365 Background: Salvage radiotherapy (RT) is an effective curative salvage of relapse after radical prostatectomy (RP). CAPRA S score predicts for relapse after salvage RT. The DADSPORT meta-analysis suggests those with low CAPRA S score do not benefit from benefit of androgen ablation (AA) to salvage RT. A rising PSA during salvage RT may be important in predicting which patients may benefit from treatment intensification such as addition of AA to salvage RT. Herein we report on outcomes of salvage RT without AA in relation to rising PSA during RT. Methods: 32 patients were treated with salvage RT alone without AA (either because of low risk or patient preference) for rising PSA rising post RP. All patients had a PSA prior to and at least twice during RT at least 3 weeks apart. Patients were treated with 66 Gy in 33# to prostate bed. Patients were followed for PSA q 6 months post RT. Those with a PSA rising to over 0.2 were considered to have relapsed. Actuarial outcomes for relapse were assessed with multivariate analysis including CAPRA S score (low, intermediate, and high), and by 6 year progression free survival estimate from MSKCC nomogram (dichotomized around the median). Results: Median and IQR of PSA at time of salvage RT were 0.24 (0.2-0.55). 19% of patients had rising PSA during RT. 19 patients (60%) also received 46 Gy in 23# to pelvic nodes in phase 1 of RT. 34% of patients had PSMA PET prior to RT (none showing involved nodes or metastases). CAPRA S scores were low (15%), intermediate (69%), and high (15%). Relapse rates did not differ by CAPRA S score, although numbers were small. Three-year freedom from relapse rates were 16% for those with rising, and 49% without rising PSA during RT respectively (p=0.006). Three-year freedom from relapse rates were 9% for those below the median MSKCC nomogram risk, and 68% for those above the median respectively (p<0.001). Only rising PSA during RT was significant on MVA. Three patients had a rising PSA and a negative PSMA prior to salvage RT: all three relapsed within 1 year of RT. Of eight patients who had a falling PSA during RT and a negative PSMA PET prior to salvage RT: only 1 relapsed within 3 years of salvage RT. Conclusions: A rising PSA during salvage RT without AA is prognostic for relapse, and may be particularly relevant in the PSMA PET era. This may be a factor to considered when deciding whether to intensify therapy during salvage RT, either by adding adjuvant ADT, and/or using a PSMA PET to guide dose escalation.

306 Background: Androgen Suppression Combined with Elective Nodal and Dose Escalated Radiation Therapy (ASCENDE-RT) trial randomized patients to prostate brachytherapy (PB) or the External beam RT (EBRT) boost (1:1). All patients received 1 year of androgen deprivation therapy and 46 Gy in 23 fractions of pelvic RT. Patients in the EBRT arm received an additional 32 Gy in 16 fractions, and those in the PB arm received a 115 Gy 125I implant. The trial previously demonstrated a large difference in biochemical relapse favoring brachytherapy (PB) boost. At present, the median follow-up from start of treatment of all patients is 15 (IQR 10.7, 17.8) years. Herein we report the 15-year actuarial survival events. Methods: Two hundred patients with a median age of 68 (IQR 62,73) were randomized to EBRT and 198 to PB. Active study follow-up stopped at 10 years. Cause of death was determined on chart review and study report forms during active study follow-up, and was augmented with death registry data, and medical records audits thereafter. Fifteen-year overall survival and cumulative risk of death from prostate cancer were estimated using Cox and Fine and Gray analysis respectively with multivariable analysis (MVA) significant variables on univariate including - randomization, clinical T stage, log of initial PSA, Gleason grade group (1-3 vs 4-5), percent positive cores, and age at treatment. A sensitivity analysis included unknown cause of death as prostate death. Results: 213 patients (54%) have died: 64 (16%) of prostate cancer, 48 (12%) of other cancer, 35 (9%) of cardiovascular disease, 49 (12%) of other known causes, and 17 (4%) of unknown cause of death. The age of patients alive at last censoring was 82 (IQR 77,88). Overall survival at 15 years was 55.0% (95% CI 48.4 – 62.4) and 60.9% (95% CI 54.4 – 68.1) for EBRT and PB arms respectively, (HR 1.02, 95%CI 0.78 – 1.33, p = 0.908 on MVA). The cumulative incidence of prostate death at 15 years was 8.6% (95%CI 5.2 – 13.0) for PB and 16.4% (95%CI 11.6 – 22.0) for EBRT (p=0.007). In a sensitivity analysis where cases of unknown cause of death were counted as prostate deaths, the cumulative incidence of prostate death at 15 years was 14.3% (95%CI 9.8 – 19.5) for PB and 19.4% (95%CI 14.2 – 25.3) for EBRT (p=0.067). Conclusions: At 15 years, there is no definite evidence of an overall survival benefit with PB boost in ASCENDE-RT and the trend to a prostate cancer specific survival advantage with PB is limited by ascertainment of cause of death. Thus, although prostate cancer was the single most common cause of mortality in ASCENDE-RT, our results suggest that even large improvements in b-NED, such as those demonstrated with PB in ASCENDE-RT, are unlikely to improve 15-year overall survival by more than 10% for a population whose median age, performance status, and prognostic variables are similar to ASCENDE-RT participants. Clinical trial information: NCT00175396 .

