What are the treatment options for prostate cancer?

Treatment Options for Prostate Cancer

The treatment of prostate cancer should be based on risk stratification, with options including active surveillance, radical prostatectomy, radiation therapy, hormone therapy, and chemotherapy depending on disease stage and risk category. 1, 2

Risk Stratification

Risk stratification is essential for determining appropriate treatment:

• Low-risk disease: Gleason score ≤6, PSA <10 ng/mL 2
• Intermediate-risk disease: Gleason score 7 or PSA 10-20 ng/mL 2
• High-risk disease: Gleason score 8-10 or PSA >20 ng/mL 2
• Very high-risk/locally advanced disease: T3b-T4 2
• Metastatic disease: Presence of distant metastases 1

Treatment Options by Risk Category

Low-Risk Disease

• Active surveillance is recommended for patients with low-risk disease and life expectancy 10-20 years 1, 2
• Watchful waiting with delayed hormone therapy is appropriate for men not suitable for or unwilling to have radical treatment 1
• Radical prostatectomy, external beam radiotherapy, or brachytherapy are curative options 1
• Immediate hormone therapy alone is not recommended 1

Intermediate-Risk Disease

• Radical prostatectomy with pelvic lymph node dissection 1
• External beam radiation therapy with or without androgen deprivation therapy (ADT) 1
• Brachytherapy (permanent implants or high-dose rate) 1
• Active surveillance may be considered in select cases 1

High-Risk or Locally Advanced Disease

• External beam radiation therapy plus long-term ADT 1
• Radical prostatectomy plus pelvic lymphadenectomy 1
• Neoadjuvant and concurrent ADT for 4-6 months is recommended for men receiving radical RT 1
• Adjuvant ADT for 2-3 years is recommended for men at high risk of prostate cancer mortality 1

Metastatic Disease

• ADT plus novel hormonal agents (abiraterone, enzalutamide, apalutamide) is recommended as first-line treatment 1, 3
• ADT plus docetaxel is recommended for men fit enough for chemotherapy 1, 4
• Continuous ADT is recommended as first-line treatment of metastatic hormone-naïve disease 1
• For castration-resistant prostate cancer: abiraterone, enzalutamide, docetaxel, or radium-223 (for bone metastases) 1

Special Considerations

Active Surveillance

• Active surveillance involves close monitoring with PSA measurements, digital rectal examinations, and repeat biopsies 2, 5
• It helps avoid overtreatment of indolent disease while maintaining the option for curative treatment if progression occurs 6, 7
• In prospective studies, 10-year prostate cancer-specific survival approaches 100% for properly selected patients 1
• Approximately 14-41% of patients on active surveillance progress to active treatment with intermediate-term follow-up 5

Radical Prostatectomy

• Radical prostatectomy can increase rates of erectile dysfunction (80% vs 45%) and urinary leakage (49% vs 21%) compared to watchful waiting 1
• In the SPCG-4 trial, radical prostatectomy showed a beneficial impact on prostate cancer mortality compared to watchful waiting, particularly in men aged ≤65 years 1
• Following radical prostatectomy, serum PSA should be undetectable after 2 months 2

Radiation Therapy

• External beam radiotherapy should use conformal techniques with a minimum target dose of 74 Gy given in 2.0 Gy fractions or equivalent 1, 2
• Brachytherapy with permanent implants has shown similar long-term survival to radical prostatectomy in non-randomized prospective series 1
• After external beam radiotherapy, serum PSA should reach 1 mg/L within 16 months 2

Metastatic Disease Management

• For metastatic castration-resistant prostate cancer, docetaxel (75 mg/m² every 3 weeks) with prednisone 5 mg orally twice daily is an approved treatment 4
• Abiraterone acetate inhibits androgen biosynthesis and is effective for metastatic castration-resistant prostate cancer 3
• The addition of androgen receptor pathway inhibitors to ADT improves survival in metastatic prostate cancer (median overall survival improved from 36.5 to 53.3 months with abiraterone) 8

Common Pitfalls and Caveats

• Primary ADT alone should not be used for localized prostate cancer as it does not improve survival 2
• Cryotherapy, HIFU, and focal therapy are not recommended as standard initial treatments 1, 2
• A single elevated PSA level should not prompt a prostate biopsy and should be verified by a second value 1
• Patients with obstructive urinary symptoms may be better candidates for surgical approaches rather than radiation 2
• Brachytherapy can exacerbate urinary obstructive symptoms 2
• Regular exercise for men starting ADT reduces fatigue and improves quality of life 1