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acr-appropriateness-criteria--definitive-externalbeam-irradiation-in-stage-t1-and-t2-prostate-cancer
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<h1>ACR Appropriateness Criteria® definitive external-beam irradiation in stage T1 and T2 prostate cancer.</h1>
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<table><tr><td>Nguyen PL, Aizer A, Davis BJ, Assimos DG, D'Amico AV, Frank SJ, Gottschalk AR, Gustafson GS, Hsu IC, McLaughlin PW, Merrick G, Rosenthal SA, Showalter TN, Taira AV, Vapiwala N, Yamada Y, Expert Panel on Radiation Oncology–Prostate. ACR Appropriateness Criteria® definitive external-beam irradiation in stage T1 and T2 prostate cancer. [online publication]. Reston (VA): American College of Radiology (ACR); 2013. 18 p. [104 references]</td></tr></table> <p><a href="/web/20180713052516/https://www.guideline.gov/Home/Disclaimer?id=47696&contentType=fulltextlink&redirect=https%253a%252f%252facsearch.acr.org%252fdocs%252f69350%252fNarrative">View the original guideline documentation</a> <img alt="External Web Site Policy" src="/web/20180713052516im_/https://www.guideline.gov/UI/images/icon_externallink.gif"/></p>
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<p><div class="content_para"><p>This is the current release of the guideline.</p>
<p>This guideline updates a previous version: Moran BJ, DeRose P, Merrick G, Hsu IC, Abdel-Wahab M, Arterbery VE, Ciezki JP, Frank SJ, Mohler JL, Rosenthal SA, Rossi CJ Jr, Yamada Y, Expert Panel on Radiation Oncology-Prostate. ACR Appropriateness Criteria® definitive external beam irradiation in stage T1 and T2 prostate cancer. [online publication]. Reston (VA): American College of Radiology (ACR); 2010. 20 p.</p></div></p>
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<h4>UMLS Concepts <a href="/web/20180713052516/https://www.guideline.gov/help-and-about/search-browse/umls-concepts" class="what-is">(what is this?)</a></h4>
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<h5 class="field-label">ICD9CM</h5>
<div class="field-content">
<a href="/web/20180713052516/https://www.guideline.gov/search?f_ICD9CM_CUI=C0376358&fLockTerm=Malignant+neoplasm+of+prostate">Malignant neoplasm of prostate</a>
(185), <a href="/web/20180713052516/https://www.guideline.gov/search?f_ICD9CM_CUI=C0194810&fLockTerm=Radical+prostatectomy">Radical prostatectomy</a>
(60.5) </div>
<!-- /.field-content -->
</div>
<!-- /.field -->
<div class="field">
<h5 class="field-label">MSH</h5>
<div class="field-content">
<a href="/web/20180713052516/https://www.guideline.gov/search?f_MSH_CUI=C0002842&fLockTerm=Androgen+Antagonists">Androgen Antagonists</a>
, <a href="/web/20180713052516/https://www.guideline.gov/search?f_MSH_CUI=C0006098&fLockTerm=Brachytherapy">Brachytherapy</a>
, <a href="/web/20180713052516/https://www.guideline.gov/search?f_MSH_CUI=C0162563&fLockTerm=Catheter+Ablation">Catheter Ablation</a>
, <a href="/web/20180713052516/https://www.guideline.gov/search?f_MSH_CUI=C0085533&fLockTerm=Chemotherapy%2c+Adjuvant">Chemotherapy, Adjuvant</a>
, <a href="/web/20180713052516/https://www.guideline.gov/search?f_MSH_CUI=C0010408&fLockTerm=Cryosurgery">Cryosurgery</a>
, <a href="/web/20180713052516/https://www.guideline.gov/search?f_MSH_CUI=C0887832&fLockTerm=Imaging%2c+Three-Dimensional">Imaging, Three-Dimensional</a>
, <a href="/web/20180713052516/https://www.guideline.gov/search?f_MSH_CUI=C0029189&fLockTerm=Orchiectomy">Orchiectomy</a>
, <a href="/web/20180713052516/https://www.guideline.gov/search?f_MSH_CUI=C0033573&fLockTerm=Prostatectomy">Prostatectomy</a>
, <a href="/web/20180713052516/https://www.guideline.gov/search?f_MSH_CUI=C0033578&fLockTerm=Prostatic+Neoplasms">Prostatic Neoplasms</a>
, <a href="/web/20180713052516/https://www.guideline.gov/search?f_MSH_CUI=C0436226&fLockTerm=Proton+Therapy">Proton Therapy</a>