PURPOSE:To characterize global practice patterns in prostate brachytherapy (BT) and evaluate variation in practice, identifying alignment with guidelines and opportunities for harmonization. METHODS AND MATERIALS:A 75-item survey was distributed via international BT societies. One response per institution was requested, completed by a radiation oncologist and medical physicist. Domains included departmental characteristics, BT utilization, prescriptions, imaging, planning, verification, and salvage practices. Data were summarized descriptively. RESULTS:A total of 116 institutions responded (64.1%), mainly from North America and Europe. Most had >10 years' experience, though case volumes were modest (11-50 de novo; <10 salvage annually). High-dose-rate (HDR) BT was most used for combination and salvage, while HDR and low-dose-rate BT were evenly used for monotherapy. Prescription regimens were heterogeneous, particularly for HDR monotherapy and salvage. Androgen-deprivation therapy duration varied across risk groups. Transrectal ultrasound was the primary planning modality; only 46% used fused diagnostic imaging for intraprostatic lesion definition. Most used ≤3 mm margins and standard coverage metrics, though organ-at-risk constraints varied. Focal BT use was increasing, particularly in salvage settings. CONCLUSIONS:Substantial international variability exists across BT practice. While core technical principles are consistent, heterogeneity highlights the need for harmonized guidelines, prospective studies, and global collaboration.

Multiple instance learning (MIL) has become a popular approach in computational pathology and whole slide image (WSI) analysis for their weakly-supervised nature. The introduction of attention-based instance pooling in particular has enabled enhanced interpretation of both model decision-making and the underlying data by leveraging attention weights. However, the interpretation of the attention weights, specifically its indication of instance classes, have been contested. We demonstrate that noise or heterogeneity in bagged data can require MIL classifiers to predict bag class based on prevalence of the positive instance class, as opposed to its presence; altering the behavior of the attention mechanism and likely contributing to the aforementioned discrepancies of attention weight interpretation. Here, we introduce an approach to identify and score instances which contribute to a positive bag label, robust against altered attention behavior, in two discreet settings. First, we elucidate how the behavior of attention-based pooling is altered, using the MNIST dataset, where bagged datasets are generated with a different threshold (t) of positive class instances defining the bag label. While maintaining a high bag-level classification score, the distribution of attention weights between positive and negative changed with t, where the mechanism attended more to positive instances for lower values of t, but favored negative instances for high values of t. We also apply our method to an in-house dataset of prostate cancer nuclei to predict the aggressiveness of the disease, and demonstrate how our method may be used to identify a subgroup of nuclei more highly associated with aggressiveness.

