From the Guidelines
Gleason score 9 prostate cancer should be managed with External Beam Radiation Therapy (EBRT) plus Androgen Deprivation Therapy (ADT) for 2-3 years, or EBRT plus brachytherapy with or without ADT for 2-3 years, as initial therapy, according to the National Comprehensive Cancer Network (NCCN) guidelines 1. This approach is recommended due to the high-risk nature of Gleason score 9 tumors, which are associated with a high likelihood of disease progression and poor prognosis.
Initial Therapy Options
- EBRT plus ADT for 2-3 years
- EBRT plus brachytherapy with or without ADT for 2-3 years
Rationale
The NCCN guidelines 1 categorize Gleason score 9 as a high-risk feature, and recommend aggressive multimodal therapy to manage the disease. The guidelines suggest that patients with high-risk features, including Gleason score 8-10, should receive EBRT plus ADT for 2-3 years, or EBRT plus brachytherapy with or without ADT for 2-3 years, as initial therapy.
Adjuvant Therapy
Adjuvant therapy may be considered for patients with adverse features, such as positive margins, seminal vesicle invasion, extracapsular extension, or detectable PSA 1. In such cases, EBRT or EBRT plus ADT, with or without docetaxel, may be recommended.
Monitoring
Regular monitoring is essential to assess treatment response and detect potential disease progression. This includes monitoring PSA levels every 3-6 months, as well as regular clinical exams and imaging studies as needed 1.
Quality of Life Considerations
The management of Gleason score 9 prostate cancer should prioritize not only morbidity and mortality but also quality of life. Treatment decisions should take into account the potential side effects of therapy, such as urinary, sexual, and bowel dysfunction, and strive to minimize these effects while maximizing treatment efficacy 1.
From the Research
Management of Gleason Score 9 Prostate Cancer
- The management of Gleason score 9 prostate cancer involves various treatment options, including radiotherapy, radical prostatectomy, and androgen deprivation therapy (ADT) 2, 3.
- A study published in the European Urology journal found that extremely dose-escalated radiotherapy with ADT offers improved systemic control compared to external beam radiotherapy (EBRT) or radical prostatectomy (RP) for patients with biopsy Gleason score 9-10 prostate cancer 2.
- Another study published in the Urologic Oncology journal found that there were no significant differences in cancer-specific mortality rates between patients who underwent RP ± adjuvant radiation therapy (aRT) and those who received EBRT for clinically localized prostate cancer with biopsy Gleason score 9-10 3.
Treatment Outcomes
- A multi-institutional study published in the Strahlentherapie und Onkologie journal found that higher radiotherapy doses (≥78 Gy) and longer ADT duration (≥2 years) were significant predictors for improved distant metastases-free survival in patients with Gleason score 9-10 prostate cancer treated with external beam radiotherapy (EBRT) + ADT 4.
- A study published in the Cancer journal found that the addition of ADT and docetaxel to adjuvant radiation therapy (ART) resulted in a freedom from progression rate ≥70% compared to an expected rate of 50% in patients with high-risk prostate cancer post-prostatectomy 5.
Systemic Therapy
- A review published in the Urologie journal discussed the use of combination therapies, including ADT, docetaxel chemotherapy, and androgen receptor-targeting agents, for metastatic hormone-sensitive prostate cancer 6.
- The review found that triplet therapy consisting of ADT + docetaxel + abiraterone/darolutamide resulted in a significantly longer overall survival compared to doublet therapy consisting of ADT + docetaxel in patients with high-volume metastatic hormone-sensitive prostate cancer 6.