The outcomes of a combined regimen of hormone therapy, external beam radiation therapy (EBRT) and brachytherapy compare favorably with those of standard treatments in men with prostate cancer who have a Gleason score of 8–10. This three-pronged approach is “better able to control disease compared to ... radical prostatectomy or EBRT alone” asserts lead author Richard Stock from the Mount Sinai School of Medicine, New York.

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The trimodal regimen takes advantage of two important advances in radiation therapy for prostate cancer—concomitant hormone treatment and dose escalation. In Stock et al.'s 181-strong series, patients with locally advanced disease received neoadjuvant hormone therapy for 3 months before implantation of a low-dose (100 Gy) brachytherapy device. Starting 2 months later, 3-dimensional conformal and intensity-modulated techniques were used to deliver 25 1.8 Gy fractions of EBRT, together with a further 6 months of hormone therapy. The mean biologically effective dose generated by brachytherapy plus EBRT was very high, at 206 Gy2.

Follow-up at 6-month intervals continued for a median of 65 months. At 8 years, overall rates of freedom from biochemical failure, freedom from distant metastasis, prostate-cancer-specific survival and overall survival were 73%, 80%, 87% and 79%, respectively.

Gleason score was the best predictor of response to treatment. The poorer outcomes among the subset of men with a Gleason score of 10—70% biochemical failure, 70% distant metastases, and 63% prostate cancer-specific survival—necessitate development of “better systemic approaches to combine with local therapy”.