INTRODUCTION: With the emergence of imaged -based planning and hybrid applicators the complexity of gynecologic brachytherapy has dramatically increased. Despite the known advantages of brachytherapy, notable national declines in utilization of brachytherapy have been documented. Clearly improved education in the sphere of gynecologic brachytherapy is needed. We hypothesize that a hands-on applicator -based training session would improve trainee comfort with gynecologic brachytherapy. METHODS AND MATERIALS: An in -person, applicator -based, hands-on training session was held with trainees from both radiation and gynecologic oncology programs. Trainees practiced assembling and handling applicators while receiving instruction on clinical scenarios in which various applicators are used in gynecologic cancer brachytherapy. Pre- and post -session, participants were administered an objective test of 10 pictorial -based case vignettes to quantify ability to select the correct applicator based on the interpretation of T2 -weighted MR images. Participants additionally received a subjective survey to quantify comfort and experience with gynecologic brachytherapy using Likert-type question formatting. RESULTS: A total of 14 trainees participated. Most common case volume experience was 0-10 intracavitary (57%), 0-10 hybrid (71%), and 0-10 interstitial (71%). Pre -session, the most common answer to comfort level was "not comfortable still learning" for all brachytherapy types, and most common answer to largest gap in knowledge was all facets of brachytherapy. Average case -based test score was 3.5/10 pre -session versus 5.3/10 post -session ( p = 0.028). Post -session, all respondents reported improved comfort level with brachytherapy. Post -session, most common answer to largest gap in knowledge was applicator/patient selection, and applicator/patient selection was also the largest area of identified improvement. 100% of participants felt repeating the session in the future would be helpful. CONCLUSIONS: Hands-on training with applicators improves both subjective and objective comfort with gynecologic brachytherapy. With 100% of participants requesting to implement this session into resident training, we suggest national opportunities might exist to expand educational processes and improve utilization of complex gynecologic brachytherapy in practice. (c) 2024 American Brachytherapy Society. Published by Elsevier Inc. All rights reserved.

Objective: We sought to compare our results of patients treated with Cs-131 prostate brachytherapy (PB) as monotherapy to recently published results of patients treated with stereotactic body radiotherapy. Methods: We analyzed data from patients treated at our institution with Cs-131 PB as monotherapy who had at least 5 years of follow-up and who prospectively completed expanded prostate cancer index composite questionnaires at baseline, 1 year, 2 years, and 5 years. We compared our data with the recently published data from radiation therapy oncology group (RTOG) 0938 and PACE-B (NCT01584258). Results: A total of 138 patients were included in our cohort. Using RTOG 0938's definition, the frequency of a decline in urinary function in our PB cohort was 43% compared with 41.3% in RTOG 0938. According to PACE-B's definition, our PB cohort had minimal clinically important differences in the urinary incontinence domain of 26.4% and in the urinary obstructive/irritative domain of 40.7% at 2 years compared with PACE-B's reported rate of 32% and 33%, respectively. The frequency of a >5-point change in the expanded prostate cancer index composite bowel summary score at 5 years was 25% compared with 30.7% in RTOG 0938. Our bowel difference at 2 years was 23% compared with PACE-B's reported 24%. Our 5-year biochemical disease free survival (bDFS) was 97.8%, compared with 91.3% in RTOG 0938 and 95.8% in PACE-B. Conclusions: Low dose rate (LDR) PB with Cs-131 as monotherapy provides excellent biochemical control of prostate cancer in low and intermediate-risk patients. Our cohort of patients had modest differences in patient-reported urinary and bowel quality of life compared with baseline. These differences were comparable to recently published stereotactic body radiotherapy data. When comparing prostate cancer treatments in terms of patient convenience and available resources, PB certainly should be considered.

