Balancing Efficacy and Toxicity in Salvage Brachytherapy and SBRT for Radio-Recurrent Prostate Cancer: Insights Beyond the UroGEC Review.

Salvage treatment for locally recurrent prostate cancer after primary radiotherapy remains a clinical challenge, with multiple modalities- including stereotactic body radiotherapy (SBRT), high-dose-rate (HDR) brachytherapy, and low-dose-rate (LDR) brachytherapy-competing for optimal use. The recent UroGEC expert review in Radiotherapy & Oncology provides a timely synthesis of available evidence and underscores the potential role of brachytherapy in this setting. Here, we contextualize these findings with recently published meta-analyses that expand the evidence base and refine our understanding of salvage outcomes. Updated analyses highlight significant differences across modalities: HDR brachytherapy achieves favorable disease control with low gastrointestinal toxicity, whereas LDR appears to offer superior relapse- free survival in selected subgroups at the cost of higher late genitourinary morbidity. By contrast, SBRT, although attractive for its non-invasiveness, demonstrates lower long-term relapse-free survival when scrutinized in broader pooled cohorts, despite acceptable toxicity. Collectively, these findings emphasize that the "one-size-fits-all" paradigm is inadequate. Clinical decision-making must instead be individualized, integrating oncologic efficacy, toxicity risks, patient comorbidities, and personal preferences. Looking forward, prospective trials and harmonized outcome reporting will be essential to strengthen the comparative evidence. Until then, a nuanced, patient-centered approach-anchored in multidisciplinary discussion-remains the cornerstone of salvage treatment planning. This perspective complements and extends the UroGEC review, underscoring the need to balance efficacy with quality of life in managing radio- recurrent prostate cancer.