What are the treatment options for managing prostate cancer?

Prostate Cancer Management

For localized prostate cancer, treatment selection depends on risk stratification: low-risk disease warrants active surveillance, intermediate-risk disease offers a choice between radical prostatectomy or radiotherapy, and high-risk disease requires either radical prostatectomy with pelvic lymphadenectomy or external beam radiotherapy combined with 2-3 years of androgen deprivation therapy (ADT). 1

Risk Stratification

Before selecting treatment, classify patients into risk categories based on PSA level, Gleason score, and clinical stage 1:

• Low-risk: PSA <10 ng/mL AND Gleason score ≤6 AND clinical stage T1-T2a 1
• Intermediate-risk: PSA 10-20 ng/mL OR Gleason score 7 OR clinical stage T2b (but not meeting high-risk criteria) 1
• High-risk: PSA >20 ng/mL OR Gleason score 8-10 OR clinical stage T2c 1

Life expectancy is critical—curative treatment is generally not recommended for patients with life expectancy <10 years 1.

Treatment by Risk Category

Low-Risk Disease

Active surveillance is the preferred approach for low-risk prostate cancer, particularly for patients with PSA <10 ng/mL and Gleason 3+3 tumors 1, 2. This strategy has demonstrated 99% disease-specific survival at 8 years 1.

Active surveillance protocol includes 1:

• Serial PSA measurements every 6 months
• Repeat prostate biopsies or multi-parametric MRI monitoring
• Initiate definitive treatment if Gleason score or tumor stage increases

Alternative curative options for low-risk disease include 1:

• Radical prostatectomy
• External beam radiotherapy (minimum 70 Gy in 2.0 Gy fractions or equivalent)
• Brachytherapy with permanent implants (appropriate as monotherapy for low-risk patients) 1

Important caveat: Watchful waiting (palliative approach without intent to cure) differs from active surveillance and is only appropriate for patients aged ≥70 years with low-risk tumors or those with significant comorbidities limiting life expectancy 1.

Intermediate-Risk Disease

Radical prostatectomy and radiotherapy are equally effective treatment options for intermediate-risk disease 1. The choice should be guided by patient preference after counseling about side effects 1.

Treatment options include 1:

• Radical prostatectomy
• External beam radiotherapy with consideration of neoadjuvant and concurrent ADT for 4-6 months 1
• Brachytherapy (may be considered in select cases)

High-Risk and Locally Advanced Disease

For high-risk prostate cancer, external beam radiotherapy combined with ADT is the standard approach, with neoadjuvant/concurrent ADT for 4-6 months followed by adjuvant ADT for 2-3 years 1. This combination significantly improves outcomes compared to radiotherapy alone.

Alternative option 1:

• Radical prostatectomy plus pelvic lymphadenectomy (for select patients)

Critical point: Primary ADT alone is not recommended as standard initial treatment for non-metastatic disease 1.

Staging Workup

Perform risk-appropriate staging 1:

For intermediate or high-risk disease:

• Nodal staging with CT, MRI, choline PET/CT, or pelvic lymphadenectomy
• Metastatic staging with technetium bone scan and thoraco-abdominal CT or whole-body MRI

For low-risk disease:

• Generally no pelvic imaging needed if PSA <10 and Gleason <7 1

Post-Treatment Management

After Radical Prostatectomy

Monitor with sensitive PSA assays 1. Salvage radiotherapy to the prostate bed should be initiated early (PSA <0.5 ng/mL) for biochemical recurrence 1.

Adjuvant radiotherapy immediately after surgery is not routinely recommended, but patients with positive surgical margins or extracapsular extension should be counseled about pros and cons 1.

After Radiotherapy

For biochemical relapse, early ADT is not routinely recommended unless patients have symptomatic local disease, proven metastases, or PSA doubling time <3 months 1. When ADT is initiated after radiotherapy failure, intermittent ADT is recommended 1.

Metastatic Disease

For metastatic hormone-naïve prostate cancer, continuous ADT plus docetaxel chemotherapy is first-line treatment for patients fit enough to receive it 1, 3. This combination extends median overall survival from 36.5 months to 53.3 months compared with ADT alone 4.

Key management principles 3:

• Use LHRH agonist (e.g., goserelin 5) with 3-4 week antiandrogen cover to prevent testosterone flare
• Recommend regular exercise to reduce fatigue and improve quality of life
• Monitor for ADT side effects including osteoporosis and metabolic syndrome

Castration-Resistant Prostate Cancer (CRPC)

Treatment options for metastatic CRPC 3:

• Abiraterone or enzalutamide for asymptomatic/mildly symptomatic chemotherapy-naïve patients
• Docetaxel chemotherapy
• Radium-223 for bone-predominant symptomatic disease without visceral metastases
• Denosumab or zoledronic acid for patients at high risk of skeletal-related events

Common Pitfalls

• Overtreatment of low-risk disease: Many patients significantly overestimate survival benefits of treatment 1. Ensure proper counseling about active surveillance as a safe option.
• Delayed salvage radiotherapy: After prostatectomy, salvage radiotherapy is most effective when PSA is <0.5 ng/mL 1.
• Inadequate biopsy sampling: Obtain minimum 10-12 cores (not the traditional 6 cores) to avoid missing cancer 1.
• Ignoring life expectancy: Curative treatment offers minimal benefit when life expectancy is <10 years 1.