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Radiotherapy is given as a total dose split into a number of treatments (fractions). For most common cancers there is a standard schedule backed by trials: for example one week for early breast cancer, four weeks for prostate cancer, and often a single treatment for painful bone metastases. Fewer, larger treatments are now standard for many cancers because trials showed they work as well.
The RCR's Radiotherapy dose fractionation (fourth edition, January 2024) is the UK reference: evidence-based schedules for 22 sites, each graded on the Oxford CEBM scale (A consistent level 1 studies to D expert opinion). It covers external beam only (brachytherapy is excluded), avoids recommending fields, volumes or technique, and states that inclusion does not mean a schedule is commissioned by the NHS in any of the four nations. It also sets out what a complete prescription contains.
Examples, as printed: adjuvant non-nodal breast or chest wall without immediate reconstruction 26 Gy in 5 fractions over 1 week (A), the same for external beam partial breast (A), regional nodes 40 Gy in 15 (B); prostate only 60 Gy in 20 fractions over 4 weeks (A); radical bladder 55 Gy in 20 (A); short-course preoperative rectal 25 Gy in 5 (A); medically inoperable peripheral T1 to T2b N0 lung SABR 54 Gy in 3 (B); glioblastoma with good performance status under 70, 60 Gy in 30 with or without temozolomide (A); painful bone metastases 8 Gy single dose (A); spinal cord compression in non-ambulant patients or a prognosis under 6 months 8 Gy single dose (A), and 20 Gy in 5 or 30 Gy in 10 for ambulant patients with a good prognosis or after surgery (B).
ASTRO differs in places: its 2018 whole-breast guideline prefers 40 Gy in 15 or 42.5 Gy in 16 (not 26 Gy in 5); its 2024 bone metastasis guideline lists 8 Gy in 1, 20 Gy in 5, 24 Gy in 6 or 30 Gy in 10 as equally recommended and conditionally prefers SBRT for selected patients with good performance status; its October 2026 prostate guideline recommends moderate hypofractionation over conventional fractionation for all risk groups and ultrahypofractionation as a standard option for low and intermediate risk.
Why: The prescription is the legal record of the treatment and is used as evidence that the treatment was justified and checked.
“The legal record of the radiotherapy treatment to be delivered is the radiotherapy treatment prescription.”
The Royal College of Radiologists 2024 · ungraded (introduction)
Why: Since the UK FAST-Forward trial in 2020, one week has replaced three weeks as standard for early breast cancer.
“For adjuvant radiotherapy of non-nodal breast or chest wall without immediate reconstruction: • 26 Gy in 5 fractions over 1 week (Grade A)”
The Royal College of Radiologists 2024 · Grade A
Why: Three weeks remains the standard when the lymph node areas are treated.
“For regional nodal irradiation: • 40 Gy in 15 fractions over 3 weeks (Grade B)”
The Royal College of Radiologists 2024 · Grade B
Why: Four weeks controls the cancer as well as the older seven-and-a-half-week course.
“Prostate-only RT: • 60 Gy in 20 fractions over 4 weeks (Grade A)”
The Royal College of Radiologists 2024 · Grade A
Why: Four weeks is the UK regimen of choice for curative bladder radiotherapy, graded on the strongest level of evidence.
“For radical radiotherapy to the bladder: • 55 Gy in 20 fractions over 4 weeks is the regimen of choice (Grade A)”
The Royal College of Radiologists 2024 · Grade A
Why: One week of radiotherapy before surgery lowers the chance of the cancer returning in the pelvis.
“Short-course preoperative radiotherapy: • 25 Gy in 5 daily fractions (Grade A)”
The Royal College of Radiologists 2024 · Grade A
Why: A few very precise high doses control small lung cancers in people who cannot have surgery.
“SABR using: • 54 Gy in 3 fractions over 5–8 days (Grade B)”
The Royal College of Radiologists 2024 · Grade B
Why: Six weeks of radiotherapy, usually with temozolomide, is the standard for fit people with this tumour.
