Dr Stone has raised meritorious points regarding the treatment of intermediate-risk prostate cancer and the potential concerns of supplemental external beam radiotherapy (EBRT) (1). However, within all the arguments he posed to support the routine use of brachytherapy alone for intermediate-risk disease, there are inconsistencies. Indeed, some of his perspectives actually represent cogent reasons to support our viewpoint for adding supplemental EBRT to brachytherapy in this patient population. So for this rebuttal, let's carefully analyze Dr Stone's arguments for the use of brachytherapy alone. The following key points will be critically assessed: (i) benefit of further dose escalation to allow the delivery of a higher biologic effective dose (BED); (2) the efficacy for achieving the "trifecta" with brachytherapy alone, namely, low urinary toxicity and maintained sexual function with durable tumor control; (5) secondary malignancy risk with EBRT; and (4) theoretical financial burden of more aggressive therapy using supplemental EBRT.
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