Radiation Oncology

Prostate Cancer   

Questions discussed in this category



If a patient presents with de novo oligometastatic (i.e., meeting STAMPEDE low met burden criteria) prostate cancer with no prior history of primary t...

For example, if MRI revealed prostate-confined disease but PSMA had moderate avidity in the bilateral seminal vesicles, would you obtain further biops...

How does time since radiation, original PSA and grade group/gleason score inform your decision? 

Would you treat this patient any differently than any other very high risk prostate cancer patient? Are there any additional dose constraints for the ...

With the recent publication of PSMAfore, what are your current criteria for offering Lu-177 therapy?

The study showed no benefit in terms of cancer control or toxicity. There was a significant finding of worse sexual function, but this was deemed to b...

If pursuing a sequential approach with boost to dominant prostate nodules as seen on MRI, what dosing and fractionation would you use in the initial a...

Would you be willing to treat an elderly patient on blood thinners who has PSMA+ PET, elevated PSA, and multiple urologists have deemed biopsy too ris...

If delivering 300 cGy per fraction to the DIL, what urethra dose constraints to you use for 26 and 28 fraction regimens?

With the advent of PSMA PET/CT, this is my study of choice for high risk prostate cancer. Are there scenarios where standard FDG PET is useful? For ex...

The recently published executive summary from ASTRO/ASCO/AUA hypofractionated radiation therapy for localized prostate cancer states "Five-fracti...

Long-term ADT is deleterious to multiple organ systems (bone/sexual/psychiatric) and increases the risk of MACE. What level 1 evidence do we have to c...

On the EMBARK trial (Freedland et al., PMID 37851874), 25% of men had a prostatectomy and the publication states, "Patients were excluded … if ...

What fields? Would you treat the pelvis? What factors would help you determine this?

NCCN, NRG contouring guidelines, and NRG-GU-009 all recommend treating non-metastatic high risk prostate cancer with dose escalation to involved gross...

RADICALS-HD trial (ESMO 2022) demonstrated metastasis free survival benefit with 24 months compared to 6 months of ADT.

Which criteria/factors would you use to decide whether to de-intensify prostate bed/fossa treatment? For instance, surgical margin status or biochemic...

STAMPEDE answer is yes, intuitively it seems there must be a line somewhere though. For patients staged only with PET that is widely M1, should a CT ...

Current NCCN guidelines recommended not combining relugolix with these agents until more data is available.  Any drug interaction concerns or ot...

Would a specific Gleason score, age, pathological feature, or PSA be an indication for covering the pelvic nodes? Would giving concurrent ADT affect y...

If so, do you modify your external beam dose? 

Which patients specifically benefit from both mpMRI and PET-PSMA?

How would it change your risk group or management? Does Decipher help further inform treatment?

I have a pair of patients with MRI+ and biopsy+ disease who have staging PSMA PET/CT that do not show disease within the prostate (or anywhere else).&...

In particular, in the modern era of multi-parametric prostate MRI and PSMA-PET, certain findings such as EPE, SVI, or pelvic lymphadenopathy may be no...

In the setting of EBRT alone, a "FLAME"-style boost may increase bPFS. Does anyone have experience with increasing the EBRT dose in combination EBRT+L...

He cannot sense bladder fullness but has no incontinence. Intermittently he urinates by increasing intra-abdominal pressure resulting in a good stream...

For example do you use Prolaris, or other genetic tests to guide ADT decision making? 

Assume recurrence is biopsy proven. Would you ever consider focal vs whole gland brachytherapy? 

Patients in their later 40s with favorable intermediate-risk prostate cancer s/p 7000cGy/28 EBRT only.

24 months ADT + abiraterone + definitive RT is indicated for cN1 disease but not for pN1 disease per NCCN. Can the data be extrapolated to this popula...

Notably, the patient presented with renal failure due to ureteral obstruction and hydronephrosis, receives hemodialysis, and has limited systemic opti...

For example: radiation fractionation schedule, modality (proton, MRI linac, cyberknife, etc), risk categorization, prostate size, history of IBS, hist...

How would you sequence therapy, and what dose and volumes would you use for radiation? Prostate cancer is localized, Gleason 4+3, PSA 65.

Pretreatment PSA 25.3 with Gleason 4+3=7 and MRI suspicious for ECE. Eight months after pelvic nodal and prostate XRT to 79 Gy, PSA is 5.02 (down from...

A recent NCBD analysis (Rusthoven et al., PMID 27325855) suggests that the addition of prostate RT significantly improves survival compared to AD...

