What is the recommended treatment approach for a patient with prostate cancer Gleason 7?

Treatment Approach for Prostate Cancer Gleason 7

For patients with intermediate-risk prostate cancer (Gleason 7), the recommended treatment options include radical prostatectomy with pelvic lymph node dissection, external beam radiation therapy with or without androgen deprivation therapy, or brachytherapy. 1, 2

Risk Classification and Assessment

• Gleason 7 prostate cancer is classified as intermediate-risk disease 1, 2
• Further risk stratification depends on:
  • PSA level (10-20 ng/mL increases risk) 1
  • Primary Gleason pattern (4+3 carries worse prognosis than 3+4) 3
  • Percentage of positive biopsy cores 2
  • Clinical stage (T2a or higher increases risk) 2

Treatment Options

Radical Prostatectomy

• Standard treatment option for patients with intermediate-risk disease and life expectancy >10 years 2
• Benefits include complete removal of the prostate with accurate pathological staging 2
• Potential complications include:
  • Erectile dysfunction (up to 80% of patients) 2
  • Urinary incontinence (up to 49% of patients) 2
  • Less than 5% of patients should have severe incontinence requiring multiple pads at 1 year post-surgery 2

External Beam Radiation Therapy (EBRT)

• Effective treatment option for intermediate-risk disease 2
• Should be delivered using conformal techniques to a minimum target dose of 70 Gy given in 2.0 Gy fractions 2
• Consider adding androgen deprivation therapy (ADT) for 4-6 months for intermediate-risk disease 2
• Late complications affecting bladder and rectum should be less than 5% at 2 years 2

Brachytherapy

• Can be used as monotherapy or as a boost with EBRT 2, 1
• For patients with low-intermediate risk prostate cancer (Gleason 7, PSA <10 ng/mL), low-dose rate (LDR) brachytherapy alone may be offered as monotherapy 2
• For patients with intermediate-risk disease choosing EBRT, brachytherapy boost (LDR or HDR) should be offered to eligible patients 2
• Long-term outcomes are excellent with 10-year biochemical progression-free survival of 95.7% 3
• Primary Gleason pattern 3 (3+4) has better outcomes than primary pattern 4 (4+3) with brachytherapy (97.8% vs 93.1% 10-year biochemical progression-free survival) 3

Active Surveillance

• May be considered for selected patients with Gleason 3+4=7 disease, particularly those with comorbidities or limited life expectancy 4
• Less appropriate for Gleason 4+3=7 disease due to higher risk of progression 4
• Protocol includes PSA monitoring every 6 months and repeat prostate biopsy within 12 months 1

Comparative Effectiveness

• A retrospective study comparing radical prostatectomy versus radiotherapy for Gleason 7 prostate cancer showed superior 5-year PSA relapse-free survival with radiotherapy (82.6% vs 55.4%) 5
• However, there was no difference in disease-specific survival between the two approaches 5
• Brachytherapy has shown excellent long-term outcomes with 10-year biochemical progression-free survival of 95.7% and cause-specific survival of 98.6% 3

Treatment Selection Algorithm

1. Assess patient factors:

   • Age and life expectancy (treatment recommended if >10 years) 2
   • Comorbidities and surgical risk 1
   • Urinary function (poor function may favor radiation over surgery) 1

2. Assess disease characteristics:

   • Primary Gleason pattern (3+4 vs 4+3) 3
   • PSA level and density 1
   • Clinical stage 2
   • Percentage of positive cores 2

3. Treatment recommendation:

   • For younger patients (<65 years) with good health: Consider radical prostatectomy 2, 1
   • For patients with urinary obstructive symptoms: Consider radical prostatectomy 1
   • For patients with higher surgical risk: Consider radiation therapy (EBRT or brachytherapy) 1
   • For selected patients with Gleason 3+4 and limited life expectancy: Consider active surveillance 4

Common Pitfalls and Caveats

• Primary ADT alone is not recommended as standard initial treatment for localized prostate cancer 2, 1
• Adjuvant radiotherapy immediately following radical prostatectomy has not been shown to improve survival 2
• Brachytherapy can exacerbate urinary obstructive symptoms and should be used cautiously in patients with significant lower urinary tract symptoms 1
• Patients should be informed that ADT with radiation increases adverse effects on sexual function 1
• Older men experience higher rates of permanent erectile dysfunction and urinary incontinence after prostatectomy compared to younger men 1