Radiotherapy Protocol for the management of Prostate Cancer This is radiotherapy protocol for the East Midlands RT Operational Delivery Network (ODN). Tumour sites are: Prostate Document revision History Version Number Date Document History. 0.01 Initial Draft by Priyesh Mistry 0.02 Aug 2023 Edited with KD 0.03 Oct 2023 Edited post M.S-Howell feedback 0.04 Nov 8th 2023 Changes following 1st Network review. In attendance: K.Das, M.Panades, S.Sundar, M.S- Howell, J.Branagan 0.05 Dec 1st 2023 Changes following 2nd Network review In attendance: K.Das, M.Panades, R.Russell, M.S- Howell, J.Branagan, A.F-Ots, C.Vithanage, J.Davies, N.Bhuvanendran 0.06 Dec 15th 2023 Edited following 3rd Network review. In attendance: A.Nair, L.Alder, G.Chetiyawardana, V.M- Smith, K.Kancherla, R.Russell, M.S- Howell, A.F-Ots, 0.07 March 19th 2024 Reviewed by Radiotherapy planning team. In attendance: D.Holmes, V.Ohlendorf, M.Bland, L.Martins. V. M-Smith, J. Sutton Updated draft shared to planning team for any further comments 0.08 23rd April 2024 Table changes In attendance: D.Holmes, L.Martins. V. M-Smith, 1.0 4th June 2024 Shared at ECAG 1.0 13th September 2024 Ratified at NOG 1.1 January 2025 KD/PM- References improved as per Dec 2024 NOG action Radiotherapy Protocol for the management of Prostate Cancer ......................................................... 1 1. Treatments to include ............................................................................................................... 3 2. Indications for treatment ......................................................................................................... 3 3. Investigations Required ............................................................................................................ 6 4. Information given to patients ................................................................................................... 6 5. Consent ...................................................................................................................................... 6 6. Trials Open ................................................................................................................................ 6 7. Position and immobilization ..................................................................................................... 7 8. Planning ..................................................................................................................................... 8 9. Organs at risk .......................................................................................................................... 11 10. Palliative Intent ................................................................................................................... 15 11. Treatment ............................................................................................................................ 16 12. Late effects .......................................................................................................................... 17 13. Peer Review ......................................................................................................................... 17 14. Glossary ............................................................................................................................... 18 15. References ........................................................................................................................... 19 Appendix 1[8] .................................................................................................................................... 20 Appendix 2 [9] ................................................................................................................................... 21 FIG 1 [9] ............................................................................................................................................. 21 Fig 2 [9] .............................................................................................................................................. 22 Appendix 3- Contouring CTVn [13] ................................................................................................... 23 Appendix 4- (Optional) Regional cross site brachytherapy referral process ................................ 