Purpose Over the past decade there has been an expansion of brachytherapy (BT) education and practice in Canada including recognition of several BT fellowship programs as eligible for Area of Focused Competence (AFC) designation by the Royal College of Physicians and Surgeons of Canada. This study aims to characterize the extent of BT availability, expertise and utilization after implementation of these initiatives. Materials and Methods A 68-question survey covering expertise, training, resources and future challenges to BT programs was created and sent to a single representative at each of the 36 centers in Canada identified to have an active BT program. Absolute count (proportions) and medians (inter-quartile-range) were used to describe the data. Results 30 responses (response rate 83%) representing all provinces with at least one available BT program (9) were obtained. Twelve (40%) serviced catchment areas with populations >1 million. The median number of radiation oncologists practicing BT in each centre was 5 (3-6); this represented 33% (23%-43%) of overall workforce at each centre. 9 (30%) centers had at least one AFC trained brachytherapist on site while 27 (90%) had at least one non-AFC fellowship trained brachytherapist on site. Of the 10 respondent centers offering BT fellowship programs, 6 (60%) are AFC accredited. All 30 respondents (100%) offered BT treatment for endometrial cancer, 26 (87%) for cervical cancer, 25 (83%) for prostate cancer and 20 (67%) for vaginal cancer. Breast, penile and anal canal BT was offered at 4 (13%), 3 (10%) and 2 (7%) centers, respectively. No center offered lymph node/metastases or bladder BT. In 2024, the median number of endometrial, cervical, prostate and vaginal cancers cases treated were 38 (22-50), 19 (7-33), 66 (41-138) and 1 (0-3), respectively. Sixteen, (62%) respondents anticipated an increase in demand for BT resources within the next 5 years. Conclusions BT programs in Canada are supported by highly trained brachytherapists. BT programs most commonly treat gynecologic cancers (endometrial, cervical and vaginal); while case loads are highest for prostate cancer. These survey results will allow comprehensive assessment of BT access and utilization across the country, and allow strategic planning where there is an anticipated increase in BT demand.

PURPOSE/OBJECTIVE:Brachytherapy (BT) techniques, skillsets and resource requirements have advanced over the past decade. This study aimed to characterize the current extent of BT availability, expertise and utilization in Canada. MATERIALS AND METHODS:A 68-question survey covering expertise, training, resources and future challenges to BT programs was created and sent to a single representative at each of the 36 of 49 radiotherapy centers in Canada identified to have an active BT program. Responses were then analyzed in aggregate. RESULTS:Thirty-one responses (response rate 86%) representing all provinces with at least 1 available BT program (9) were obtained. The median number of radiation oncologists practicing BT in each center was 5 (3-6); this represented 33% (24%-43%) of the workforce at each center. Thirty (97%) centers had at least 1 fellowship trained brachytherapist on site. Eleven (35%) respondent centers offered BT fellowship programs and 7 (64%) of those offered the nationally accredited brachytherapy designations at the end of training. All 30 respondents (100%) offered BT treatment for endometrial cancer, 26 (87%) for cervical cancer, 25 (83%) for prostate cancer and 20 (67%) for vaginal cancer. In 2024, the median number of endometrial, cervical, prostate and vaginal cancers cases treated were 38 (22-50), 19 (7-33), 66 (41-138) and 1 (0-3), respectively. Sixteen (62%) respondents anticipated an increase in demand for BT resources within the next 5 years. CONCLUSION:BT programs across Canada are supported by highly trained brachytherapists. BT programs most commonly treat gynecologic and genitourinary malignancies.

