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Urology: Prostate radical RT hypofractionation

Free question published 21 July 2026

UrologyProstate radical RT hypofractionation

A 71-year-old man with intermediate-risk localised prostate cancer (cT2a, Gleason 3+4=7, PSA 9 ng/mL) elects radical external beam radiotherapy in combination with androgen deprivation therapy after multidisciplinary discussion. He has no inflammatory bowel disease and no prior pelvic radiotherapy, and image-guided IMRT is available. What is the most appropriate first-line fractionation schedule?

  1. A60 Gy in 20 fractions using image-guided IMRT
  2. B74 Gy in 37 fractions using conventional fractionation
  3. C36.25 Gy in 5 fractions using stereotactic body radiotherapy
  4. D55 Gy in 20 fractions using 3D-conformal radiotherapy
  5. E64 Gy in 32 fractions using image-guided IMRT

Why A is correct

NICE NG131 (recommendation 1.3.19) and the CHHiP trial support moderate hypofractionation: offer 60 Gy in 20 fractions using image-guided IMRT as first-line, reserving 74 Gy in 37 fractions for those who cannot have hypofractionation. CHHiP showed 60 Gy in 20 fractions was non-inferior to 74 Gy in 37 fractions at 5 years without a significant increase in late toxicity. Since June 2026, NHS England routinely commissions 5-fraction SABR (36.25 Gy, the PACE-B regimen) as an alternative to hypofractionated IMRT, but only for low- or intermediate-risk patients who do not require androgen deprivation therapy; because this patient is having combined ADT per NG131 1.3.21, he falls outside that SABR pathway, and 60 Gy in 20 fractions remains the appropriate first-line schedule.

And why the others are not

  • BIncorrect first-line: conventional 74 Gy in 37 fractions is reserved by NICE NG131 for people who cannot have hypofractionated radiotherapy.
  • CIncorrect for this patient: 5-fraction SABR is now NHS England-commissioned, but only for patients who do not require androgen deprivation therapy; this patient is having combined ADT, so he is not eligible for that pathway.
  • DIncorrect: 55 Gy in 20 fractions is not the validated dose, and CHHiP/NICE specify image-guided IMRT rather than 3D-conformal radiotherapy.
  • EIncorrect: 64 Gy in 32 fractions is not a NICE-recommended schedule for localised prostate cancer.

Source NICE NG131 — Prostate cancer: diagnosis and management — National Institute for Health and Care Excellence. Prostate cancer: diagnosis and management. NICE guideline NG131. Published 09/05/2019, updated 15/12/2021.

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