Alternatives to custodial remand for women in the criminal justice system: A multi-sector approach.

Throughout the world, women involved in criminal justice systems often present with substantial needs and vulnerabilities. Diverting vulnerable people away from prison is government policy in England and Wales, but full psychiatric and social assessments are expensive and hard to access. A screening and quick response initiative - alternatives to custodial remand for women (ACRW) - was implemented across three areas of London (West, South and East) to supplement existing court liaison and diversion services, to assess the feasibility of a supplementary custodial remand service as part of a women's specialist service pathway in the criminal justice system in England. Three mental health trusts and two voluntary sector providers offered this service enhancement - a screening and service link provision in three London boroughs between 2012 and 2014. We conducted a service evaluation using routinely collected service use record data. The service made 809 contacts, of whom 104 had contact on multiple occasions. Many were identified as at risk of self-harm (46%) or had histories of hospital admission for mental disorder (36%), but few were referred either to the liaison and diversion service or specialist mental health services. The largest group of referrals was to women's community services outside the health service (e.g. counselling, domestic violence or sexual abuse services). 180 women had dependent children and 22 were pregnant, increasing the urgency to find non-custodial alternatives. As well as confirming high levels of need amongst women entering the criminal justice system, this evaluation confirms the feasibility of working across sectors in this field, providing an extra layer of service that can complement existing liaison and diversion service provision. The service was responsive and most women using it were kept out of custody. Research is now required to understand the appropriateness of the referrals, the extent to which women follow them through and the impact on their mental health and desistance from offending.

Taxonomy development for term standardization in activity resulting from medication review processes: a Delphi study.

BACKGROUND: Medication review (MR) is the systematic assessment of a patient's medications for safety and effectiveness by a healthcare professional. The language used to describe MR activity, such as stopped medicine and increased dose, should be consistent across studies to assist researchers compare how different services operate and identify their mechanism of impact. AIM: To develop an international taxonomy of standardized terms and activity definitions related to medication reviews. METHOD: This was a three-stage Delphi-based consensus study with international medication review experts. A systematic review provided MR activity terms for the survey. Experts rated their consensus on each activity term and its definition on a Likert scale and provided written feedback. The consensus was 75% panel agreement. At each stage, consensus elements were retained, and feedback was used to revise definitions. RESULTS: Seven experts were recruited for the study (response rate 15.2%) from four countries: the United Kingdom (n = 4), New Zealand (n = 1), Australia (n = 1), and Malaysia (n = 1). The following terms achieved consensus: the term Medication as a descriptor for MR terms; discontinue medication, start medication, dose increase, dose decrease, dosage form change, and medication safety and efficacy monitor to describe MR activity; Educate to describe the delivery of healthcare professionals and patients/carers education. CONCLUSION: Standardized medication review activity terms and definitions have been selected for universal adoption in all future MR research to facilitate a meaningful comparison of process evaluations within different settings.

Living with gout in New Zealand: an exploratory study into people's knowledge about the disease and its treatment.

BACKGROUND: In New Zealand, gout disproportionately affects Maori and Pacific people who also experience symptoms at an earlier age. Gout occurs predominantly in men and is associated with cardiovascular disease, diabetes, and renal disease. The impact on daily social activities, family, and work is enormous, and many people remain inadequately treated. OBJECTIVES: The objectives of this study were to explore the knowledge and perceptions of people with gout toward the disease and to determine the impact gout has on lifestyle including possible barriers to treatment. METHODS: Sixty people with gout from the Auckland and Waikato regions of New Zealand were invited to participate in 30-minute semistructured interviews. The data were analyzed using a general inductive thematic approach. RESULTS: Although 85% of participants were aware of dietary triggers of gout, these were not always avoided. Less than 50% knew something about how their medicines worked, and only 33% knew which medicines to use both acutely and chronically. The negative impact of gout episodes was noted through the number participants unable to work or participate in family activities. Healthcare professionals were not always the main source of information, which is an area that could be developed to improve knowledge about gout. CONCLUSIONS: There were substantial gaps in the knowledge about gout and its causes and management. All healthcare providers could help identify patients with suboptimal knowledge and improve the management of gout.