, <a href="/web/20180713052516/https://www.guideline.gov/search?f_MSH_CUI=C0085203&fLockTerm=Radiosurgery">Radiosurgery</a>
, <a href="/web/20180713052516/https://www.guideline.gov/search?f_MSH_CUI=C1522449&fLockTerm=Radiotherapy">Radiotherapy</a>
, <a href="/web/20180713052516/https://www.guideline.gov/search?f_MSH_CUI=C0242939&fLockTerm=Radiotherapy%2c+Adjuvant">Radiotherapy, Adjuvant</a>
, <a href="/web/20180713052516/https://www.guideline.gov/search?f_MSH_CUI=C1512814&fLockTerm=Radiotherapy%2c+Intensity-Modulated">Radiotherapy, Intensity-Modulated</a>
, <a href="/web/20180713052516/https://www.guideline.gov/search?f_MSH_CUI=C0936234&fLockTerm=Tomography+Scanners%2c+X-Ray+Computed">Tomography Scanners, X-Ray Computed</a>
, <a href="/web/20180713052516/https://www.guideline.gov/search?f_MSH_CUI=C0040405&fLockTerm=Tomography%2c+X-Ray+Computed">Tomography, X-Ray Computed</a>
, <a href="/web/20180713052516/https://www.guideline.gov/search?f_MSH_CUI=C0040771&fLockTerm=Transurethral+Resection+of+Prostate">Transurethral Resection of Prostate</a>
</div>
<!-- /.field-content -->
</div>
<!-- /.field -->
<div class="field">
<h5 class="field-label">MTH</h5>
<div class="field-content">
<a href="/web/20180713052516/https://www.guideline.gov/search?f_MTH_CUI=C0002842&fLockTerm=Androgen+Antagonists">Androgen Antagonists</a>
, <a href="/web/20180713052516/https://www.guideline.gov/search?f_MTH_CUI=C0006098&fLockTerm=Brachytherapy">Brachytherapy</a>
, <a href="/web/20180713052516/https://www.guideline.gov/search?f_MTH_CUI=C0162563&fLockTerm=Cardiac+ablation">Cardiac ablation</a>
, <a href="/web/20180713052516/https://www.guideline.gov/search?f_MTH_CUI=C0936234&fLockTerm=Computed+Tomography+Scanning+Systems">Computed Tomography Scanning Systems</a>
, <a href="/web/20180713052516/https://www.guideline.gov/search?f_MTH_CUI=C0010408&fLockTerm=Cryosurgery">Cryosurgery</a>
, <a href="/web/20180713052516/https://www.guideline.gov/search?f_MTH_CUI=C0376358&fLockTerm=Malignant+neoplasm+of+prostate">Malignant neoplasm of prostate</a>
, <a href="/web/20180713052516/https://www.guideline.gov/search?f_MTH_CUI=C0029189&fLockTerm=Orchiectomy">Orchiectomy</a>
, <a href="/web/20180713052516/https://www.guideline.gov/search?f_MTH_CUI=C0033573&fLockTerm=Prostatectomy">Prostatectomy</a>
, <a href="/web/20180713052516/https://www.guideline.gov/search?f_MTH_CUI=C0033578&fLockTerm=Prostatic+Neoplasms">Prostatic Neoplasms</a>
, <a href="/web/20180713052516/https://www.guideline.gov/search?f_MTH_CUI=C0302617&fLockTerm=Radiographic-therapeutic+unit+device">Radiographic-therapeutic unit device</a>
, <a href="/web/20180713052516/https://www.guideline.gov/search?f_MTH_CUI=C0085203&fLockTerm=Radiosurgery">Radiosurgery</a>
, <a href="/web/20180713052516/https://www.guideline.gov/search?f_MTH_CUI=C0796419&fLockTerm=Taxanes">Taxanes</a>
, <a href="/web/20180713052516/https://www.guideline.gov/search?f_MTH_CUI=C0419095&fLockTerm=Teleradiotherapy+procedure">Teleradiotherapy procedure</a>
, <a href="/web/20180713052516/https://www.guideline.gov/search?f_MTH_CUI=C1522449&fLockTerm=Therapeutic+radiology+procedure">Therapeutic radiology procedure</a>
, <a href="/web/20180713052516/https://www.guideline.gov/search?f_MTH_CUI=C0040771&fLockTerm=Transurethral+Resection+of+Prostate">Transurethral Resection of Prostate</a>
, <a href="/web/20180713052516/https://www.guideline.gov/search?f_MTH_CUI=C0040405&fLockTerm=X-Ray+Computed+Tomography">X-Ray Computed Tomography</a>
</div>
<!-- /.field-content -->
</div>
<!-- /.field -->
<div class="field">
<h5 class="field-label">PDQ</h5>
<div class="field-content">
<a href="/web/20180713052516/https://www.guideline.gov/search?f_PDQ_CUI=C0006098&fLockTerm=brachytherapy">brachytherapy</a>
, <a href="/web/20180713052516/https://www.guideline.gov/search?f_PDQ_CUI=C0040405&fLockTerm=computed+tomography">computed tomography</a>
