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Hypofractionated radiotherapy for organ-confined prostate cancer: is less more?

Nature Reviews Urology volume 13, pages 400–408 (2016)Cite this article

Subjects

Key Points

  • Moderate and extreme hypofractionation are alternatives to conventional radiotherapy for organ-confined prostate cancer that were developed following technological advances in radiation delivery and tumour imaging

  • In strategies of moderate and extreme hypofractionation, increased radiation doses are administered per treatment session, reducing overall treatment duration and improving patient compliance

  • Prostate cancer seems particularly suitable for hypofractionated radiotherapy as these tumours have unique sensitivity to increased radiation dose fractions in comparison with surrounding healthy tissues

  • Trials investigating clinical and toxicity outcomes of moderate hypofractionation schedules have sufficient follow-up data to show that efficacy and toxicity of these schedules are similar to those of conventionally fractionated regimens

  • Several phase II trials of extremely hypofractionated radiotherapy in men with low-risk or intermediate-risk prostate cancer show excellent short-term outcomes, but extended follow-up monitoring is required to confirm long-term safety

  • Extreme hypofractionation schedules are highly cost-effective, despite the need for cutting-edge technologies, but the efficacy and safety of dose escalation and single-dose treatments still need to be confirmed in carefully conducted clinical trials

Abstract

Moderate hypofractionation of radiotherapy is widely considered a viable alternative to conventional fractionation for the treatment of patients with organ-confined prostate cancer, but stereotactic body radiotherapy (SBRT) is rapidly emerging as a novel treatment modality for this disease. Advances in treatment planning, image guidance, target position reproducibility and on-line tracking, coupled with a compelling radiobiological rationale, have promoted SBRT as a safe and effective treatment. Dose escalation to the tumour tissue through a decreased number of radiation fractions improves patient comfort and convenience, as well as treatment cost-effectiveness, compared with conventional radiotherapy regimens. Several clinical trials have investigated moderate and extreme hypofractionation of radiotherapy in patients with prostate cancer. Evidence is accumulating which suggests that the use of moderately hypofractionated radiotherapy can be recommended regardless of cancer risk group. Regimens of extremely hypofractionated radiotherapy have shown very good short-term efficacy and safety outcomes, but appropriately designed trials with extended follow-up monitoring are required to confirm long-term outcomes.

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Figure 1: Radiotherapy fractionation schedules for the management of patients with prostate cancer.

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Authors and Affiliations

  1. Department of Radiation Oncology, Champalimaud Centre for the Unknown, Avenida Brasilia, 1400–038, Lisbon, Portugal

    Stefano Arcangeli & Carlo Greco

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S.A. researched data for the article and wrote the manuscript. Both authors made substantial contributions to the discussion of the article content and reviewed and/or edited the manuscript before submission.

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Correspondence to Stefano Arcangeli.

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FURTHER INFORMATION

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PowerPoint slides

Glossary

Intensity-modulated radiotherapy

A type of 3D radiotherapy that uses thin radiation beams of differing intensities aimed at the tumour from many angles.

Image-guided radiation therapy

Radiotherapy that employs image guidance at the time of radiation delivery to ensure adherence to the planned treatment.

Stereotactic body radiotherapy

Radiotherapy that concentrates therapeutic doses into few, high-dose, highly conformal and precisely targeted treatments.

α/β ratio

A parameter that determines the sensitivity of particular types of tissues to radiation doses, derived from the underlying dose–effect curves (linear or quadratic).

Isoeffective

Radiotherapy regimens that achieve the same tumour control probability.

Tumour control probability

The probability that a tumour is being eradicated or controlled by a prescribed dose of radiation taking into account factors such as cell proliferation between fractions, which can be used to compare different radiotherapy regimens.

3D-conformal radiotherapy

A type of radiotherapy that uses computers and special imaging techniques to define the size and shape of the tumour in three dimensions (width, height and depth).

2D-volume imaging

Any planar imaging that uses 'flat' X-ray images generated by a fluoroscopic simulator to plan the radiation treatments.

Fiducial markers

Small metal spheres, coils or cylinders that are placed in or near a tumour to help guide the placement of radiation beams during treatment.

Expanded prostate cancer index composite

A standardized self-administered disease-specific questionnaire developed to measure health-related quality of life in patients treated for prostate cancer.

Fast flattening-filter-free beam radiation

Procedure that enables a considerable reduction in treatment time through radiotherapy delivery via unflattened beams.

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Arcangeli, S., Greco, C. Hypofractionated radiotherapy for organ-confined prostate cancer: is less more?. Nat Rev Urol 13, 400–408 (2016). https://doi.org/10.1038/nrurol.2016.106

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