What are the preventive measures and treatment options for prostate cancer?

Prostate Cancer Prevention and Treatment Options

For prostate cancer management, treatment should be based on risk stratification with options including active surveillance, surgery, radiation therapy, and hormone therapy depending on disease stage, patient age, and life expectancy.

Risk Stratification

Risk stratification is essential for determining appropriate management strategies:

• Very Low Risk: T1c, Gleason ≤6, PSA <10 ng/mL, <3 positive biopsy cores, ≤50% cancer in any core, PSA density <0.15 ng/mL/g 1
• Low Risk: T1-T2a, Gleason ≤6, PSA <10 ng/mL 1
• Intermediate Risk: T2b-T2c, Gleason 7, or PSA 10-20 ng/mL 1
• High Risk: T3a, Gleason 8-10, or PSA >20 ng/mL 1
• Very High Risk: T3b-T4 (locally advanced) 1

Diagnostic Approach

• Serum PSA measurement and digital rectal examination (DRE) should be performed in patients with urinary symptoms 1
• Prostate biopsy is indicated for abnormal DRE or elevated PSA 1
• Biopsy should be performed under transrectal ultrasound guidance with a minimum of 8 cores 1
• Pathology report should include Gleason score and extent of involvement 1

Treatment Options by Risk Category

Very Low/Low Risk Disease

• Life expectancy <10 years: Observation (watchful waiting) 1
• Life expectancy 10-20 years: Active surveillance recommended 1
• Life expectancy >20 years: Options include 1:
  • Active surveillance
  • Radical prostatectomy
  • Radiation therapy (external beam or brachytherapy)

Intermediate Risk Disease

• Life expectancy <10 years: Observation or watchful waiting 1
• Life expectancy >10 years: Options include 1:
  • Radical prostatectomy with pelvic lymph node dissection (PLND) if risk of lymph node metastasis ≥2%
  • External beam radiation therapy (EBRT) with or without 4-6 months of androgen deprivation therapy (ADT)
  • Brachytherapy (for selected patients with favorable intermediate risk)
  • Active surveillance may be offered to select patients with favorable intermediate risk, though this comes with higher risk of metastases compared to definitive treatment 1

High Risk Disease

• Standard treatment options 1:
  • Radical prostatectomy with PLND (selected patients)
  • Radiation therapy plus ADT (2-3 years)
  • EBRT plus brachytherapy with or without ADT
• Not recommended: Active surveillance, primary ADT alone (unless limited life expectancy with local symptoms), cryosurgery, focal therapy, or HIFU outside clinical trials 1

Very High Risk/Locally Advanced Disease

• Treatment options 1:
  • Radiation therapy with long-term ADT (category 1 recommendation)
  • EBRT plus brachytherapy with or without long-term ADT
  • Radical prostatectomy with PLND (selected patients without fixation to adjacent organs)
  • ADT alone (only for patients not eligible for definitive therapy)

Metastatic Disease

• First-line treatment: Androgen suppression using bilateral orchiectomy or LHRH agonist 1
• Short-course antiandrogen should be used to prevent disease flare when starting LHRH agonist 1
• Castration-refractory disease: Continue androgen suppression 1
• Chemotherapy (docetaxel) combined with prednisone may palliate pain and has modest effect on survival 1

Special Considerations

Active Surveillance Protocol

• PSA determination no more often than every 6 months unless clinically indicated 1
• DRE no more often than every 12 months unless clinically indicated 1
• Repeat prostate biopsy no more often than every 12 months unless clinically indicated 1
• Initial repeat biopsy within 6 months if original biopsy had fewer than 10 cores 1

Radiation Therapy Considerations

• External beam radiotherapy should use conformal techniques 1
• Minimum target dose of 70 Gy given in 2.0 Gy fractions or equivalent 1
• For high-risk disease, brachytherapy boost should be offered to eligible patients 1
• Patients should be informed that ADT with radiation increases adverse effects on sexual function 1

Surgical Considerations

• Older men experience higher rates of permanent erectile dysfunction and urinary incontinence after prostatectomy compared to younger men 1
• PLND is recommended for unfavorable intermediate risk or high-risk disease 1
• Patients should be counseled about potential adjuvant radiotherapy when locally extensive disease is found at prostatectomy 1

Preventive Measures

• Finasteride (5-alpha-reductase inhibitor) has shown reduction in overall prostate cancer risk but is not FDA-approved for prostate cancer prevention 2, 3
• The PCPT trial showed finasteride reduced overall prostate cancer incidence but had a higher rate of high-grade cancers 2, 3
• Current FDA labeling specifically states: "Finasteride tablets are not approved for the prevention of prostate cancer" 2

Follow-up After Treatment

• After radical prostatectomy, serum PSA should be below detection level after 2 months 1
• After external beam radiotherapy, serum PSA should reach 1 mg/L within 16 months 1
• First follow-up visit should be at 3 months after radical treatment 1
• Follow-up should include PSA measurement, digital rectal examination, and assessment of treatment-related symptoms 1

Common Pitfalls and Caveats

• Avoid primary ADT alone for localized prostate cancer as it does not improve survival 1
• Cryotherapy, HIFU, and focal therapy are not recommended as standard initial treatments for localized prostate cancer 1
• Genetic counseling should be considered for high-risk patients with strong family history of specific cancers (breast, ovarian, pancreatic, etc.) 1
• Patients with obstructive urinary symptoms may be better candidates for surgical approaches rather than radiation 1
• Brachytherapy can exacerbate urinary obstructive symptoms 1