Treatment Options for Prostate Cancer
Treatment for prostate cancer should be based on risk stratification, with active surveillance for low-risk disease, while intermediate or high-risk disease requires more aggressive interventions such as radical prostatectomy, radiation therapy, or combination treatments. 1
Risk Classification
Prostate cancer is classified into three risk categories that guide treatment decisions:
- Low-risk: T1-2a, Gleason <7, PSA <10 ng/ml
- Intermediate-risk: T2b-c, Gleason 7, PSA 10-20 ng/ml
- High-risk: T3-4, Gleason >7, PSA >20 ng/ml 1
Treatment Options by Risk Category
Low-Risk Disease
- Active surveillance: Preferred option with close monitoring using PSA, repeat biopsies, and MRI 2
- Radical prostatectomy: Complete surgical removal of the prostate
- Brachytherapy: Placement of radioactive seeds directly into the prostate
- External beam radiotherapy: Conformal techniques with minimum target dose of 74 Gy 2
Active surveillance has shown 99% disease-specific survival at 8 years for appropriately selected patients 2.
Intermediate-Risk Disease
- Radical prostatectomy: Often with pelvic lymphadenectomy
- External beam radiotherapy: May be combined with neoadjuvant androgen deprivation therapy (ADT)
- Brachytherapy: With or without external beam radiation
- Active surveillance: May be appropriate for select patients 2
The Scandinavian Prostate Cancer Group Study 4 demonstrated that radical prostatectomy improved overall survival at 12 years by 5.4% compared to watchful waiting (12.5% vs 17.9% mortality, p=0.03), with the benefit primarily seen in men ≤65 years 2.
High-Risk or Locally Advanced Disease
- Long-term ADT + radical radiotherapy: Standard approach
- Radical prostatectomy + pelvic lymphadenectomy: For selected patients
- Neoadjuvant ADT + radical radiotherapy + adjuvant ADT: Combination approach 2
Metastatic Disease
Hormone-naive metastatic disease:
- ADT + abiraterone
- ADT + docetaxel
- ADT + enzalutamide
- ADT + apalutamide
- Radiation therapy for low-volume disease 2
Castration-resistant (first line):
- Abiraterone
- Docetaxel
- Enzalutamide 2
Treatment-Related Considerations
Side Effects
Radical prostatectomy increases the rate of:
- Erectile dysfunction (80% vs 45% with watchful waiting)
- Urinary incontinence (49% vs 21% with watchful waiting) 2
These rates may vary depending on surgical expertise and technique.
Medication Specifics
Docetaxel: For metastatic castration-resistant prostate cancer, the recommended dose is 75 mg/m² every 3 weeks as a 1-hour intravenous infusion, with prednisone 5 mg orally twice daily administered continuously 3
Abiraterone: An androgen biosynthesis inhibitor that improves survival in metastatic prostate cancer. When added to ADT, it improved median overall survival from 36.5 months to 53.3 months compared with medical castration alone 4
Diagnostic Evaluation
Before treatment selection:
- PSA and digital rectal examination: Initial screening tools
- Prostate biopsy: Minimum of 8-12 cores under transrectal ultrasound guidance
- Imaging for staging:
- Intermediate-risk: MRI or CT (abdomen and pelvis) and bone scan
- High-risk: CT (chest, abdomen, pelvis) and bone scan 2
Follow-up Care
After radical treatment:
- PSA should be below detection limit within 2 months after prostatectomy
- PSA should reach 1 ng/ml within 16 months after radiation therapy
- First follow-up visit recommended at 3 months after radical treatment 1
Important Considerations
- Treatment decisions should account for life expectancy, comorbidities, and potential side effects
- Novel imaging techniques like PET-CT and PSMA-PET-CT have better sensitivity but have not been shown to improve clinical outcomes 2
- Population-based PSA screening is not recommended due to risks of overdiagnosis and overtreatment 1
- Approximately 75% of patients present with localized disease (5-year survival rate nearly 100%), while 10% present with metastatic disease (5-year survival rate 37%) 4