24 1. Treatments to include  Radical external beam Radiotherapy +/- hormone therapy  Brachytherapy +/- EBRT +/- Hormones  Palliative Radiotherapy 2. Indications for treatment  Histological confirmation of tumour and/or MDT consensus.  Staging should be offered to patients being considered for radical treatment i.e. good performance status, life expectancy of 10 years (utilising a suitable life expectancy calculator) or if symptomatic.  Local staging of tumour with physical examination, multi parametric pelvic MRI and prostate biopsy is undertaken by the Urology team prior to referral. Indications for treatment type: Active Surveillance Consider for asymptomatic men with Cambridge Prognostic Group (CPG) 1-3[17] Radical prostatectomy Medically fit. Laparoscopic Prostatectomy may be offered to selected patients. Radical external beam radiotherapy:  Performance status 0 - 2, life expectancy ≥10 years, localised disease within the pelvis, no history of bowel or bladder disease, which may impair tolerance of radiotherapy.  Neo-adjuvant or adjuvant hormone therapy is considered for all patients (except CPG 1 +/- CPG 2). This consists of monthly injections for 3 – 6 months (minimum 3) before Radiotherapy and then continues through the Radiotherapy treatment. For patients having long term hormone treatment aim to start after 4-6 months. On completion of Radiotherapy no further injections should be given for low or intermediate risk patients unless specified otherwise. *Option: minimal neo-adjuvant hormones (less than 4 weeks) followed by adjuvant hormones for 4 months*  Patients that satisfy the inclusion criteria for PACE-B[9] could be considered for SBRT (36.25 in 5#) as per PACE protocol if the treating centre has participated in any PACE QA process. *nb. 73% of patients had fiducial markers inserted and 41% of patients were treated on cyberknife as part of trial*  For high risk patients (CPG 4 & 5)[17] long term hormone treatment for 18 months - 3 years (+/- abiraterone when commissioned) should be considered if: -T3a or above -Gleason score > 8 -PSA > 20  Radiotherapy to prostate and seminal vesicles, as per CHiPP trial[12] (and PACE- B pending commissioning).  Rectal spacer may be offered to the patient, if available and clinically appropriate SPACEOAR/Rectal Spacer Criteria[18]:  Histologically proven prostate cancer  Radiologically T1, T2 and anterior or lateral T3a , N0 M0  Prostate size up to 70 cc can consider up to 80 cc if patients is on LHRH agonist)  IPSS 18 or below  No anaesthetic contraindication Exclusion criteria  Active bleeding disorder or clinically significant coagulopathy  Anticoagulants (discontinuation usually possible)  Active inflammatory or infectious disease in the perineum or injection area (prostatitis, anorectal inflammatory disease with increased risk of ulceration, fistula or bleeding such as ulcerative colitis or Crohn’s disease)  Previous treatment of prostate with high risk of adhesions (high-intensity focused ultrasound, cryotherapy, radiotherapy) Nodal Radiotherapy:  Pelvic nodal radiotherapy can be considered for patients who do not meet CHiPP[12] inclusion criteria or CPG3 and above using a hypo-fractionated regime (60Gy/20# to prostate, 44-47Gy to elective nodes with boost to 51-60Gy) - (Clinician Discretion) Gross nodes: May be treated as high as clinically feasible up to a maximum of the dose being delivered to the prostate, whilst respecting OAR tolerances. Nodal volumes should be examined pre and post ADT, with the post ADT tumour volume serving as the high dose boost volume.[14]  Conventional fractionation (74Gy/37# to prostate, 55-60Gy to elective nodes with boost to 60-66Gy) remains an option  PA nodes may be considered to be included in accordance to local clinical decisions and clinician discretion Salvage RT:  Salvage Radiotherapy can be considered for post prostatectomy patients with 3 consecutive PSA rises or PSA > 0.2ng/ml, after radical prostatectomy. [15][19]  Hypo-fractionated regime is recommended as per RCR recommendations.  Adjuvant hormones can be offered.  +/- ADT with anti-androgen or LHRH analogues between 6-24 months  +/- pelvic nodes Brachytherapy[3] :  Prostate brachytherapy allows radiation dose escalation beyond what would be achievable by EBRT. In addition, there are fewer issues with changes in prostate position during treatment delivery.  