The General Practitioner-Pharmacist Collaboration (GPPC) study: a randomised controlled trial of clinical medication reviews in community pharmacy.

OBJECTIVES: There are conflicting results in studies of pharmacists undertaking medication reviews for older people. With increasing promotion and funding for 'medication reviews' there is a need for them to be standardised, and to determine their effectiveness and the feasibility of providing them from a community pharmacy. The objective was to determine whether involvement of community pharmacists undertaking clinical medication reviews, working with general practitioners, improved medicine-related therapeutic outcomes for patients. METHODS: A randomised controlled trial was carried out in people 65 years and older on five or more prescribed medicines. Community pharmacists undertook a clinical medication review (Comprehensive Pharmaceutical Care) and met with the patient's general practitioner to discuss recommendations about possible medicine changes. The patients were followed-up 3-monthly. The control group received usual care. The main outcome measures were Quality of Life (SF-36) and Medication Appropriateness Index. KEY FINDINGS: A total of 498 patients were enrolled in the study. The quality-of-life domains of emotional role and social functioning were significantly reduced in the intervention group compared to the control group. The Medication Appropriateness Index was significantly improved in the intervention group. Only 39% of the 44 pharmacists who agreed to participate in the study provided adequate data, which was a limitation of the study and indicated potential barriers to the generalisability of the study. CONCLUSION: Clinical medication reviews in collaboration with general practitioners can have a positive effect on the Medication Appropriateness Index. However, pharmacist withdrawal from the study suggests that community pharmacy may not be an appropriate environment from which to expand clinical medication reviews in primary care.

Compounding inequity: a qualitative study of gout management in an urban marae clinic in Auckland.

INTRODUCTION Gout remains a health equity issue; Maori and Pacific peoples are disproportionately afflicted, with increased burden and loss of quality of life, yet are less likely to receive appropriate management, which mainly occurs in primary care. AIM This study aims to understand the perspectives of the mainly Maori and Pacific clinicians and staff at an urban marae practice about barriers and challenges to delivering effective care to a Maori and Pacific community with high burden of gout. METHODS Semi-structured interviews were conducted with 10 staff members delivering health care to a mostly Indigenous community. Interviews sought to ascertain staff views of enablers and barriers to optimal gout management and analyse them thematically. RESULTS Three themes were identified: community disadvantage; demands unique to Indigenous providers; and challenges and opportunities for optimising gout management. High prevalence and heavy impact of gout on wellbeing in the community was intertwined with socioeconomic disadvantage, precariousness of employment and entrenched inaccurate (yet pliable) patient views on gout, to the detriment of focused, effective care. Structural and funding demands on providers inhibited staff focus on the clear community need. Providers saw the culturally safe and competent approach necessary for improvement as requiring community empowerment with appropriate clinical tools and adequate resourcing. DISCUSSION Despite provider intent to deliver culturally appropriate and safe care and equitable health outcomes for patients suffering from gout, general practice initiatives without aligned resourcing or incentives are inhibited when inequity is pervasive. Simply asking Maori providers to do more for the same amount of resource may not be effective.

The inequity of access to health: a case study of patients with gout in one general practice.

