How to focal boost in prostate cancer radiotherapy: ESTRO clinical practice consensus recommendations

Over the past decades, both hypofractionation and (focal) dose escalation have been studied in trials for prostate cancer (PCa) radiotherapy. Several studies have demonstrated a benefit of dose escalation in terms of improved biochemical progression-free survival (bPFS). Whole-gland dose escalation, however, is associated with an increased risk of side effects. The concept of isotolerated focal boosting was tested in the phase III FLAME trial and showed improved bPFS survival in patients with intermediate- and (mainly) high-risk PCa, without significantly increasing side effects. Following this publication, a steady increase in the number of patients treated with focal boosting of the intraprostatic tumour(s) is anticipated. Thus, the current ESTRO recommendation has been developed to provide practical suggestions for the implementation of focal boosting of the intraprostatic tumour(s). We here present an overview of the existing literature and, based on evaluation of the current evidence and expert opinion, we formulate a set of practical 'how-to' recommendations to support the integration of focal boosting of the intraprostatic tumour(s) using either external beam radiotherapy or brachytherapy into routine clinical practice.