BACKGROUND We sought to assess the impact of bladder neck dose (BND) on patient reported urinary toxicity, and feasibility of relative urethral sparing technique in prostate brachytherapy (PB). METHODS AND MATERIALS We retrospectively identified bladder neck as a point dose on post-implant CT scans in patients treated with 131Cs PB. Urinary symptoms were assessed through EPIC questionnaires. Patient cohorts were identified based on mean BND as a percentage of prescription dose with toxicity assessment at each time point. RESULTS In our cohort of 542 patients, BND was associated with clinically significant acute urinary symptoms and chronic symptoms, as patients receiving >70% of the prescription dose had significantly worse overall EPIC scores than patients receiving ≤70% of prescription dose. There was no difference in bDFS between patients receiving BND ≤70% (96% bDFS) and >70% (94% bDFS) at a median follow up of 57 months. CONCLUSIONS BND has a significant impact on both acute and chronic urinary symptoms, with reduced symptoms reported with BND <70% of prescription dose. With a median follow up of 4.7 years, excellent bDFS has thus far been achieved with relative urethral and bladder neck sparing. Utilizing this constraint should improve urinary symptoms without impacting disease control.

Objective: We sought to compare our results of patients treated with Cs-131 prostate brachytherapy (PB) as monotherapy to recently published results of patients treated with stereotactic body radiotherapy. Methods: We analyzed data from patients treated at our institution with Cs-131 PB as monotherapy who had at least 5 years of follow-up and who prospectively completed expanded prostate cancer index composite questionnaires at baseline, 1 year, 2 years, and 5 years. We compared our data with the recently published data from radiation therapy oncology group (RTOG) 0938 and PACE-B (NCT01584258). Results: A total of 138 patients were included in our cohort. Using RTOG 0938’s definition, the frequency of a decline in urinary function in our PB cohort was 43% compared with 41.3% in RTOG 0938. According to PACE-B’s definition, our PB cohort had minimal clinically important differences in the urinary incontinence domain of 26.4% and in the urinary obstructive/irritative domain of 40.7% at 2 years compared with PACE-B’s reported rate of 32% and 33%, respectively. The frequency of a >5-point change in the expanded prostate cancer index composite bowel summary score at 5 years was 25% compared with 30.7% in RTOG 0938. Our bowel difference at 2 years was 23% compared with PACE-B’s reported 24%. Our 5-year biochemical disease free survival (bDFS) was 97.8%, compared with 91.3% in RTOG 0938 and 95.8% in PACE-B. Conclusions: Low dose rate (LDR) PB with Cs-131 as monotherapy provides excellent biochemical control of prostate cancer in low and intermediate-risk patients. Our cohort of patients had modest differences in patient-reported urinary and bowel quality of life compared with baseline. These differences were comparable to recently published stereotactic body radiotherapy data. When comparing prostate cancer treatments in terms of patient convenience and available resources, PB certainly should be considered.

Single modality PB with Cs131 provides excellent long-term bDFS, especially when compared to recently published RTOG 0938 as 47% of our patients had intermediate-risk disease (RTOG 0938 had low-risk disease only and only 5-year data). Our patients had modest changes in urinary and bowel QOL compared to baseline, also comparable to published SBRT data. At 5 years in our cohort, 46% and 41% reported improvement in their urinary and bowel EPIC scores. The reason for this needs to be explored.

