What is the best treatment option for a patient with a PSA of 9, Gleason score 3+4, and localized prostate cancer with no lymph node involvement or distant metastasis, considering radical radiotherapy or robotic prostatectomy?

Treatment Recommendation for Intermediate-Risk Localized Prostate Cancer

For a patient with PSA 9, Gleason Grade Group 3 (3+4=7), and localized disease without nodal or distant metastases, both radical prostatectomy and external beam radiotherapy (with or without short-course androgen deprivation therapy for 4-6 months) are equally effective treatment options, and the choice should be based primarily on the patient's life expectancy and tolerance for specific side effects. 1, 2

Risk Stratification

Your patient falls into the intermediate-risk category based on the following criteria: 1, 2

• PSA 9 ng/mL (within 10-20 ng/mL range)
• Gleason 3+4=7 (Grade Group 3)
• Clinical stage T1-T2a (localized, no nodes, no metastases)

This risk classification is critical because it determines both treatment options and prognosis. 1, 2

Treatment Options Based on Life Expectancy

Life Expectancy ≥10 Years

Both radical prostatectomy and external beam radiotherapy are appropriate curative options. 1, 2

Radical Prostatectomy (Robotic or Open)

• Robotic-assisted laparoscopic prostatectomy is now the most common approach and offers comparable oncologic outcomes to open surgery with shorter hospital stays, less blood loss, and potentially faster recovery of continence and potency. 1

• Expected outcomes: 15-year prostate cancer-specific mortality of approximately 12% overall (5% for low-risk patients, higher for intermediate-risk). 1

• Post-operative monitoring: PSA should become undetectable (<0.2 ng/mL) within 2 months. 1, 2

• Side effects to discuss: Higher rates of urinary incontinence and erectile dysfunction compared to baseline, though robotic approaches show statistically significant advantages in 12-month continence and potency recovery compared to open surgery. 1

External Beam Radiotherapy

• Dose requirement: Minimum 66 Gy (modern standards typically 74-78 Gy) delivered in 1.8-2.0 Gy fractions over 6-7 weeks. 1

• Androgen deprivation therapy (ADT): Short-course ADT for 4-6 months significantly improves local control, reduces disease progression, and improves overall survival in intermediate-risk disease. 1

• Expected outcomes: Equivalent cancer-specific survival and overall survival compared to surgery. 1, 3

• Side effects to discuss: Higher rates of bowel dysfunction compared to surgery, but lower rates of urinary incontinence and erectile dysfunction in the first 2 years. 1

Life Expectancy <10 Years

Observation (watchful waiting) or external beam radiotherapy are appropriate options. 1, 2

• Radical prostatectomy should generally be avoided due to perioperative morbidity risks that may not be justified given limited life expectancy. 1

Critical Decision-Making Factors

Pathologic Upgrading Risk

Important caveat: With biopsy Gleason 3+4 and PSA 9 ng/mL, there is approximately a 30-40% risk that final pathology after prostatectomy will show more aggressive disease (Gleason 4+3 or higher). 4, 5

• This upgrading risk is relevant because Gleason 4+3 has significantly worse prognosis than 3+4 (hazard ratio 5.1 vs 1.9 compared to Gleason 6). 5

Lymph Node Staging

For intermediate-risk patients undergoing prostatectomy, discuss the risk/benefit of lymph node dissection informed by nomogram estimates. 1

• With PSA 9, Gleason 3+4, and clinical stage T1-T2a, the risk of lymph node metastasis is approximately 5-10%. 1

• If choosing radiotherapy: Pelvic imaging with CT or MRI should be performed unless surgical lymph node staging has already been done. 1

Percentage of Positive Biopsy Cores

This information is critical but not provided in your question. 6

• Intermediate-risk patients with ≤17% positive biopsies have only 3% risk of seminal vesicle invasion and 9% risk of extracapsular extension with positive margins, with 90% biochemical disease-free survival. 6

• If >17% positive biopsies, risks increase significantly and may favor more aggressive local therapy or consideration of pelvic radiotherapy fields. 6

Comparative Effectiveness

Surgery and external beam radiotherapy are almost equally effective in treating intermediate-risk prostate cancer. 1

• A randomized trial comparing radical prostatectomy to watchful waiting showed significant improvements in disease-specific survival, overall survival, and risk of metastasis with surgery (number needed to treat = 15 overall, 7 for men <65 years). 1

• No high-quality randomized trials directly compare surgery to modern dose-escalated radiotherapy with ADT, but observational data show equivalent cancer-specific survival and overall survival. 1, 3

Post-Treatment Surveillance

After Radical Prostatectomy

• PSA monitoring: Every 3 months during year 1, then every 6 months for 7 years. 2

• Biochemical recurrence definition: Confirmed PSA >0.2 ng/mL. 1

• Salvage radiotherapy: Should be initiated early (PSA <0.5 ng/mL) if biochemical recurrence occurs, with 6-year progression-free survival of 48% when PSA <0.5 ng/mL versus only 18% when PSA >1.5 ng/mL. 1, 2

After Radiotherapy

• Biochemical recurrence definition: Nadir PSA plus 2 ng/mL (Phoenix definition). 1

• PSA nadir: Should reach ≤1 ng/mL within 16 months after completing radiotherapy. 1

Common Pitfalls to Avoid

• Do not use cryotherapy, HIFU, or focal therapy as standard initial treatments for this intermediate-risk disease—these are not guideline-recommended options. 2

• Do not delay salvage radiotherapy if biochemical recurrence occurs after surgery—early intervention (PSA <0.5 ng/mL) dramatically improves outcomes. 1, 2

• Do not omit ADT if choosing radiotherapy for intermediate-risk disease—the survival benefit is well-established. 1

• Prevent gynecomastia if using ADT by administering breast irradiation (8-15 Gy in 1-3 fractions) 1-2 weeks before initiating antiandrogen therapy. 1