Brachytherapy as monotherapy for low and intermediate risk patients with favorable features can be used as a single implant, most commonly with Iodine-125 (I125) seeds. For low dose rate (LDR) I-125 monotherapy the prescription dose to the CTV is 145 Gy.  An alternative option is fractionated high dose rate (HDR) brachytherapy with a recommended dose of 27 Gy in 2 treatments 1-2 weeks apart  For high risk patients LDR or HDR brachytherapy in combination with ADT and EBRT to the prostate or prostate and pelvic nodes is an effective treatment.  Brachytherapy boost may be delivered before or after EBRT. Recommended fractionation schedule for LDR boost is 110 Gy and for HDR boost it is 15Gy.  Recommended EBRT schedules are 37Gy in 15 fractions for prostate only RT. Most published series for brachytherapy and EBRT combinations have used 46Gy in 23 fractions for PNRT. For the discussion regarding the pelvic nodal dose, please refer to the discussion below. Cross site referral  Brachytherapy for prostate cancer is not offered locally at all centres in the East Midlands.  Eligible patients that wish to pursue this option may be offered this treatment by their consultant and referred to one of the regional providers delivering this service.  An optional workflow is shown in Appendix 4 to provide considerations for this process 3. Investigations Required  Histological confirmation of malignancy  PSA  Diagnostic/staging imaging to include: -Bone Scan (if PSA >20 or T3 disease or CPG 3 or above) -Staging pelvic MRI -Consider CT chest/abdo/pelvis if PSA > 30 -Consider choline/PSMA PET if concerns about metastases and other staging equivocal or PSA >50 (as per PEARLS) and other scans negative Review of clinical history to include: -Previous radiotherapy -History and examination, PS Special Circumstances to consider: -Chronic conditions or disease that affects radiosensitivity -Ongoing medication that may affect response to radiotherapy 4. Information given to patients  General radiotherapy booklet  Site specific treatment leaflet including long term side effects 5. Consent  By IR(ME)R Practitioner at new patient / planning clinic  By Entitled IR(ME)R Operator under delegated authority at new patient / planning clinic 6. Trials Open  Consider current trials open in any of the radiotherapy centres in the East Midlands. [EMRTN TRIALS TRACKER LINK]  If a patient is being treated in a clinical trial then the Trial Protocol overrides the departmental protocol. 7. Position and immobilization All patients will be CT scanned as per local protocol and should consider including the following:  Patients taking hormones therapy should be scanned accordingly to their ECAD  Appropriate scan levels - Prostate only should include the whole pelvis up to the iliac crests and below the ischium. - Pelvic nodes should extend from L2/3 interspace and extend to down to the level of the lesser trochanter  Suitable pelvic patient immobilisation should consider: Knee rest, foot stocks, head support and vacuum cushions if appropriate.  Patients should be supine with appropriate bladder and rectum preparation as per local protocol.  Laxatives and micro enemas to be used as per local protocol  Use of IV contrast to aid delineation of pelvic vessels  Following the CT scan, the size of the rectum is reviewed. If it is larger than local protocol requirements and cannot be rectified, the patient should be sent away with advice and return for a rescan  If the patients bladder is also outside local protocol and unable to be rectified, the patient should be sent away with advice and return for a rescan  Fiducial markers if available 8. Planning Radical Treatment  VMAT is the primary choice of planning technique for radical patients. Conformal Radiotherapy will be considered on a case by case basis.  Target coverage and OAR requirements, both objectives and mandatory constraints are documented on OAR Dose constraints table. Standard IMRT practice of editing lower dose levels off higher dose levels following contouring. Constraints applicable for edited volume only.  If a patient is being treated in a clinical trial, then the trial protocol overrides the departmental protocol.  