PURPOSE: This study evaluates long-term patient-reported bowel quality of life (QOL), rectal bleeding, and bleeding bother in patients with prostate cancer treated with external beam radiation therapy (EBRT) and Cesium-131 LDR brachytherapy (LDR-BT) boost with and without hydrogel rectal spacer.METHODS AND MATERIALS: This is a retrospective analysis of prostate cancer patients treated between 2007 and 2022 with 45 Gy EBRT followed by 85 Gy Cs-131 LDR-BT boost with or without hydrogel rectal spacer. Expanded Prostate Cancer Index Composite (EPIC) QOL questionnaires pre-treatment and at each follow-up were collected. Patient-reported rectal bleeding occurring more than "rarely" and bother from rectal bleeding occurring more than a "very small problem" were deemed clinically significant. Fisher's exact test was used to test the association of rectal spacer use and the incidence of clinically significant rectal bleeding and bleeding bother. Paired samples t-test was used to analyze mean bowel scores at each time point.RESULTS: Three hundred and forty-one patients were included in the analysis. The rectal spacer was used in 108 patients. Overall median follow-up was 48 months (IQR, 24-72), with a median follow-up of 24 months (IQR, 12-37.5) for the hydrogel group and 60 months (IQR, 36-84) for the non-hydrogel group. EPIC questionnaire response rates at median follow-up were 33% and 37% for the hydrogel and non-hydrogel groups, respectively. A clinically significant decrease in mean bowel domain scores was seen in the bowel bother domain at 6 and 12 months for patients who did not receive a rectal spacer. At the last follow-up of 60 months, the prevalence of clinically significant rectal bleeding and bleeding bother were 2.2% and 2.2%, respectively. The cumulative incidence of clinically significant long-term rectal bleeding was 2.8% and 18.9% in the hydrogel group and non-hydrogel group, respectively (Fisher's exact test, p < 0.0001). The cumulative incidence of clinically significant long-term bowel bother was 4.6% and 19.7% in the hydrogel group and non-hydrogel group, respectively (Fisher's exact test, p < 0.001).CONCLUSIONS: Use of hydrogel rectal spacer with EBRT and Cs-131 LDR-BT boost was significantly associated with a lower incidence of patient-reported rectal bleeding and bother from rectal bleeding, and better long-term bowel QOL. Cumulative incidence was 2.8% (hydrogel group) versus 18.9% (non-hydrogel group) and 4.6% (hydrogel group) versus 19.7% (non-hydrogel group) for clinically significant long-term rectal bleeding and long-term bleeding bother, respectively.(c) 2023 American Brachytherapy Society. Published by Elsevier Inc. All rights re-served.

Long-term patient-reported clinically significant decreases in urinary function and urinary incontinence mean EPIC scores occurred up to 18 months following combined external beam radiation and Cs-131 prostate brachytherapy and returned to baseline at 24 months, while clinically significant decrease in urinary irritability/obstructive mean scores occurred at 9 months and returned to baseline at 12 months. At 42 months follow-up, mean urinary domain scores improved from pre-treatment baseline in 15-30% of patients.

Purpose Prostate brachytherapy (PB) as monotherapy has been established as a definitive treatment for low and favorable intermediate risk prostate cancer. Patients choose PB in part due to it being minimally invasive with a quick return to full activity. Recently, there has been growing interest in using shorter (ultrahypofractionated) radiotherapy regimens for the management of prostate cancer, citing the same rationale. We present data from a cohort of our patients treated with PB using Cs131 to compare our results with the 5-year data from the recently published SBRT trial from NRG Oncology RTOG 0938. Materials and Methods We analyzed data from patients treated at our institution who were treated with Cs131 LDR PB as monotherapy (115 Gy) and who prospectively completed EPIC questionnaires at baseline and at timepoints after the procedure including at 5 years. Urinary and bowel function was evaluated based on these EPIC scores exactly as they were in the recent 0938 publication, assessing the proportion of patients with a deterioration from baseline of >5 points for the bowel and > 2 points for the urinary score. We also report the bDFS in our cohort, calculated via the Kaplan Meier method. Results 138 patients were included in our analysis. Median patient age was 66 years old with a median follow up of 121.5 months. In terms of brachytherapy dosimetry, median prostate volume was 40.8 cc, median D90 was 104.3% and median V100 was 93.4%. The 5-year frequency for >2 point change in urinary score was 45.9% (61/133), compared to 41.3% in RTOG 0938. The 5-year frequency for >5 point change in bowel score was 30.7% (40/130), compared to 30.7% in RTOG 0938. Our 5-year bDFS was 97.8% (compared to 91.3% in RTOG 0938) and 96.0% at 10 years. 73 of our patients had low risk and 65 patients had intermediate risk disease, compared to all low risk patients in RTOG 0938. Conclusions LDR Brachytherapy with Cs131 as monotherapy provides excellent bDFS at 5 and 10 years, comparable to recently published outcomes with SBRT, especially considering that 47% of our PB patients had intermediate risk disease (compared to all low risk in the SBRT data). Our cohort of patients treated with PB had modest differences in patient-related urinary and bowel QOL at 5 years compared to baseline, also very comparable to published SBRT data. When comparing prostate cancer treatments in terms of patient convenience and available resources, PB certainly should be considered. Prostate brachytherapy (PB) as monotherapy has been established as a definitive treatment for low and favorable intermediate risk prostate cancer. Patients choose PB in part due to it being minimally invasive with a quick return to full activity. Recently, there has been growing interest in using shorter (ultrahypofractionated) radiotherapy regimens for the management of prostate cancer, citing the same rationale. We present data from a cohort of our patients treated with PB using Cs131 to compare our results with the 5-year data from the recently published SBRT trial from NRG Oncology RTOG 0938. We analyzed data from patients treated at our institution who were treated with Cs131 LDR PB as monotherapy (115 Gy) and who prospectively completed EPIC questionnaires at baseline and at timepoints after the procedure including at 5 years. Urinary and bowel function was evaluated based on these EPIC scores exactly as they were in the recent 0938 publication, assessing the proportion of patients with a deterioration from baseline of >5 points for the bowel and > 2 points for the urinary score. We also report the bDFS in our cohort, calculated via the Kaplan Meier method. 138 patients were included in our analysis. Median patient age was 66 years old with a median follow up of 121.5 months. In terms of brachytherapy dosimetry, median prostate volume was 40.8 cc, median D90 was 104.3% and median V100 was 93.4%. The 5-year frequency for >2 point change in urinary score was 45.9% (61/133), compared to 41.3% in RTOG 0938. The 5-year frequency for >5 point change in bowel score was 30.7% (40/130), compared to 30.7% in RTOG 0938. Our 5-year bDFS was 97.8% (compared to 91.3% in RTOG 0938) and 96.0% at 10 years. 73 of our patients had low risk and 65 patients had intermediate risk disease, compared to all low risk patients in RTOG 0938. LDR Brachytherapy with Cs131 as monotherapy provides excellent bDFS at 5 and 10 years, comparable to recently published outcomes with SBRT, especially considering that 47% of our PB patients had intermediate risk disease (compared to all low risk in the SBRT data). Our cohort of patients treated with PB had modest differences in patient-related urinary and bowel QOL at 5 years compared to baseline, also very comparable to published SBRT data. When comparing prostate cancer treatments in terms of patient convenience and available resources, PB certainly should be considered.

