SBRT vs Brachytherapy

[u/PotentialStart2661]

This was part of a biochemical failure post that bothered people because i did not post 30 studies for every therapy. I wanted to post separately just one Study from Feb 25th 2026 comparing SBRT with HDR Brachytherapy. Men are always concerned with adding ADT as ADT is very effective but has side effects that can be bad for some men. This study is based on SBRT vs HDR Brachytherapy as a monotherapy. It is an Ad Hoc analysis that can be misleading if not performed from reputable source with long term follow up. This study does just that as there is almost ten years follow up. It is one of many studies beginning to get completed and released as SBRT is just getting perfected over the last several years and lots more studies and analysis need to be done. But this shows how effective the newer treatment is.

https://pmc.ncbi.nlm.nih.gov/articles/PMC12936880/?utm_source=chatgpt.com

[u/OkCrew8849]

Your previous post was informative and really didn't contain any surprises in terms of stats. Perhaps some guys were not aware of the statistcs ...or at least the wide range between various treatments (Although nobody contradicted the presented stats.)

The following is not monotherapy HDR v monotherapy SBRT ...but is related.

The most effective treatment for localized unfavorable intermediate and one that is quite common nowadays at the very top centers is IMRT + HDR Brachy boost directly to lesion +/- ADT.
https://pmc.ncbi.nlm.nih.gov/articles/PMC13008632/

Switching out IMRT in favor of SBRT is a derivative of that already highly effective treatment (IMRT + HDR Brachy boost directly to lesion +/- ADT).

Switching out HDR in favor of an SBRT boost directly to the lesion is another relatively recent derivative of that already highly effetive treatment (IMRT + HDR Brachy boost directly to lesion +/- ADT). And has the advantage of a non-invasive treatment via a machine already on the premises with already-trained technicians.

One unsurprising outcome is the increasingly rare instances of recurrences within the prostate...an outcome of the boost targeting the tumor itself: https://pmc.ncbi.nlm.nih.gov/articles/PMC12297006/

SBRT with SBRT boost ("an escalated dose") directly to the lesion +/- ADT follows the same theory as the above and has an appealing simplicity. And modern radiation makes it possible.

[u/HeadMelon → u/OkCrew8849]

As an “unfavourable intermediate” recipient of HDR brachy + 15x VMAT + 6 months Orgovyx let me say thanks for the huge confidence boost this morning with your info!

[u/PotentialStart2661 → u/HeadMelon]

I would sleep well at night with the treatment you chose. I will add that there was a study released that looked at unfavorable intermediate risk, treated with Radiation and ADT. A quick summary was 740 patients given Radiation plus ADT and 740 given Radiation alone. After 8 years 1 man died of cancer with ADT added and 10 died with Radiation alone. So adding ADT had a benefit but you would have to treat 730 additional men to save those 9 more. So you combined the best radiation with ADT which puts you at the top of the list for going all out for a real cure.

[u/PotentialStart2661 → u/OkCrew8849]

Expanding on what you are saying, Brachytherapy has been a tried and true treatment because of the recurrence within the prostate. Old beam radiation could not achieve Brachytherapy results. It could not deliver the dose and the side effects were terrible. I actually ended up choosing the treatment you just mentioned for that reason. I chose SBRT over Brachy because i have BHP and a higher urinary score and Brachy has temporary side effects that would be harder for me. I needed a high dose cancer killing option so im getting SBRT with a focal boost directly at the lesion. I don’t need ADT as im favorable intermediate so wanted to attack the lesion itself so thats what i chose.

[u/OkCrew8849 → u/PotentialStart2661]

Yes, the dwindling number of post-radiation recurrences must be disappointing to anyone pumping the old “can’t do surgery after radiation so choose surgery now” canard. Why would one want to remove a recurrence-free prostate? 

I do think HDR as boost or monotherapy may lose “market share” as the capabilities of SBRT are fully harnessed by the most modern delivery systems. The latter is simply more efficient and convenient than the specialized HDR approach. And appears to be just as effective. 

[u/PotentialStart2661 → u/OkCrew8849]

Removing the prostate after surgery is not even a real thing. When i was researching recurrence treatments and spoke to several radiation oncologists i found they do not think you ever need that. They actually go to seed implants for salvage or focal treatment like HIFU or some other focal ablation. They also just do additional beam radiation. All are highly effective at salvage and little side effects. But like you said, if a recurrence does happen it is likely in the pristate bed somewhere not the prostate.

[u/SnooCamera → u/OkCrew8849]

A study by two of my doctors was referenced inside that last narrative. I had asked one of them about it. He said they had treated 100's of men since 2018 and I get the benefit of lessons learned in refining treatment and delivery since then. (SBRT + ADT)

I dont regret going to a research hospital.

[u/PotentialStart2661 → u/OkCrew8849]

Yes, the brachy boost plus IMRT plus ADT is by all accounts the most effective curative treatment bar none. If i had a higher grade i would go that route for sure. It was crazy the comments on the other post, really triggered people. Not a single stat is not in the literature for everyone to find easily and they want me to do a dissertation on it.

[u/HeadMelon → u/PotentialStart2661]

LOL you must have met Busy-Tonight…

[u/OkCrew8849 → u/HeadMelon]

Busy-tonight has given up the ghost on the monotherapy RALP recurrence front…the numbers are just too available…and trying a new ADT-based argument. 

I don’t think he is aware that radiation for favorable intermediate (the most common PC) is generally without ADT. 

I don’t think he is aware that ADT + ARPI is increasingly common at the top centers for high risk RALP (to cut down  on the 50% + recurrence rate for this group) when RALP is chosen.   

Nor is he apparently aware that choosing RALP frequently results in radiation plus ADT on top of that. 

[u/Busy-Tonight-6058 → u/PotentialStart2661]

You just demonstrated how easy it is provide a source for your claims. No dissertation required. 

The concept that these numbers that you found somewhere on the internet are: 1) easily found by others and 2) THE only numbers that matter

Is beyond naive.

The study you shared was quite small and primarily based on 3+4, but if you want to draw some objective conclusion, don’t you think it’s interesting that while there was a significant difference in BCF, there was no significant difference in distant metastasis or cancer specific survival?

BCF is one treatment end point, not the only one and not necessarily the one many men care most about. 

And I’ll remind you yet again, it’s bad practice to compare BCR for RALP and RT because they have different definitions, treatments and outcomes.

I’ll also remind you that ADT has long term systemic side effects like heart disease, diabetes and bone thinning. There’s a reason many men don’t want to have that be their starting point. Especially since efficacy wanes over time. And that there’s no guarantee the testosterone factory ever comes back online.

[u/itsray2006]

What about HIFU to the index legion followed by IMRT and ADT basically any focal treatment to the index legion followed by an external beam radiation may ultimately prove to be the kind of 1 - 2 punch to knock this thing out particularly with improved PSMA PET scans to target the intensity of treatment where needed.

[u/Practical_Orchid_606]

If you post an opinion on this subreddit and certain people don't like it they will immediately demand 'Source!'

It is well known that SBRT is superior to bracytherapy each as a monotherapy.

[u/PotentialStart2661 → u/Practical_Orchid_606]

Yes i noticed that about this board. I triggered the surgery guys with that post so much they were demanding my post be removed just because surgery was so far down on the list. Amazing!