Would you recommend elective nodal radiation and sequential boost to the node? What dose? Would you recommend treatment similar to OLIGOPELVIS-GETUG P...

There is a recent publication that nicely summarizes the molecular/genetic tests for prostate cancer (Ross et al., PMID 26123120). What should be done...

Is there an extent of nodal involvement in prostate cancer above which you would not offer definitive XRT? With PSMA/PET we see some patients with inc...

If a patient who has undergone radical prostatectomy many years previously presents with biochemical failure and is found to have a nodule in the pros...

Specifically, in the TZ and PZ? What references do use for prostate nodule boost as done in FLAME trial?  Hypointensities are contoured on T2W M...

How high would you try to boost those involved nodes if they are in a favorable location with respect to his rectum and small bowel? 

Would you treat with ADT if no metastatic disease? Does absolute PSA (e.g. PSA<2) inform decision?

Additional imaging of the potential lesions, biopsy or assume negative given normal PSMA PET/CT. 

Do you allow this finding to change your management, or ignore it, as the "lesion" was not malignant?

Would you offer adjuvant radiation? (Dose? Target?) vs Salvage? Would you add ADT? Would you add abiraterone? Would the number of lymph nodes involv...

Patient has ED unresponsive to cialis/viagra; would you recommend testosterone replacement therapy?

At what PSA would you become suspicious for biochemical recurrence and pursue restaging? Is there a threshold value? What imaging modality would you ...

Would you use it for initial staging or at time of biochemical recurrence?

Would you consider boosting the nodes?  What dose?  Would this change your recommendation for length of ADT?  

Are there clinical features (post-op PSA, Decipher score, pN+, pT3, etc) that would inform your decision?

Given GU003 presented at ASTRO 2021- how does this impact your recommendations for adjuvant and salvage prostate RT?

Do you worry about false negatives on PET, CT, MRI if ADT is started before the scan? Scheduling scans can sometimes book 2-4 weeks out. 

Per lutathera information, a patient who had previous treatment for describes an estimated radiation absorbed dose of 12.8 Gy to the bladder. Would yo...

Is there a role of EBRT to the prostate with extended fields to cover the retroperitoneal nodes plus ADT (definitive therapy) or would you treat as ca...

GS 4+4. PSA low (1-2). CT and bone scan negative for lymphadenopathy or metastatic disease.  Prostate MRI pending. 

Would you recommend surgery first or neoadjuvant therapy such as concurrent cisplatin/RT or another regimen?

Did you change your practice given the SRE results in the control arm of EORTC 1333 at ASCO 2021? When using bisphosphonates or denosumab, what dosin...

For the purpose of this question, please assume an initially undetectable post-prostatectomy PSA, no presence of positive margins, extracapsular exten...

Are there certain situations where a hydrogel spacer is most useful based on treatment modality (SBRT, protons, brachy, etc) or other factors?

Specifically, would you offer salvage radiation to a patient who underwent a prostatectomy with PLND and had a post-op PSA of 12 with pathology reveal...

Is there data and FDA approval for this indication? What about for nodal failure after radiation? 

What dose constraint would you use for the neobladder? Small bowel constraint of 54Gy? Or would you recommend observation or ADT alone or low dose RT ...

How would a much higher risk cancer affect decision making? How would you treat him? 

For instance, if the fluclicovine scan shows a few small avid nodes not only in the pelvis but extending to the paraaortic region, would you treat the...

Will your recommendation change if there is suspicious/confirmed locally recurrent nodule in the prostate bed?

Per the ALSYMPCA study, they excluded patients with > 3cm lymphadenopathy. Patient is currently on enzalutamide and leuprolide and refuses docetaxe...

Does the STAMPEDE trial, showing a survival benefit with the addition of docetaxel to standard treatment, change the standard of care for high risk, n...

Is there a benefit to one fractionation schedule v. the other?

Abstract LBA5_PR ‘Radiotherapy (RT) to the primary tumour for men with newly-diagnosed metastatic prostate cancer (PCA): survival results from S...

Is there a dose response relationship, as suggested in the phase I MSKCC dose escalation study presented at ASTRO 2017?

Based on the updated results of the PCS IV trial is 18 months of ADT the new standard of care for men with high-risk prostate cancer treated with...

In the case of patients many years out from RP who have a slowly rising PSA, do you offer salvage RT while the PSA is still very low or follow the PSA...

In patients with new bone pain and without any evidence of bone metastases receiving GnRH agonists, how do you manage pain symptoms?

With biopsy-proven, negative systemic restaging disease, what dose and fractionation is appropriate if treating with IMRT? Should ADT generally b...

Would you consider this an indication to treat lymph nodes, if you would typically not do so?

