Clinically Localized Prostate Cancer: Radiation and Future Directions

Publication Date: May 9, 2022
Last Updated: May 11, 2022

Principles of Radiation

Clinicians should utilize available target localization, normal tissue avoidance, simulation, advanced treatment planning/delivery, and image-guidance procedures to optimize the therapeutic ratio of external beam radiation therapy (EBRT) delivered for prostate cancer. (Clinical Principle, )
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Clinicians should utilize dose escalation when EBRT is the primary treatment for patients with prostate cancer. (Strong, A)
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Clinicians may counsel patients with prostate cancer that proton therapy is a treatment option, but it has not been shown to be superior to other radiation modalities in terms of toxicity profile and cancer outcomes. (Conditional, C)
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Clinicians should offer moderate hypofractionated EBRT for patients with low- or intermediate-risk prostate cancer who elect EBRT. (Strong, A)
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Clinicians may offer ultra hypofractionated EBRT for patients with low- or intermediaterisk prostate cancer who elect EBRT. (Conditional, B)
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In patients with low- or favorable intermediate-risk prostate cancer electing radiation therapy, clinicians should offer dose-escalated hypofractionated EBRT (moderate or ultra), permanent low-dose rate (LDR) seed implant, or temporary high-dose rate (HDR) prostate implant as equivalent forms of treatment. (Strong, B)
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In patients with low- or intermediate-risk prostate cancer electing radiation therapy, clinicians should not electively radiate pelvic lymph nodes. (Strong, B)
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In patients with low- or favorable intermediate-risk prostate cancer electing radiation therapy, clinicians should not routinely use ADT. (Moderate, B)
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In patients with unfavorable intermediate-risk prostate cancer electing radiation therapy, clinicians should offer the addition of short-course (four to six months) ADT with radiation therapy. (Strong, A)
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Clinicians should offer moderate hypofractionated EBRT for patients with high-risk prostate cancer who are candidates for EBRT. (Moderate, C)
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In patients with unfavorable intermediate- or high-risk prostate cancer electing radiation therapy, clinicians should offer dose-escalated hypofractionated EBRT or combined EBRT + brachytherapy (LDR, HDR) along with a risk-appropriate course of ADT. (Strong, A)
Evidence Level: Grade A/B
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In patients with high-risk prostate cancer electing radiation therapy, clinicians may offer radiation to the pelvic lymph nodes. (Conditional, B)
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When treating the pelvic lymph nodes with radiation, clinicians should utilize IMRT with doses between 45 Gy to 52 Gy. (Strong, B)
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In patients with high-risk prostate cancer electing radiation therapy, clinicians should recommend the addition of long-course (18 to 36 months) ADT with radiation therapy. (Strong, A)
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When combined ADT and radiation are used, ADT may be initiated neoadjuvantly, concurrently, or adjuvantly. (Conditional, C)
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When combining ADT with radiation therapy, clinicians may use combined androgen suppression (LHRH agonist with an antiandrogen), an LHRH agonist alone, or an LHRH antagonist alone. (Expert Opinion, )
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Recommendation Grading

Abbreviations

  • 3DCRT: 3-D Conformal Radiation Therapy
  • ADT: Androgen Deprivation Therapy
  • ASCO: American Society Of Clinical Oncology
  • ASTRO: American Society For Radiation Oncology
  • AUA: American Urologic Association
  • CI: Confidence Interval
  • CT: Computed Tomography
  • DE-EBRT: Dose-escalated External Beam Radiation Therapy
  • EBRT: External Beam Radiotherapy
  • GC: Genomic Classifier
  • HDR: High-dose Rate
  • HR: Hazard Ratio
  • IMRT: Intensity-modulated Radiation Therapy
  • LDR: Low-dose Rate
  • LHRH: Luteinizing Hormone-releasing Hormone
  • MRI: Magnetic Resonance Imaging
  • NCCN: National Comprehensive Cancer Network
  • NGI: Next Generation Imaging
  • PBRT: Proton Beam Radiation Therapy
  • PET: Positron Emission Tomography
  • PSMA: Prostate-specific Membrane Antigen
  • QOL: Quality Of Life
  • RR: Relative Risk
  • SBRT: Stereotactic Body Radiation Therapy
  • VMAT: Volumetric Modulated Arc Therapy

Overview

Title

Clinically Localized Prostate Cancer: Radiation and Future Directions

Authoring Organizations

American Society for Radiation Oncology

American Urological Association

Publication Month/Year

May 9, 2022

Last Updated Month/Year

September 3, 2024

Supplemental Implementation Tools

Document Type

Guideline

Country of Publication

US

Document Objectives

The summary presented herein represents Part III of the three-part series dedicated to Clinically Localized Prostate Cancer: AUA/ASTRO Guideline, discussing principles of radiation and offering several future directions of further relevant study in patients diagnosed with clinically localized prostate cancer. Please refer to Parts I and II for discussion of risk assessment, staging, and risk-based management (Part I), and principles of active surveillance and surgery and follow-up (Part II). 

This guideline aims to inform clinicians treating patients with clinically localized prostate cancer. Continued research and publication of high-quality evidence from future trials will be essential to further improve care for these men.

Target Patient Population

Patients with clinically localized prostate cancer

Target Provider Population

Urologists, radiation oncologists, medical oncologists and other allied providers caring for patients with prostate cancer

Inclusion Criteria

Male, Adult, Older adult

Health Care Settings

Ambulatory, Hospital, Outpatient, Radiology services

Intended Users

Nurse, nurse practitioner, physician, physician assistant, radiology technologist

Scope

Management

Diseases/Conditions (MeSH)

D011467 - Prostate, D011471 - Prostatic Neoplasms

Keywords

prostate cancer, radiation therapy

Source Citation

Eastham JA, Auffenberg GB, Barocas DA, Chou R, Crispino T, Davis JW, Eggener S, Horwitz EM, Kane CJ, Kirkby E, Lin DW, McBride SM, Morgans AK, Pierorazio PM, Rodrigues G, Wong WW, Boorjian SA. Clinically Localized Prostate Cancer: AUA/ASTRO Guideline. Part III: Principles of Radiation and Future Directions. J Urol. 2022 May 10:101097JU0000000000002759. doi: 10.1097/JU.0000000000002759. Epub ahead of print. PMID: 35536141.

Supplemental Methodology Resources

Data Supplement

Methodology

Number of Source Documents
297
Literature Search Start Date
July 31, 2021
Literature Search End Date
August 31, 2021