Polish Brachytherapy Society clinical recommendations and expert consensus on radical high-dose-rate brachytherapy for prostate cancer.

Abstract

High-dose-rate brachytherapy (HDR-BT) is an established and highly effective modality for the radical treatment of localized prostate cancer. Despite its widespread use in Poland, relevant aspects of patient selection, treatment qualification, dose and fractionation, integration with external beam radiotherapy (EBRT), and target and organ-at-risk definition vary between centers. The aim of this document was to develop national recommendations and expert consensus statements to standardize the use of radical HDR-BT for prostate cancer. The Polish Brachytherapy Society convened a multidisciplinary panel of radiation oncologists with extensive experience in prostate brachytherapy. Recommendations were developed through a structured literature review focusing on prospective trials, meta-analyses, and large retrospective studies. Evidence quality and strength of recommendations were assessed using the GRADE framework. A modified two-round Delphi process was applied, involving a core expert panel and an extended national panel. Consensus was predefined as ≥ 75% agreement. Consensus recommendations were formulated across the entire HDR-BT treatment pathway, including patient assessment, diagnostic work-up, risk stratification, indications for HDR-BT monotherapy and HDR-BT boost combined with EBRT, dose and fractionation schedules, use and duration of androgen deprivation therapy, timing of HDR-BT relative to EBRT, and target volume delineation with organ-at-risk dose constraints. The consensus supports fractionated HDR-BT monotherapy in selected low- and intermediate-risk clinical scenarios, and confirms the role of HDR-BT boost combined with EBRT as a key component of dose-escalation strategies in high- and very high-risk prostate cancer. An EQD₂-based approach to dosimetric constraints was endorsed to enhance treatment safety and consistency. These recommendations represent the first national expert consensus of the Polish Brachytherapy Society on radical HDR-BT for prostate cancer. They provide a comprehensive, evidence-informed framework to harmonize clinical practice, support decision-making, and improve comparability of outcomes across Polish centers. Regular updates will be required as new clinical evidence emerges.