Higher Radiation Doses Improve Survival in High-Risk Prostate Cancer: New Evidence Supports Dose Escalation

The Figure 1 graph shows how well patients with high-risk prostate cancer did over time after receiving radiation therapy.  in simple terms:

The Two Lines:

  • Blue line (Overall Survival): Shows the percentage of patients who were still alive at different time points
  • Orange/Yellow line (Metastasis-Free Survival): Shows the percentage of patients whose cancer hadn't spread to other parts of their body

Key Numbers Over Time

At 10 years:

  • About 91% of patients were still alive (blue line)
  • About 87% had no cancer spread (orange line)

At 15 years:

  • About 71% of patients were still alive (blue line)
  • About 60% had no cancer spread (orange line)

What This Means

  1. Very Good Long-term Outcomes: Even with high-risk prostate cancer, the vast majority of men (9 out of 10) were still alive at 10 years after treatment.

  2. Cancer Control: Most men also kept their cancer from spreading - 87% at 10 years had no metastases (cancer spread).

  3. Natural Decline Over Time: As expected with any long-term study, the percentages gradually decrease over time, but the decline is relatively gentle, showing the treatment was effective.

  4. Fewer Patients Over Time: The numbers at the bottom show that the study started with 424 patients, but fewer patients remained in the study at later time points (down to 36 at 15 years) - this is normal as some patients may move, change doctors, or choose not to continue follow-up visits.

The graph essentially shows that radiation dose escalation led to excellent long-term survival rates for high-risk prostate cancer patients, with most men living cancer-free lives many years after treatment.

Higher Radiation Doses Improve Survival in High-Risk Prostate Cancer: New Evidence Supports Dose Escalation

Breaking Research Update for IPCSG Members

Key Findings: Every Gray Counts

A major new study from Spain provides compelling real-world evidence that higher radiation doses significantly improve survival outcomes for men with high-risk prostate cancer. The research, published in Radiation Oncology in 2025, followed 424 high-risk prostate cancer patients for nearly 10 years and found that each additional Gray (Gy) of radiation meaningfully contributed to better outcomes.

What the Numbers Show

The Spanish study found impressive long-term survival rates with dose-escalated radiation therapy:

  • 10-year overall survival: 91%
  • 10-year cancer-specific survival: 97%
  • 15-year overall survival: 71%
  • 15-year cancer-specific survival: 90%

Most importantly, patients who received higher radiation doses (above 74 Gy) had significantly better outcomes than those receiving standard doses, with a 10-year overall survival rate of 95% compared to 81% for those receiving lower doses.

Safety Profile Remains Strong

Despite the higher doses, toxicity rates remained acceptably low:

  • Only 13% experienced grade 2 or higher urinary complications at 10 years
  • Only 10% experienced grade 2 or higher rectal complications
  • Serious grade 3+ complications occurred in less than 3% of patients

Landmark GETUG-AFU 18 Trial Confirms Benefits

The Spanish findings align with groundbreaking results from the French GETUG-AFU 18 trial, presented at the 2024 ASCO Genitourinary Cancer Symposium. This randomized controlled trial of 505 high-risk patients compared 80 Gy versus 70 Gy radiation, both combined with 3 years of hormone therapy.

The results were striking:

  • 10-year overall survival: 77% (high dose) vs. 65.9% (standard dose)
  • Progression-free survival: 83.6% vs. 72.2% at 10 years
  • No increase in side effects despite the higher dose

Dr. Christophe Hennequin, the lead investigator, concluded: "We now have level 1 evidence that high-dose radiotherapy with long-term ADT must be the standard of care in high-risk prostate cancer patients."

Game-Changing PACE-B Trial: 5 Treatments vs. 20+

In parallel developments, the PACE-B trial published in the New England Journal of Medicine in October 2024 demonstrated that stereotactic body radiotherapy (SBRT) delivered in just 5 sessions over 1-2 weeks is as effective as conventional radiation given over 7-8 weeks.

Key PACE-B findings:

  • 5-year cancer control: 95.8% (SBRT) vs. 94.6% (conventional radiation)
  • Treatment duration: 5 days vs. 39-40 treatments
  • Comparable safety profile with slightly higher urinary side effects for SBRT that resolved over time

This trial included 874 patients with low- to intermediate-risk prostate cancer across 38 centers in the UK, Ireland, and Canada.

What This Means for Patients

For High-Risk Disease

If you have high-risk prostate cancer, these studies provide strong evidence that:

  1. Dose escalation matters: Higher radiation doses (around 80 Gy) improve both cancer control and overall survival
  2. Modern techniques are safe: Advanced radiation techniques (IMRT/IGRT) allow safe delivery of higher doses
  3. Long-term hormone therapy remains important: The benefit of higher doses was seen even when combined with extended hormone therapy

For Low- to Intermediate-Risk Disease

The PACE-B trial offers a new option:

  1. Ultra-short treatment courses: 5 treatments instead of 20-40
  2. Excellent cancer control: Over 95% success rate at 5 years
  3. Reduced burden: Fewer hospital visits and shorter treatment time

Questions to Discuss With Your Team

When considering radiation therapy, ask your oncologist:

  • Am I a candidate for dose-escalated radiation therapy?
  • What radiation dose are you planning and why?
  • Am I eligible for SBRT (5-fraction treatment)?
  • What technology will be used for my treatment (IMRT, IGRT, etc.)?
  • How does the radiation dose relate to my specific risk factors?

