A clinician’s perspective on the consultation, the evidence, and the choices that matter
When a patient arrives in my clinic with a new prostate cancer diagnosis, they have usually already seen a urologist, had a biopsy and staging MRI. Sometimes, they will have had a meeting with a surgeon to discuss prostatectomy as an alternative treatment. They arrive informed but often overwhelmed. My role in that first oncology consultation is to reframe the decision clearly: the evidence for radical radiotherapy and radical surgery in localised and locally advanced prostate cancer is broadly comparable in terms of cancer control. That equivalence matters, because it means the choice between them should be shaped by what the individual patient values most and not by the order in which they happened to see specialists. The discussion around radiotherapy can be complex and has evolved considerably, and is where I spend much of the consultation.
The current standard for most patients with localised prostate cancer is a course of 20 treatments over four weeks — a change from the historical 37-fraction, seven-and-a-half week course that was standard for many years, established as non-inferior by the UK CHHiP trial. For patients with locally advanced disease requiring pelvic lymph node treatment alongside hormone therapy, 20 fractions remains appropriate. But for men with low or intermediate risk localised prostate cancer who do not need hormone therapy, the PACE-B trial, a randomised international study published in The Lancet Oncology, demonstrated that five treatments of stereotactic body radiotherapy, or SABR, achieves equivalent cancer control to longer courses with an acceptable toxicity profile. Five treatments over one to two weeks is now a supported standard of care for this group, and it is the option I discuss in detail with eligible patients. SABR uses highly precise, image-guided delivery to concentrate a higher dose per treatment to the prostate, with steep dose fall-off protecting surrounding structures facilitated, where appropriate, by a hydrogel spacer inserted between the prostate and rectum to reduce bowel exposure.
What I am careful to explain is that SABR is not the right answer for everyone, and the consultation is precisely where those distinctions are made. High-risk and locally advanced disease requires treatment of wider pelvic volumes at doses per fraction incompatible with SABR. 20 fractions remains the standard here, often alongside 18 to 36 months of hormone therapy. Even within the low and intermediate risk group where SABR is appropriate, individual factors shape the recommendation. Pre-existing urinary symptoms matter: significant bladder outflow obstruction increases the risk of a difficult urinary recovery after treatment, and in some cases optimising urinary flow medically or surgically before starting radiotherapy is the right first step. Radiotherapy requires lying still and in a reproducible position for ten to fifteen minutes per session. This is manageable for most, but worth discussing honestly with patients who have significant hip or back pain, or who find enclosed spaces difficult. Bowel function, implanted metalwork, and anatomical factors can all influence technical planning and risk. The consent process covers all of this directly and individually, not as a list of warnings, but as a genuine explanation of why I am recommending what I am recommending for this specific patient. There is rarely a single right answer that applies to everyone, but there is almost always a right answer for the person sitting in front of me, and