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For patients with higher risk disease (higher Gleason Grade, PSA or T stage), escalated doses of radiation appears to improve outcomes.
High dose rate (HDR) brachytherapy allows for dose escalation. There is published data phase III data demonstrating improved disease control with dose escalated external beam radiotherapy alone and data from several institutions showing excellent outcomes by dose escalation using HDR (+/- external beam radiotherapy) such as the data from William Beaumont Hospital.
Unlike permanent seeds, this procedure is: done as a temporary implant; combined with a 5 week course of external beam radiation; requires overnight hospitalization. As this treatment requires overnight hospitalization with catheters placed through the skin in the prostate, it requires a motivated patient who is able to lie in bed for about 36 hours.
In addition, advances in image-guided, intensity modulated external beam radiotherapy, allow high dose radiation to be given safely without the need for invasive placement of HDR catheters. The advantage of HDR over newer external beam techniques remains to be demonstrated. Multi-institutional studies further investigating this procedure are ongoing.