What is your radiotherapy fractionation recommendation for favorable intermediate risk prostate cancer who has ~70 cc prostate?

This may seem controversial in 2026 and seems to contradict evidence, but I just wanted to relay what I've seen.

I was a fairly early adopter of moderate hypo-fractionation, not the first, but not the last - probably around 2012-2013. I pretty much changed to that for all patients for around 11-12 y...

For a patient with intermediate-risk prostate cancer and a 73 cc gland, I would offer any validated EBRT fractionation schedule so long as the burden of LUTS was manageable. In my practice, this includes a 28-fraction, 20-fraction, and 5-fraction regimen off study, although there are multiple fracti...

Dr. @Dr. First Last has a nice review of some of the literature, and in general, I think this is an area that will probably remain debated for some time, as multiple drivers of urinary events and developing biomarkers.

Another paper I like is the Urinary Tract Events after Prostate RT, which uses a ...

I have the same hot take as Simul - 79.2 Gy in 1.8 Gy per fraction. If you look at the supplementary data in PACE-B, you can see that late adverse effects were about 10% worse with SBRT. Although technically meeting noninferiority, adverse effects are in the direction of SBRT. If you look at the adv...

I believe there are some excellent responses noted, but I wanted to add one more element. I agree that the conventional fractionation does have less acute urinary side effects than the hypofractionated or SBRT approach, but the increased burden of treatments probably makes it not worth it for a majo...

For big prostates and corresponding AUA scores, I migrate from hypo to standard fx. The cutoff is not hard and fast, but 75 cc and above, it's due for consideration.

Having feelings about using IPSSs to determine long-term GU effects of RT remains a little hazy to me. Last time I studied this in depth, I found a (mostly) inverse correlation between pre-treatment and post-treatment IPSSs (using 81 Gy/45). The linear regression equation was

change in IPSS = 6.2...