, gave 4 reasons, and none of them was the evidence. Venkatesulu spoke with CancerNetwork® at the 2026 UPMC Hillman Cancer Center Radiation Oncology Symposium.

The first roadblock he pointed to was that not many radiation oncologists are comfortable performing brachytherapy. Without clinicians able to do the procedure, a department cannot offer it as an option at all. The second is that brachytherapy is an invasive procedure, and stereotactic body radiation therapy (SBRT) now delivers treatment in 5 sessions with what Venkatesulu described as probably an equivalent outcome. He framed the patient's reasoning directly: the invasiveness is the main reason many of them declined surgery in the first place, so being asked to accept a procedure anyway changes how they weigh the choice.

Among the remaining reasons were the economics of the clinician's day, having to wake up at 5 or 6 in the morning and getting to the hospital, and that external beam radiation therapy has become more precise and accurate.

Despite performing a high volume of brachytherapy, Venkatesulu said he is not someone who would argue brachytherapy is better, and said it was just another option available to patients. He named one exception, and it was specific: in patients who have had prior radiation and now have a local recurrence, he said brachytherapy outdoes external radiation or other forms of focal therapy.

Venkatesulu is a clinical assistant professor in the Department of Radiation Oncology at the University of Pittsburgh and a radiation oncologist at University of Pittsburgh Medical Center (UPMC) Hillman Cancer Center.

Transcript:

CancerNetwork: Brachytherapy use has fallen in the United States. What is causing that?

Venkatesulu: There are a few reasons. One of them is that not many radiation oncologists are comfortable performing brachytherapy in general. If you don’t have people to do it, you’re obviously not going to get that as an option for you.

Second, it’s an invasive procedure. Especially with the advent of SBRT, where you can do 5 treatments, get the treatment done, and probably achieve an equivalent outcome to brachytherapy, patients question, “Why do I have to go through an invasive procedure? That’s the main reason I did not want surgery in the first place.” The perspective may be a little bit different in that regard.

And from an economic standpoint of view, if [a clinician] has to do brachytherapy, they usually have to wake up at 5 or 6 in the morning, and get to the hospital. It’s more work in general. A lot of radiation oncologists [consider] their work-life balance, [and think], “Why should I do this when I can easily [achieve] the exact same cure rate with just an external radiation treatment?”

There are various reasons. Some of it is physicians not having enough training. Some of it is physician reluctance as well; some of it is because [there’s] another [available] option which is as [short] as possible, because historically, when we used to do brachytherapy, the number of treatments for prostate cancer was 39 to 44 treatments. Now it has come down to 28 for external radiation. For SBRT, it’s just 5. Some of that is also because the external beam’s ability to deliver external radiation has become much more precise and accurate.

But at the end of the day, though I do a lot of brachytherapy, I’m not somebody who would say that brachytherapy is better. At the end of the day, it’s another option. But in patients who have had prior radiation and have a local recurrence, it’s a really good option. I do think it outdoes external radiation or other forms of focal therapies in that regard.