105 Background: Several studies have highlighted the decline in brachytherapy (BT) utilization for localized prostate cancer, possibly due to reduced reimbursement, decreased provider efficiency, and decline in operative training. We sought to evaluate the most contemporary trends in BT versus dose-escalated external beam radiation therapy (DE-EBRT) use, as well as its impact on survival. Methods: We identified 134,713 men in the National Cancer Database with favorable risk prostate cancer (Gleason 6-7, clinical stage T1-2, and PSA < 20 ng/mL) who were treated with BT or DE-EBRT alone from 2004 to 2014. Multivariable logistic regression was used to identify independent determinants of treatment modality. Overall survival (OS) was compared between modalities using Kaplan-Meier and log-rank tests in propensity score-matched cohorts adjusted for age, race, comorbidities, year of diagnosis, and treatment facility. Results: The 10-year OS rate was higher for BT compared to DE-EBRT (BT 74.5%, DE-EBRT 68.2%, P< .0001). However, consistent with prior analyses, BT use decreased significantly from 59.3% in 2004 to 34.7% in 2014 ( P value for trend < .0001), with a corresponding rise in EBRT. The rate of decline was similar in academic and community centers; however, BT was consistently more often utilized in the community (63% in 2004, 61% in 2014). On multivariable analysis, BT was least likely to be used in men who were black (vs. white or Asian), treated at an academic (vs. community) center, and insured by Medicaid (vs. Medicare or private). Conclusions: Nationally, despite its superior survival and cost-effectiveness, prostate brachytherapy continues to be superseded by DE-EBRT in favorable risk prostate cancer, especially in men treated at academic centers and insured by Medicaid, with striking racial disparities. Payment reform, patient/provider education, and more robust resident training in prostate brachytherapy are urgently needed to help reverse this trend and ensure equal access to this efficacious treatment modality.
Magnetic resonance-only simulation and dose calculation in external beam radiation therapy: a feasibility study for pelvic cancers