Is there an upper limit to offer definitive RT? Is it possible to have a PSA of 100-500 and still have only local disease?

Is there a role for salvage LN dissection or salvage RT to the node? And is there a role for systemic therapy (ADT or chemotherapy) in addition? If yo...

Should the workup change with the PSA level (for example, >2 vs <2 ng/ml post-op PSA)?  Is there a PSA level for which salvage radiotherapy...

Two retrospective studies from Stanford showed that patients who received ADT had an increased risk of dementia and Alzheimer's. Is this finding ...

Do you use a PSA threshold, PSA doubling time, or only evidence of metastatic disease to trigger ADT? For those without rapid doubling time, do you ev...

In the recent 10 year update of the ARO (adjuvant pelvic RT versus observation) trial, their definition of PSA failure was 2 successive rise...

Given recent advancements in the understanding of biological differences in prostate cancer patients of African vs. other ancestry, does your manageme...

Does PSADT play a factor in your decision-making? If so, how specifically?  I've tended to wait until the PSA is 10-15, re-image, and then begin...

In situations where there is a significant risk of either local or nodal persistence/recurrence post prostatectomy with a rising PSA, or nodal involve...

 In a patient with node positive disease, treated definitively with radiation, should continuous or intermittent ADT be administered? If a patien...

Guidelines dont seem to account for this possibility. Could it just be normal prostate tissue growing back that is leading to PSA, why just assume it ...

In starting prostate SBRT at an instutution, what are issues with the treatment that one should pay special attention to?

On what other factors should be considered in making a treatment recommendation for salvage radiation therapy?

What factors should be considered with offering SBRT to oligometastatic bone disease in prostate cancer patients? Should this been done off of a proto...

With ultra-sensitive PSA, it's unclear to me whether a doubling from 0.01 to 0.02 or 0.02 to 0.04 is significant. Is there a certain value that you wo...

If a patient is deemed high risk enough to require hormones with RT in the salvage setting, how long would you maintain them on ADT? Would you extrapo...

When counseling patients with organ-confined prostate cancer, what rates of impotence, incontinence, rectal toxicity, and urethral stricture shou...

The optimal timing of post-prostatectomy RT in high-risk patients is debatable and currently the question of prospective randomized trials; however, g...

Do you use a particular cut-off? For example, someone in their 40's?

The patient has a positive bone scan (2 lesions), grade 4+5=9/10 prostate, and cancer cannot urinate without a catheter.

More specifically, which cardiac risk factors do you look for? Diabetes? Previous MI? Dyslipidemia? Peripheral vascular disease? CHF?

In general how do you counsel patients with high risk prostate cancer when choosing radiation verse prostatectomy? What numbers do you quote for ...

This is a patient who would have been an appropriate candidate for radiation upfront, but was managed with androgen deprivation therapy instead. On th...

Sometimes the scans don’t line up well because of differences in rectal and bladder fullness- any tips to optimize the fusion?

I ask this because I am seeing more and more patients who have had surgery despite presenting with high risk disease.

I know many do not treat the pelvis at all, but for those who do, what criteria do you use? Risk? Gleason? PSA? T stage?

And should special precautions be taken (such as dose reduction, prophylactic symptom management, etc)?


