{"entity":{"id":"idea-pu-prostate-hypofractionation-default","kind":"idea","name":"Four weeks or five treatments, not seven and a half weeks, for prostate radiotherapy","aka":[],"tldr":"Randomised trials showed that 20 treatments over four weeks, and for many men five, control localised prostate cancer as well as 37 to 39, and England's national guideline has offered the four-week course since 2019. In New South Wales its use rose from 5.2 to 40.3 per cent of men between 2014 and 2018, and an international survey found it used less for high-risk disease.","summary":"The evidence. CHHiP randomised 3,216 men between 74 Gy in 37 fractions over 7.4 weeks and two shorter schedules. At five years, 88.3 per cent were free of biochemical or clinical failure with 74 Gy and 90.6 per cent with 60 Gy in 20 fractions, which was non-inferior; 57 Gy in 19 fractions was not shown to be non-inferior. Long-term bowel and bladder side effects were similar. PACE-B randomised 874 men with low or, mostly, intermediate-risk disease between five-fraction stereotactic radiotherapy (36.25 Gy) and 20 or 39 fractions: five-year freedom from failure was 95.8 against 94.6 per cent, also non-inferior, but late grade 2 or worse urinary side effects were more common with five fractions, 26.9 against 18.3 per cent, while bowel effects were the same. The five-treatment course is therefore a trade a man can be offered with its numbers, not a free gain.\n\nThe guideline. NICE NG131 recommendation 1.3.19 (2019): \"offer hypofractionated radiotherapy (60 Gy in 20 fractions) using image-guided intensity modulated radiation therapy (IMRT), unless contraindicated\".\n\nThe measured gap. In New South Wales outpatient radiotherapy data for 4,915 men treated with curative intent between 2014 and 2018, the four-week schedule rose from 5.2 to 40.3 per cent, and the treating oncologist and the facility had the largest influence on which schedule a man received. In the 2018 to 2019 ESTRO Global Impact of Radiotherapy in Oncology survey of 1,157 radiation oncologists, 52 and 47 per cent reported using hypofractionation in at least half of low- and intermediate-risk patients, falling to 35 per cent for high-risk disease and 20 per cent where the pelvic nodes were treated; respondents in middle- and low-income countries were less likely to prefer it, and the commonest barrier given was fear of worse late side effects. OnCo did not find a national audit of fractionation in England.","asOf":"2026-10-20","links":[{"label":"Dearnaley et al., Conventional versus hypofractionated high-dose intensity-modulated radiotherapy for prostate cancer: 5-year outcomes of the CHHiP trial (Lancet Oncology 2016)","url":"https://doi.org/10.1016/S1470-2045(16)30102-4"},{"label":"van As et al., Phase 3 trial of stereotactic body radiotherapy in localized prostate cancer, PACE-B (New England Journal of Medicine 2024)","url":"https://doi.org/10.1056/NEJMoa2403365"},{"label":"NICE guideline NG131, Prostate cancer: recommendation 1.3.19 (60 Gy in 20 fractions, 2019)","url":"https://www.nice.org.uk/guidance/ng131/chapter/Recommendations"},{"label":"Nithiyananthan et al., Population-level uptake of moderately hypofractionated definitive radiation therapy in the treatment of prostate cancer (International Journal of Radiation Oncology, Biology, Physics 2021)","url":"https://doi.org/10.1016/j.ijrobp.2021.04.033"},{"label":"Sabbagh et al., Hypofractionation adoption in prostate cancer radiotherapy: results of an international survey (JCO Global Oncology 2023)","url":"https://doi.org/10.1200/go.23.00046"}],"tags":["protocol-upgrade","upgrade:proven-unevenly-used","evidence:strong"],"related":["idea-acc-hypofractionation-default-lmic","idea-cost-hypofractionation-payment","idea-pu-five-fraction-breast-default","idea-pu-rectal-spacer-prostate"],"cancers":["prostate"],"sections":["radiation"],"technologies":["hypofractionated-radiotherapy","sbrt","imrt-igrt"],"targets":[],"drugs":[],"companies":[],"institutions":["nice"],"pathways":[],"terms":["hypofractionation","prostate-radiotherapy-fractionation"],"trials":["chhip","pace-b","hypo-rt-pc"],"people":[],"bottlenecks":["b-knowledge-diffusion","b-incentive-misalignment","b-global-access"],"keyPapers":["paper-chhip-lancet-oncol-2016","paper-van-as-n-engl-j-med","paper-widmark-lancet"],"journals":[],"dependsOn":[],"notes":[],"hypothesis":"Making 60 Gy in 20 fractions the written default for localised prostate radiotherapy, with five-fraction stereotactic treatment offered