The use of brachytherapy in combination with EBRT, based on data from randomized controlled trials, is considered a standard of care in published guidelines. As most trials on dose escalation, combo BT-EBRT has also shown an increase in toxicity. Most of the recent prospective studies evaluating toxicity after BT-EBRT have demonstrated extremely low rates of grade 3 toxicity. On the other hand, this treatment has demonstrated to get the best outcomes to date in terms of biochemical and local control, when radiation is the primary treatment for localized prostate cancer. Although in last years the value of biochemical and local control after radical treatment for localized prostate cancer has been challenge, lately, it has been shown in different publications that these outcomes may be appropriate surrogates of more important outcomes such as metastases free survival.
Although trade-offs must be accepted, the optimal approach to treatment may not necessarily be the one that is associated with the least morbidity, but instead the one that is most effective in preventing the need for subsequent treatment. Patients with a biochemical and local failure face the anxiety, costs, and adverse effects of salvage treatments, and all these could be diminished if combo BT-EBRT is used. The efforts should be focused towards decreasing the toxicity of the BT-EBRT while maintaining its efficacy. To relegate brachytherapy just to the salvage setting is a mistake that will not help our patients.