, <a href="/web/20180713052516/https://www.guideline.gov/search?f_PDQ_CUI=C0010408&fLockTerm=cryosurgery">cryosurgery</a>
, <a href="/web/20180713052516/https://www.guideline.gov/search?f_PDQ_CUI=C1831786&fLockTerm=hypofractionated+radiation+therapy">hypofractionated radiation therapy</a>
, <a href="/web/20180713052516/https://www.guideline.gov/search?f_PDQ_CUI=C1512814&fLockTerm=intensity-modulated+radiation+therapy">intensity-modulated radiation therapy</a>
, <a href="/web/20180713052516/https://www.guideline.gov/search?f_PDQ_CUI=C0029189&fLockTerm=orchiectomy">orchiectomy</a>
, <a href="/web/20180713052516/https://www.guideline.gov/search?f_PDQ_CUI=C1522449&fLockTerm=radiation+therapy">radiation therapy</a>
</div>
<!-- /.field-content -->
</div>
<!-- /.field -->
<div class="field">
<h5 class="field-label">SNOMEDCT_US</h5>
<div class="field-content">
<a href="/web/20180713052516/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0002842&fLockTerm=Antiandrogen">Antiandrogen</a>
(103024009), <a href="/web/20180713052516/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0002842&fLockTerm=Antiandrogen">Antiandrogen</a>
(346324007), <a href="/web/20180713052516/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0006098&fLockTerm=Brachytherapy+-+action">Brachytherapy - action</a>
(313029009), <a href="/web/20180713052516/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C1139859&fLockTerm=Brachytherapy+system">Brachytherapy system</a>
(706279005), <a href="/web/20180713052516/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0040405&fLockTerm=Computerized+axial+tomography">Computerized axial tomography</a>
(77477000), <a href="/web/20180713052516/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0729707&fLockTerm=Computerized+tomography%2c+3+dimensional+reconstruction">Computerized tomography, 3 dimensional reconstruction</a>
(22400007), <a href="/web/20180713052516/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0010408&fLockTerm=Cryosurgery">Cryosurgery</a>
(129393004), <a href="/web/20180713052516/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0010408&fLockTerm=Cryosurgery">Cryosurgery</a>
(281609006), <a href="/web/20180713052516/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0010408&fLockTerm=Cryosurgery">Cryosurgery</a>
(281698007), <a href="/web/20180713052516/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0010408&fLockTerm=Cryosurgery">Cryosurgery</a>
(427357007), <a href="/web/20180713052516/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C1512814&fLockTerm=Intensity+modulated+radiation+therapy">Intensity modulated radiation therapy</a>
(441799006), <a href="/web/20180713052516/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0376358&fLockTerm=Malignant+tumor+of+prostate">Malignant tumor of prostate</a>
(399068003), <a href="/web/20180713052516/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0033578&fLockTerm=Neoplasm+of+prostate">Neoplasm of prostate</a>
(126906006), <a href="/web/20180713052516/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0033573&fLockTerm=Prostatectomy">Prostatectomy</a>
(90470006), <a href="/web/20180713052516/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0436226&fLockTerm=Proton+therapy">Proton therapy</a>
(169314007), <a href="/web/20180713052516/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C1522449&fLockTerm=Radiation+oncology+AND%2fOR+radiotherapy">Radiation oncology AND/OR radiotherapy</a>
(108290001), <a href="/web/20180713052516/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C1522449&fLockTerm=Radiation+oncology+AND%2fOR+radiotherapy">Radiation oncology AND/OR radiotherapy</a>
(53438000), <a href="/web/20180713052516/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0194810&fLockTerm=Radical+prostatectomy">Radical prostatectomy</a>
