Treatment Options for Prostate Cancer
The standard treatment options for prostate cancer include active surveillance, radical prostatectomy, external beam radiation therapy, brachytherapy, and androgen deprivation therapy, with selection based primarily on disease risk stratification, patient age, and life expectancy. 1
Risk Stratification
Risk stratification is essential for determining the appropriate treatment approach:
- Very low/low risk: Gleason score ≤6, PSA <10 ng/mL, <3 positive biopsy cores, ≤50% cancer in any core, and PSA density <0.15 ng/mL/g 1
- Intermediate risk: Gleason score 7, or PSA 10-20 ng/mL 1, 2
- High risk: Gleason score 8-10, or PSA >20 ng/mL 1
- Very high risk: Locally advanced disease (T3b-T4) 1
Treatment Options by Risk Category
Very Low/Low Risk Disease
- For patients with life expectancy <10 years: Observation (watchful waiting) 1
- For patients with life expectancy 10-20 years: Active surveillance 1
- Protocol includes PSA monitoring every 6 months, digital rectal exam annually, and repeat prostate biopsy within 12 months 1
Intermediate Risk Disease
- Radical prostatectomy with pelvic lymph node dissection 1, 2
- External beam radiation therapy (EBRT) with or without androgen deprivation therapy (ADT) for 4-6 months 1, 3
- Brachytherapy (low-dose rate as monotherapy for selected patients with Gleason 3+4=7 and PSA <10 ng/mL) 1, 2
High Risk/Locally Advanced Disease
- EBRT plus long-term ADT (2-3 years) 3
- Radical prostatectomy with pelvic lymph node dissection (for selected patients) 3
- EBRT plus brachytherapy with or without ADT 1
Metastatic Disease
- Continuous androgen deprivation therapy (ADT) is the first-line treatment 3
- ADT plus docetaxel for patients fit enough for chemotherapy 3
- ADT plus novel androgen receptor pathway inhibitors like abiraterone improves survival (median overall survival from 36.5 to 53.3 months) 4
Considerations for Treatment Selection
Age and Life Expectancy
- Comorbidity-adjusted life expectancy should be calculated to determine appropriate treatment 3
- Patients with limited life expectancy (<5 years) and high-risk disease should consider observation only 3
Treatment-Related Side Effects
- Radical prostatectomy: Higher rates of urinary incontinence (up to 49%) and erectile dysfunction (up to 80%) 2
- Radiation therapy: Lower immediate urinary incontinence but may cause bowel problems and gradual development of erectile dysfunction 5
- ADT: Hot flashes, decreased libido, erectile dysfunction, and increased risk of metabolic syndrome 3
Special Considerations
- Primary ADT alone is not recommended for localized prostate cancer as it does not improve survival 1
- Brachytherapy can exacerbate urinary obstructive symptoms and should be used cautiously in patients with significant lower urinary tract symptoms 1, 2
- Men starting ADT should be informed that regular exercise reduces fatigue and improves quality of life 3
Follow-up After Treatment
- After radical prostatectomy: PSA should be undetectable after 2 months 3
- After radiation therapy: PSA should reach 1 ng/mL within 16 months 1
- First follow-up visit should be at 3 months after radical treatment, including PSA measurement, digital rectal examination, and assessment of treatment-related symptoms 1
Common Pitfalls
- Delaying treatment in high-risk disease can lead to increased mortality 3
- Overtreatment of low-risk disease in elderly patients with limited life expectancy 3
- Not considering quality of life impacts when selecting treatment modalities 2
- Failure to recognize that older men experience higher rates of permanent erectile dysfunction and urinary incontinence after prostatectomy compared to younger men 1