Treatment Options for Prostate Cancer
The treatment of prostate cancer should be based on risk stratification (low, intermediate, or high risk) and disease stage, with options ranging from active surveillance to multimodal approaches combining surgery, radiation therapy, and systemic treatments depending on disease characteristics.
Risk Stratification and Staging
Risk stratification is essential for determining appropriate treatment:
- Low-risk disease: T1-2a, Gleason ≤6, PSA <10 mg/l 1
- Intermediate-risk disease: T2b-c, Gleason 7, PSA 10-20 mg/l 1
- High-risk disease: T3-4, Gleason 8-10, PSA >20 mg/l 1
Proper staging requires:
- Digital rectal examination (DRE) for clinical T stage
- PSA measurement
- Bone scan (if Gleason >4+3 or PSA >15 mg/l) 1
- MRI or CT for intermediate/high-risk disease 1
Treatment Options by Disease Stage
1. Localized Disease
Low-Risk Disease
- Active surveillance: Preferred approach for men with less aggressive disease (PSA <10 ng/mL, Gleason 3+3) 1
- Radical prostatectomy: Effective treatment with 90-94% 10-year survival rate 1
- External beam radiotherapy (EBRT): Minimum target dose of 70 Gy given in 1.8-2.0 Gy fractions 1
- Brachytherapy: With permanent implants, similar outcomes to radical prostatectomy with less urinary morbidity 1, 2
Intermediate-Risk Disease
- Radical prostatectomy with pelvic lymphadenectomy 1
- EBRT with neoadjuvant ADT: 4-6 months of ADT improves outcomes 1, 2
- Brachytherapy (alone or combined with EBRT) 1
High-Risk Disease
- Long-term ADT (2-3 years) + radical RT: Significantly improves local control, reduces disease progression, and improves overall survival 1
- Radical prostatectomy + pelvic lymphadenectomy: For highly selected cases 1
- Neoadjuvant docetaxel: May be considered in appropriate patients 1, 3
2. Locally Advanced Disease (T3-T4)
- Neoadjuvant ADT + radical RT + adjuvant ADT: Standard approach 1
- Radical prostatectomy + pelvic lymphadenectomy: For selected cases 1
3. Metastatic Disease
Hormone-Sensitive Metastatic Disease
- ADT (LHRH agonist or surgical castration): First-line treatment 1
- ADT + abiraterone: Improves survival from 36.5 to 53.3 months compared to ADT alone 4
- ADT + docetaxel: For patients with high-volume disease 1, 3
- ADT + enzalutamide or apalutamide: Newer options with survival benefits 1
Castration-Resistant Prostate Cancer
- Abiraterone or enzalutamide: First-line options 1
- Docetaxel: 75 mg/m² every 3 weeks with prednisone 5 mg twice daily 1, 3
- Radium-223: For bone-predominant metastases without visceral disease 1, 2
- Cabazitaxel: Second-line chemotherapy after docetaxel 1
Special Considerations
Radiation Therapy Specifics
- Conformal techniques should be used to reduce toxicity 1
- Dose escalation above 74 Gy benefits intermediate-risk patients 1, 2
- Stereotactic body radiation therapy (SBRT) is emerging for oligometastatic disease 2
Androgen Deprivation Therapy
- Short-course antiandrogen should be used when starting LHRH agonist to prevent disease flare 1
- Breast irradiation (8-15 Gy in 1-3 fractions) should be given 1-2 weeks before antiandrogen therapy to prevent painful gynecomastia 1
Post-Treatment Monitoring
- After radical prostatectomy, PSA should be undetectable (<0.1 mg/l) 1
- After radiotherapy, PSA should reach 1 mg/l within 16 months 1
- First follow-up visit at 3 months, then yearly visits 1
Common Pitfalls to Avoid
- Inadequate risk stratification: Treatment decisions must be based on proper risk assessment 1
- Inappropriate patient selection: Not all patients benefit from the same approach; consider age, comorbidities, and life expectancy 1, 2
- Insufficient radiation dose: Doses below 70 Gy for EBRT result in inferior outcomes 2
- Overlooking combination therapy: High-risk disease requires multimodal approaches 1, 2
- Delayed salvage therapy: Early salvage RT is crucial after biochemical failure post-prostatectomy 2
By following these evidence-based approaches, clinicians can optimize treatment outcomes while minimizing treatment-related morbidity for patients with prostate cancer.