Latest Guideline Updates on Prostate Cancer Management
The most significant recent updates in prostate cancer management emphasize active surveillance as the preferred strategy for low-risk disease, combination therapy (ADT plus novel androgen receptor inhibitors or docetaxel) for metastatic hormone-naïve disease, and early salvage radiotherapy (PSA <0.5 ng/mL) for biochemical recurrence after surgery. 1, 2, 3
Risk Stratification for Treatment Selection
Risk classification drives all treatment decisions and is based on three key parameters: 1, 3
- Low-risk disease: PSA <10 ng/mL AND Gleason score ≤6 (ISUP grade 1) AND clinical stage T1-T2a 1, 3
- Intermediate-risk disease: PSA 10-20 ng/mL OR Gleason score 7 OR clinical stage T2b, with further subdivision into favorable (Gleason 3+4, PSA <10, <3 cores positive, <50% core involvement) and unfavorable 1, 3
- High-risk disease: PSA >20 ng/mL OR Gleason score ≥8 (ISUP grade ≥4) OR clinical stage T2c-T4 1, 3
Life expectancy is critical—curative treatment is generally not recommended when life expectancy is <10 years. 1
Localized Disease Management
Low-Risk Disease
Active surveillance is now the preferred approach for low-risk prostate cancer, representing a major shift from historical overtreatment patterns. 1, 4 This strategy achieves 99% disease-specific survival at 8-10 years while avoiding treatment-related morbidity. 5, 4
Alternative options for patients who decline surveillance include: 1, 3
- Radical prostatectomy (open, laparoscopic, or robotic-assisted)
- External beam radiotherapy (minimum 70 Gy in 2.0 Gy fractions or equivalent) 5
- Brachytherapy with permanent implants 1
Common pitfall: Overtreatment of low-risk disease remains prevalent. Proper counseling about active surveillance as a safe option is essential, as many patients unnecessarily undergo radical treatment. 1
Intermediate-Risk Disease
Treatment options are equally effective and include radical prostatectomy or radiotherapy (external beam or brachytherapy). 1, 3 For patients receiving radiotherapy, neoadjuvant and concurrent ADT for 4-6 months should be considered. 5, 1
High-Risk and Locally Advanced Disease
External beam radiotherapy combined with ADT is the standard approach for high-risk disease. 1 Specifically: 5
- Neoadjuvant and concurrent ADT for 4-6 months is recommended
- Adjuvant ADT for 2-3 years is recommended for patients at high risk of prostate cancer mortality
Alternative option: Radical prostatectomy plus pelvic lymphadenectomy 5, 3
Primary ADT alone is not recommended as standard initial treatment for non-metastatic disease. 5
Post-Treatment Management and Biochemical Recurrence
After Radical Prostatectomy
Salvage radiotherapy to the prostate bed should be initiated early (PSA <0.5 ng/mL) for biochemical recurrence, as effectiveness decreases significantly with delayed treatment. 5, 1, 3 This represents a critical update emphasizing early intervention.
Immediate post-operative radiotherapy is not routinely recommended, but patients with positive surgical margins or extracapsular extension should be counseled about adjuvant RT. 5, 3
Common pitfall: Delayed salvage radiotherapy reduces effectiveness. Monitor PSA closely and intervene early. 1
After Radiotherapy
Early ADT is not routinely recommended for biochemical relapse unless patients have: 5, 3
- Symptomatic local disease
- Proven metastases
- PSA doubling time <3 months
For patients starting ADT after radiotherapy, intermittent ADT is recommended. 5
Metastatic Hormone-Naïve Disease
The landmark update is that continuous ADT plus docetaxel chemotherapy is now first-line treatment for patients fit enough to receive it, improving median overall survival from 36.5 to 53.3 months (HR 0.66,95% CI 0.56-0.78). 5, 2, 6
Alternative combination options include ADT plus: 3
- Abiraterone
- Enzalutamide
- Apalutamide 7
Men starting ADT should be informed that regular exercise reduces fatigue and improves quality of life. 5, 2
When initiating LHRH agonists, antiandrogen should be given for 3-4 weeks to prevent testosterone flare. 2
Important monitoring: Men on long-term ADT require surveillance for osteoporosis (bone densitometry) and metabolic syndrome. 5, 2
Castration-Resistant Prostate Cancer (CRPC)
Chemotherapy-Naïve Metastatic CRPC
Abiraterone or enzalutamide are recommended as first-line agents for asymptomatic or mildly symptomatic patients. 5, 2, 3
Other options include: 5
- Docetaxel chemotherapy (75 mg/m² every 3 weeks with prednisone 5 mg twice daily) 8
- Radium-223 for bone-predominant disease without visceral metastases 5, 2
Post-Docetaxel CRPC
Recommended options include abiraterone, enzalutamide, cabazitaxel, and radium-223 (for those without visceral disease). 5
Bone Metastases Management
A single fraction of external beam radiotherapy is recommended for palliation of painful bone metastases, offering equal pain-reducing efficacy to multi-fraction regimens. 5, 2
For patients at high risk of skeletal-related events, denosumab or zoledronic acid is recommended. 5, 2
Critical safety measure: MRI of the spine to detect subclinical cord compression is recommended in men with CRPC and vertebral metastases. Urgent MRI is mandatory for those with neurological symptoms. 5, 2
Special Populations
Patients with neuroendocrine differentiation should receive chemotherapy in addition to ADT, as PSA is not a reliable disease indicator in this population. 5, 2
Diagnostic Considerations
Common pitfall: Inadequate biopsy sampling can miss cancer. A minimum of 10-12 cores should be obtained under antibiotic prophylaxis. 1
Bone imaging is not routinely recommended for low-risk disease but should be performed for high-risk disease. 5