What are the treatment options for prostate cancer?

Treatment Options for Prostate Cancer

The treatment of prostate cancer should be risk-stratified based on disease characteristics, with active surveillance being the preferred management strategy for low-risk disease, while surgery or radiation therapy (with or without androgen deprivation therapy) is recommended for intermediate and high-risk disease. 1

Risk Stratification

Treatment decisions should be based on risk classification:

Low-Risk Disease

• Clinical stage T1-T2a
• Gleason score ≤6 (ISUP grade 1)
• PSA <10 ng/mL

Intermediate-Risk Disease

• Clinical stage T2b-T2c, or
• Gleason score 7, or
• PSA 10-20 ng/mL

High-Risk Disease

• Clinical stage T3a, or
• Gleason score 8-10, or
• PSA >20 ng/mL

Very High-Risk Disease

• Clinical stage T3b-T4 (locally advanced)

Treatment Options by Risk Category

Low-Risk Prostate Cancer

1. Active surveillance (preferred approach) 1, 2

   • Regular monitoring with PSA testing every 3-6 months
   • Digital rectal examination every 6-12 months
   • Confirmatory biopsy within 6-12 months of diagnosis
   • Subsequent biopsies every 1-2 years
   • Intervention triggered by disease progression

2. Radical prostatectomy

   • Consider for patients with life expectancy >10 years
   • Associated with risks of erectile dysfunction (up to 80%) and urinary incontinence (up to 49%) 1

3. Radiation therapy options

   • External beam radiation therapy (minimum 74 Gy)
   • Brachytherapy (permanent seed implants or high-dose rate)

Intermediate-Risk Prostate Cancer

1. Radical prostatectomy with pelvic lymph node dissection (if risk of lymph node involvement ≥2%)

2. Radiation therapy

   • External beam radiation with or without 4-6 months of ADT
   • External beam radiation plus brachytherapy boost
   • Brachytherapy alone (for favorable intermediate-risk)

3. Active surveillance is not generally recommended for patients with life expectancy >10 years 1

High-Risk Prostate Cancer

1. External beam radiation therapy plus 2-3 years of ADT (preferred, category 1) 1

2. External beam radiation plus brachytherapy boost (with or without ADT)

3. Radical prostatectomy with pelvic lymph node dissection (for selected patients) 1

Very High-Risk/Locally Advanced Disease

1. External beam radiation plus long-term ADT (category 1) 1

2. External beam radiation plus brachytherapy (with or without long-term ADT)

3. Radical prostatectomy plus pelvic lymph node dissection (for selected patients without fixation to adjacent organs)

Metastatic Disease

1. ADT plus additional systemic therapy:

   • ADT plus abiraterone 1, 3
   • ADT plus docetaxel 1, 4
   • ADT plus enzalutamide or apalutamide 1

2. Radiation therapy to the primary tumor (for low-volume metastatic disease) 1

Castration-Resistant Prostate Cancer (CRPC)

For patients who progress despite ADT:

1. First-line options:

   • Abiraterone plus prednisone
   • Enzalutamide
   • Docetaxel chemotherapy

2. Second-line or post-docetaxel options:

   • Abiraterone (if not used first-line)
   • Enzalutamide (if not used first-line)
   • Cabazitaxel
   • Radium-223 (for bone-predominant disease)

Important Considerations

Active Surveillance

• Preserves quality of life by avoiding treatment side effects
• Excellent cancer-specific survival rates (>99% at 8 years) 1
• Requires patient commitment to follow-up protocol
• Consider intervention if: Gleason grade progression, increase in positive cores, PSA doubling time <3 years, or clinical progression 2

Surgery vs. Radiation

• Similar oncologic outcomes for localized disease
• Different side effect profiles:
  • Surgery: Higher risk of urinary incontinence and erectile dysfunction
  • Radiation: Higher risk of bowel dysfunction, delayed erectile dysfunction

Androgen Deprivation Therapy (ADT)

• Not recommended as primary monotherapy for localized disease 1
• Essential component of treatment for high-risk and metastatic disease
• Associated with significant side effects: hot flashes, sexual dysfunction, osteoporosis, metabolic syndrome
• Regular exercise reduces fatigue and improves quality of life for men on ADT 1

Emerging Approaches

• Novel imaging techniques (PSMA-PET) may improve staging but should not alter standard treatment approaches without evidence of benefit 1
• Cryotherapy, HIFU, and focal therapy are not recommended as standard initial treatments 1

By following this risk-stratified approach to prostate cancer management, clinicians can optimize outcomes while minimizing unnecessary treatment-related morbidity.