AIM: Gout is a health equity issue for Maori and Pacific peoples because disparities in quality of care exist. This study aims to describe domains of access that may contribute to the optimisation of gout care and, therefore, address health inequity. METHODS: The practice management system at one general practice in Auckland was used to identify enrolled patients with gout, using disease codes and medication lists. Barriers to access for the cohort were investigated using staff knowledge and the practice management system. The general practice is uniquely situated within an urban marae (traditional meeting house) complex serving a predominantly Maori community. This enables a focus on domains of access other than cultural safety. RESULTS: Of 3,095 people enrolled at the practice, 268 were identified as having gout. Of these, 94% had at least one other long-term health condition. The majority of people with gout enrolled at the practice have employment roles incongruent with the clinic's opening hours. CONCLUSIONS: Social circumstances, such as employment and availability of transport, should be actively discussed with all patients and recorded in the practice management system. Reorientation of health services, including hours of access, is evidentially required to ensure optimal management of gout and possibly other health conditions.

Randomised trial of external-beam radiotherapy alone or with high-dose-rate brachytherapy for prostate cancer: Mature 12-year results.

BACKGROUND AND PURPOSE: A randomised phase-III trial compared external beam radiotherapy (EBRT) alone with EBRT combined with high-dose-rate brachytherapy boost (HDR-BTb) in localised prostate adenocarcinoma. Previous analysis, at median follow up of 85 months, demonstrated improved relapse free survival (RFS) with EBRT + HDR-BTb. This data has now been updated with a median follow up of 131 months. MATERIALS AND METHODS: From December 1997 to August 2005, patients were assigned either to EBRT alone delivering 55 Gy in 20 fractions over 4 weeks or EBRT followed by a temporary high-dose-rate implant delivering 2 × 8·5 Gy over 24 h. The primary endpoint was RFS defined by a PSA rise ≥2.0 µg/l above nadir, clinical progression or death. Actuarial survival rates and Hazard Ratios (HRs) were calculated using the Kaplan-Meier method and Cox's Proportional Hazard Model, respectively. Secondary endpoints were overall survival (OS), urinary and bowel toxicity. RESULTS: One hundred and six patients received EBRT alone and 110 EBRT + HDR-BTb. Median time to relapse was 137 months in the HDR-BTb arm compared to 82 months for EBRT alone (p = 0·01). A 27% risk of recurrence with EBRT alone was observed (p = 0·001), resulting in a 21% improvement in RFS at 12 years with EBRT + HDR-BTb. In multivariate analysis treatment arm, risk category and no androgen deprivation therapy were significant covariates for risk of relapse. Differences in overall survival were not significant. CONCLUSION: At 12 years there remains a significant improvement in RFS after EBRT + HDR-BTb; both treatments were equitoxic for severe late urinary and bowel events and urethral strictures.

Medicines reclassification from a pharmaceutical industry perspective: An international qualitative study.

BACKGROUND: Widening access to medicines through reclassification ('switching') of medicines from prescription to non-prescription is an international trend generally welcomed by community pharmacists. Research has focused on scheduling and committee deliberations affecting reclassification, rather than industry aspects, despite industry's role in driving reclassifications. The research aimed to identify how pharmaceutical industry and product-related factors influence reclassification, and to explore stakeholder acceptability of government or third-party driven reclassifications. METHODS: Sixty-five in-depth, semi-structured interviews were conducted with 80 key informants (including representatives from regulatory bodies, industry, pharmacy and medicine) in developed countries including the United States, the United Kingdom, Japan, Australia, and New Zealand. The questions explored barriers and enablers to reclassification at the local (micro-), regional (meso-) and global (macro-) levels. Analysis of transcribed interviews entailed descriptive and thematic approaches. RESULTS: Pharmaceutical industry decisions to drive medicine reclassification reflect characteristics of the company, product, and external environment at all levels. For the company, financial factors, company focus (e.g. on prescription business versus non-prescription business), and capability in non-prescription medicines and reclassification were common influences. Products with significant non-prescription market potential and a well-known prescription medicine brand name most suited reclassification, usually near patent expiry. Barriers included immediate generic entry post-reclassification, and a short-term profitability and/or prescription business focus. Some countries allow government or a third-party (including pharmacy) to drive reclassifications, with examples of successful reclassifications ensuing. Some industry and other participants held concerns about this practice, particularly in the United States. Concerns included insufficient resourcing, and the pharmaceutical company's business, potentially encouraging product withdrawal or legal challenge. CONCLUSIONS: This study is the first to explore both pharmaceutical industry factors affecting reclassification and acceptability of alternate drivers of reclassification. Factors beyond clinical safety and efficacy and the local reclassification environment can influence reclassification. Pharmacy-driven reclassification might be one alternative.

