All of these radiation modalities are reasonable; however, the benefit of protons over IMRT is questionable to marginal at best.

1. Radiation oncology evaluation- discussion of all modalities and availability, as well as patient preference is the key. Majority of the institutions prefer IMRT as efficacy, safety are comparable to other modalities and it is less expensive, proton therapy is more expensive and has minimal added benefits, so can be utilized as well, but it is not as widely available as IMRT is

I am a urologist who specializes in prostate cancer treatment and robotic surgery. I think most practitioners tend to recommend what they do best.

I tried to go over all the options with my patients including surgery and radiation and active surveillance and the lesser used therapies. I tried to avoid any radiotherapy for younger patients and recommend radiotherapy for most older patients.

I tried to give early stage patient's the options of surgery which is presented by myself and I recommend a Radiation Oncology opinion for most patients so they can ask questions and understand or radiation therapy needs from a radiation oncologist.

Our group provides IMRT with our partner who is a radiation oncologist for patients. This is done at an outpatient center. We disclose the financial interest.

The main reason why we provide this service is that we feel this is the best therapy in the radiation field with his combination of proven results, safety profile, and effectiveness.

We also have 2 centers that provide CyberKnife here by and I have partners who perform brachytherapy if that's what the patient opts to have done.

Proton therapy is not located nearby, but patients can travel about 45 minutes to have a consultation if they want one.

I think the most important thing is provider can do is to try to give a fair and balanced and transparent opinion so patient can help choose what is best for them.

I do not have any financial stake in any modality of radiation therapy. Seems this factor can drive the decision made by some urologists and radiation oncologists. Proton therapy is certainly more expensive. Knowing some patients are able to have hypofractioned treatment is attractive for Cyberknife. As others have said, I leave the decision completely to the Rad-Onc. As a whole, my opinion of radiation therapy remains that the outcomes are variable and unpredictable. Some patients do wonderfully and remain NED. Some patients are crippled by the short but mostly long-term effects that are incredibly difficult to treat as urologists. This is likely a combination of patient factors, Rad-Onc physician factors, and maybe treatment modality.

In my area, Cyberknife is only available at 1 center which significantly limits this technology. The insurance piece now seems less of an issue which is a positive.

Brachytherapy is a strong option for low- and some small volume intermediate risk prostate cancer. Our results have been quite favorable minimal toxicity. We have not incorporated SpaceOAR into the brachytherapy space at this time.

IMRT is overall safe and the addition of SpaceOAR has certainly helped lessen toxicity even further. Length of treatment continues to be a major draw back for patients.

Proton therapy, although in theory safer, clinical data has not proven this to be the case. Cost is significantly higher than standard radiation options. Some insurance companies have actually refused to pay for proton therapy due to lack of clinical benefit and significantly increased costs on top of this.

I do have concerns with IMRT/Cyberknife/proton therapy for younger patients and the potential of developing secondary high grade cancers of bladder and rectum due to radiation exposure in the path of the prostate radiation. Whether SpaceOAR changes this risk, time will tell

At my institution, Cyberknife radiation if most often used for patients with low grade and low-risk intermediate grade prostate cancer. Five simple 15 minute treatments over 2 weeks allow for cure and essentially no side effects to the patients. I only recommend IMRT (with or without ADT) for those patients with high-grade intermediate or high risk prostate cancer. In addition, I haven't done a brachytherapy case in 15 years as it has been replaced by the above radiation treatments. Proton therapy treatment is not currently used as it is currently not reimbursed.

I have referred patients for IMRT and on occasions some brachytherapy. In my experience, the IMRT seems to confer better efficacy and more favorable out comes of the three modalities of radiation therapies.

The spaceoar technology seems to have value particularly when the patient is getting brachytherapy and XRT

Clearly a multidisciplinary approach is important

I am not convinced that brachytherapy with IMRT is better than IMRT alone.

I have had good results with adjuvant radiation therapy (IMRT) with localized recurrence following radical prostatectomy

I have few patients go on to get Proton beam therapy or cyber knife therapy.