(26294005), <a href="/web/20180713052516/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0302617&fLockTerm=Radiographic-therapeutic+unit">Radiographic-therapeutic unit</a>
(10850003), <a href="/web/20180713052516/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C1276484&fLockTerm=T1%3a+Clinically+inapparent+prostate+tumor+not+palpable+or+visible+by+imaging">T1: Clinically inapparent prostate tumor not palpable or visible by imaging</a>
(369832002), <a href="/web/20180713052516/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C1276626&fLockTerm=T2%3a+Tumor+confined+within+the+prostate">T2: Tumor confined within the prostate</a>
(369978006), <a href="/web/20180713052516/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0419095&fLockTerm=Teleradiotherapy+procedure">Teleradiotherapy procedure</a>
(33195004), <a href="/web/20180713052516/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0029189&fLockTerm=Testis+excision">Testis excision</a>
(120001005), <a href="/web/20180713052516/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0029189&fLockTerm=Testis+excision">Testis excision</a>
(236334001), <a href="/web/20180713052516/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0040771&fLockTerm=Transurethral+prostatectomy">Transurethral prostatectomy</a>
(90199006) </div>
<!-- /.field-content -->
</div>
<!-- /.field -->
<div class="field">
<h5 class="field-label">SPN</h5>
<div class="field-content">
<a href="/web/20180713052516/https://www.guideline.gov/search?f_SPN_CUI=C0936234&fLockTerm=SYSTEM%2c+X-RAY%2c+TOMOGRAPHY%2c+COMPUTED">SYSTEM, X-RAY, TOMOGRAPHY, COMPUTED</a>
</div>
<!-- /.field-content -->
</div>
<!-- /.field -->
<div class="field">
<h5 class="field-label">UMD</h5>
<div class="field-content">
<a href="/web/20180713052516/https://www.guideline.gov/search?f_UMD_CUI=C1139859&fLockTerm=Brachytherapy+Systems">Brachytherapy Systems</a>
(20-352), <a href="/web/20180713052516/https://www.guideline.gov/search?f_UMD_CUI=C0302617&fLockTerm=Radiotherapy+Systems">Radiotherapy Systems</a>
(13-279), <a href="/web/20180713052516/https://www.guideline.gov/search?f_UMD_CUI=C1322638&fLockTerm=Radiotherapy+Systems%2c+Proton+Beam">Radiotherapy Systems, Proton Beam</a>
(20-546), <a href="/web/20180713052516/https://www.guideline.gov/search?f_UMD_CUI=C0936234&fLockTerm=Scanning+Systems%2c+Computed+Tomography">Scanning Systems, Computed Tomography</a>
(13-469) </div>
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<p class="text-label"><label for="citation">Citation: </label></p>
<textarea id="citation">National Guideline Clearinghouse (NGC). Guideline summary: ACR Appropriateness Criteria® definitive external-beam irradiation in stage T1 and T2 prostate cancer. In: National Guideline Clearinghouse (NGC) [Web site]. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 2013 Jan 01. [cited 2018 Jul 13]. Available: https://www.guideline.gov</textarea>
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<h2 id="420" class="accordion-title section-420 is-active" role="tab" aria-expanded="true"><a href="#">Recommendations</a></h2>
<div class="accordion-panel is-active" role="tabpanel">
<h3><a href="#">Major Recommendations</a></h3>
<p><div class="content_para"><p><strong>ACR Appropriateness Criteria®</strong></p>
<p><strong><span style="text-decoration: underline;">Clinical Condition:</span> Definitive External-Beam Irradiation in Stage T1 and T2 Prostate Cancer</strong></p>
<p><strong><span style="text-decoration: underline;">Variant 1:</span> 60-year-old man, asymptomatic in PSA screening program. PSA 5.2 ng/mL. Prostate within normal limits. No palpable lesions. Multiple needle biopsies of the prostate showed adenocarcinoma. Gleason score 3+3=6. Metastatic workup negative.</strong></p>