Purpose To evaluate long-term patient reported rectal bleeding in patients with prostate cancer treated at our institution with and without SpaceOAR following external beam radiation therapy and Cesium-131 (131Cs) prostate LDR brachytherapy boost. Materials and Methods We started routinely offering SpaceOAR to patients treated with external beam radiation therapy and 131Cs prostate LDR brachytherapy boost from 2016 with goal of potentially reducing rectal toxicity, including late rectal bleeding. We analyzed patients treated with and without SpaceOAR with at least 6 months of follow-up, with treatment from January 2007 to February 2021. Patients were asked to fill out Expanded Prostate Cancer Index Composite (EPIC) QOL questionnaire pre-treatment and at each scheduled follow-up appointment. The EPIC questionnaire included the following categories related to rectal bleeding and bother from rectal bleeding. Rectal bleeding occurring more than "rarely" was deemed clinically significant and severe rectal bleeding was defined as occurring "usually" or "always". Clinically significant bother from rectal bleeding was defined as considering bleeding to be more than a "very small problem." Severe bother from rectal bleeding was defined as being a "moderate" or "big" problem. Univariate Cox regression was performed to assess for impact of SpaceOAR on incidence of clinically significant rectal bleeding, with censorship at maximum follow-up. Results 317 patients were included in the analysis, all of whom were treated with a combination of external beam radiation therapy and LDR brachytherapy boost. 172 patients (54.3%) had intermediate-risk prostate cancer, while 145 patients (45.7%) had high-risk disease. 157 patients (49.5%) received androgen deprivation therapy, while 160 patients (50.5%) did not. 87 patients (27.4%) underwent prostate LDR brachytherapy boost with SpaceOAR inserted in the operating room following completion of prostate seed implant, with remaining 230 patients (72.5%) treated without SpaceOAR. Median follow-up for patients who received SpaceOAR was 18 months (IQR 12-30 months), whereas median follow-up for patients who did not receive SpaceOAR was 54 months (IQR 36-72 months). Incidence of acute clinically significant rectal bleeding, occurring before 6 months, was 3.9% in the cohort treated without SpaceOAR and 3.4% in the cohort treated with SpaceOAR. Incidence of late clinically significant rectal bleeding was 19.6% without SpaceOAR and 0% with SpaceOAR. For patients who developed late clinically significant rectal bleeding, median time to development was 18 months (IQR 9-24 months). Prevalence of late clinically significant rectal bleeding at last follow-up was 3.5% without SpaceOAR. Incidence and prevalence of late severe rectal bleeding without SpaceOAR was 4.7% and 1.3%, respectively. Incidence of late clinically significant bother from rectal bleeding was 20% without SpaceOAR and 0% with SpaceOAR. Prevalence of late clinically significant bother from rectal bleeding at last follow-up was 4.3% without SpaceOAR. Incidence and prevalence of late severe bother from rectal bleeding without SpaceOAR was 10.9% and 2.2%, respectively. On univariate analysis, SpaceOAR utilization was significantly associated with reduction in incidence of clinically significant rectal bleeding (p=0.035, hazard ratio 0.033; 95% confidence interval 0.001-0.784). Conclusions Overall prevalence of late rectal bleeding following 131Cs LDR prostate brachytherapy at last follow-up was less than 5%. SpaceOAR was associated with lower incidence of clinically significant rectal bleeding occurring at 6 months post-treatment or later as assessed by the EPIC questionnaire. Given the lower median follow-up in the SpaceOAR group, additional follow-up is warranted to determine whether this reduction is maintained long-term.

