Declining prostate brachytherapy utilization has been reported in several studies, despite strong evidence for its efficacy and safety compared to alternatives. This systematic review examines the economic evidence for low-dose-rate brachytherapy (LDR-BT) as a primary treatment for localised and locally advanced prostate cancer.
The clinical and economic context
Prostate cancer is the most commonly diagnosed male cancer in over half the countries of the world. The major clinical guidelines lack consensus on which treatment is most effective for early locoregional disease, with the oncological outcomes of the three standard approaches — active surveillance (AS), radical prostatectomy (RP) and radiation therapy (RT) — found to be equivalent in terms of cancer-specific mortality, though each approach carries its own distinct pattern of quality-of-life consequences.
LDR-BT is a type of internal radiotherapy in which radioactive seeds are placed close to or within the tumour. It can be delivered as a one-time outpatient procedure, enables a higher radiation dose to reach the tumour than external sources can achieve and is associated with favourable toxicity outcomes. Despite these attributes and its potential cost advantages, LDR-BT utilisation has been in decline — making a systematic assessment of the economic evidence both timely and necessary.
The method
I searched MEDLINE, EMBASE and the Tufts Medical Center Cost-Effectiveness Analysis Registry for studies published between 2008 and 2023 (PROSPERO protocol CRD42023-442027). With the help of a second reivewer titles, abstracts and full texts were independently reviewed against pre-defined inclusion criteria. The Drummond checklist was used to critically appraise the methodological quality of included studies. Given the established equivalency of oncological outcomes across the standard treatment approaches, we included both full economic evaluations (cost-effectiveness, cost-utility and cost-minimisation analyses) and partial evaluations in the form of cost-comparison analyses — a design that is expressly permitted under NICE’s reference case methods for technologies likely to provide equivalent health benefits at similar or lower cost.
Key findings
After screening 453 records, 14 eligible studies were included — seven full economic evaluations and seven partial (cost-comparison) analyses. Eleven studies compared treatments for low- and/or favourable intermediate-risk disease, two compared options for unfavourable intermediate- and/or high-risk disease and one analysed both risk groups. There was considerable heterogeneity in populations, perspectives, time horizons and cost data across the included studies. US-based studies dominated, accounting for nine of the fourteen evaluations.
The results were consistently favourable for LDR-BT. It was the most cost-effective type of radiation therapy in nine (75%) of twelve studies, was more cost-effective than radical prostatectomy in six (67%) of nine studies and, depending on the time horizon, was less costly than active surveillance in three (60%) of five studies. LDR-BT was more cost-effective than high-dose-rate brachytherapy (HDR-BT) in all four studies that made this comparison — an outcome that is unsurprising given the two techniques sit at opposite ends of the fractionation spectrum, with LDR-BT’s practicality as a one-time procedure conferring a clear economic advantage. Overall, LDR-BT was the least costly of all active treatment options in half the included studies.
One of the more unexpected findings was that three out of five studies found LDR-BT monotherapy can become cheaper than active surveillance from the seventh year of follow-up onwards — challenging the orthodoxy that AS is always the most economically advantageous strategy for men with low-risk disease. If surveillance protocols evolve to employ more costly procedures, such as the replacement of transrectal biopsy with a transperineal approach requiring sedation, this crossover point could arrive even sooner.
Implications
The available health economic evidence suggests that LDR-BT has significant cost advantages and an important role to play in the delivery of value-based prostate cancer care. For healthcare providers in systems facing cost pressures, including those in low- and middle-income countries, these findings should provide reassurance that investing in LDR-BT as an alternative to expensive surgical robots need not disadvantage patients.
However, the economic landscape is not static. LDR-BT’s advantages could be challenged if radiotherapy continues to favour ultrahypofractionated strategies such as stereotactic body radiation therapy and reduced fractionation in HDR-BT, both of which are capable of compressing treatment into fewer sessions and driving down costs. Additionally, I identified a strong need for further full evaluations from European settings, where public healthcare systems currently face significant cost pressures but where the economic case for LDR-BT remains largely unstudied.
The review also highlighted important methodological concerns. The reporting of cost estimates and health outcome measurements was frequently opaque, the type of brachytherapy being evaluated was not clearly stated in several studies, and cost data were sometimes sparse or oversimplified. These limitations underscore the need for higher-quality economic evaluations that build the evidence base for LDR-BT in settings where it is declining in popularity or remains underutilised.
Stanberry B, Webber-Jones N. Low-dose-rate brachytherapy as a primary treatment for localised and locally advanced prostate cancer: a systematic review of economic evaluations. Prostate Cancer Prostatic Dis. 2025 Mar; 28(1): 23-36. DOI: 10.1038/s41391-024-00817-z