<table border="1" cellspacing="1" cellpadding="5" summary="Table: Variant 1: 60-year-old man, asymptomatic in PSA screening program. PSA 5.2 ng/mL. Prostate within normal limits. No palpable lesions. Multiple needle biopsies of the prostate showed adenocarcinoma. Gleason score 3+3=6. Metastatic workup negative">
<thead>
<tr>
<th width="30%" class="Center" valign="bottom" scope="col">Treatment</th>
<th width="20%" class="Center" valign="bottom" scope="col">Rating</th>
<th width="50%" class="Center" valign="bottom" scope="col">Comments</th>
</tr>
</thead>
<tbody>
<tr>
<td valign="top">External-beam radiation therapy (EBRT) alone</td>
<td class="Center" valign="top">8</td>
<td valign="top"> </td>
</tr>
<tr>
<td valign="top">EBRT with brachytherapy boost</td>
<td class="Center" valign="top">3</td>
<td valign="top">This treatment might only be considered if highly adverse features are present, such as >50% of cores positive.</td>
</tr>
<tr>
<td valign="top">EBRT with short course (4–6 months) androgen ablation</td>
<td class="Center" valign="top">3</td>
<td valign="top">This treatment might only be considered if highly adverse features are present, such as >50% of cores positive.</td>
</tr>
<tr>
<td valign="top">EBRT with long course (2–3 years) androgen ablation</td>
<td class="Center" valign="top">1</td>
<td valign="top"> </td>
</tr>
<tr>
<td valign="top">Inclusion of pelvic nodes (44–50.4 Gy) in radiation field</td>
<td class="Center" valign="top">2</td>
<td valign="top"> </td>
</tr>
<tr>
<td valign="top">Addition of taxane-based chemotherapy</td>
<td class="Center" valign="top">1</td>
<td valign="top"> </td>
</tr>
<tr>
<th valign="top" colspan="3">Prostate Dose (conventional fractionation)</th>
</tr>
<tr>
<td valign="top">
<p>>81 Gy</p>
</td>
<td class="Center" valign="top">4</td>
<td valign="top">Perform this treatment only if standard dose constraints can be met.</td>
</tr>
<tr>
<td valign="top">
<p>78–81 Gy</p>
</td>
<td class="Center" valign="top">8</td>
<td valign="top"> </td>
</tr>
<tr>
<td valign="top">
<p>>75–<78 Gy</p>
</td>
<td class="Center" valign="top">8</td>
<td valign="top"> </td>
</tr>
<tr>
<td valign="top">
<p>>73–75 Gy </p>
</td>
<td class="Center" valign="top">6</td>
<td valign="top"> </td>
</tr>
<tr>
<td valign="top">
<p>70–73 Gy</p>
</td>
<td class="Center" valign="top">3</td>
<td valign="top">This dose level is awaiting survival results from RTOG 0126.</td>
</tr>
<tr>
<th valign="top" colspan="3">Hypofractionated EBRT</th>
</tr>
<tr>
<td valign="top">
<p>70 Gy in 2.5 or 2.7 Gy fractions</p>
</td>
<td class="Center" valign="top">5</td>
<td valign="top"> </td>
</tr>
<tr>
<td valign="top">
<p>Hypofractionation using 3.0–4.3 Gy per fraction</p>
</td>
<td class="Center" valign="top">5</td>
<td valign="top">Ideally on trial.</td>
</tr>
<tr>
<td valign="top">
<p>SBRT (in the range of 6.7–7.25 Gy per fraction for 5 fractions)</p>
</td>
<td class="Center" valign="top">4</td>
<td valign="top">Ideally on trial.</td>
</tr>
<tr>
<th valign="top">External-beam Treatment Plan</th>
<td valign="top"> </td>
<td valign="top"> </td>
</tr>
<tr>
<td valign="top">
<p>IMRT</p>
</td>
<td class="Center" valign="top">8</td>
<td valign="top"> </td>
</tr>
<tr>
<td valign="top">
<p>Proton therapy</p>
</td>
<td class="Center" valign="top">7</td>
<td valign="top"> </td>
</tr>
<tr>
<td valign="top">
<p>3-D-CT based plan</p>
</td>
<td class="Center" valign="top">6</td>
<td valign="top"> </td>
</tr>
<tr>
<td valign="top">
<p>2-D plan</p>
</td>
<td class="Center" valign="top">2</td>
<td valign="top"> </td>
</tr>
</tbody>
<tfoot>
<tr>
<th valign="top" colspan="3"><span style="text-decoration: underline;">Rating Scale:</span> 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate</th>
</tr>
</tfoot>
</table>
<p>Note: Abbreviations used in the table are listed at the end of the "Major Recommendations" field.</p>