Papers discussed in this category


International journal of radiation oncology, biology, physics, 2005-04-01

Int J Radiat Oncol Biol Phys, 2005 Sep 1

International journal of radiation oncology, biology, physics, 2004-06-01

International journal of radiation oncology, biology, physics, 2007-08-01

International journal of radiation oncology, biology, physics, 2014-04-01

Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2013-11-01

Int. J. Radiat. Oncol. Biol. Phys., 2012-12-01

European urology, 2013-12

CA Cancer J Clin, 2010 May-Jun

J Natl Cancer Inst, 2010 Jan 6

BJU international, 2014-12

JAMA, 2011-12-07

Cancer, 2013 May 15

International journal of radiation oncology, biology, physics, 2010-11-01

American journal of clinical oncology, 2016-02

Radiother Oncol, 2013-01-01

Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2010-03-20

Eur. Urol., 2009-05-01

The American journal of surgical pathology, 2005-09

The New England journal of medicine, 2012-07-19

BMJ, 2014-01-08

International journal of radiation oncology, biology, physics, 2012-05-01

International journal of radiation oncology, biology, physics, 2012-02-01

N. Engl. J. Med., 2009-06-11

JAMA, 2006-11-15

Practical radiation oncology, 2013

N Engl J Med, 2008 Mar 20

The Journal of urology, 2011-09

Practical radiation oncology, 2013

Urologic oncology, 2014-04

BJU international, 2014-03

Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2015-03-10

J. Urol., 1998-01-01

Eur. Urol., 2014-03-01

BJU international, 2015-10

The New England journal of medicine, 2011-07-14

International journal of radiation oncology, biology, physics, 2010-04

JAMA, 2015

Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2008-06-20

The Journal of urology, 2012-01

Cancers, 2022 Jan 29

International journal of radiation oncology, biology, physics, 2013-03-15

Cancer, 2014-06-15

Cancer, 2006 Jun 15

International journal of radiation oncology, biology, physics, 2003-03-15

Urology, 2008-11

Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2004-05-15

American journal of clinical oncology, 2014-06

International journal of radiation oncology, biology, physics, 2011-07-15

International journal of radiation oncology, biology, physics, 2010-07-15

Frontiers in oncology, 2011

Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 1999-04

Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2016-10-20

The New England journal of medicine, 2017-02-02

JAMA Oncol, 2017-10-01

Seminars in radiation oncology, 2013-07

Eur Urol, 2015 Jul 16

BJU Int, 2009 Feb

European urology, 2014-06

Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2007-05-20

The New England journal of medicine, 2013-07-18

JAMA Oncol, 2020 Aug 27

Lancet, 2016 Mar 19

Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2019-05-10

European urology, 2011-04

Urology, 2001-11

Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2016-01-20

J. Nucl. Med., 2015 Jun 25

Int. J. Radiat. Oncol. Biol. Phys., 2015 Apr 23

Brachytherapy, 2020 Apr 21

Int. J. Radiat. Oncol. Biol. Phys., 2020 Jan 24

Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2008-04-01

Lancet Oncol., 2010-02-01

Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2006-03-20

The Journal of urology, 2005-08

Mol Clin Oncol, 2015 May 04

Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2010-12-10

Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2013-11-10

The Journal of urology, 1999-07

Annals of oncology : official journal of the European Society for Medical Oncology, 2009-03

Mayo Clin Proc, 2004 Oct

JNCI Cancer Spectr, 2019 Oct 21

N Engl J Med, 1994 Aug 11

The New England journal of medicine, 2018-05-03

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The Journal of urology, 2002-09

Clinical cancer research : an official journal of the American Association for Cancer Research, 2009-01-15

Nature, 2005-12-08

J Clin Oncol, 1999 Jul

Lancet, 2015 Jan 3

The New England journal of medicine, 2001-12-06

Lancet, 2001-09-22

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PLoS ONE, 2016-01-01

J. Urol., 2002-04-01

Lancet Oncol., 2015 Sep 09

European urology, 2018-02

Lancet, 2018 Oct 18

The New England journal of medicine, 2015-08-20

JAMA, 2008-06-18

International journal of radiation oncology, biology, physics, 2007-11-01

The Lancet. Oncology, 2006-06

Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2015-06-20

Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2016-02-20

JAMA oncology, 2016-04

JAMA oncology, 2017-01-01

Int J Radiat Oncol Biol Phys, 2012 Jul 15

International journal of radiation oncology, biology, physics, 2011-06-01

Lancet, 2008 Dec 16

Lancet, 2011-12-17

Urology, 2017-04

Eur Urol Oncol, 2020 May 22

Int J Radiat Oncol Biol Phys, 1986 Mar

Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2015-06-10

Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2014-12-10

JAMA Oncol,

J Urol,

Frontiers in oncology, 2017

International journal of radiation oncology, biology, physics, 2008-09-01

European urology, 2018-07

International journal of radiation oncology, biology, physics, 2008-04-01

International journal of radiation oncology, biology, physics, 2014-07-01

International journal of radiation oncology, biology, physics, 2016-07-01

Radiotherapy and oncology : journal of the European Society for Therapeutic Radiology and Oncology, 2013-11

Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2011-05-20

Frontiers of radiation therapy and oncology, 2011

Semin Radiat Oncol, 2016 Aug 31

International journal of radiation oncology, biology, physics, 2018-06-01

J. Clin. Oncol., 2015 May 26

J. Clin. Oncol.,

International journal of radiation oncology, biology, physics, 2012-04-01

Brachytherapy, 2016

J Clin Oncol, 2021 Jan 26

J Clin Oncol, 2021 Jan 20

Lancet, 2021 Dec 23

Practical radiation oncology, 2018

Practical radiation oncology, 2018

International journal of radiation oncology, biology, physics, 2008-01-01

Frontiers in oncology, 2014

International journal of radiation oncology, biology, physics, 2017-04-01

The Journal of urology, 2004-03

International journal of radiation oncology, biology, physics, 2018-10-01

Journal of contemporary brachytherapy, 2016-10

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Radiother Oncol, 2009 Apr

Semin Radiat Oncol, 2004-01-01

Practical radiation oncology, 2017

The Lancet. Oncology, 2019-03

N. Engl. J. Med., 2017-07-27

Eur. Urol., 2018 Jul 03

Lancet, 2019 Apr 11

J. Clin. Oncol., 2017 Dec 14

Eur. Urol., 2019 Jul 19

Ann. Oncol.,

Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2005-02-01

Urology, 2001-08

BMC Cancer, 2014 Sep 15

JAMA Oncol,

Lancet Oncol., 2016-06-01

JAMA Oncol, 2020 Mar 26

Lancet, 2020 Sep 28

Lancet Oncol,

Lancet Oncol,

The New England journal of medicine, 2017-07-27

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The Lancet. Oncology, 2012-02

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Urology, 2000-11-01

Abdom Radiol (NY), 2019 Aug 29

Lancet, 2021 May 07

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J Urol, 2020 Apr 13

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J Urol,

Lancet Oncol, 2010 Oct 07

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Prostate Cancer Prostatic Dis, 2020 May 13

The Lancet. Oncology, 2018-11

Pancreas, 2010-08

European urology, 2018-08

American journal of clinical and experimental urology, 2014

The Prostate. Supplement, 1998

The Prostate, 2001 May 15

Clinical nuclear medicine, 2017 Jan

The New England journal of medicine, 2018-04-12

The New England journal of medicine, 2018-06-28

The New England journal of medicine, 2019-03-28

Clin Cancer Res, 2019 Sep 11

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JAMA Oncol,

J Urol, 2021 Feb 26

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International journal of radiation oncology, biology, physics, 2017-06-01

Proceedings of the National Academy of Sciences of the United States of America, 2011-06-07

Journal of nuclear medicine : official publication, Society of Nuclear Medicine, 2017-01

European journal of nuclear medicine and molecular imaging, 2018-11

European urology oncology, 2018-05

J Nucl Med, 2021 Dec 16

J Nucl Med, 2018 Dec 14

Eur J Nucl Med Mol Imaging, 2019 Nov 15

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J Urol, 2021 Feb 03

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J Clin Oncol, 2022 Mar 15

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Prostate, 2022 Jun 08

International journal of radiation oncology, biology, physics, 2006-07-15

J Nucl Med, 2021 Jun 24

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J Clin Oncol, 2014 Dec 15

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JAMA Oncol,

BJU Int, 2022 Apr 03

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International journal of radiation oncology, biology, physics, 1998-03-01

Front Oncol, 2022 Jun 07

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J Clin Oncol, 2023 Apr 27

Front Oncol, 2022 Mar 29

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Scandinavian journal of urology and nephrology, 2004

BJU international, 2005-10

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N Engl J Med, 2021 Jun 23

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Lancet Oncol., 2018 Dec 19

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Pract Radiat Oncol, 2022 Mar-Apr

Prostate, 2020 Feb

BJUI Compass, 2021 Jan 05

Lancet, 2022 Apr 08

Eur Urol, 2018 Sep 25

Eur Urol, 2015 May 21

JAMA oncology, 2023 Jun 01

International journal of radiation oncology, biology, physics, 2019-08-01

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BJU Int, 2021 Dec 13

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Lancet Oncol, 2019 Sep 17

Lancet Oncol, 2021 Feb

The Lancet. Oncology, 2022 Sep 13

Radiother Oncol, 2018 Jan 11

Brachytherapy, 2022 Apr 06

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The Lancet. Oncology, 2014-05

The New England journal of medicine, 2023 Oct 19

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International journal of cancer, 2022 May 16

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European urology, 2022 Apr 18

The New England journal of medicine, 2018-05-10

The New England journal of medicine, 2020 Mar 05

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European urology oncology, 2020 Jun 24

BMC Cancer, 2020 May 12

La Radiologia medica, 2021 Nov 30

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JAMA network open, 2020 Sep 01

The Prostate, 2023 May 27

Lancet Oncol, 2016 Aug

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Radiation oncology (London, England), 2012-06-09

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International journal of radiation oncology, biology, physics, 2022 Aug 17

Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2023 Sep 25

International journal of radiation oncology, biology, physics, 2022 Jun 05

BMC Cancer, 2019 Aug 19

BMC Cancer, 2020 May 5

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Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2015 Feb 17

European urology, 2021 Aug 28

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Acta oncologica (Stockholm, Sweden), 2005

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Radiation oncology (London, England), 2015-10-24

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The Prostate, 2023 Mar 22

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