What is the recommended management for a 70-year-old male with intermediate-risk prostate cancer, characterized by a Gleason score of 7 and a Prostate-Specific Antigen (PSA) level of 12?

Management of Intermediate-Risk Prostate Cancer (Gleason 7, PSA 12)

For a man in his 70s with intermediate-risk prostate cancer (Gleason 7, PSA 12), the primary management decision hinges on life expectancy: if >10 years, offer definitive treatment with either radical prostatectomy with pelvic lymph node dissection or external beam radiotherapy with 4-6 months of androgen deprivation therapy; if <10 years, active surveillance is reasonable. 1

Risk Stratification

This patient clearly falls into the intermediate-risk category based on:

• Gleason score of 7 1
• PSA of 12 ng/mL (within the 10-20 ng/mL intermediate-risk range) 1
• The combination of these factors places him at meaningful risk of disease progression and prostate cancer-specific mortality 2

Life Expectancy Assessment

The critical first step is determining whether this patient has a life expectancy greater or less than 10 years 1. This assessment should focus on:

• Specific comorbidities (cardiovascular disease, diabetes, COPD severity, renal function) 1
• Functional status and performance status 1
• Age-adjusted life expectancy tables (a healthy 70-year-old typically has >10 years life expectancy) 1

If Life Expectancy <10 Years

Active surveillance becomes a reasonable option 1. The rationale is that intermediate-risk disease progresses slowly enough that competing causes of mortality become more relevant 3. The surveillance protocol should include:

• PSA testing every 3-6 months 4
• Digital rectal examination at least annually 4
• Repeat prostate biopsies at 1 year, then every 1-3 years 4
• Triggers for intervention: Gleason grade progression, PSA doubling time <3 years, increased tumor volume on biopsy 4

If Life Expectancy >10 Years

Definitive treatment is strongly recommended 1. The evidence shows that intermediate-risk disease carries substantial prostate cancer-specific mortality risk—41% at 8 years for Gleason 7 disease managed non-curatively 2. This underscores that observation alone in a healthy 70-year-old would constitute undertreatment.

Definitive Treatment Options

Option 1: Radical Prostatectomy with Pelvic Lymph Node Dissection

Radical prostatectomy should include pelvic lymph node dissection (PLND) if the predicted probability of lymph node metastasis is ≥2% 1. For intermediate-risk patients:

• Extended bilateral PLND is recommended 1
• The decision should be informed by nomogram estimates of nodal involvement 1
• Patients must be counseled about risks: erectile dysfunction, urinary incontinence, and infertility 1

Important caveat: The Scandinavian trial demonstrating survival benefit for radical prostatectomy over watchful waiting included mostly T2 disease, providing high-quality evidence for surgery 1. However, this patient's age (70s) approaches the upper limit where surgical benefit has been clearly demonstrated.

Option 2: External Beam Radiotherapy with Short-Term Androgen Deprivation Therapy

The preferred radiation approach is 3D-CRT/IMRT with daily image-guided radiotherapy (IGRT), combined with 4-6 months of neoadjuvant/concomitant/adjuvant androgen deprivation therapy (ADT) 1. The evidence supporting this includes:

• The DFCI 95096 trial (which included 60% intermediate-risk patients) demonstrated both overall and cancer-specific survival benefit with short-course ADT added to radiation 1
• TROG 9601 (20% intermediate-risk patients) showed cancer-specific survival benefit 1
• Radiation therapy has shown superior 5-year PSA relapse-free survival compared to radical prostatectomy alone (82.6% vs 55.4%) in Gleason 7 patients 5

Brachytherapy as monotherapy is NOT recommended for this patient 1. Risk stratification analysis shows brachytherapy alone is inferior to external beam RT or surgery for patients with Gleason pattern 4 or 5 or PSA >10 ng/mL 1.

Staging Before Treatment

Before initiating definitive therapy, this patient requires staging for metastases 1:

• Technetium bone scan 1
• Thoraco-abdominal CT scan or whole-body MRI or choline PET/CT 1
• Pelvic imaging (CT or MRI) for nodal staging 1

Multidisciplinary Consultation

This patient should be offered consultation with both a urologist and a radiation oncologist 1. Given the comparable outcomes but different side-effect profiles, the patient's values regarding sexual function, urinary control, and bowel function should guide the final decision 1.

Common Pitfalls to Avoid

• Do not rely on a single elevated PSA: Verify with a second value before proceeding to biopsy or treatment decisions 1
• Do not offer brachytherapy monotherapy: This is inferior for intermediate-risk disease 1
• Do not omit ADT with radiation: The survival benefit of adding 4-6 months ADT to radiation is well-established for intermediate-risk disease 1
• Do not perform PLND in low-risk patients or omit it in high-risk patients: For intermediate-risk, use nomograms to guide the decision 1
• Do not screen men >70 years: While this patient is already diagnosed, future PSA testing should be carefully evaluated 1

Age-Specific Considerations

For men in their 70s specifically:

• Testing beyond age 70 should be individualized based on health status and life expectancy >10 years 1
• Men aged 70-74 with intermediate-risk disease derive less favorable benefit-to-harm ratios from immediate treatment compared to younger men 3
• However, the 8-year prostate cancer-specific mortality of 41% for Gleason 7 disease means that healthy men in their early 70s still face substantial risk 2