with its urinary trade-off stated for eligible low- and intermediate-risk men, reduces average fractions per course by at least 40 per cent across a network with no change in biochemical control at five years.","rationale":"Two large non-inferiority trials, a national guideline, and population data showing that the oncologist a man happens to see decides his schedule more than his disease does.","test":"A network-level audit of fractions per course by risk group and by clinician, published back to clinicians with the guideline, measured before and after against five-year biochemical control and patient-reported urinary and bowel function.","maturity":"being-tested-at-scale","actor":"clinic","cost":"small","horizonYears":2},"route":"/ideas/idea-pu-prostate-hypofractionation-default/","neighbours":{"idea":[{"id":"idea-pu-pelvic-filling-protocol","kind":"idea","name":"A measured drink of water before pelvic radiotherapy, and bowel preparation kept to what trials support","route":"/ideas/idea-pu-pelvic-filling-protocol/"},{"id":"idea-pu-rectal-spacer-prostate","kind":"idea","name":"An absorbable gel or balloon between prostate and rectum before radiotherapy, used under audit","route":"/ideas/idea-pu-rectal-spacer-prostate/"},{"id":"idea-acc-hypofractionation-default-lmic","kind":"idea","name":"Make one-week radiotherapy the default in overloaded systems","route":"/ideas/idea-acc-hypofractionation-default-lmic/"},{"id":"idea-pu-five-fraction-breast-default","kind":"idea","name":"One week of breast radiotherapy in five treatments as the default after surgery","route":"/ideas/idea-pu-five-fraction-breast-default/"},{"id":"idea-cost-hypofractionation-payment","kind":"idea","name":"Pay for a course of radiotherapy, not for each fraction","route":"/ideas/idea-cost-hypofractionation-payment/"},{"id":"idea-acc-single-fraction-palliative-radiotherapy-default","kind":"idea","name":"Single-fraction radiotherapy as the default for painful bone metastases","route":"/ideas/idea-acc-single-fraction-palliative-radiotherapy-default/"}],"cancer":[{"id":"prostate","kind":"cancer","name":"Prostate cancer","route":"/cancers/prostate/"}],"section":[{"id":"radiation","kind":"section","name":"Radiation Therapy","route":"/fronts/radiation/"}],"technology":[{"id":"hypofractionated-radiotherapy","kind":"technology","name":"Hypofractionated radiotherapy","route":"/technologies/hypofractionated-radiotherapy/"},{"id":"imrt-igrt","kind":"technology","name":"IMRT / IGRT (modern external beam)","route":"/technologies/imrt-igrt/"},{"id":"sbrt","kind":"technology","name":"SBRT / SABR (stereotactic radiotherapy)","route":"/technologies/sbrt/"}],"institution":[{"id":"nice","kind":"institution","name":"National Institute for Health and Care Excellence","route":"/institutions/nice/"}],"term":[{"id":"prostate-radiotherapy-fractionation","kind":"term","name":"How many radiotherapy visits: the prostate fractionation trials","route":"/terms/prostate-radiotherapy-fractionation/"},{"id":"hypofractionation","kind":"term","name":"Hypofractionation (fewer, larger radiotherapy doses)","route":"/terms/hypofractionation/"}],"trial":[{"id":"chhip","kind":"trial","name":"CHHiP","route":"/trials/chhip/"},{"id":"hypo-rt-pc","kind":"trial","name":"HYPO-RT-PC","route":"/trials/hypo-rt-pc/"},{"id":"pace-b","kind":"trial","name":"PACE-B","route":"/trials/pace-b/"}],"bottleneck":[{"id":"b-incentive-misalignment","kind":"bottleneck","name":"Incentives reward me-too drugs and marginal gains","route":"/bottlenecks/b-incentive-misalignment/"},{"id":"b-knowledge-diffusion","kind":"bottleneck","name":"Knowledge reaches practice too slowly","route":"/bottlenecks/b-knowledge-diffusion/"},{"id":"b-global-access","kind":"bottleneck","name":"Most of the world has almost no cancer care","route":"/bottlenecks/b-global-access/"}],"paper":[{"id":"paper-chhip-lancet-oncol-2016","kind":"paper","name":"CHHiP: conventional versus hypofractionated high-dose intensity-modulated radiotherapy for prostate cancer","route":"/key-papers/paper-chhip-lancet-oncol-2016/"},{"id":"paper-van-as-n-engl-j-med","kind":"paper","name":"Phase 3 Trial of Stereotactic Body Radiotherapy in Localized Prostate Cancer","route":"/key-papers/paper-van-as-n-engl-j-med/"},{"id":"paper-widmark-lancet","kind":"paper","name":"Ultra-hypofractionated versus conventionally fractionated radiotherapy for prostate cancer: 5-year outcomes of the HYPO-RT-PC randomised, non-inferiority, phase 3 trial","route":"/key-papers/paper-widmark-lancet/"}]}}