Multiple instance learning (MIL) has become a popular approach to analyze histopathology datasets due to its weakly supervised nature. In particular, attention-based models can learn key instances of which labels are usually unknown or unavailable. For instance, large-scale DNA organization (LDO) analysis aims to make patient prognoses from quantitative features of nuclear morphometry and chromatin condensation calculated from images of the nucleus. Leveraging attention mechanisms allows a model to identify nuclei with alterations which likely contribute to patient outcome without individual cell labels. However, a crucial assumption of MIL that is often overlooked in histopathology applications, wherein a bag is positive if it has at least one positive instance. In a cancer context, this assumption is not robust, as a single malignantly transformed cell may be necessary but insufficient to cause carcinogenesis or malignant cancer progression. A reasonable adjustment is to learn a tolerable threshold of aberrant cells. The attention mechanism can be modified so that both key aggressive and indolent nuclei are identified in contrast to traditional MIL attention mechanisms which only give weight to positive instances. We demonstrate that this is an effective approach for prostate cancer (PCa) prognosis. A binary MIL classifier was trained to identify PCa patients (bags) of the indolent (negative) and aggressive (positive) outcomes. The cohort includes 38 Gleason score (GS) 6 patients who did not display signs of progression during active surveillance (AS) and 22 patients with GS 9 who died within 2 years of consultation. A linear attention layer identifies aggressive and indolent nuclei (instances) to generate a weighted mean representation of LDO features for the patient, reducing the influence of nuclei of ambiguous labels. To mitigate overfitting, weights are shared between the attention layer and patient classification layer and trained to optimize a combination of binary cross entropy loss on the nuclear and patient level. Patients in the training set were classified with a balanced accuracy of 0.851, and an F1-score of 0.815. This performance also translated to the patients in the holdout set, where the balanced accuracy and F1-scores of patient classification was 0.857 and 0.833 respectively. Tests on an independent cohort of 147 patients with GS 7+ also demonstrate that LDO score is correlated with GS, biochemical recurrence following brachytherapy, and progression in GS6 active surveillance patients. Future studies will analyze the performance of the trained classifiers on patients with GS7 and GS8 further, such as the classifier’s ability to rank severity of clinical outcomes with c-index. These results demonstrate the potential of the MIL-based LDO biomarker for prostate cancer patient prognosis and management. Further validation on the brachytherapy-treated cohort, and survival analysis will be done to assess the performance of the MIL classifier, and its potential benefit for prostate cancer management. Fumiya Inaba, Zhaoyang Chen, Anita Carraro, Paul Gallagher, Mira Keyes, Martial Guillaud, Calum MacAulay. Multiple instance learning of large-scale DNA organization to characterize prostate cancer aggressiveness [abstract]. In: Proceedings of the AACR Special Conference in Cancer Research: Artificial Intelligence and Machine Learning; 2025 Jul 10-12; Montreal, QC, Canada. Philadelphia (PA): AACR; Clin Cancer Res 2025;31(13_Suppl):Abstract nr B030.

INTRODUCTION:Brachytherapy is a critical skill in the field of radiation oncology and remains an essential treatment modality in several disease sites. Multiple surveys conducted in the US suggest that a large proportion of residents do not feel comfortable performing several types of brachytherapy procedures upon graduation, highlighting a significant gap in training. To understand if similar issues exist outside the US, a scoping review was conducted to characterize the state of brachytherapy training internationally. METHODS:An electronic search was conducted on PubMed on June 8, 2024 with a restriction on publication year prior to 2015 with the search terms "brachytherapy" and "resident." Across the eight studies identified, a total of 1187 survey responses reported resident self-assessment of brachytherapy competence. RESULTS:Surveys of residents from multiple continents report high variability in brachytherapy skill confidence with many techniques reporting less than 50% confidence. Surveys that also assessed barriers to brachytherapy training found that low caseload and lack of formal training or assessments were common issues. CONCLUSIONS:These low rates of brachytherapy confidence across the globe are troubling and dedicated interventions, such as the establishment of competency-based assessments and effective simulation-based training, are needed to ensure that future radiation oncologists have the skills to deliver safe, high-quality patient care across the globe.

