Abstract
Following adoption of moderately hypofractionated radiotherapy as a standard for localised prostate cancer, ultrahypofractioned radiotherapy delivered in five to seven fractions is rapidly being embraced by clinical practice and international guidelines. However, the question remains: how low can we go? Can radiotherapy for prostate cancer be delivered in fewer than five fractions? The current review summarises the evidence that radiotherapy for localised prostate cancer can be safely and effectively delivered in fewer than five fractions using high dose rate brachytherapy or stereotactic body radiotherapy. We also discuss important lessons learned from the single-fraction high dose rate brachytherapy experience.
Highlights
It is well established that higher radiation dose improves biochemical control for prostate cancer [1,2]
Caution should be used in undertaking single-fraction radiotherapy for localised prostate cancer on the basis of the high dose rate (HDR) monotherapy experience
Given the evidence of inferior biochemical control compared with two-fraction HDR [25], singlefraction HDR brachytherapy should not be used
Summary
It is well established that higher radiation dose improves biochemical control for prostate cancer [1,2]. Given that the a/b ratio for prostate cancer is hypothesised to be about 1.5 Gy [7,8], the linear-quadratic model suggests that larger doses per fraction may result in an improved therapeutic ratio by being selectively sparing to organs at risk that have a higher a/b. The optimal numbers of fractions in HDR and SBRT remain to be determined. In this narrative review, we summarise the oncological outcomes and toxicity profiles of emerging ultrahypofractionated treatment techniques (HDR and SBRT) for localised prostate cancer when delivered in fewer than five fractions
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