How would you optimally boost patients with high or very high risk prostate cancer receiving definitive radiotherapy in 2025?

1. Micro-boost is my preferred strategy for dose escalation. The FLAME trial demonstrated a bDFS benefit (Kerkmeijer et al., PMID 33471548). The secondary analysis demonstrated reduced regional+distant metastasis and reduced local recurrence, as well (Groen et al., PMID 34953603). These benefits were ...

Dr. @Dr. First Last's answer is thorough and highlights the current state of data well.

What remains unclear is in the era of SBRT, which is increasingly being used in high-risk prostate cancer, and is allowed on trials like NRG GU009, is being tested in NRG GU013, and is supported by NCCN guideline...

Data suggests a higher dose to a visible lesion leads to better local control. Once the decision is made to do boost, the location and volume of disease can also help decide the boost technique. Microboost like FLAME is driven by location (OAR could be a limiting factor) and the number of lesions (l...

Great answers so far. Agree that best data supports FLAME and Brachy and generally wouldn't offer experimental arms before trials read out (at least when outcomes are generally favorable).

Some additional thoughts that can help individualize for different scenarios

• High volume cores or large DIL: th...

Great discussions and answers so far!

The answer to this question will and should vary based on the institution and access to high-quality brachytherapy.

I approach these cases by asking myself two fundamental questions (in addition to the typical ones mentioned above):

1. Does this patient have a highe...

FLAME SIB, data for std, hypo, and SBRT. ASCENDE-RT outcomes may have been driven by a few high-volume poor brachytherapists… would like a redo comparing (good) brachy with good FLAME.