Artificial intelligence (AI) is becoming an integral part of pathological assessment and diagnostic procedures in modern pathology. As most prostate cancers (PCa) arise from glandular epithelial tissue, an AI-based methodology has been developed to recognize glandular epithelial nuclei in prostate biopsy tissue. An integrated machine-learning network, named GlandNet, was developed to correctly recognize the epithelial cells within prostate glands using cell-centric patches selected from the core biopsy specimens. Feulgen-Thionin (a DNA stoichiometric label) was used to stain biopsy sections (4–7 µm in thickness) from 82 active surveillance patients diagnosed with PCa. Images of these sections were human-annotated, and the resultant dataset consisted of 1,264,772 segmented, cell-centric nuclei patches, of which 449,879 were centered on epithelial gland nuclei from 110 needle biopsies (training set: n = 66; validation set: n = 22; and test set: n = 22). The training of GlandNet used semi-supervised machine-learning knowledge of the training and validation cohorts and integrated both human and AI predictions to enhance its performance on the test cohort. The performance was evaluated against a consensus deliberation from three observers. The GlandNet demonstrated an average accuracy, sensitivity, specificity, and F1-score of 94.1%, 95.7%, 87.8%, and 95.2%, respectively, when tested on the 20,735 glandular cells found in the three needle biopsies with the visually best consensus predictions. Conversely, the average accuracy, sensitivity, specificity, and F1-score were 90.9%, 86.4%, 94.0%, and 89.7% when assessed on 57,217 cells found in the three needle biopsies with the visually worst consensus predictions. GlandNet is a first-generation AI with an excellent ability to differentiate between epithelial and stromal nuclei in core biopsies from patients with early prostate cancer.

Purpose: Breast arterial calcifications (BAC) on mammography have been correlated with increased cardiovascular risk. The Canadian Society of Breast Imaging released a position statement on BAC reporting in January 2023. This study evaluates the awareness of the clinical significance of BAC and reporting preferences of referring physicians in Canada. Methods: A 15-question survey was distributed to Canadian physicians who may review mammography results via regional and subspecialty associations and on social media following local institutional ethical approval. Responses were collected over 10 weeks from February to April 2023. Results: Seventy-two complete responses were obtained. We are unable to determine the response rate, given the means of distribution. Only 17% (12/72) of responding physicians were previously aware of the association between BAC and increased cardiovascular risk, and 51% (37/72) preferred the inclusion of BAC in the mammography report. Fifty-six percent (40/72) indicated that BAC reporting would prompt further investigation, and 63% (45/72) would inform patients that their mammogram showed evidence of BAC. Sixty-nine percent (50/72) would find grading of BAC beneficial and 71% (51/72) agreed that there is a need for national guidelines. Conclusion: Less than a quarter of responding Canadian referring physicians were previously aware of the association between BAC and cardiovascular risk, although half of respondents indicated a preference for BAC reporting on mammography. Most participating physicians would inform their patients of the presence of BAC and consider further cardiovascular risk management. There was consensus that a national BAC grading system and clinical management guidelines would be beneficial.

Purpose Over the past decade there has been an expansion of brachytherapy (BT) education and practice in Canada including recognition of several BT fellowship programs as eligible for Area of Focused Competence (AFC) designation by the Royal College of Physicians and Surgeons of Canada. This study aims to characterize the extent of BT availability, expertise and utilization after implementation of these initiatives. Materials and Methods A 68-question survey covering expertise, training, resources and future challenges to BT programs was created and sent to a single representative at each of the 36 centers in Canada identified to have an active BT program. Absolute count (proportions) and medians (inter-quartile-range) were used to describe the data. Results 30 responses (response rate 83%) representing all provinces with at least one available BT program (9) were obtained. Twelve (40%) serviced catchment areas with populations >1 million. The median number of radiation oncologists practicing BT in each centre was 5 (3-6); this represented 33% (23%-43%) of overall workforce at each centre. 9 (30%) centers had at least one AFC trained brachytherapist on site while 27 (90%) had at least one non-AFC fellowship trained brachytherapist on site. Of the 10 respondent centers offering BT fellowship programs, 6 (60%) are AFC accredited. All 30 respondents (100%) offered BT treatment for endometrial cancer, 26 (87%) for cervical cancer, 25 (83%) for prostate cancer and 20 (67%) for vaginal cancer. Breast, penile and anal canal BT was offered at 4 (13%), 3 (10%) and 2 (7%) centers, respectively. No center offered lymph node/metastases or bladder BT. In 2024, the median number of endometrial, cervical, prostate and vaginal cancers cases treated were 38 (22-50), 19 (7-33), 66 (41-138) and 1 (0-3), respectively. Sixteen, (62%) respondents anticipated an increase in demand for BT resources within the next 5 years. Conclusions BT programs in Canada are supported by highly trained brachytherapists. BT programs most commonly treat gynecologic cancers (endometrial, cervical and vaginal); while case loads are highest for prostate cancer. These survey results will allow comprehensive assessment of BT access and utilization across the country, and allow strategic planning where there is an anticipated increase in BT demand.

