Surgery is NOT a standard treatment option for stage IV (metastatic) prostate cancer
For stage IV prostate cancer with distant metastases (M1), the standard of care is androgen deprivation therapy (ADT), not surgery. 1 Radical prostatectomy is reserved for localized disease and select cases of locally advanced disease without distant metastases.
Standard Treatment for Stage IV Disease
Immediate continuous castration (medical or surgical) is the preferred treatment option for metastatic hormone-naïve prostate cancer. 1 This represents Level I evidence with a strength of recommendation B. 1
- Medical castration using LHRH agonists or surgical castration (bilateral orchiectomy) forms the backbone of treatment 1
- An antiandrogen should be given for 3-4 weeks when starting LHRH agonist therapy to counteract testosterone flare 1
- Concomitant cytotoxic chemotherapy is not recommended outside clinical trials for newly diagnosed metastatic disease 1
When Surgery May Be Considered (Not Stage IV)
Surgery has extremely limited and specific indications that do NOT include stage IV disease:
Locally advanced T3-4 disease (NOT metastatic): A decision to recommend radical prostatectomy should only be made after careful staging and discussion in a multidisciplinary team. 1 This carries Level III evidence with strength of recommendation C. 1
Node-positive disease (N1 M0): Radical locoregional therapy is recommended for N1 M0 patients suitable for aggressive management, but this is NOT stage IV disease. 1 This represents patients with pelvic lymph node involvement but no distant metastases.
Critical Distinction: Stage IV Definition
Stage IV prostate cancer includes:
- Any T, Any N, M1 (distant metastases present) - Surgery is NOT indicated 1
- This is fundamentally different from locally advanced (T3-4) or node-positive (N1 M0) disease where surgery might rarely be considered 1
Common Pitfall to Avoid
Do not confuse locally advanced disease (T3-4 N0-1 M0) with stage IV metastatic disease (M1). The former may occasionally be considered for surgery in highly selected cases at expert centers, while the latter should receive systemic therapy with ADT as the standard of care. 1 Attempting surgery on truly metastatic disease exposes patients to surgical morbidity without addressing the systemic nature of their cancer.
Progression to Castration-Resistant Disease
When patients develop castration-resistant prostate cancer (CRPC), they should continue androgen suppression and be considered for:
- Further hormone therapies 1
- Chemotherapy with docetaxel for symptomatic patients with good performance status 1
- Second-line agents like cabazitaxel after docetaxel failure 1
Surgery plays no role in the management algorithm for metastatic castration-resistant disease. 1