PURPOSE: To evaluate short-term patient reported urinary quality of life scores in patients with prostate cancer treated at our institution with and without perioperative prednisone following Cesium-131 (Cs-131) prostate LDR brachytherapy. METHODS AND MATERIALS: We started routinely using a perioperative 7-day course of prednisone at a dose of 5 mg per day, beginning 1 day prior to Cs-131 prostate LDR brachyther-apy from 2013 with goal of improving acute urinary symptomatology. One hundred consecutive patients treated with prednisone were selected, with comparison to 100 consecutive patients who were not treated with prednisone. We analyzed for differences in mean change with standard deviation (SD) in EPIC and AUA scores at 0.5-1 month and 3 months with or without pred-nisone by Mann-Whitney U Test. Binary logistic regression was performed to assess for impact of prednisone on postoperative urinary catheter use. RESULTS: Pretreatment EPIC and AUA scores were available in 197 patients. Less reduction in EPIC US score was noted at 0.5-1.0 month in the group who received prednisone with mean change of-22.9 (SD 15.4) when compared to the group who did not receive prednisone with mean change of-31.7 (SD 19.3), p < 0.01, with significance lost at 3 months. There was no significant difference in acute urinary retention requiring postoperative urinary catheter placement with perioperative prednisone (OR 1.13, p = 0.71). CONCLUSIONS: A short course of perioperative low-dose prednisone was associated with less severe worsening in urinary symptoms by the EPIC questionnaire at the 0.5-1.0-month timepoint suggesting some improvement in acute urinary quality of life, although differences did not re-main statistically significant at 3 months.(C) 2022 American Brachytherapy Society. Published by Elsevier Inc. All rights reserved.

PURPOSE: To evaluate our institutional outcomes utilizing Cs-131 prostate brachytherapy (PB) for the intermediate-risk (IR) group of prostate cancer patients. METHODS AND MATERIALS: We reviewed a prospectively collected database of men treated with Cs-131 PB between 2006 and 2019. Patients with less than 24-months follow-up were excluded. Patients were classified as IR if they had one of the following factors: Gleason Score 7, prostate specific antigen > 10 but < 20 ng/mL, or T2b-c on clinical exam. We defined unfavorableIR (UIR) as having either Grade Group 3, > 1 IR factors, or >50% positive core biopsies. The Kaplan-Meier method was used to estimate actuarial event-time probabilities for biochemical freedom from disease (BFD). RESULTS: A total of 335 patients with a median follow-up of 70.1 months (IQR 48.3-106.3 months) were identified. Androgen deprivation therapy (ADT) was used in 7.2% of patients. Favorable-IR (FIR) patients were commonly treated with PB alone (91.8%). FIR patients who underwent PB alone had a 5-year BFD of 98.1%. UIR patients were commonly treated with external beam radiotherapy plus PB (61.2%). These patients had 5-year BFD of 91.1%. The 5 year BFD for UIR patients treated without ADT was 90.9%, whereas it was 95.0% among UIR patients treated with ADT (log-rank p = 0.83). CONCLUSIONS: FIR patients have excellent outcomes when treated with PB alone. External beam radiotherapy plus PB is a reasonable treatment approach for UIR patients. Future studies may elucidate which IR patients would benefit from treatment intensification. (C) 2021 American Brachytherapy Society. Published by Elsevier Inc. All rights reserved.

