Prostate Cancer Management
Treatment for prostate cancer must be stratified by disease stage and risk category: localized disease is managed through active surveillance for low-risk patients or definitive therapy (radical prostatectomy or radiation) for intermediate/high-risk patients, while metastatic disease requires continuous androgen deprivation therapy combined with androgen receptor pathway inhibitors like abiraterone or docetaxel chemotherapy for fit patients. 1
Risk Stratification Framework
Risk stratification is mandatory before selecting treatment, as it determines prognosis and guides all therapeutic decisions 1. Classification includes:
- Very low/low risk: Gleason score ≤6, PSA <10 ng/mL, clinical stage T1c-T2a 1, 2
- Intermediate risk: Gleason score 7, PSA 10-20 ng/mL, or clinical stage T2b 1, 3
- High risk: Gleason score 8-10, PSA >20 ng/mL, or clinical stage ≥T2c 4
- Metastatic disease: Distant metastases present on imaging 1
Staging Workup Requirements
For intermediate or high-risk disease, perform nodal staging using CT, MRI, choline PET/CT, or pelvic lymph node dissection 4, 1. Evaluate for distant metastases using technetium bone scan and thoraco-abdominal CT scan, whole-body MRI, or choline PET/CT 4, 1.
Treatment by Risk Category
Very Low and Low-Risk Disease
For patients with life expectancy <10 years, observation (watchful waiting) is recommended, involving monitoring without immediate curative intent, with delayed hormone therapy only if symptomatic progression occurs 4, 1.
For patients with life expectancy ≥10 years, active surveillance is the preferred option 1, 2. The protocol includes:
- PSA measurement every 6 months 1, 2
- Digital rectal examination every 12 months 1, 2
- Repeat prostate biopsy every 12 months 1, 2
- First follow-up visit at 3 months to establish baseline 2
Triggers for intervention during active surveillance include Gleason score upgrade to ≥7 on repeat biopsy, PSA velocity >2.0 ng/mL/year, or increased tumor volume (>3 cores positive or >50% involvement per core) 2.
Intermediate-Risk Disease (Gleason 7)
Treatment options for patients with life expectancy >10 years include 3:
Radical prostatectomy with pelvic lymph node dissection provides complete removal with accurate pathological staging 4, 3. Be aware that erectile dysfunction occurs in up to 80% and urinary incontinence in up to 49% of patients 4, 3.
External beam radiation therapy (EBRT) with minimum target dose of 70 Gy in 2.0 Gy fractions 3. Add androgen deprivation therapy for 4-6 months for intermediate-risk disease 4, 3.
Brachytherapy can be used as monotherapy for Gleason 3+4=7 disease with PSA <10 ng/mL, or as a boost with EBRT 3. Caution: brachytherapy can exacerbate urinary obstructive symptoms in patients with significant lower urinary tract symptoms 3.
High-Risk and Locally Advanced Disease
Options include external beam radiation therapy plus hormone treatment for 2-3 years, or radical prostatectomy plus pelvic lymphadenectomy 4, 1. Primary androgen deprivation therapy alone is not recommended as standard initial treatment 4, 3.
Post-Treatment Management
After Radical Prostatectomy
PSA should be undetectable (<0.2 ng/mL) within 2 months after surgery 1. Follow-up includes PSA measurement every 3 months during year 1, then every 6 months for 7 years 1.
For biochemical recurrence (rising PSA), salvage radiation therapy to the prostate bed should be initiated early when PSA <0.5 ng/mL, which improves outcomes compared to delayed treatment 4, 1. Immediate post-operative radiotherapy is not routinely recommended 4.
After Radiation Therapy
For biochemical relapse after radical radiation therapy, intermittent androgen deprivation therapy is recommended 4. Early androgen deprivation therapy is not routinely recommended unless patients have symptomatic local disease, proven metastases, or PSA doubling time <3 months 4.
Metastatic Disease Management
Continuous androgen deprivation therapy is the recommended first-line treatment for metastatic hormone-naïve prostate cancer, achieved through bilateral orchiectomy (surgical castration) or LHRH agonists (medical castration) 4, 1.
For patients fit enough for chemotherapy, adding docetaxel to androgen deprivation therapy at initial diagnosis provides survival benefit 4, 1. Alternatively, adding androgen receptor pathway inhibitors like abiraterone improves median overall survival from 36.5 months to 53.3 months (hazard ratio 0.66,95% CI 0.56-0.78) compared with medical castration alone 5.
Abiraterone acetate is dosed at 1,000 mg once daily taken at least 1 hour before or 2 hours after a meal, in combination with prednisone 5 mg twice daily 6. Taking abiraterone with food increases systemic exposure 5-10 fold and should be avoided 6.
Critical Pitfalls to Avoid
- Do not use cryotherapy, HIFU, or focal therapy as standard initial treatments for localized prostate cancer 1
- Do not perform PSA screening in asymptomatic men over age 70 years 4
- Do not use adjuvant radiotherapy immediately following radical prostatectomy, as it has not been shown to improve survival 3
- Do not rely solely on PSA for monitoring in patients with neuroendocrine features 1
Supportive Care
Men starting androgen deprivation therapy should be informed that regular exercise reduces fatigue and improves quality of life 4, 1. Monitor patients on long-term androgen deprivation therapy for osteoporosis and metabolic syndrome 1.