Localized Prostate Cancer
Very Low Risk
PSA <10 & Grade Group 1 & clinical stage T1-T2a & <34% of biopsy cores positive & no core with >50% involved & PSA density <0.15
PSA <10 & Grade Group 1 & clinical stage T1-T2a
Intermediate Risk Favorable
Grade Group 1 (with PSA 10-<20) OR Grade Group 2 (with PSA<10)
Intermediate Risk Unfavorable
Grade Group 2 (with either PSA 10-<20 OR clinical stage T2b-c) OR Grade Group 3 (with PSA < 20)
PSA >20 ng/ml OR Grade Group 4-5 OR clinical stage >T3
Localized Prostate Cancer Management
We recommend observation or watchful waiting for low and intermediate risk patients who have life expectancy of ≤ 5 years.
We may consider observation or watchful waiting for asymptomatic high risk patients who have life expectancy of ≤ 5 years. We may consider androgen deprivation therapy or radiation therapy for selected patients in this group.
We recommend active surveillance for very low risk patients and most of low risk patients.
Radical prostatectomy/ Radiation Therapy
We recommend radical prostatectomy or radiation therapy plus androgen deprivation therapy for intermediate and high risk patients.
We recommend moderate hypofractionation for patients who choose radiation therapy. IGRT is recommended. Regimens include 6000 cGy delivered in 20 fractions of 300 cGy and 7000 cGy delivered in 28 fractions of 250 cGy.
Ultrahypofractionation may be suggested to low and intermediate, but not to high risk patients. IGRT is recommended. This protocol consists of 3500 to 3625 cGy in 5 fractions of 700 to 725 cGy. Prostate should be smaller than 100 cm3.
Androgen deprivation therapy
We recommend 24-36 months of androgen deprivation therapy for high risk patients who choose radiation therapy.
Locally Advanced Prostate Cancer Management
Radical prostatectomy, if technically doable, can result in disease-free survival in more than half of men at 8 to 10 years.
We recommend adjuvant radiotherapy to the patients who have seminal vesicle invasion, positive surgical margins, and extraprostatic extension.
Radiation therapy plus androgen deprivation therapy is the other option in this setting.
Biochemical Recurrence after Radical Prostatectomy
PSA > 0.2 with a second confirmatory level > 0.2.
Multiparametric MRI can detect local recurrences in the prostatic bed, but its sensitivity in patients with PSA level < 0.5 ng/mL remains controversial.
We generally do not take biopsy. Decision is made based on biochemical recurrence.
We recommend salvage radiotherapy to patients with PSA or local recurrence after radical prostatectomy, preferably when the PSA level is < 0.5.
If PSA ≥ 1, we recommend a prostate-specific membrane antigen positron emission tomography computed tomography (PSMA PET/CT), if available, or a choline PET/CT imaging.
We recommend hormone therapy to patients treated with salvage radiotherapy
Biochemical Failure after Radiation Therapy
PSA ≥ 2.0 above the nadir. This definition is used for external beam radiotherapy and interstitial prostate brachytherapy, even if these treatments were accompanied by androgen deprivation therapy.
We recommend prostate biopsy before treating the patient.
Biopsy should be obtained 18-24 months after treatment.
Transrectal US is not reliable in depicting local recurrences after radiation therapy.
Multiparametric MRI has been associated with excellent results and can be used for biopsy targeting and guiding local salvage treatment.
We recommend PSMA PET/CT (if available) or choline PET/CT imaging to rule out positive lymph nodes or distant metastases before curative salvage treatment.