The article published by Maroongroge et al 1 Maroongroge S Wallington DG Taylor PA et al. Geographic access to radiation therapy facilities in the United States. Int J Radiat Oncol Biol Phys. 2022; 112: 600-610 Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar is an important comment on the future of our field of radiation oncology. This paper is excellent proof that radiation oncologists are not geographically evenly distributed, leading to a disparity of care for rural, older, and underprivileged patients. These disparities have been shown before, 2 Chowdhary M Chhabra AM Switchenko JM et al. Domestic job shortage or job maldistribution? A geographic analysis of the current radiation oncology job market. Int J Radiat Oncol Biol Phys. 2017; 99: 9-15 Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar ,3 Bates JE Parekh AD Chowdhary M Amdur RJ. Geographic distribution of radiation oncologists in the United States. Pract Radiat Oncol. 2020; 10: e436-e443 Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar and this study provides current data indicating that, though things have improved, we still have a long way to go in terms of ensuring that the millions of patients in these groups are not left behind.

PURPOSE:Updates to consensus guidelines in October 2018 recommending moderately hypofractionated external beam radiotherapy (mHF-EBRT) in prostate cancer lagged several years after publication of evidence supporting its efficacy. In January 2018, we amended our prostate cancer clinical pathway (CP) to facilitate adoption of mHF-EBRT. Herein, we analyze patterns of care and changes in mHF-EBRT use after the CP modification.METHODS:Our prostate CP was amended in January 2018 to make mHF-EBRT the recommended treatment for patients with low- and intermediate-risk prostate cancer pursuing curative EBRT monotherapy. Normal-tissue dose constraints accompanied the CP modification to guide planning. Use of mHF-EBRT from 2015 to 2017 was compared with use in 2018 after the CP modification, using the Cochran-Armitage test for trend. Predictors of mHF-EBRT use and adherence to dose constraints were analyzed with binary logistic regression.RESULTS:In 560 patients treated with EBRT monotherapy, mHF-EBRT use increased from 3.7% in 2015-2017 to 85.6% in 2018 (P < .001), whereas conventionally fractionated EBRT (CF-EBRT) use decreased from 96.3% to 14.4% (P < .001). Consultation year of 2018 (odds ratio [OR], 214.6; 95% CI, 94.5 to 484.6; P < .001), treatment at an academic facility (OR, 4.5; 95% CI, 1.8 to 11.3; P = 0.001), and having a smaller prostate (OR, 0.99; 95% CI, 0.97 to 1.00; P = .028) predicted for mHF-EBRT use. At least five of six recommended bladder and rectal dose constraints were met in 89.4% of patients.CONCLUSION:Modification of our prostate cancer CP, in concert with institutional policies to monitor and audit CP compliance, facilitated rapid adoption of mHF-EBRT in our large, integrated cancer center with good adherence to dosimetric constraints.

Purpose: Optimal sequencing of high-dose rate (HDR) brachytherapy (BT) boost and whole pelvis intensity-modulated radiotherapy (IMRT) for definitive treatment of prostate cancer (PCa) is not defined. The prospective Timing of HDR brachytherapy with EBRT in Prostate Cancer (THEPCA) trial is ongoing to address this question. To our knowledge, we present the first report comparing early toxicity and disease outcomes for PCa patients treated with HDR-BT upfront vs. IMRT upfront combined with androgen deprivation therapy (ADT).