A Phase II study of high-dose-rate afterloading brachytherapy as monotherapy for the treatment of localized prostate cancer.

PURPOSE: A Phase II dose escalation study has been undertaken to evaluate high-dose-rate brachytherapy (HDRBT) monotherapy for prostate cancer. METHODS AND MATERIALS: A total of 110 patients have been entered, all with locally advanced cancer. Three dose levels have been used; 34 Gy in four fractions, 36 Gy in four fractions, and 31.5 Gy in three fractions. These equate to 226Gy(1.5), 252Gy(1.5), and 252Gy(1.5), respectively. Thirty patients have received 34 Gy, 25 received 36 Gy, and 55 patients received 31.5 Gy. Acute and late toxicity was analyzed using the International Prostate Symptom Score, and urologic and rectal events were scored using the Radiation Therapy Oncology Group/Common Terminology Criteria scoring systems. RESULTS: Seven patients required urethral catheterization at 2 weeks; 3 receiving 34 Gy, 1 receiving 36 Gy, and 3 receiving 31.5 Gy. Only 3 patients remained catheterized at 12 weeks. Radiation Therapy Oncology Group 1 and 2 gastrointestinal toxicity at 2 weeks was seen in 61%, 68%, and 77%, respectively. Grade 3 bladder toxicity was seen in 2 patients at 6 months, 1 each from the 36 Gy and 31.5 Gy arms. One patient from the 31.5-Gy cohort reported Grade 2 bowel toxicity at 6 months. Prostate-specific antigen (PSA), stratified for androgen deprivation therapy (ADT) and no-ADT patients ranged from 16.1-22.9 microg/L and 11.1-12.5 microg/L, respectively. This fell at 12 months to 0.2-0.6 microg/L and 0.5-1.4 microg/L, respectively. No PSA relapses have yet been seen with a median follow-up of 30 months (34 Gy), 18 months (36 Gy), and 11.8 months (31.5 Gy). CONCLUSIONS: Early results suggest an excellent biochemical response with no differences seen in acute and late toxicity between doses of 34 Gy/four fractions, 36 Gy/four fractions, or 31.5 Gy/three fractions.

Pounamu: Achieving health equity in Aotearoa New Zealand: the contribution of medicines optimisation.

This paper aims to consider the various parts of what is required to achieve the best possible health outcomes from medicines in partnership with the person for whom they are prescribed. Specifically, it looks to highlight the process from an Indigenous view with respect to Maori in Aotearoa New Zealand, and claims a multi-dimensional approach is imperative. Attaining optimal use of medicines is necessary to help achieve health equity. There is an urgent need to understand and investigate models of care that achieve this optimal state.

Focal boost to residual gross tumor volume in brachytherapy for cervical cancer-A feasibility study.

