The use of conformal radiotherapy and the selection of radiation dose in T1 or T2 low or intermediate risk prostate cancer – a systematic review

BACKGROUND AND PURPOSE: The purpose was to develop a systematic review that would address the following questions: (a) when single-modality treatment external-beam radiotherapy is selected as the modality of choice, what is the role of three-dimensional (3D) conformal radiotherapy in treating clinically localized (T1, T2/NO, NX/MO) prostate cancer? The outcomes of interest are biochemical freedom from failure (bNED) rates, clinical recurrence-free survival, disease-specific survival and acute and late toxicity; (b) what is the appropriate dose and fractionation prescription in this clinical setting? MATERIALS AND METHODS: A systematic review of the English published literature was undertaken to provide evidence relevant to the above outcomes. RESULTS: One randomized controlled trial comparing conventional radiotherapy to conformal therapy with dose escalation reported bNED rates. Three additional randomized controlled trials reported acute or chronic late outcome assessments. Additionally, phase II studies of dose escalation in sequential patient cohorts and non-randomized comparative assessments of dose-response and bNED rates in controlled analyses were reviewed. There is convincing evidence from randomized trials that the use of conformal therapy reduces acute and late treatment-related morbidity. There is preliminary evidence suggesting that when external-beam therapy alone is used to treat patients, conformal therapy with dose-escalation is more efficacious than doses of 70Gy. The increased efficacy appears to be predominantly seen in the subset of patients with intermediate-risk disease (PSA 10-20). There is conflicting evidence of the efficacy of dose-escalation in patients with low initial PSA (<10) and in patients with initial PSA greater than 20. Conformal radiotherapy at a dose of 78Gy appears to be relatively safe with no increase in acute or late effects compared with conventional treatment (up to 70Gy) so long as appropriate technological principles are considered. CONCLUSIONS: Patients who have external-beam radiotherapy should be treated using a 3D conformal technique. Patients with intermediate-risk disease (PSA 10-20) who are treated with external-beam radiotherapy alone should be offered doses of 75-78Gy in 180-200cGy fractions.