<p><strong><span style="text-decoration: underline;">Variant 2:</span> 69-year-old generally healthy man. Screening PSA 15.2. Gleason score 4+3 in 3/6 cores on the right, 1/6 on the left. cT2a on examination.</strong></p>
<table border="1" cellspacing="1" cellpadding="5" summary="Table: Variant 2: 69-year-old generally healthy man. Screening PSA 15.2. Gleason score 4+3 in 3/6 cores on the right, 1/6 on the left. cT2a on examination">
<thead>
<tr>
<th width="30%" class="Center" valign="bottom" scope="col">Treatment</th>
<th width="20%" class="Center" valign="bottom" scope="col">Rating</th>
<th width="50%" class="Center" valign="bottom" scope="col">Comments</th>
</tr>
</thead>
<tbody>
<tr>
<td valign="top">External-beam radiation therapy (EBRT) alone</td>
<td class="Center" valign="top">7</td>
<td valign="top"> </td>
</tr>
<tr>
<td valign="top">EBRT with brachytherapy boost</td>
<td class="Center" valign="top">8</td>
<td valign="top">The role of brachytherapy is discussed in the NGC summary <a href="/web/20180713052516/https://www.guideline.gov/content.aspx?id=47697" title="Guideline #10182">ACR Appropriateness Criteria® high dose rate brachytherapy for prostate cancer</a>.</td>
</tr>
<tr>
<td valign="top">EBRT with short course (4–6 months) androgen ablation</td>
<td class="Center" valign="top">8</td>
<td valign="top"> </td>
</tr>
<tr>
<td valign="top">EBRT with long course (2–3 years) androgen ablation</td>
<td class="Center" valign="top">4</td>
<td valign="top">This treatment may be more appropriate if radiographic staging suggests higher risk disease.</td>
</tr>
<tr>
<td valign="top">Inclusion of pelvic nodes (44–50.4 Gy) in radiation field</td>
<td class="Center" valign="top">4</td>
<td valign="top"> </td>
</tr>
<tr>
<td valign="top">Addition of taxane-based chemotherapy</td>
<td class="Center" valign="top">1</td>
<td valign="top"> </td>
</tr>
<tr>
<th valign="top" colspan="3">Prostate Dose (conventional fractionation)</th>
</tr>
<tr>
<td valign="top">
<p>>81 Gy</p>
</td>
<td class="Center" valign="top">4</td>
<td valign="top">Perform this treatment only if standard dose constraints can be met.</td>
</tr>
<tr>
<td valign="top">
<p>78–81 Gy</p>
</td>
<td class="Center" valign="top">8</td>
<td valign="top"> </td>
</tr>
<tr>
<td valign="top">
<p>>75–<78 Gy</p>
</td>
<td class="Center" valign="top">7</td>
<td valign="top"> </td>
</tr>
<tr>
<td valign="top">
<p>>73–75 Gy</p>
</td>
<td class="Center" valign="top">5</td>
<td valign="top"> </td>
</tr>
<tr>
<td valign="top">
<p>70–73 Gy</p>
</td>
<td class="Center" valign="top">3</td>
<td valign="top"> </td>
</tr>
<tr>
<th valign="top" colspan="3">Hypofractionated EBRT</th>
</tr>
<tr>
<td valign="top">
<p>70 Gy in 2.5 or 2.7 Gy fractions</p>
</td>
<td class="Center" valign="top">5</td>
<td valign="top"> </td>
</tr>
<tr>
<td valign="top">
<p>Hypofractionation using 3.0–4.3 Gy per fraction</p>
</td>
<td class="Center" valign="top">5</td>
<td valign="top">Ideally on trial.</td>
</tr>
<tr>
<td valign="top">
<p>SBRT (in the range of 6.7–7.25 Gy per fraction for 5 fractions)</p>
</td>
<td class="Center" valign="top">4</td>
<td valign="top">Ideally on trial.</td>
</tr>
<tr>
<th valign="top">External-beam Treatment Plan</th>
<td valign="top"> </td>
<td valign="top"> </td>
</tr>
<tr>
<td valign="top">
<p>IMRT</p>
</td>
<td class="Center" valign="top">9</td>
<td valign="top"> </td>
</tr>
<tr>
<td valign="top">
<p>Proton therapy</p>
</td>
<td class="Center" valign="top">7</td>
<td valign="top"> </td>
</tr>
<tr>
<td valign="top">
<p>3-D-CT based plan</p>
</td>
<td class="Center" valign="top">6</td>
<td valign="top"> </td>
</tr>
<tr>
<td valign="top">
<p>2-D plan</p>
</td>
<td class="Center" valign="top">2</td>
<td valign="top"> </td>
</tr>
</tbody>
<tfoot>
<tr>
<th valign="top" colspan="3"><span style="text-decoration: underline;">Rating Scale:</span> 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate</th>