Looking Ahead: Future Developments

Several exciting developments are on the horizon:

  • PACE-C trial: Testing SBRT for higher-risk patients receiving hormone therapy
  • PSMA-PET imaging: Better disease staging may refine treatment selection
  • Focal dose escalation: Targeting specific areas within the prostate with even higher doses
  • Combination therapies: Adding newer medications to radiation and hormone therapy

The Bottom Line

These studies represent a significant advance in prostate cancer treatment. The evidence now clearly shows that:

  • Higher radiation doses improve survival in high-risk disease
  • Modern radiation techniques make dose escalation safe
  • Ultra-short treatment courses (SBRT) offer equivalent outcomes for appropriate patients
  • The "one-size-fits-all" approach to radiation dosing is becoming obsolete

As Dr. Nicholas van As from the PACE trial noted: "To be able to sit with a patient and say, 'We can treat you with a low toxicity treatment in 5 days, and your chance of keeping the cancer at bay for 5 years is 96%,' is a very positive conversation to have."

These advances give men with prostate cancer and their families more reasons for optimism and more treatment options tailored to their specific situation.

Sources and References

  1. Zapatero, A., et al. "Risk-adapted intensification therapy in high-risk prostate cancer: how relevant is the role of radiation dose." Radiation Oncology 20, 102 (2025). DOI: 10.1186/s13014-025-02665-0. Available at: https://ro-journal.biomedcentral.com/articles/10.1186/s13014-025-02665-0

  2. Hennequin, C., et al. "Long-term results of dose escalation (80 vs 70 Gy) combined with long-term androgen deprivation in high-risk prostate cancers: GETUG-AFU 18 randomized trial." Journal of Clinical Oncology 42, no. 4_suppl (2024): LBA259. DOI: 10.1200/JCO.2024.42.4_suppl.LBA259. Available at: https://ascopubs.org/doi/10.1200/JCO.2024.42.4_suppl.LBA259

  3. van As, N., et al. "Phase 3 Trial of Stereotactic Body Radiotherapy in Localized Prostate Cancer." New England Journal of Medicine 391, no. 15 (2024): 1413-1425. DOI: 10.1056/NEJMoa2403365. Available at: https://www.nejm.org/doi/full/10.1056/NEJMoa2403365

  4. Tree, A.C., et al. "Intensity-modulated radiotherapy versus stereotactic body radiotherapy for prostate cancer (PACE-B): 2-year toxicity results from an open-label, randomised, phase 3, non-inferiority trial." The Lancet Oncology 23, no. 10 (2022): 1308-1320. DOI: 10.1016/S1470-2045(22)00517-4. Available at: https://www.thelancet.com/journals/lanonc/article/PIIS1470-2045(22)00517-4/fulltext

  5. National Cancer Institute. "SBRT Proves Effective for Some Prostate Cancers." Cancer Currents Blog (2024). Available at: https://www.cancer.gov/news-events/cancer-currents-blog/2024/prostate-cancer-sbrt-effective-safe

  6. American Society of Clinical Oncology. "High-Risk Localized Prostate Cancer Survival Benefit With Long-Term ADT and Dose-Escalated Radiation Therapy." The ASCO Post (February 25, 2024). Available at: https://ascopost.com/issues/february-25-2024/high-risk-localized-prostate-cancer-survival-benefit-with-long-term-adt-and-dose-escalated-radiation-therapy/

  7. Pasalic, D., et al. "Dose escalation for prostate adenocarcinoma: a long-term update on the outcomes of a phase 3, single institution randomized clinical trial." International Journal of Radiation Oncology, Biology, Physics 104, no. 4 (2019): 790-797. DOI: 10.1016/j.ijrobp.2019.01.009

  8. Takano, S., et al. "Impact of radiation doses on clinical relapse of biochemically recurrent prostate cancer after prostatectomy." Scientific Reports 14, 113 (2024). DOI: 10.1038/s41598-023-50434-4. Available at: https://www.nature.com/articles/s41598-023-50434-4

  9. Michalski, J.M., et al. "Effect of Standard vs Dose-Escalated Radiation Therapy for Patients With Intermediate-Risk Prostate Cancer: The NRG Oncology RTOG 0126 Randomized Clinical Trial." JAMA Oncology 4, no. 6 (2018): e180039. DOI: 10.1001/jamaoncol.2018.0039. Available at: https://jamanetwork.com/journals/jamaoncology/fullarticle/2675014

  10. UroToday. "ASCO GU 2024: Long-Term Results of Dose Escalation (80 vs 70 Gy) Combined with Long-Term Androgen Deprivation in High-Risk Prostate Cancer: GETUG-AFU 18 Randomized Trial." Available at: https://www.urotoday.com/conference-highlights/asco-gu-2024/asco-gu-2024-prostate-cancer/149339-asco-gu-2024-long-term-results-of-dose-escalation-80-vs-70-gy-combined-with-long-term-androgen-deprivation-in-high-risk-prostate-cancer-getug-afu-18-randomized-trial.html

This article is for educational purposes only and should not replace consultation with your healthcare team. Always discuss treatment options with your oncologist based on your individual circumstances.

Risk-adapted intensification therapy in high-risk prostate cancer: how relevant is the role of radiation dose | Radiation Oncology | Full Text

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