PURPOSE: Image-guided plan optimization with MRI and CT for interstitial and intracavitary brachytherapy is an established technique in treating cervical cancer. The purpose of this study was to assess the feasibility of boosting the dose to the residual gross tumor volume (GTV-Tres) to 140% of the high-risk clinical target volume (HR-CTV) prescription. METHODS AND MATERIALS: Brachytherapy plans from 50 consecutive patients were analyzed in this study. All received external beam radiotherapy followed by brachytherapy (6 Gy × 4 fraction or 7 Gy × 4 fraction to HR-CTV). The original treatment plans were reoptimized escalating the GTV-Tres dose 140% of the original HR-CTV prescription dose to 8.4 Gy and 9.8 Gy/ per fraction, respectively, with the aim of achieving GTV-TresV140 ≥ 90% and D98 ≥ 100 Gy. The HR-CTV coverage and organ at risk (OAR) dose-volume histogram values were kept within the tolerance, which had been accepted for the original clinical plans. RESULTS: A total of 24 patients (48%) achieved the planning goal after reoptimization. There was no significant difference between the D2cc of the OARs of the clinical plan and the study boost plan. The factors having greatest impact on the delivered dose to the GTV-Tres are proximity of the OAR, intrauterine positioned outside the GTV-Tres, and suboptimal interstitial placement for boosting GTV-Tres. CONCLUSIONS: It is possible to boost the prescription dose to the GTV-Tres achieving 140% increase, which equates to an EQD2α/ß=10 > 100 Gy. Plans without both interstitial catheters and/or intrauterine within the GTV-Tres are most likely to be suboptimal. This planning study demonstrates that dose escalation to the GTV-Tres is feasible and further work into clinical application should be considered.

High dose rate brachytherapy in combination with external beam radiotherapy in the radical treatment of prostate cancer: initial results of a randomised phase three trial.

BACKGROUND AND PURPOSE: A randomised phase III trial has compared external beam radiotherapy alone with a dose escalated schedule using high dose rate brachytherapy. Patients with histologically confirmed prostate cancer, no evidence of metastases, a PSA <50, no previous TURP and fit for general anaesthetic were included. METHODS: Patients were randomised to receive either standard radiotherapy 55 Gy in 20 fractions treating Monday to Friday over 4 weeks or a combined schedule comprising external beam treatment delivering 35.75 Gy in 13 fractions treating daily Monday to Friday over 2.5 weeks followed by a temporary high dose rate afterloading implant delivering 17 Gy in two fractions over 24h. RESULTS: A total of 220 patients were randomised, balanced for important prognostic parameters including tumour stage, presenting PSA, Gleason score and use of adjuvant anti-androgens. With a median follow up of 30 months (range 3-91) a significant improvement in actuarial biochemical relapse-free survival is seen in favour of the combined brachytherapy schedule (p=0.03). A lower incidence of acute rectal discharge was seen in the brachytherapy group (p=0.025) and other acute and late toxicities were equivalent. Patients randomised to brachytherapy had a significantly better FACT-P score at 12 weeks (p=0.02). CONCLUSIONS: The use of high dose rate brachytherapy in combination with external beam radiotherapy resulted in an improved biochemical relapse-free survival compared to external beam radiotherapy alone with less acute rectal toxicity and improved quality of life in this randomised trial.

Changing perspectives of the role of community pharmacists: 1998 - 2012.

INTRODUCTION In New Zealand, extended medicines management roles proposed for pharmacists include the optimisation and monitoring of medicines in patients with long-term conditions through greater collaboration with general practitioners (GPs). Although some collaborative roles have been successfully implemented in hospitals, barriers for both pharmacists and GPs hinder interprofessional working relationships in the community. AIM To compare data from a 2012 study with two previous studies (1998, 2002) examining perceptions of community pharmacists and GPs of the expanding medicines management roles of community pharmacists. METHODS In 2012, a survey, modelled on the 1998 and 2002 studies, was sent to 600 community pharmacists and 600 GPs. Analyses considered the five-point Likert scale to be a continuous variable. A change of ≥ 10% between any two surveys indicated a relevant change for comparison. RESULTS Increasing agreement, which differed considerably between professions, was apparent for most expanding medicine management roles over the 14 study years. In all three studies, pharmacists were open to expanding their roles to include monitoring, screening, advisory and prescribing roles. GPs were most accepting of the traditional dispensing role with a positive shift towards pharmacists' involvement in medicines management over time. DISCUSSION Over 14 years, GPs became more accepting of community pharmacists' involvement in extended medicines management roles, although still had low acceptance of the more clinical roles. Pharmacists considered increased involvement in medicines management as their role, but appeared to lack confidence in their ability to do this role.