</tr>
</tfoot>
</table>
<p>Note: Abbreviations used in the table are listed at the end of the "Major Recommendations" field.</p>
<p><strong><span style="text-decoration: underline;">Variant 3:</span> 69-year-old man with long-standing history of coronary disease and diabetes. Myocardial infarction 3 years ago required percutaneous stenting, but since then his cardiac status has been stable. Screening PSA 15.2. Gleason score 4+3 in 3/6 cores on the right, 1/6 on the left. cT2a on examination.</strong></p>
<table border="1" cellspacing="1" cellpadding="5" summary="Table: Variant 3: 69-year-old man with long-standing history of coronary disease and diabetes. Myocardial infarction 3 years ago required percutaneous stenting, but since then his cardiac status has been stable">
<thead>
<tr>
<th width="30%" class="Center" valign="bottom" scope="col">Treatment</th>
<th width="20%" class="Center" valign="bottom" scope="col">Rating</th>
<th width="50%" class="Center" valign="bottom" scope="col">Comments</th>
</tr>
</thead>
<tbody>
<tr>
<td valign="top">External-beam radiation therapy (EBRT) alone</td>
<td class="Center" valign="top">7</td>
<td valign="top"> </td>
</tr>
<tr>
<td valign="top">EBRT with brachytherapy boost</td>
<td class="Center" valign="top">8</td>
<td valign="top"> </td>
</tr>
<tr>
<td valign="top">EBRT with short course (4–6 months) androgen ablation</td>
<td class="Center" valign="top">7</td>
<td valign="top"> </td>
</tr>
<tr>
<td valign="top">EBRT with long course (2–3 years) androgen ablation</td>
<td class="Center" valign="top">3</td>
<td valign="top"> </td>
</tr>
<tr>
<td valign="top">Inclusion of pelvic nodes (44–50.4 Gy) in radiation field</td>
<td class="Center" valign="top">4</td>
<td valign="top"> </td>
</tr>
<tr>
<td valign="top">Addition of taxane-based chemotherapy</td>
<td class="Center" valign="top">1</td>
<td valign="top"> </td>
</tr>
<tr>
<th valign="top" colspan="3">Prostate Dose (conventional fractionation)</th>
</tr>
<tr>
<td valign="top">
<p>>81 Gy</p>
</td>
<td class="Center" valign="top">4</td>
<td valign="top"> </td>
</tr>
<tr>
<td valign="top">
<p>78–81 Gy</p>
</td>
<td class="Center" valign="top">8</td>
<td valign="top"> </td>
</tr>
<tr>
<td valign="top">
<p>>75–<78 Gy</p>
</td>
<td class="Center" valign="top">7</td>
<td valign="top"> </td>
</tr>
<tr>
<td valign="top">
<p>>73–75 Gy</p>
</td>
<td class="Center" valign="top">5</td>
<td valign="top"> </td>
</tr>
<tr>
<td valign="top">
<p>70–73 Gy</p>
</td>
<td class="Center" valign="top">3</td>
<td valign="top"> </td>
</tr>
<tr>
<th valign="top" colspan="3">Hypofractionated EBRT</th>
</tr>
<tr>
<td valign="top">
<p>70 Gy in 2.5 or 2.7 Gy fractions</p>
</td>
<td class="Center" valign="top">5</td>
<td valign="top"> </td>
</tr>
<tr>
<td valign="top">
<p>Hypofractionation using 3.0–4.3 Gy per fraction</p>
</td>
<td class="Center" valign="top">5</td>
<td valign="top">Ideally on trial.</td>
</tr>
<tr>
<td valign="top">
<p>SBRT (in the range of 6.7–7.25 Gy per fraction for 5 fractions)</p>
</td>
<td class="Center" valign="top">4</td>
<td valign="top">Ideally on trial.</td>
</tr>
<tr>
<th valign="top">External-Beam Treatment Plan</th>
<td valign="top"> </td>
<td valign="top"> </td>
</tr>
<tr>
<td valign="top">
<p>IMRT</p>
</td>
<td class="Center" valign="top">9</td>
<td valign="top"> </td>
</tr>
<tr>
<td valign="top">
<p>Proton therapy</p>
</td>
<td class="Center" valign="top">7</td>
<td valign="top"> </td>
</tr>
<tr>
<td valign="top">
<p>3-D-CT based plan</p>
</td>
<td class="Center" valign="top">6</td>
<td valign="top"> </td>
</tr>
<tr>
<td valign="top">
<p>2-D plan</p>
</td>
<td class="Center" valign="top">2</td>
<td valign="top"> </td>
</tr>
</tbody>
<tfoot>
<tr>
<th valign="top" colspan="3"><span style="text-decoration: underline;">Rating Scale:</span> 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate</th>
