30). Radiation therapy (RT) may be associated with a small increased risk of in field SCs. Inherently, the risk may be greater for combination therapy vs. monotherapy because of the larger volume treated. Abdel-Wahab et al. (29) reviewed the 1973–2002 Surveillance, Epidemiology, and End Results database and stratified patients into four groups. He identified

67,719 patients who had undergone RT only Alectinib concentration and 40,433 patients who had not undergone RT or surgery (Group 1, no RT, no surgery). EBRT (Group 2) was the most common RT modality and was given to 48,400 patients. Brachytherapy alone (Group 3) or in combination with EBRT (Group 4) was given to 10,223 and 9096 patients, respectively. The overall incidence of secondary primary cancers was 8.8% in patients who had received RT alone and in 7.9% patients who did not undergo RT. Among the RT groups, the greatest percentage (10.3%) of secondary primary cancers was seen in the EBRT (Group 2), followed by Group 4 (combination) at 5.7%. The lowest percentage was in the brachytherapy (Group 3) at 4.7%. All differences were statistically significant. On the other hand, Zelefsky et al. (30) found no increase in SC in 2658 patients treated with radical prostatectomy (n = 1348), EBRT (n = 897), Pirfenidone or brachytherapy (n = 413). There is little controversy that EBRT (IMRT) is costlier

than brachytherapy. Shah et al. (31) compared the costs of permanent brachytherapy, high dose radiotherapy, and IMRT and found reimbursement at $9938, $17,514, and $29,356, respectively. Nguyen et al. (32) assessed temporal trends in utilization and impact on national health care spending for the different treatments for prostate cancer from 2002 to 2005. For EBRT, IMRT utilization increased substantially (28.7% vs.

81.7%; p < 0.001), and for men receiving brachytherapy, supplemental IMRT increased significantly (8.5% vs. 31.1%; p < 0 .001). The mean incremental cost of IMRT vs. 3D-CRT was $10,986 fantofarone (in 2008 dollars); of brachytherapy plus IMRT vs. brachytherapy plus 3D-CRT was $10,789. Cooperberg et al. (33) performed a cost utility analysis for the different treatments. Direct medical and lifetime costs for brachytherapy compared with combination were $14,106 vs. $29,142 and $32,553 vs. $43,553 (p < 0.001). Brachytherapy alone seems to be as effective as combination therapy in treating intermediate-risk prostate cancer. While most data support the use of implant alone, delivered radiation doses should be >140 Gy (I-125). Long-term data suggest that BED may need to be greater than 180 Gy2 (I-125 D90 >190 Gy). The addition of EBRT may increase rectal toxicity, erectile dysfunction, and risk of incontinence. The cost of treatment is markedly increased when combination therapy is used. Brachytherapists should consider implant alone as the preferred management option for intermediate-risk prostate cancer.