However, significantly less attention is paid to the primary disease site. Most patients with cN1 prostate cancer also have an advanced, often high-grade cancer in the prostate, which is associated with high risk of treatment failure. With evidence from randomized controlled trials supporting systemic therapy escalation – such as the addition of androgen receptor pathway inhibitors (ARPI) to standard androgen deprivation therapy – we sought to answer the question of whether local treatment escalation to the prostate can also improve outcomes in patients with cN1 disease.1
Building upon experience from a previous multi-institutional real-world data project, in which we were able to confirm survival benefit with high-dose-rate brachytherapy (HDR-BT) boost in N0 patients treated with primary definitive radiotherapy,2 the MUREBRANO study was designed to assess if local therapy intensification with HDR-BT is also associated with survival benefit in patients with cN1 disease.1 To our best knowledge, this retrospective multicenter study comprising 360 patients treated in this uncommon clinical scenario is the largest such analysis to date. We found that in unselected patients, HDR-BT boost was not associated with statistically significant improvement in OS or MFS. However, there was evidence for a significant overall survival improvement in those with poorly differentiated tumors (ISUP 4–5).
Our study shows that patients with N1 prostate cancer constitute a heterogeneous group, in which treatment should be highly individualized. High-grade prostate cancer was already previously indicated as a good target for dose-boosted radiotherapy by Kishan et al.3 Evidence from our study further supports the development of trials specifically addressing the question of local treatment escalation in those patients, even in the setting of N1 disease. Finally, we believe that local dose escalation is not mutually exclusive with systemic therapy escalation. Studies testing a combined radiotherapy dose-boost and ARPI approach could significantly improve outcomes in patients with advanced prostate cancer with this potentially highly effective treatment paradigm.
Written by:
- Mateusz Bilski, MD, PhD, Radiotherapy Department, Affidea Nu-Med Cancer Diagnostics and Therapy Center, Zamość, Poland
- Marcin Miszczyk, MD, PhD, Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
- Bilski M, Lelek P, Stankiewicz M, Miszczyk M, Burchardt W, Kluska A, et al. MUlticentre REtrospective comparison of definitive EBRT with or without HDR BRAchytherapy boost in patients with locally-advanced prostate cancer and regional lymph NOde metastases (MUREBRANO) - A propensity score matched analysis. Radiother Oncol 2025;212:111112.
- Miszczyk M, Magrowski Ł, Krzysztofiak T, Stando R, Majewski W, Stawiski K, et al. Brachytherapy boost improves survival and decreases risk of developing distant metastases compared to external beam radiotherapy alone in intermediate and high risk group prostate cancer patients. Radiother Oncol 2023;183:109632.
- [Kishan AU, Shaikh T, Wang P-C, Reiter RE, Said J, Raghavan G, et al. Clinical Outcomes for Patients with Gleason Score 9–10 Prostate Adenocarcinoma Treated With Radiotherapy or Radical Prostatectomy: A Multi-institutional Comparative Analysis. Eur Urol 2017;71:766–73. https://doi.org/10.1016/j.eururo.2016.06.046.