Why does increasing public access to medicines differ between countries? Qualitative comparison of nine countries.

OBJECTIVE: To identify factors associated with differences between developed countries in reclassifying (switching) medicines from prescription to non-prescription availability. METHODS: Cross-national qualitative research using a heuristic approach in the US, UK, Japan, Australia and New Zealand, supplemented by data from Canada, Denmark, the Netherlands and Singapore. In-depth interviews with 80 key informants (65 interviews) explored and compared factors in terms of barriers and enablers to reclassification of medicines in each country. Document analysis supplemented interview data. RESULTS: Each country had a unique mix of enablers and barriers to reclassification. Enablers included government policy (particularly in UK), pharmacist-only scheduling (particularly in Australia and New Zealand) and large market size (particularly in the US and Europe). Local barriers included limited market potential in small countries, the cost of a reclassification (particularly in the US), competition from distributors of generic medicines, committee inconsistency and consumer behavior. UK had more enablers than barriers, whereas in Australia the opposite was true. CONCLUSIONS: Different factors limit or enable reclassification, affecting consumer access to medicines in different countries. For countries attempting to reduce barriers to reclassification, solutions may include garnering government support for reclassification, support and flexibility from the medicines regulator, having a pharmacy-only and/or pharmacist-only category, providing market exclusivity, ensuring best practice in pharmacy, and minimizing the cost and delays of reclassification.

High dose rate afterloading intraluminal brachytherapy for advanced inoperable rectal carcinoma.

BACKGROUND AND PURPOSE: High dose rate intraluminal brachytherapy for tumours of the rectal and anal canal which were inoperable either because of the age and frailty of the patient or because of advanced disease has been evaluated. PATIENTS AND METHODS: In a retrospective review of 50 consecutive patients the two main indications for brachytherapy were as part of a radical radiation programme in those unfit for major surgery (26 patients) or as palliation for advanced or metastatic disease (22 patients). Radical treatment was either sole treatment delivering 6 Gy fraction 2 to 3 times weekly up to 36 Gy or as a boost of 12 Gy after 45 Gy in 25 fractions external beam chemoradiation. Palliative treatments were given predominantly as a single dose of 10 Gy. RESULTS: This was predominantly a group of frail elderly patients with a median age of 82 years (range 35-91). Local tumour response was seen in 21/25 assessable patients with 14 complete responses. Median survival for the entire population was 6 months (range 1-54 months); in patients treated with 'radical' intent this was 25 months (range 1.5-54) and in the palliative group 7.2 months (range 1-37). The most common presenting symptom was bleeding per rectum for which a 64% response rate was obtained with 57% complete responses. Mucous discharge responded in 64% with 28% complete responses. The median duration of response was 7 months. CONCLUSION: Intraluminal HDR brachytherapy is an effective local treatment for patients otherwise unfit for radical surgery both as a component of radical treatment, or as a simple single palliative procedure.

High dose rate afterloading brachytherapy for prostate cancer: catheter and gland movement between fractions.

Fractionated high dose rate afterloading brachytherapy for prostate cancer requires a robust means of catheter fixation with good quality assurance. Catheter position and dosimetry has been formally evaluated in 20 consecutive patients representing a total of 332 catheters undergoing two HDR afterloading brachytherapy fractions over 36 h. The mean interfraction movement of catheters as measured by external length was less than 1 mm, but within the prostate on consecutive CT scans there was a mean interfraction movement of 11.5 mm away from the prostate base. This has a significant impact on implant dosimetry as measured by D90 and the COIN index, unless corrected by repositioning the catheters.

Dosimetric predictors of biochemical control of prostate cancer in patients randomised to external beam radiotherapy with a boost of high dose rate brachytherapy.

