Beyond localisation: how MRI-guided adaptive radiotherapy is enabling a new era of precision radiotherapy in prostate cancer

The recent decision by NHS England to expand access to stereotactic ablative radiotherapy (SABR) for eligible men with localised prostate cancer reflects the growing maturity of the evidence supporting ultra-hypofractionated treatment. As treatment schedules have shortened from several weeks to just five fractions, the importance of treatment precision has increased, particularly when accounting for prostate motion, anatomical variation and the close proximity of organs at risk.

Advanced imaging techniques, including multiparametric MRI and PSMA PETCT, are increasingly influencing every stage of the prostate cancer pathway, from diagnosis and staging through to treatment planning, delivery and response assessment. MRI-guided adaptive radiotherapy (MRIgART) extends this role further by combining superior soft tissue visualisation with daily online adaptation and intrafraction motion monitoring, allowing treatment to be refined to the patient’s anatomy at the time of delivery.

This article explores the imaging challenges associated with treating a mobile target adjacent to critical structures and reviews the evidence supporting MRIgART. It also considers how MRIgART is enabling more personalised approaches, including focal boosting of dominant intraprostatic lesions, salvage re-irradiation and emerging strategies aimed at further shortening treatment and functional preservation.

Alongside these clinical opportunities, MRIgART introduces additional workflow, training and resource requirements. Drawing on published evidence and GenesisCare’s UK experience of delivering MRIgART to more than 1,000 patients with primary and recurrent prostate cancer across its UK MR-linac network, the largest network of MR-linacs in the UK, the article examines how MRIgART is evolving towards more precise, individualised treatment with the potential to reduce toxicity and preserve quality of life.

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