Updated ASTRO Guideline on Hypofractionated EBRT for Prostate Cancer

The American Society for Radiation Oncology (ASTRO) has issued a clinical practice guideline recommending moderate hypofractionation (MHF) over conventional fractionation across all risk groups for patients with localized prostate cancer receiving external beam radiation therapy (EBRT). The guideline was published in Practical Radiation Oncology.

The guideline, which replaces ASTRO’s 2018 recommendations on hypofractionated EBRT, was drafted by a multidisciplinary ASTRO task force and draws on a systematic review of the literature. It defines MHF as a fraction size of 240 to 340cGy and ultrahypofractionation (UHF) as a fraction size of at least 500cGy.

The MHF recommendation is strong and based on high-quality evidence. The authors cited 11 randomized trials since 2010 with more than 7000 patients comparing MHF with conventional fractionation and said the randomized data show comparable cancer control, toxicity, and quality of life while shortening treatment by 2 to 5 weeks. UHF is recommended as a treatment option for patients with low-risk disease who decline active surveillance and for those with intermediate-risk disease; both are strong recommendations supported by high-quality evidence, which for intermediate-risk disease applies to Grade Group 2. For high- or very high-risk disease, UHF is conditionally recommended based on low-quality evidence.

Recommended regimens include 6000 to 6200cGy in 20 fractions or 7000cGy in 28 fractions for MHF and, conditionally, 3625 to 4000cGy in 5 fractions for UHF; regimens with fewer than 5 fractions are not recommended outside a clinical trial. The guideline conditionally favors MHF over UHF for patients with significant baseline urinary symptom burden and states that decisions on androgen deprivation therapy should be independent of fractionation. For elective pelvic nodal EBRT, it recommends MHF to the prostate with concurrent conventional or near-conventional fractionation to the nodes; nodal UHF is conditionally recommended only within a clinical trial.

The authors noted that completed UHF trials mostly enrolled patients with intermediate-risk disease and that long-term results from those trials are still pending..ASTRO states that the guideline does not substitute for the treating physician's own clinical judgment.

Source: Morgan SC, Halthore A, Jia AY, et al. Hypofractionated radiation therapy for localized prostate cancer: an ASTRO clinical practice guideline. Pract Radiat Oncol. Published online October 27, 2026. Doi 10.1016/j.prro.2026.09.017