If the treatment is off protocol, this should be noted and the correct local procedure for recording/authorising off protocol treatments should be followed.  There may be situations where individual anatomy and other special conditions require that the coverage of the PTV/CTV may need to be compromised or extended. In these cases the Practitioner is required to exercise his/her clinical judgment and to clearly indicate the clinical priorities to the treatment planning team  Patients above 75 can be offered 57Gy in 19# (non-inferior in CHHiP)[12]  Prostate outlining to be completed accordingly with PACE[9] / PEARLS[6]  Prostate + Nodes outlining to take in to consideration of PACE-NODES[9]  Prostate bed outlining to take in to consideration of RADICALSRT[9]  CTV-PTV margins should also factor in local imaging capabilities and previous departmental audits.  Please see appendix 2 for PACE contouring guidelines[9] Dose Prescriptions[3] Prostate only 60 Gy in 20# over 4 weeks (Grade A) 57 Gy in 19# over 4 weeks (Grade A) (Age > 75) (In select cases according to clinician discretion) (Follow local protocol) Brachytherapy boost 37.5 Gy in 15 fractions (prostate only) over 3 weeks before or after 15 Gy HDR brachytherapy boost (Grade A) 46 Gy in 23 fractions (prostate and pelvic nodes) over 4.5 weeks followed by 15Gy HDR or 115 Gy LDR brachytherapy boost (Grade A) Stereotactic radiotherapy (SBRT) 36.25 Gy in 5 fractions (Grade A) *Not routinely commissioned currently* Can only be offered as a part SBRT treatment Prostate and pelvic lymph nodes 60 Gy in 20 fractions over 4 weeks 74 Gy in 37 Fractions over 7.5 weeks 78 Gy in 39 Fractions over 8 weeks (Follow local protocol) Post-operative RT 66 Gy in 33 fractions over 6.5 weeks or 52.5 - 55 Gy in 20 fractions over 4 weeks (Grade C)  This protocol has referenced PEARLS[9] for the delineation of Radiotherapy where the prostate is in-situ. Other protocols such as PACE[9] with clinically acceptable guidance can also be considered. Local protocols can be adapted to incorporate any of the clinically acceptable guidance protocols as per departmental preference Target volumes of interest: CPG CPG CPG 1-3 CPG 4-5 CTVp Prostate and proximal 1cm seminal vesicles + clinician may adjust for extent of seminal vesicle inclusion As per CPG 1-3 + Clinician may extend up to include all of the seminal vesicles CTVpsv Prostate and proximal 2cm seminal vesicles + clinician may adjust for extent of seminal vesicle inclusion Clinician discretion Consider: -Low risk of SV involvement: Prostate +2cm -High risk of SV involvement: include all SV within CTVp Prostate In-situ Volume of interest Prostate Only Prostate + Pelvic Lymph Nodes 60Gy in 20# 60Gy in 20# 74Gy in 37# CTV CTVp Refer to CPG table Refer to CPG table Refer to CPG table CTVpsv Refer to CPG table Refer to CPG table Refer to CPG table CTVn Prophylactic pelvic lymph nodes Drawn as per Appendix 3 – Contouring CTVn CTVnb Boost involved pelvic nodes is any involved lymph node PTV Planning margins are applied isotropically to the CTV PTVp CTV-PTV margins dependent on:  Local department audit  Immobilisation equipment  Imaging capabilities  Recommendation by department physics teams based on local audits PTVpsv PTVn (elective) PTVnb Post Prostatectomy Volume of interest Prostate Bed Prostate Bed + Nodes Dose # PTV (prostate bed) o 52.5Gy in 20# o 66Gy in 33# o 52.5-55Gy in 20# o 66Gy in 33# PTVn 44Gy- prophylactic pelvic lymph nodes PTVnb 51-60Gy- boost involved pelvic nodes CTV (Whole prostate bed) Recommended contouring guidance notes: ESTRO ACROP guideline on prostate bed delineation[4] or RANZR guidelines[11] (Appendix 3) [Prostate bed] Anterior o Cranially, CTV should cover 1–2 cm of the posterior bladder wall or stop at the posterior margin of bladder wall o Caudally, stop at the posterior margin of the pubic bone up to half to two thirds of the symphysis pubis [Prostate bed] Posterior o Contour up to the anterior rectal wall o Cranially, up to the mesorectal fascia when visualized o Include the antero-lateral angles of the rectum and existing surgical clips [Prostate bed] Lateral o Contour up to the internal margins of the internal obturator muscles o CTV should not be extended latero-anteriorly toward the region of the obturator lymph o More caudally, the lateral borders are the internal margins of the internal obturator muscles or internal borders