“Good performance status (KPS 80–100) and aged <70 with minimal residual tumour: • 60 Gy in 30 daily fractions over 6 weeks ± temozolomide (Grade A)”
The Royal College of Radiologists 2024 · Grade A
Why: Trials and their meta-analyses support a single treatment for pain; around a quarter of people need a further treatment later.
“For the initial treatment of pain from bone metastases: • 8 Gy single dose (Grade A)”
The Royal College of Radiologists 2024 · Grade A
Why: A single treatment spares people with little time from extra visits; longer courses suit those expected to live longer.
“Metastatic spinal cord compression: non-ambulant patients or ambulant patients with a prognosis <6 months: • 8 Gy single dose (Grade A)”
The Royal College of Radiologists 2024 · Grade A (single dose); Grade B (20 Gy in 5 or 30 Gy in 10)
Why: A schedule can be evidence-based and still not yet funded in a given UK nation.
“However, inclusion in this guidance does not imply that a particular treatment or schedule is commissioned by the national health services in the four UK nations.”
The Royal College of Radiologists 2024 · ungraded
How care is usually carried out, read from the guidelines and standards cited. Your own team's protocol and their judgement come first; this page is for understanding it, not for doing it yourself.
For UK practice, the RCR fourth edition (January 2024) is the current graded reference, with Grade A schedules for the commonest indications (26 Gy in 5 for non-nodal breast, 60 Gy in 20 for prostate, 55 Gy in 20 for bladder, 25 Gy in 5 short-course rectal, 60 Gy in 30 for fit glioblastoma, 8 Gy single dose for painful bone metastases and for cord compression with poor mobility or prognosis). Where the US guideline differs, both are shown: ASTRO (2018) prefers 40 Gy in 15 or 42.5 Gy in 16 for whole breast, predating the five-year FAST-Forward results the RCR grades A; ASTRO (2024) recommends 8 Gy in 1, 20 Gy in 5, 24 Gy in 6 or 30 Gy in 10 for painful bone metastases, conditionally preferring SBRT for selected fit patients, where the RCR names 8 Gy single dose; ASTRO (October 2026) recommends moderate hypofractionation for localized prostate cancer across risk groups and ultrahypofractionation as a standard option at low and intermediate risk, consistent with the RCR's 60 Gy in 20.
The Royal College of Radiologists 2024 · American Society for Radiation Oncology (Practical Radiation Oncology) 2018 · American Society for Radiation Oncology (Practical Radiation Oncology) 2024 · American Society for Radiation Oncology (Practical Radiation Oncology) 2026
Where it differs: Preferred whole-breast schedule is 40 Gy in 15 fractions or 42.5 Gy in 16 fractions; 26 Gy in 5 is not the preferred option.
Evidence: Systematic review and graded consensus (abstract read). Published before the five-year FAST-Forward results on which the RCR's Grade A rests.
American Society for Radiation Oncology (Practical Radiation Oncology) 2018 · The Royal College of Radiologists 2024
Where it differs: Recommends 8 Gy in 1, 20 Gy in 5, 24 Gy in 6 or 30 Gy in 10 for symptomatic bone metastases; for cord or cauda equina compression in people ineligible for surgery, 8 Gy in 1, 16 Gy in 2, 20 Gy in 5 or 30 Gy in 10; conditionally recommends SBRT over conventional radiotherapy for selected patients with good performance status without surgery or neurological signs; surgery then radiotherapy conditionally over radiotherapy alone for cord compression.
Evidence: Based on an AHRQ systematic review with graded consensus (abstract read).
American Society for Radiation Oncology (Practical Radiation Oncology) 2024
Where it differs: Recommends moderate hypofractionation over conventional fractionation for all risk groups and ultrahypofractionation as a standard option for low- and intermediate-risk disease, to be considered in selected high-risk patients, preferably in trials; moderate hypofractionation may be preferred with significant baseline urinary problems.