</tr>
</tfoot>
</table>
<p>Note: Abbreviations used in the table are listed at the end of the "Major Recommendations" field.</p>
<p><strong><span style="text-decoration: underline;">Variant 4:</span> 70-year-old man who presented with a 3-year history of moderate dysuria, urinary frequency, and nocturia. Rectal examination shows prostate 1.5 normal size. PSA 36 ng/mL. 12 needle biopsy of prostate shows adenocarcinoma. Gleason score 4+4=8 in both right and left lobes, totaling 7 cores. Metastatic workup negative.</strong></p>
<table border="1" cellspacing="1" cellpadding="5" summary="Table: Variant 4: 70-year-old man who presented with a 3-year history of moderate dysuria, urinary frequency, and nocturia. Rectal examination shows prostate 1.5 normal size. PSA 36 ng/mL. 12 needle biopsy of prostate shows adenocarcinoma. Gleason score 4+4=8 in both right and left lobes, totaling 7 cores. Metastatic workup negative">
<thead>
<tr>
<th width="30%" class="Center" valign="bottom" scope="col">Treatment</th>
<th width="20%" class="Center" valign="bottom" scope="col">Rating</th>
<th width="50%" class="Center" valign="bottom" scope="col">Comments</th>
</tr>
</thead>
<tbody>
<tr>
<td valign="top">External-beam radiation therapy (EBRT) alone</td>
<td class="Center" valign="top">2</td>
<td valign="top"> </td>
</tr>
<tr>
<td valign="top">EBRT with brachytherapy boost alone<br/>
</td>
<td class="Center" valign="top">4</td>
<td valign="top"> </td>
</tr>
<tr>
<td valign="top">EBRT with brachytherapy boost and androgen ablation</td>
<td class="Center" valign="top">8</td>
<td valign="top"> </td>
</tr>
<tr>
<td valign="top">EBRT with short course (4–6 months) androgen ablation</td>
<td class="Center" valign="top">5</td>
<td valign="top"> </td>
</tr>
<tr>
<td valign="top">EBRT with long course (2–3 years) androgen ablation</td>
<td class="Center" valign="top">8</td>
<td valign="top"> </td>
</tr>
<tr>
<td valign="top">Inclusion of pelvic nodes (44–50.4 Gy) in radiation field</td>
<td class="Center" valign="top">6</td>
<td valign="top"> </td>
</tr>
<tr>
<td valign="top">Addition of taxane-based chemotherapy</td>
<td class="Center" valign="top">3</td>
<td valign="top"> </td>
</tr>
<tr>
<th valign="top" colspan="3">Prostate Dose (conventional fractionation)</th>
</tr>
<tr>
<td valign="top">
<p>>81 Gy</p>
</td>
<td class="Center" valign="top">6</td>
<td valign="top"> </td>
</tr>
<tr>
<td valign="top">
<p>78–81 Gy</p>
</td>
<td class="Center" valign="top">8</td>
<td valign="top"> </td>
</tr>
<tr>
<td valign="top">
<p>>75–<78 Gy</p>
</td>
<td class="Center" valign="top">7</td>
<td valign="top"> </td>
</tr>
<tr>
<td valign="top">
<p>>73–75 Gy</p>
</td>
<td class="Center" valign="top">4</td>
<td valign="top"> </td>
</tr>
<tr>
<td valign="top">
<p>70–73 Gy</p>
</td>
<td class="Center" valign="top">3</td>
<td valign="top"> </td>
</tr>
<tr>
<th valign="top" colspan="3">Hypofractionated EBRT</th>
</tr>
<tr>
<td valign="top">
<p>70 Gy in 2.5 or 2.7 Gy fractions</p>
</td>
<td class="Center" valign="top">5</td>
<td valign="top"> </td>
</tr>
<tr>
<td valign="top">
<p>Hypofractionation using 3.0–4.3 Gy per fraction</p>
</td>
<td class="Center" valign="top">4</td>
<td valign="top">Ideally on trial.</td>
</tr>
<tr>
<td valign="top">
<p>SBRT (in the range of 6.7–7.25 Gy per fraction for 5 fractions)</p>
</td>
<td class="Center" valign="top">3</td>
<td valign="top">Ideally on trial.</td>
</tr>
<tr>
<th valign="top">External-Beam Treatment Plan</th>
<td valign="top"> </td>
<td valign="top"> </td>
</tr>
<tr>
<td valign="top">
<p>IMRT</p>
</td>
<td class="Center" valign="top">9</td>
<td valign="top"> </td>
</tr>
<tr>
<td valign="top">
<p>Proton therapy</p>
</td>
<td class="Center" valign="top">6</td>
<td valign="top">Perform this treatment only if seminal vesicles can be covered and constraints met.</td>
</tr>