of the levator ani muscles [Prostate bed] Superior  o Include region of both seminal vesicles with 3–5 mm “bridge” o If no seminal vesicles invasion, include the base (lower third) of the seminal vesicles bed (I.e., level of cut end of vas deferens) o If seminal vesicles invasion, include the entire seminal vesicle bed o Attempt to include existing surgical clips superiorly [Prostate bed] Inferior o 8–12 mm below the VUA  o The VUA is defined as the slice below the last slice where fluid (urine) is seen  o If VUA is not visible, use penile bulb as an anatomic landmark and contour to the slice right above the penile bulb PTV Planning margins are applied isotropically to the CTV PTV (prostate bed) CTV-PTV margins dependent on:  Local department audit  Immobilisation equipment  Imaging capabilities  Recommendation by department physics teams based on local audits PTVn (elective) PTVnb 9. Organs at risk  Organ dose constraints should be guided by national and international guidelines *SBRT –Not routinely commissioned. Please reference PACE[9] protocol for dose volume constraints * The following organs at risk (OAR) must be delineated by the radiographer /dosimetrist /physicist /consultant:  Rectum – outline as a whole organ from recto-sigmoid to ano-rectal junction  Bladder – outline as the whole organ  Femoral Heads (excluding neck of femur)  (Small) Bowel: mandatory for IMRT treatments which include pelvic nodes - Outlined as small bowel and large bowel down to the rectum - Consider outlining only up to 2cm above the superior extent of edge of PTV (as per PACE-NODES[16])  Penile Bulb (optional) Additional OAR (As required for designated treatment) OAR Dose constraints (Gy) Optimal Mandatory Bowel[9] 40 17cc 70cc 48 0.5cc 6cc 52 0cc 0cc Penile Bulb[9] 22 <50% - 48 10% - Femoral Heads[9] 40 - 50% Duodenum[6] 46 - 4cm3 51 - 0.5cm3 Left Kidney[6] 18Gy - 25% Right Kidney[6] 18Gy - 25% Spinal Cord[6] - - Dmax <36Gy  This protocol has referenced PACE[9], Radicals-RT[15], CHHip[12], PIVOTAL[13] and PIVOTALBOOST [10] for the dose volume constraints of OAR. There are several other protocols (e.g. PEARLS) with clinically acceptable dose volume constraint guidance. Local protocols can be adapted to incorporate any of the clinically acceptable guidance protocols as per departmental preference 60Gy /20# Based on: PACE [9] Dose-volume constraints OAR Dose constraints (Gy) Optimal Mandatory Rectum 24 70% 80% 32 51% 65% 40 38% 50% 48 27% 35% 52 - 30% 56 - 15% 60 1% 3% Bladder 40 - 50 % 48 - 25% 60 15% 5% Bowel 40 17cc 70cc 48 0.5cc 6cc 52 0cc 0cc Penile Bulb 22 <50% - 48 10% - Prostate and Sv’s 74Gy /37# Based on: CHHiP [12] Dose-volume constraints OAR Dose constraints (Gy) Optimal Mandatory Rectum 30 41% 80% 40 54% 65% 50 68% 50% 60 81% 35% 65 88% 30% 70 95% 15% 74 100% 3% Bladder 50 68 50 % 60 81 25% 74 100 5% Bowel 50 68 17cc Urethral Bulb 50 68 50% 60 81 10% Prostate Bed 52.5Gy /20# Based on: RADICALS-RT [15] Dose-volume constraints OAR Dose constraints (Gy) Optimal Mandatory Rectum 24 - <80% 32 - <70% 40 - <60% 48 - <50% 52.5 - <30% Bladder 40 - <80% 48 - <50% 66Gy /33# Based on: RADICALS-RT [15] Dose-volume constraints OAR Dose constraints (Gy) Optimal Mandatory Rectum 30 - <80% 40 - <70% 50 - <60% 50 - <50% 66 - <30% Bladder 50 - <80% 60 - <50% 60Gy /20# Based on: PIVOTALBOOST [10] Dose-volume constraints OAR Dose constraints (Gy) Optimal Mandatory Rectum 24 80% 80% 32 65% 65% 40 50% 60% 48 35% 50% 52 - 30% 56 - 15% 60 3% 5% Bladder 40 50% - 48 25% 50% 60 5% 35% Bowel 36 78cc 158cc 40 17cc 70cc 44 14cc 28cc 48 0.5cc 6cc 52 0cc 0cc Penile Bulb 40 <50% - 48 10% - Prostate and Pelvic Lymph Nodes 74Gy /37# Based on: PIVOTAL [13] Dose-volume constraints OAR Dose constraints (Gy) Optimal Mandatory Rectum 30 80% - 40 65% - 50 50% 60% 60 35% 50% 65 30% 30% 70 15% 15% 75 3% 5% Bladder 50 50% - 60 25% - 65 - 50 % 70 5% 35% Bowel 45 78cc 158cc 50 17cc 110cc 55 14cc 28cc 60 0.5cc 6cc 65 0cc 0cc 10. Palliative Intent  There may be options to treat extra-pelvic disease e.g. resection of liver or lung metastases, SABR. Patients with locally advanced disease, but are unfit for Chemo- Radiotherapy, or have metastatic disease, may be considered for palliative radiotherapy.  