Brachytherapy is an essential skill in the practice of radiation oncology and is an important component of high-quality, full-service radiation oncology departments. With rapidly changing technology, the role of brachytherapy is constantly evolving, but it remains critically important for optimal patient care in several disease sites. As a procedural aspect of radiation oncology practice, brachytherapy requires a fundamentally different and more focused training approach, with specific training objectives, a unique knowledge base, and specialized training environment. The existing gap in brachytherapy training and experience is compounded with a lack of standardized training objectives. Consensus statement objectives were in part adapted with permission from the Royal College of Physician and Surgeons of Canada, and then further reviewed, modified and enriched with expert knowledge by all authors. Training objectives were further synchronized with the US Accreditation Council for Graduate Medical Education (ACGME). This ABS/GEC-ESTRO Consensus Statement of training objectives will facilitate brachytherapy training by outlining the necessary knowledge and procedural skills for successful practice in brachytherapy. The final brachytherapy curriculum development for any individual program, country and regions, is the responsibility of the individual programs and licensing jurisdictions and should be tailored to their patient population, available equipment and facilities.

PURPOSE:Post prostatectomy PSA kinetics and General Grade Groups (GGG) are the strongest prognostic markers of biochemical recurrence (BCR) and prostate cancer (PCa)-specific mortality after radical prostatectomy. Despite having low-risk PCa, some patients will experience BCR, for some, clinically significant BCR. There is a need for an objective prognostic marker at the time of prostatectomy to improve risk stratification within this population. In this study, we investigated the prognostic potential of DNA ploidy.MATERIALS AND METHODS:Prostatectomy samples from 97 patients with GGG1 and GGG2 with a low-risk CAPRA-S score were included in this study. PCa tissue with the worst Gleason pattern underwent tissue disaggregation, cell isolation and staining with a DNA stoichiometric stain. Using image cytometry, DNA ploidy was measured and a Ploidy Score (PS) was generated.RESULTS:Among the 97 patients, 79 had no BCR, 18 experienced BCR, of which 14 had a PSA doubling time (PSA-DT) >1 year (low-risk group) and 4 had a PSA-DT of <1 year (high-risk group). Using Logistic regression analysis, only pathological T stage (pT) and PS independently predicted BCR with PS being the most significant (p = 0.001). The number of aneuploid cells was significantly higher in the high-risk group compared to the other groups (p = 1.7x10-11). PS combined with GGG diagnosis further stratified risk groups of biochemical recurrence free survival within CAPRA-S low-risk cohort.CONCLUSION:DNA ploidy is an independent prognostic marker of BCR in low-risk PCa after radical prostatectomy, which could early on identify potentially aggressive PCa recurrences and introduce a more personalized approach to salvage treatments.

Purpose:Second malignancy is a rare but potentially lethal event after prostate brachytherapy, but data remain scarce on its long-term risk. The objective of this study is to estimate the number of pelvic second malignancies following brachytherapy compared to radical prostatectomy (RP). Materials and Methods:We retrospectively reviewed patients treated with low-dose 125I brachytherapy and RP in British Columbia from 1999 to 2010. Kaplan-Meier estimates for pelvic (bladder and rectum), invasive pelvic, any second malignancy, and death from any second malignancy were assessed. Cox multivariable analyses were performed adjusting for initial treatment type, age, post-RP adjuvant/salvage external beam radiation therapy status, and smoking history. Results:Two thousand three hundred seventy-eight brachytherapy and 9089 RP patients were included. Median age was 66 years (interquartile range [IQR] 61-71) and 63 years (IQR 58-67), respectively. Median follow-up time to event or censured was 14 years (IQR 11.5-17.3). The Kaplan-Meier estimates for pelvic second malignancy at 15 and 20 years were 6.4% and 9.8%, respectively, after brachytherapy, and 3.2% and 4.2% after RP. Time to any second malignancy and time to death from any second malignancy were not significantly different (P > .05). On Cox multivariable analysis, brachytherapy, compared to surgery, was an independent factor for pelvic (hazard ratio [HR] 1.81 [95% CI 1.45-2.26], P < .001) and invasive pelvic second malignancy (HR 2.13 [95% CI 1.61-2.83], P < .001). Increased age and smoking were also associated with higher estimates of events (P < .001). Conclusions:After adjustment for age, post-RP adjuvant/salvage external beam radiation therapy status, and smoking status, numerically higher long-term HRs of pelvic and invasive pelvic second malignancy in patients treated with brachytherapy compared to RP were noted.

