A randomized phase II trial of MR-guided prostate stereotactic body radiotherapy administered in 5 or 2 fractions for localized prostate cancer (FORT)

Abstract

Background: Ultra-hypofractionated regimens for definitive prostate cancer (PCa) radiotherapy are increasingly utilized due in part to promising safety and efficacy data complemented by greater patient convenience from a treatment course requiring fewer sessions. As such, stereotactic body radiation therapy (SBRT) is rapidly emerging as a standard definitive treatment option for patients with localized PCa. The commercially available magnetic resonance linear accelerator (MR-LINAC) integrates MR imaging with radiation delivery, providing several theoretical advantages compared to computed tomography (CT)-guided radiotherapy. MR-LINAC technology facilitates improved visualization of the prostate, real-time intrafraction tracking of prostate and organs-at-risk (OAR), and online adaptive planning to account for target movement and anatomical changes. These features enable reduced treatment volume margins and improved sparing of surrounding OAR. The theoretical advantages of MR-guided radiotherapy (MRgRT) have recently been shown to significantly reduce rates of acute grade ≥ 2 GU toxicities as reported in the prospective randomized phase III MIRAGE trial, which compared MR-LINAC vs CT-based 5 fraction SBRT in patients with localized PCa (Kishan et al. JAMA Oncol 9:365-373, 2023). Thus, MR-LINAC SBRT-utilizing potentially fewer treatments-is warranted and clinically relevant for men with low or intermediate risk PCa electing for radiotherapy as definitive treatment.

Methods/design: A total of 136 men with treatment naïve low or intermediate risk PCa will be randomized in a 1:1 ratio to 5 or 2 fractions of MR-guided SBRT using permuted block randomization. Randomization is stratified by baseline Expanded PCa Index Composite (EPIC) bowel and urinary domain scores. Patients undergoing 5 fractions will receive 37.5 Gy to the prostate over 10-14 days and patients undergoing 2 fractions will receive 25 Gy to the prostate over 7-10 days. The co-primary endpoints are GI and GU toxicities as measured by change scores in the bowel and urinary EPIC domains, respectively. The change scores will be calculated as pre-treatment (baseline) score subtracted from the 2-year score.

Discussion: FORT is an international, multi-institutional prospective randomized phase II trial evaluating whether MR-guided SBRT delivered in 2 fractions versus 5 fractions is non-inferior from a gastrointestinal (GI) and genitourinary (GU) toxicity standpoint at 2 years post-treatment in men with low or intermediate risk PCa.

Trial registration: Clinicaltrials.gov identifier: NCT04984343 . Date of registration: July 30, 2021.

Protocol version: 4.0, Nov 8, 2022.

Keywords: Definitive radiotherapy; Gastrointestinal (GI); Genitourinary (GU); MR-guided radiotherapy (MRgRT); Magnetic resonance linear accelerator (MR-LINAC); Prostate cancer (PCa); Stereotactic body radiotherapy (SBRT); Toxicity; Ultra-hypofractionation.

Fig. 1

Trial Schema. Expanded PCa Index Composite (EPIC), EuroQol-5D Index (EQ-5D) and International Prostate Symptom Score (IPSS) quality of life (QOL) surveys are collected at screening, baseline (before or first day of radiotherapy), end of radiotherapy, and at 3 month, 6 month, 9 month, 12 month, 15 month, 18 month, 21 month, 24 month and 60 month follow-up visits. *EPIC score groups determined as: high bowel score > 96, low bowel score ≤ 96, high urinary score > 84, low urinary score ≤ 84. ** GI, gastrointestinal; GU, genitourinary; RT, radiotherapy