High-risk localised disease, unsuitable for longer-course fractionation and hormone sensitive disease with low metastatic burden[2] : Dose Fractionations o 55–60Gy in 20# over 4 weeks (Grade A) o 30–36Gy in 6# over 6 weeks (Grade A) Definition of low metastatic burden[1] o No visceral metastases o 3 or fewer bony metastases confined to pelvis and spine Where chemotherapy is given o Treatment should ideally start 6 weeks after o Within the first year on hormones. o Consider lifelong hormones Planning considerations - Posterior margin may be reduced for rectal sparing -Consider planning constraints and treatment imaging as for per radical regime and the below table: 36Gy in 6# 55Gy in 20# Max Volume Rectal Dose Volume Constraints 33.3Gy 52.5Gy 50% 27.8Gy 43.5Gy 60% 16.7Gy 26.1Gy 80% Bladder Dose Volume Constraints 33.3Gy 52.5Gy 25% 27.8Gy 43.5Gy 50%  Castration-resistant disease with local progression and/or symptoms[2] : Dose Fractionations o 30-36Gy in 5-6# once weekly o 30Gy in 10# over 2 weeks o 20Gy in 5# over 1 week o 21Gy in 3# over 1 week (alternate days) o 8-10Gy in 1#  Conformal Radiotherapy is common for the planning technique of palliative patients with symptomatic and/or locally progressed, castration-resistant disease. However IMRT/VMAT Radiotherapy can be considered where it is justifiably, patient appropriate and also in circumstances where constraints/targets cannot be achieved through conformal Radiotherapy. 11. Treatment  Final pre-treatment, Physics and 1st day checks should be carried out as per local protocol.  These should ideally cover or take into account the following: -Monitoring and managing Radiotherapy delays to ensure patients start treatment according to national guidelines -Checking plan approval status and parameters as per local protocol -All prior preparatory and required patient information is available -Imaging requirements for the planned treatment are adequate according to patient plan and local protocol -Any prior In vivo dosimetry has been performed as per local protocol.  During treatment: -Any other monitoring as specified in the local protocol should be performed e.g. dietician review, weight checks, weekly blood counts. -On treatment imaging as per local protocols; For all radical urology patients it is recommended to use IGRT utilising online CBCT, unless otherwise contraindicated.  For gaps in treatment follow local policy  On treatment and follow up reviews as per local protocols. 12. Late effects Late effects will have been discussed as part of the initial discussions and counselling by the treating clinician and is dependent on the radiotherapy target volumes. o Erectile dysfunction-can be supported by referral to Erectile Dysfunction Clinic o Infertility o Leg or groin lymphedema -depending on whether pelvic nodes are covered and if a pelvic nodal dissection has been completed o Change in bladder or bowel habit/capacity o Rectal bleeding requiring surgical investigation/intervention(in region of <5%) o Pelvic bone thinning, insufficiency fractures or avascular necrosis is rare o Bladder or bowel incontinence is rare o Possible small, long-term increase in risk of rectal cancer is rare(<1%) 13. Peer Review  Peer Review will enable clinicians to provide high quality treatments despite potentially limited referrals. Documenting peer review is essential as per RCR peer review 2nd Edition[7]  In order to meet the RCR standards the review will cover patient selection, prescription and target / OAR delineation. For some cases it may be necessary to review the final treatment plan also.  The reviewee must provide the reviewer with all relevant clinical information to peer review, which may include demographics, diagnosis and details of proposed treatment. Any relevant clinical tests or images must also be provided (see Table 1 above).  