Neoadjuvant hormone therapy has been recommended in higher grade tumors

I use prostate brachytherapy with lower grade non palpable disease in reasonable sized glands. IMRT for higher grade lesions which can be palpable.

I have had the best success with Prostate Brachytherapy and IMRT in appropriately selected patients

IMRT is certainly the most common modality used at our institution and surrounding area mainly because of the lack of proton beam close by and then the lack of radiation oncologists performing brachytherapy. While this is anecdotal, the most horrific radiation complications I've seen have been from brachytherapy.

Our radiation oncologists routinely use IMRT. Proton therapy is not available to my knowledge. Androgen deprivation therapy is used where indicated based on disease risk and prostate size. We are careful to counsel patients regarding both short term and long term toxicity. We have had patients with radiation induced fistulae as well as secondary malignancies in the treatment field.

The recent utilization of Spaceoar has added to the safety of xrt and brings the urologist back into the treatment realm, which is good for patients' peace of mind as we typically follow these patients much longer and establish long term relationships with them.

My radiation oncology colleagues are very interactive and help guide the most beneficial option for XRT, whether IMRT or any of its related treatment options. I typically offer neoadjuvant hormonal therapy when prostate size and pathology indicates such

For pts choosing radiation therapy, my routing is to schedule Spaceoar and hormone therapy if indicated. When pts do well on IMRT, they do very well. When they have complications, they have terrible ones and it can be very challenging to address these issues sometimes. I get asked all the time about "proton" beam therapy. I tell pts that the best track record is IMRT. Sometimes newer is NOT better.

Thanks for the wonderful input! Please feel free to share your thoughts regarding rectal spacers.

What are your insights regarding the use rectal spacers? Please share your thoughts.

Proton therapy has limited availability and may not offer any efficacy benefit over IMRT/IGRT. Toxicity data very limited. SBRT data looks promising and offers pt shorter treatment time. Use of rectal spacers to minimize rectal toxicity encouraged.

Proton based therapy is not widely available, and in terms of efficacy seems equivalent to other modalities, with the toxicity benefits mentioned, at the expense of logistics and lack of reimbursement. IMRT is used widely with successful results.

An important toxicity of prostate cancer treatment usually over-looked is the loss of testosterone and the loss of male secondary characteristics. Treated patients often gain body fat and loose muscle mass. This does increase the risk of cardiovascular disease and emotional disorders. Testosterone does not cause cancer. In early prostate cancer therapy the patient should be asked "what is more important in your life-curing cancer with potential loss of some function or localized therapy with preservation of function?

at my clinic we dont have proton therapy and I believe most dat awith proton therapy is in prostate and patients often get excited about it; I personally saw less proctitis bu i am not sure if its same with others; we try to do the IMRT as it is the only therapy available; I often leave it to rad-onc

Proton therapy is not universally available, we do not have this at our institution. My radiation oncology colleague says that proton therapy is an option but there is no data to show that it is more efficacious but there may be some toxicity improvements but there is selection bias.

Proton therapy is interesting but definately more data in solid tumors compared to heme malig. Interesting to study:

Proton therapy is interesting but definately more data in solid tumors compared to heme malig. Interesting to study:

Proton therapy is not available at my institution. We are routinely using IMRT for primary prostate radiation. SBRT for primary prostate cancer looks good in initial studies. We will have to see how it holds up in long term follow up.

Multidisciplinary team discussion really helps in discussing the pro and cons and also educating the others members of the team. Final decision about radiation is made by the Rad Onc but collateral information about other comorbid conditions are crucial as patients with pre existing bowel conditions like inflammatory bowel disease (ulcerative colitis) may avoid protein beam due to its associated bowel toxicity etc. so far IMRT has been in the forefront.

I prefer IMRT for better protection, radiation oncology suggest different strategies and discuss with our team and patient, then we come to a final plan, which is mainly driven by input and experience of the radiation oncology attending for a given patient.

I will leave to Rad onc to chose cyberknife vs regular IMRT has more favorable result

My institution has a strong cyberknife program, so I favor this approach for localized prostate cancer. Among IMRT and SBRT I think the side effect profile is as important and efficacy, so IMRT seems to be favorable.