History of Present Illness
62-year-old male with Stage IIIB (cT3a N0 M0) very high-risk prostate cancer (Gleason 3+5=8, PSA 13.4 ng/mL) status post definitive radiation therapy completed May 2024, currently on androgen deprivation therapy with last dose July 2025, presenting for routine follow-up.
The patient completed definitive external beam radiation therapy delivering 7000 cGy to the prostate and seminal vesicles with 5040 cGy to regional lymphatics. He remains on long-term ADT as recommended for very high-risk disease, with his most recent injection administered two months ago. He reports no new symptoms, complications from radiation, or concerns related to ADT side effects at this visit.
Recommended Management Plan
Continue Long-Term ADT for 2-3 Years Total Duration
For this patient with very high-risk prostate cancer (cT3a, Gleason 8), continuation of ADT for a total duration of 2-3 years from initiation is the standard of care and provides survival benefit. 1, 2
The NCCN guidelines specifically recommend long-term neoadjuvant/concomitant/adjuvant ADT (2-3 years) for very high-risk disease (T3b-T4) and high-risk disease (T3a, Gleason 8-10, or PSA >20 ng/mL) treated with definitive radiation 1
RTOG 92-02 demonstrated superior outcomes with long-term (2+ years) versus short-term (4 months) ADT in high-risk patients, with particular benefit in Gleason 8-10 disease showing improved overall survival (45% vs 32%, P=0.0061) 1
EORTC 22961 confirmed superior survival when 2.5 years of ADT was added to RT in patients with T2c-T3 disease 1
Calculate the total ADT duration from initiation (likely started before or during radiation in May 2024) to determine when to discontinue, targeting 24-36 months total 1, 2
PSA Monitoring Schedule
Measure PSA every 3-6 months for the first 5 years, then annually thereafter. 1, 3
More frequent PSA testing (every 3 months) may be warranted given his very high-risk classification 1
The end-of-radiation PSA is a critical prognostic marker—if it was detectable (≥0.1 ng/mL), this patient faces significantly higher risk of biochemical failure, distant metastasis, and prostate cancer-specific mortality 4
Men with very high-risk disease and detectable end-of-radiation PSA have 10-year prostate cancer-specific mortality of 31.0% versus 13.7% for those with undetectable PSA 5
PSA velocity and doubling time should be calculated at each visit to assess for biochemical recurrence 1
Digital Rectal Examination
Perform DRE every 6-12 months to assess for local recurrence. 1, 3
Local recurrence can occur even with undetectable PSA in rare cases 1
Any palpable abnormality warrants further investigation with multiparametric MRI and potential PSMA PET imaging 1
Advanced Imaging Considerations
Consider baseline PSMA PET/CT if not already performed, particularly if PSA becomes detectable or rises. 1, 2
PSMA PET has superior sensitivity for detecting recurrence compared to conventional imaging 1
For biochemical recurrence with positive PSMA PET but negative conventional imaging, novel hormonal agents like enzalutamide are recommended 2
Multiparametric MRI combined with PSMA PET provides optimal detection of local intraprostatic recurrence 1
Monitor for ADT-Related Complications
Assess for metabolic, cardiovascular, and bone health complications at each visit. 1
ADT side effects are cumulative over time and include hot flashes, weight gain, loss of libido, erectile dysfunction, osteoporosis, metabolic syndrome, and cardiovascular risk 1
Consider bone density screening and calcium/vitamin D supplementation 1
Monitor lipid profile, glucose, and cardiovascular risk factors 1
Screen for depression, anxiety, and body image concerns, which are common with ADT 1
Consideration of Intensified Therapy
Given very high-risk features, discuss potential addition of second-generation antiandrogens (abiraterone acetate with prednisone) to standard ADT. 6
Recent STAMPEDE trial data and updated ASCO/NCCN guidelines support consideration of adding abiraterone acetate to ADT in men with high and very high-risk nonmetastatic or node-positive disease receiving definitive RT 6
This intensified approach provides overall survival benefit and increased disease-free and metastasis-free survival 6
Second-generation antiandrogens provide more potent androgen receptor inhibition and may offer radiosensitization through DNA repair inhibition 6
This decision should be made through informed shared decision-making, weighing potential benefits against increased toxicity 6
Plan for Biochemical Recurrence
If PSA rises (biochemical failure defined as nadir + 2 ng/mL), initiate workup with PSMA PET/CT and multiparametric MRI. 1, 2
For local-only intraprostatic recurrence confirmed by imaging and biopsy, salvage options include SBRT, HDR brachytherapy, or LDR brachytherapy with favorable toxicity profiles 1
Systematic and targeted biopsies are both necessary, as each detects approximately 6-8% of cancers missed by the other modality 1
For metastatic recurrence, continue or intensify systemic therapy rather than local salvage 2
Critical Prognostic Factors to Track
This patient's very high-risk classification (primary Gleason pattern 5, cT3a) places him at distinctly worse outcomes compared to standard high-risk disease. 5
Very high-risk patients experience 10-year biochemical failure of 54.0% versus 35.4% for other high-risk patients 5
10-year distant metastasis rate is 34.9% versus 13.4% 5
10-year prostate cancer-specific mortality is 18.5% versus 5.9% 5
These outcomes emphasize the need for vigilant monitoring and consideration of treatment intensification 5
Competing Mortality Considerations
Assess competing mortality risk using age and cardiometabolic comorbidities to guide ADT duration decisions. 7
ADT provides significant reduction in prostate cancer-specific mortality (adjusted HR 0.35) only in men with low competing mortality risk 7
In men with high competing mortality scores, ADT does not reduce prostate cancer-specific mortality (adjusted HR 1.33) 7
At age 62 with presumably low comorbidity burden, this patient likely benefits from full-duration ADT 7