Responsibility for the patient will remain with the clinician under whom the patient receives their care. If a peer review does not occur, whatever the reason may be, it is that clinician’s responsibility to address this. 14. Glossary Abbreviation Definition # Fraction (i.e. Fractions of treatment) 3DCT Three dimensional computed tomography (standard CT scan) CBCT Cone Beam computed tomography CPG Cambridge Prognostic Group ChemoRT Chemotherapy with Radiotherapy CT Computed tomography CTV Clinical target volume EMRTN East Midlands Radiotherapy Network GTV Gross tumour volume Gy Gray (unit of measure for radiation dose) ICRU International commission on radiation units and measurements IMRT Intensity modulated radiotherapy ITV Internal target volume IR(ME)R Ionising Radiation (Medical Exposure) Regulations ADT Androgen deprevation therapy MDT Multi-disciplinary team MRI Magnetic resonance imaging LHRH Luteinising Hormone Releasing Hormone NOG Network oversight group LDR Low dose rate - (Brachytherapy) HDR High dose rate - (Brachytherapy) OAR Organs at risk PSA Prostate specific antigen PET (PET-CT) Positron emission tomography (Positron emission tomography – computed tomography) PSMA PET Prostate specific membrane antigen, positron emission tomography PNRT Prostate nodal Radiotherapy PRV Planning organ at risk volume PS Performance status PTV Planning target volume RCR Royal college of radiologists RT Radiotherapy SABR Stereotactic ablative Radiotherapy SBRT Stereotactic Body Radiotherapy SV Seminal Vesicles U+E Urea and electrolytes VMAT Volumetric modulated arc therapy PACE International randomised study of prostatectomy vs stereotactic body radiotherapy (SBRT) and conventional radiotherapy vs SBRT for organ-confined prostate cancer PEARLS Trial of Primary radiothErapy for Androgen sensitive pRostate cancer patients with Lymph nodeS PIVOTAL Trial of Prostate and pelvIc Versus prOstaTe ALone radiotherapy treatment volumes using high dose IMRT for locally advanced prostate cancer PIVOTALBOOST Trial of prostate and pelvis versus prostate alone radiotherapy with or without prostate boost CHHiP Conventional or hypofractionated high dose intensity modulated radiotherapy for prostate cancer 15. References [1]  Clinical Commissioning Policy: External beam radiotherapy for patients presenting with hormone sensitive, low volume metastatic prostate cancer at the time of diagnosis. NHS England November 2020. [2]  Parker CC, James ND, Brawley CD et al. Radiotherapy to the primary tumour for newly diagnosed, metastatic prostate cancer (STAMPEDE): a randomised controlled phase 3 trial. Lancet 2018; 392: 2253-2366. [3]  https://www.rcr.ac.uk/media/yprjvkag/13-prostate-cancer-radiotherapy-dose-fractionation-fourth-edition.pdf [4]  ESTRO ACROP guideline on prostate bed delineation for postoperative radiotherapy in prostate cancer - ScienceDirect [5]  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7736505/pdf/nihms-1637222.pdf [6]  https://www.sciencedirect.com/science/article/pii/S2405630822000787 [7]  https://www.rcr.ac.uk/media/bpvngu2n/rcr-publications_radiotherapy-target-volume-definition-and-peer- review-second-edition-rcr-guidance_october-2022.pdf [8]  https://www.nice.org.uk/guidance/ng131/evidence/evidence-reviews-for-risk-stratification-of-localised- prostate-cancer-pdf-10895771342 [9] https://www.icr.ac.uk/media/docs/default-source/default-document- library/pace_protocol_v12_clean.pdf?sfvrsn=130f3069_0 [10]  https://www.icr.ac.uk/media/docs/default-source/default-document-library/pivotalboost_protocol__v5-0_24- 05-19.pdf?sfvrsn=c8f22369_0 [11]  https://www.ranzcr.com/college/document-library/post-prostatectomy-radiation-therapy-consensus- guidelines-of-the-australian-and-new-zealand-radiation-oncology-genito-urinary-group- 2008?searchword=Prostatectomy [12]  https://www.thelancet.com/journals/lanonc/article/PIIS1470-2045(16)30102-4/fulltext [13] https://www.icr.ac.uk/our-research/centres-and-collaborations/centres-at-the-icr/clinical-trials-and-statistics- unit/our-research/clinical-trials/pivotal [14]  https://www.redjournal.org/article/S0360-3016(20)34124-9/fulltext [15]  https://www.thelancet.com/article/S0140-6736(20)31553-1/fulltext [16]  https://www.icr.ac.uk/media/docs/default-source/default-document-library/pace-nodes-protocol-v2_20-03- 2023_clean.pdf?sfvrsn=273a3b69_0 [17]  https://www.nice.org.uk/guidance/ng131/resources/prostate-cancer-diagnosis-and-management-pdf- 66141714312133 [18]  https://bmjopen.bmj.com/content/bmjopen/12/7/e060506.full.pdf [19]  https://www.nejm.org/doi/full/10.1056/NEJMoa1607529#:~:text=This%20randomized%20trial%20showed%20that,of%20an%20abnormal%20PSA%20level. Appendix 1[8] Cambridge prognostic group scoring CPG Calculator- https://cambridgeprognosticgroup.com/index.php Appendix 2 [9] FIG 1 [9] Fig 2 [9] Appendix 3- Contouring CTVn [13] Appendix 4- (Optional) Regional cross site brachytherapy referral process