Evidence: Systematic review with graded consensus; high-quality randomised data (abstract read). The schedules it lists were not read.
American Society for Radiation Oncology (Practical Radiation Oncology) 2026
A trial of 4,000 people showed that five treatments over one week control breast cancer as well as three weeks, and England's national guideline has offered it as standard since 2023 when the lymph nodes are not treated. In United States hospitals, ten treatments or fewer were used for 11.4 per cent of women with early breast cancer after breast-conserving surgery in 2020 and 2021.
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.
Randomised trials and meta-analyses show a single 8 Gy radiotherapy session relieves pain from uncomplicated bone metastases as well as ten sessions, with a higher retreatment rate, yet habit and per-fraction payment keep most patients on the longer course. Making one session the default, with an opt-out justification and payment neutrality, would spare patients trips and free machines.
| Recommendation | Grade, as printed | Source |
|---|---|---|
| Non-nodal breast or chest wall without immediate reconstruction: 26 Gy in 5 fractions | Grade A | The Royal College of Radiologists 2024 |
| Partial breast external beam: 26 Gy in 5 fractions “For partial breast radiotherapy using external beam radiotherapy: • 26 Gy in 5 fractions over 1 week (Grade A)” | Grade A | The Royal College of Radiologists 2024 |
| Prostate only: 60 Gy in 20 fractions | Grade A | The Royal College of Radiologists 2024 |
| Ambulant cord compression with a good prognosis, or after surgery: 20 Gy in 5 or 30 Gy in 10 “Metastatic spinal cord compression: ambulant patients with a good prognosis or post-spinal surgery: • 20 Gy in 5 daily fractions over 1 week (Grade B) or • 30 Gy in 10 daily fractions over 2 weeks (Grade B)” | Grade B | The Royal College of Radiologists 2024 |
| Reirradiation of bone metastases: 8 Gy single dose or 20 Gy in 5 “For the reirradiation of bone metastases: • 8 Gy single dose (Grade B) • 20 Gy in 5 daily fractions (or 8 fractions over the spinal cord) over 1 week (Grade B)” | Grade B | The Royal College of Radiologists 2024 |
Shares American Society for Radiation Oncology, Four weeks or five treatments, not seven and a half weeks, for prostate radiotherapy, One week of breast radiotherapy in five treatments as the default after surgery, SBRT / SABR (stereotactic radiotherapy).
Shares Metastatic spinal cord compression (MSCC), American Society for Radiation Oncology, Bone metastases and skeletal-related events, SBRT / SABR (stereotactic radiotherapy).
Shares Bladder filling and rectal preparation for prostate radiotherapy, Four weeks or five treatments, not seven and a half weeks, for prostate radiotherapy, Bladder & urothelial cancer, Rectal cancer.
Shares Bladder filling and rectal preparation for prostate radiotherapy, Four weeks or five treatments, not seven and a half weeks, for prostate radiotherapy, SBRT / SABR (stereotactic radiotherapy), Prostate cancer.
Shares Four weeks or five treatments, not seven and a half weeks, for prostate radiotherapy, One week of breast radiotherapy in five treatments as the default after surgery, SBRT / SABR (stereotactic radiotherapy), Prostate cancer.
Shares Bladder filling and rectal preparation for prostate radiotherapy, Four weeks or five treatments, not seven and a half weeks, for prostate radiotherapy, Hypofractionation (fewer, larger radiotherapy doses), SBRT / SABR (stereotactic radiotherapy).
Shares Single-fraction radiotherapy as the default for painful bone metastases, Bone metastases and skeletal-related events, Non-small-cell lung cancer.
Shares Breast radiotherapy positioning, immobilisation and daily set-up verification, One week of breast radiotherapy in five treatments as the default after surgery, Hypofractionation (fewer, larger radiotherapy doses), Breast cancer (all types).