High-dose external beam radiation for localized prostate cancer: current status and future challenges

Since the 1960s, external beam radiation has been one of the major curative treatment options for patients with clinically localized prostate cancer. Efforts to improve the efficacy of this modality have focused on delivering a higher dose, and several recent randomized trials have confirmed that this higher dose results in improved oncological outcomes, particularly for patients with intermediate-risk disease. Technological advancements over the past 2 decades have allowed highly conformal treatments that spare more normal tissue and reduce early and long-term treatment side effects. In a complementary fashion, methods have been developed for better real-time localization of the prostate such that radiation fields can be shifted before each treatment to match the daily shifts in the position of the target, leading to greater accuracy and allowing for smaller treatment margins that in turn will overlap with less normal tissue. With newer and more expensive technologies such as intensity-modulated radiation therapy and protons being used with increasing frequency for the treatment of prostate cancer, it becomes imperative to study the risks and benefits of each new modality so that informed cost-benefit decisions can be made. Similarly, there has been a growing interest in hypofractionation as a means of exploiting the supposed low alpha/beta ratio of prostate cancer to shorten overall treatment time and thereby improve convenience and lower costs. However, as with any new technology, it is necessary to proceed with caution in the arena of hypofractionation while we await the results of trials that will help us to determine the long-term risks and benefits of hypofractionation and whether biological assumptions about the underlying alpha/beta ratio can translate into a true clinical advantage.