Prostate Ultrahypofractionation - Rising to Challenges Presents Opportunities in the COVID-19 Era.

Madam — The provision of cancer care has had to adapt rapidly to the demands of COVID-19. A flurry of changes in the way we interact with patients and prioritise the use of treatment modalities has facilitated change in practice at an unprecedented rate.

Ultrahypofractionation (UHF) without hormone therapy is appealing as we move into the endemic COVID-19 era, as the shorter treatment schedules reduce exposure to staff and patients, and facilitate social distancing. A recent meta-analysis [1] reported similar disease-free survival in localised prostate cancer for UHF compared with conformal and hypofractionated radiotherapy. We eagerly await outcome and late toxicity data from the UK PACE-B PIII trial (36.25 Gy/five fractions versus 62 Gy/20 fractions without hormone therapy) [2]. Cancer Waiting Times Guidance now recognises active surveillance as management in low/low–intermediate prostate cancer, allowing time to consider treatment options that do not include hormone therapy, e.g. UHF [3].

To estimate the impact on our clinical service if we implemented UHF in low/low–intermediate risk prostate cancer, we reviewed the case notes for 100 consecutive patients treated in 2019 with 60 Gy/20 fractions and applied the PACE-B criteria: clinical stage T2c and below, prostate-specific antigen <20 ng/ml, Gleason score 7 (3 + 4 only) and performance status 0–2. Median age of the whole cohort was 71 years (range 51–80), 97% performance status 0–1, 27% on anticoagulants/antiplatelets. Twenty-seven percent were intermediate risk/eligible for PACE-B (73% high risk and ineligible). Eighty-nine per cent of eligible patients were prescribed hormone therapy, which would be avoided with PACE-B treatment.

Therefore, our centre is commencing UHF for this group of patients, using rectal spacers, and maintaining a streamlined pathway with a magnetic resonance-only workflow and cone-beam computed tomography soft-tissue matching, as described previously [4,5]. COVID-19 is one of the biggest public health challenges we have faced, which the bringing forward of UHF can help mitigate for, but we remain mindful that novel treatment pathways must not compromise safe, high-quality care.

Conflict of interest

The authors declare no conflicts of interest.