Prostate Brachytherapy Utilization in the COVID-19 Era: A Cross-Sectional Study of Radiation Oncologists in the United States

PURPOSE/OBJECTIVE(S): Brachytherapy (BT) is indicated as monotherapy for lower risk prostate cancer (PC) or to boost external beam radiation therapy (EBRT) for higher risk disease. Despite its advantages, such as decreased treatment time and cost, BT utilization in the United States (US) is declining. We surveyed US radiation oncologists (ROs) to determine the proportion of providers who offer BT for PC, by risk group, and whether the COVID-19 pandemic influenced practice patterns. We hypothesized that rates of utilization would continue to lag EBRT. MATERIALS/METHODS: From July-October 2021, an anonymized survey was distributed to currently practicing US ROs. Demographic and practice characteristics were collected. Questions assessing utilization of BT and EBRT for patients of varying risk group and the effect of the pandemic on practice patterns were administered. The primary endpoint was the rate of BT utilization by risk group. Descriptive statistics were performed. The bivariate relationships between provider characteristics and likelihood of offering BT were assessed using 2-sided chi-squared tests (α=0.05). RESULTS: Of 203 respondents (72% male, 72% white, 53% non-academic, 69% >10 years in practice), 156 (77%) treated PC. For low (41% total; 25% low dose rate [LDR], 10% high dose rate [HDR], 6% both) and favorable intermediate (FI) (37% total; 21% LDR, 10% HDR, 6% both) PC, BT was less commonly offered then stereotactic body (SBRT – 54% and 48%), moderately hypofractionated (MHFRT – 83% and 87%), and conventionally fractionated (CFEBRT – 37 and 38%) radiation therapy. For unfavorable intermediate PC, BT alone (7%) and BT+EBRT (37%) were less offered then moderately HFRT (82%) and CFEBRT (46%). For high and very high-risk PC, BT boost was not routinely offered (44% and 37%, respectively). For every risk group, academic ROs were more likely to offer BT (50-60% vs. 29-46%, all p < 0.05) (Table 1). For FI only, ROs treating both urban and rural patients were less likely to offer BT than those in an urban or rural setting (p=0.045). No other characteristics were associated with offering BT. <1% of respondents reported increased BT usage due to the pandemic. CONCLUSION: Despite its advantages for patients, BT remains underutilized, particularly in non-academic settings, with <1/2 of surveyed ROs offering BT monotherapy for low to FI risk PC or to boost higher risk disease. Practice patterns were unaffected by COVID-19 likely due to barriers to starting a BT program. Provider retraining may be critical to increasing utilization rates.