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Prostate Cancer Treatment Options

Guidelines and review literature: (EAU Guidelines Prostate Cancer) (S3-Leitlinie Prostatakarzinom) (Walsh-Campbell Urology).

Treatment Algorithm for Prostate Cancer Depending On Clinical Risk and Life Expectancy

For the clinical risk stratification, see table D'Amico risk stratification of prostate cancer.

Localized Prostate Cancer

Low-Risk Prostate Cancer (PSA <10 ng/ml and Gleason Score ≤6):

The cancer-specific mortality is low within 10–15 years; randomized trials did not show a significant differences between observation and radical prostatectomy after ten years (Wilt et al., 2012) (Hamdy et al., 2016). After 20 years, the PIVOT trial showed 5% survival benefit for patients after radical prostatectomy vs. observation, but the risk of hormone therapy (22% vs. 44%) was significantly reduced by surgery (Wilt et al., 2017).

Life Expectancy Over 15 Years:

Active surveillance is a treatment option for patients who wish deferred therapy to avoid side effects. If treatment is desired or if patients progress under active surveillance, patients can choose between radical prostatectomy, external beam radiation therapy, or brachytherapy.

Life Expectancy Below 15 Years:

Active surveillance is the therapy of choice. If patients progress under active surveillance, curative radiation therapy or radical prostatectomy are possible. As an alternative to active treatment with immediate side effects, watchful waiting for metastatic disease and start of hormone therapy is also an option.

Intermediate and High-Risk Prostate Cancer (PSA > 10 ng/ml or Gleason Score ≥7):

There is a relevant risk within ten years of progressing to metastatic disease or dying from prostate cancer within 15 years. Curative treatment is necessary for patients with a life expectancy of over 5–10 years (depending on the co-morbidities).

Life expectancy Over 10 years:

Radical prostatectomy is the treatment of choice. Patients with R1 resection may need adjuvant radiotherapy, and patients with lymph node metastases may need adjuvant hormonal therapy. As an alternative, curative radiotherapy with adjuvant hormonal therapy is an option. For poorly differentiated tumors, radical prostatectomy has better results in retrospective comparative series than radiotherapy.

Life Expectancy Below 10 Years:

Curative radiotherapy with adjuvant hormone therapy is treatment of choice. For patients with subvesical obstruction, radical prostatectomy should be preferred.

Life Expectancy Below 5 Years:

TURP for patients with subvesical obstruction. A curative therapy is unnecessary. Hormone therapy is indicated for local or systemic progression.

Metastatic Prostate Cancer:

Antiandrogen therapy is the initial treatment of choice. Depending on clinical risk or progression, numerous additional or sequential therapy options are available. In oligometastatic patients with high life expectancy, local therapy (percutaneous radiotherapy or radical prostatectomy) and radiation of the metastases may be considered in addition to hormone therapy. Important is the palliation of symptoms in patients with systemic progression: pain therapy, bisphosphonates, denosumab, and radiotherapy of painful bone metastases.

Prostate cancer staging

Index

Prostate cancer active surveillance

Index: 1–9 A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

References

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Deutsche Version: Leitlinien: Therapie Optionen des Prostatakarzinoms