What are the management options for intermediate risk prostate cancer?

Management Options for Intermediate Risk Prostate Cancer

Radical prostatectomy or radiotherapy plus androgen deprivation therapy (ADT) are the standard treatment options for patients with intermediate risk prostate cancer, with the choice depending on patient factors and disease characteristics. 1

Risk Stratification

Before selecting treatment, it's important to stratify intermediate risk patients:

• Favorable intermediate risk: Single intermediate risk factor, Grade Group 2 or less, and less than 50% of biopsy cores positive 2, 3
• Unfavorable intermediate risk: Multiple intermediate risk factors, Grade Group 3, or 50% or more of biopsy cores positive 2, 3
• Cross-sectional imaging (CT or MRI) and bone scan should be considered for unfavorable intermediate risk patients 1

Standard Treatment Options

Radical Prostatectomy

• First-line option for intermediate risk prostate cancer 1
• Some retrospective analyses suggest potential mortality benefits compared to radiation therapy 1
• Better for younger patients with fewer comorbidities 4
• Provides accurate pathological staging 4

Radiation Therapy

• External Beam Radiation Therapy (EBRT) plus ADT: Strong recommendation for intermediate risk disease 1
  • Particularly important for unfavorable intermediate risk patients 1, 3
  • Short-term ADT (4-6 months) improves overall survival 1
• Radiation alone: Can be considered for favorable intermediate risk, but evidence is less robust 1, 5
• Brachytherapy: Valid option for intermediate risk patients 4, 6
  • Can be used as monotherapy for favorable intermediate risk 6
  • For unfavorable intermediate risk, may be used as boost with EBRT 6
  • ADT should not be added to brachytherapy except to reduce prostate size for dosimetry optimization 1

Alternative Treatment Options

Active Surveillance

• May be offered to select patients with favorable intermediate risk disease [1, @19@]
• Patients must be informed of higher risk of developing metastases compared to definitive treatment 1, 3

Cryosurgery

• May be considered in select patients based on preferences, comorbidities, and life expectancy [1, @18@]
• Limited comparative effectiveness research available 1

Observation/Watchful Waiting

• Recommended for men with life expectancy ≤5 years [1, @20@]
• Different from active surveillance - less intensive monitoring 4

Novel Therapies

• Focal therapy and HIFU (High-Intensity Focused Ultrasound):
  • Not standard care options due to lack of comparative outcome evidence [1, @21@]
  • May provide quality of life advantages but should be discussed as investigational 1, 5

Treatment Selection Algorithm

1. Assess patient factors:

   • Life expectancy (≤5 years: consider observation/watchful waiting) [1, @20@]
   • Comorbidities and surgical risk 4
   • Patient preferences regarding side effect profiles 6

2. Stratify risk:

   • Favorable vs. unfavorable intermediate risk 2, 3

3. Select treatment based on risk stratification:

   • Favorable intermediate risk:

     • Radical prostatectomy 1, 6
     • Radiation therapy alone 1, 5
     • Brachytherapy monotherapy 6
     • Active surveillance in select patients [1, @19@]

   • Unfavorable intermediate risk:

     • Radical prostatectomy 1
     • EBRT plus short-term ADT 1
     • EBRT plus brachytherapy boost 6

Important Considerations and Pitfalls

• Intermediate risk prostate cancer is heterogeneous - treatment should be based on specific risk factors rather than treating all intermediate risk patients the same 2, 3
• When using ADT with radiation therapy, timing is important - typically starts 8 weeks prior to radiation and continues during treatment 7
• Patients should be informed about the side effect profiles of each treatment option, as they differ significantly 4, 6
• The evidence basis for radiation alone is less robust than for combining radiotherapy with ADT, particularly for unfavorable intermediate risk patients 1
• Novel therapies like HIFU should be discussed as investigational options, not standard care [1, @21@]