No AccessJournal of UrologyReply to Editorial Comment7 May 2024Reply by Author Marie-Pier St-Laurent, George Acland, Sarah N. Hamilton, Jeremy Hamm, Katherine Sunderland, Peter C. Black, Michael McKenzie, Mira Keyes, Stacy Miller, Martin E. Gleave, and Scott Tyldesley Marie-Pier St-LaurentMarie-Pier St-Laurent https://orcid.org/0000-0002-7823-4857 , George AclandGeorge Acland , Sarah N. HamiltonSarah N. Hamilton , Jeremy HammJeremy Hamm , Katherine SunderlandKatherine Sunderland , Peter C. BlackPeter C. Black , Michael McKenzieMichael McKenzie , Mira KeyesMira Keyes , Stacy MillerStacy Miller , Martin E. GleaveMartin E. Gleave , and Scott TyldesleyScott Tyldesley View All Author Informationhttps://doi.org/10.1097/JU.0000000000004006AboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack Citations ShareFacebookLinked InTwitterEmail "Reply by Author." The Journal of Urology, Publish Ahead of Print, pp. REFERENCE 1. . Long term second malignancies in prostate cancer patients treated with low-dose-rate brachytherapy and radical prostatectomy. J Urol.2024; 212(2):000-000. doi: 10.1097/JU.0000000000003965 Link, Google Scholar © 2024 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Advertisement Copyright & Permissions© 2024 by American Urological Association Education and Research, Inc.Metrics Author Information Marie-Pier St-Laurent More articles by this author George Acland More articles by this author Sarah N. Hamilton More articles by this author Jeremy Hamm More articles by this author Katherine Sunderland More articles by this author Peter C. Black More articles by this author Michael McKenzie More articles by this author Mira Keyes More articles by this author Stacy Miller More articles by this author Martin E. Gleave More articles by this author Scott Tyldesley More articles by this author Expand All Advertisement PDF downloadLoading ...

Prostate cancer management is a critical component of men's health with ongoing controversies in screening and treatment. The purpose of this manuscript is to review contemporary evidence-based strategies in the management of localized prostate cancer to optimize patient outcomes, satisfaction, and shared decision making, to improve physician education and awareness, and to emphasize the importance of brachytherapy in the curative management of prostate cancer. The Bottom Line: 1. Selective screening and selective treatment reduces prostate cancer mortality rates. 2. Active surveillance is recommended for low risk prostate cancer. 3. Both radiation and surgery are appropriate options for patients with intermediate-risk and high-risk prostate cancer. 4. Quality of life and patient satisfaction favors brachytherapy for sexual function and urinary incontinence and surgery for urinary bother. 5. For patients with intermediate risk prostate cancer, brachytherapy achieves very high cure rates, acceptable sided effects, high patient satisfaction and is the most cost-effective treatment. 6. For patients with unfavorable intermediate-risk and high-risk prostate cancer, the combination of external beam radiation, brachytherapy, and ADT (Androgen Deprivation Therapy) achieves the highest rates of biochemical control and the lowest need for salvage therapies. 7. A collaborative shared decision making (SDM) process yields a well-informed, high-quality decision that is consistent with patients' preferences and value.