BACKGROUND: To correlate dose and volume dosimetric parameters (D90 and V100) with biochemical control in advanced prostate cancer treated with high-dose rate brachytherapy (HDR-BT). METHODS: One hundred and eight patients received external beam radiotherapy (EBRT) to 35.75 Gy in 13 fractions followed by HDR-BT of 2 × 8.5 Gy. Kaplan-Meier freedom-from-biochemical relapse (FFbR; nadir+2 µg/L) fits were grouped by the first (Q1), second (Q2) and third (Q3) D90 and V100 quartiles. Groups were compared with the log-rank test. Univariate and multivariate Hazard Ratios (HR) for D90 and V100 and other co-variates (PSA, androgen deprivation therapy (ADT) were obtained using Cox's proportional hazard model. RESULTS: FFbR was significantly higher in patients whose D90 and V100 were at or above the second and third quartile (log rank p ≤ 0·04). In multivariate analysis D90, V100 were significant covariates for risk of relapse. CONCLUSIONS: Dichotomising the data using 6 levels of response (above and below Q1, Q2 and Q3) showed a progressive and continuous improvement in biochemical control of disease across the entire dose (and volume) range. The data show that a minimum D90 of 108% of the prescribed dose should be the target to achieve.

High-dose-rate brachytherapy alone given as two or one fraction to patients for locally advanced prostate cancer: acute toxicity.

BACKGROUND: To evaluate early urinary (GU) and gastrointestinal (GI) adverse events (AEs) after two or one fraction of high-dose rate brachytherapy (HDR-BT) in advanced prostate cancer. PATIENTS AND METHODS: 165 patients were treated with 2 × 13 Gy (n=115), or a single dose of 19 Gy (n=24) or 20 Gy (n=26) HDR-BT. Early AEs were assessed using the RTOG scoring system and the International Prostate Symptom Score (IPSS). RESULTS: Week-2 prevalence of severe IPSS symptoms was higher after 20 Gy than after 26 or 19 Gy but by 12 weeks all groups were at pre-treatment levels or less. Grade-3 GU toxicity was observed ≤9% of patients. No Grade 4 GU and no Grade 3 or 4 GI complications were observed. However, there was a significant increase in catheter use in the first 12 weeks after implant after 19 and 20 Gy compared with 2 × 13 Gy. CONCLUSION: Single dose HDR-BT is feasible with acceptable levels of acute complications; tolerance may have been reached with the single 19 Gy schedule.

High-dose-rate brachytherapy with two or three fractions as monotherapy in the treatment of locally advanced prostate cancer.

BACKGROUND: To evaluate late urinary (GU) and gastrointestinal (GI) adverse events (AEs) and biochemical control of disease after high-dose rate brachytherapy (HDR-BT) in locally advanced prostate cancer. PATIENTS AND METHODS: 227 consecutive patients were treated with 3 × 10.5 Gy (n = 109) or 2 × 13 Gy (n = 118) HDR-BT alone. Biochemical failure was assessed using the Phoenix definition of PSA nadir + 2 µg/l and late AEs using the RTOG scoring system and the International Prostate Symptom Score (IPSS). RESULTS: Kaplan-Meier estimates and prevalence of late events indicate that urinary, bowel and IPSS symptoms are higher after 31.5 Gy than after 26 Gy, however differences are significant only for Grade 1 and 2 urinary toxicity. Kaplan-Meier estimates of morbidity are consistently and considerably higher than time-point estimates of prevalence; which reflects the transient nature of most symptoms. At 3 years 93% and 97% of patients treated with 26 and 31.5 Gy, respectively, were free from biochemical relapse (p = 0.5) and 91% for the latter regimen at 5 years. In univariate and multivariate analysis risk-category was the only significant predictor of relapse (p < 0.03). CONCLUSION: These HDR-BT schedules achieved high levels of biochemical control of disease in patients with advanced prostate cancer with few severe complications seen throughout the first 3 years.