LAUSR

The role of brachytherapy boost (BB) for definitive irradiation of prostate cancer (PC) gains in popularity, due to rising proof levels in terms of biochemical control (1, 2). However, one might notice a decrease of BB’s application (3, 4), whereas high-proof level is now available to consider BB as a standard of care for intermediate and high-risk PC (1, 2). Regarding those new recommendations, a potential ‘‘conflict of disinterest’’ is emerging. In 2016, Orio PF et al. (5) observed that omission of BB for cervical cancer leads to a significant decrease of overall survival. Considering this element, we might worry about the consequences of keeping BB aside of PC irradiation. Insufficient care offer and nonadapted reimbursement appear to be the two main reasons explaining the suspected disinterest for BB. Care offer is facing an issue: is the number of Radiation Oncologists able to perform BB sufficient to take care of all the potential patients eligible for definitive PC irradiation? A recent European data coming from Borras JM et al. (6) reported that the number of PC irradiations in 2012 was 243,669 with a projection to the year 2025 of about 300,000 (þ25%). In 2012, in France, among the 192,769 irradiated patients, 27,630 were treated for PC (35,000 expected in 2025) (7). Considering that 50% of those patients were irradiated after radical prostatectomy or for metastatic disease, about 14,000 patients were treated by definitive irradiation (20,000 expected in 2025). According to this hypothesis, and estimating (optimistically) that among the 172 French radiation facilities, a maximum of 50 would be able to routinely provide BB; the estimated number of BB to perform in 2025, per week, per center, over 10 months, would then be ranged between 8 and 10. This high number of procedures may imply a deep reorganization of brachytherapy facilities, mainly in terms of trained human resources, to reach the balance between care offer and care demand. This analysis based on European and French data could easily be transposed to other countries, leading to consider the lack of care offer as a crucial obstacle preventing from BB’s adoption. Financial considerations represent the other key point impacting on the potential use of BB. Indeed, according to the French health care reimbursement system, a definitive external beam radiation therapy (EBRT), using intensity-modulated/image-guided technique, delivering a