What is the treatment for stage 3 prostate cancer?

Treatment for Stage 3 Prostate Cancer

For stage T3 (locally advanced) prostate cancer, the standard treatment is external beam radiotherapy combined with long-term androgen deprivation therapy (ADT) for at least 2 years, which provides superior outcomes compared to radiation alone. 1, 2

Primary Treatment Approach

Combined Radiotherapy and Hormone Therapy (Standard of Care)

• External beam radiotherapy plus long-term hormone therapy is the recommended standard treatment for locally advanced disease (stage T3). 1, 2
• Radiation should be delivered using conformal techniques to a minimum target dose of 70 Gy given in 2.0 Gy fractions or equivalent to reduce late toxicity. 2
• Hormone therapy should be continued for at least 2 years in combination with 3D radiation therapy for high-risk patients. 2
• This combination significantly reduces local failure rates (16% vs 33% at 4 years with radiation alone, P<0.001) and improves median disease-free survival (4.4 vs 2.6 years, P<0.001). 3

Short-Term Hormone Therapy Option

• Short-term hormone therapy can be prescribed for patients with good prognosis features (lower Gleason scores, lower PSA levels), though long-term therapy remains standard for most T3 disease. 1

Alternative Treatment Considerations

Radical Prostatectomy

• Prostatectomy can be considered for stage T3 cancers, but should ideally be undertaken within a clinical trial setting to assess its efficacy alone or in combination with other treatments. 1
• Prostatectomy is NOT recommended for stage pN1 high-grade tumors (Gleason score >7). 1
• Adjuvant radiotherapy may be considered in patients with widespread stage pT3a cancer or positive surgical margins following prostatectomy. 1
• Adjuvant hormonal therapy can be prescribed after radical prostatectomy for patients with node involvement. 1

Hormone Therapy Alone

• Hormone therapy alone can be considered in patients with nonmetastatic disease if curative treatment is not planned due to comorbidities or patient preference. 1
• This approach is appropriate for patients who are not candidates for surgery or radiation. 1

Staging Workup Required Before Treatment

• Renal ultrasound and CT scan should be performed for all patients with stage T3 cancer to assess for metastatic disease. 4
• Abdominal and pelvic CT scan should be performed in patients with T2a stage disease or higher, PSA >15 ng/mL, and Gleason score ≥7. 4
• Bone scan should be performed if Gleason grade is present or PSA is elevated, or if bone pain is present. 4

Prognostic Factors to Guide Treatment Intensity

• Clinical tumor stage, Gleason score, and pretreatment PSA concentration are the primary prognostic factors that determine treatment strategy. 1, 2
• Additional useful prognostic factors include Gleason grades present, number of affected biopsies, extent of tumor tissue in core biopsy, and perineural invasion. 1, 2
• Partin tables can help evaluate the risk of extraprostatic spread and pelvic node invasion before treatment. 1, 2

Treatment Approaches NOT Recommended

• Chemotherapy is NOT recommended for nonmetastatic prostate cancer, including stage T3 disease. 1
• Brachytherapy alone is not appropriate for T3 disease, though combination of external-beam radiotherapy and brachytherapy can be considered in patients with intermediate prognosis within clinical trials. 1

Follow-Up Monitoring

• PSA determination and digital rectal examination should be undertaken every 6 months for an indefinite period. 1
• The criterion for progression after external-beam radiotherapy is an increase in PSA concentration measured on three successive occasions at monthly intervals. 2

Common Pitfalls to Avoid

• Do not use radiation alone without hormone therapy for T3 disease—this significantly increases local failure rates and reduces survival. 3
• Do not perform radical prostatectomy outside of clinical trial settings without careful patient selection, as outcomes data are limited for T3 disease. 1
• Ensure life expectancy exceeds 10 years before pursuing aggressive curative treatment, as patients with shorter life expectancy may not benefit from the morbidity of definitive therapy. 4