Initial approach to low- and very low-risk clinically localized prostate cancer
- Eric A Klein, MD
Eric A Klein, MD
- Chairman, Glickman Urological and Kidney Institute
- Professor of Surgery
- Cleveland Clinic
- Jay P Ciezki, MD
Jay P Ciezki, MD
- Staff Physician
- Cleveland Clinic Department of Radiation Oncology
- Section Editors
- Nicholas Vogelzang, MD
Nicholas Vogelzang, MD
- Section Editor — Prostate Cancer
- Professor of Medicine
- University of Nevada School of Medicine
- US Oncology Research
- W Robert Lee, MD, MS, MEd
W Robert Lee, MD, MS, MEd
- Section Editor — Prostate Cancer
- Professor of Radiation Oncology
- Duke University Medical Center
- Jerome P Richie, MD, FACS
Jerome P Richie, MD, FACS
- Section Editor — Cancer of the Urethra, Penis, and Ureter; Urologic Surgery; Prostate Cancer
- Elliott Carr Cutler Professor of Surgery
- Harvard Medical School
Most prostate cancers now are diagnosed while clinically localized, based in part upon the widespread use of serum prostate specific antigen (PSA) measurement. Treatment planning needs to incorporate the natural history of the disease and the risk of progression, since many of these cancers are biologically indolent and may never threaten the health or life of the patient.
For patients diagnosed with prostate cancer confined to the prostate, standard management options include radical prostatectomy, radiation therapy (external beam, brachytherapy), and, for carefully selected patients with very low or low-risk disease, active surveillance.
Key factors in choosing treatment for a man with low-risk prostate cancer include the likelihood of recurrence or metastasis following treatment (risk stratification), the patient's age and life expectancy, the presence or absence of significant comorbidity, and patient preferences. (See "Prostate cancer: Risk stratification and choice of initial treatment", section on 'Risk stratification'.)
This topic discusses the initial management approach for men with low-risk prostate cancer. The approach to treatment of men with intermediate and high-risk prostate cancer, locally advanced (very high risk) disease, and stage IV disease (clinical lymph node involvement or disseminated metastases) are discussed separately:To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- National Comprehensive Cancer Network (NCCN). NCCN Clinical practice guidelines in oncology. http://www.nccn.org/professionals/physician_gls/f_guidelines.asp (Accessed on February 27, 2016).
- Dahabreh IJ, Chung M, Balk EM, et al. Active surveillance in men with localized prostate cancer: a systematic review. Ann Intern Med 2012; 156:582.
- Sheets NC, Goldin GH, Meyer AM, et al. Intensity-modulated radiation therapy, proton therapy, or conformal radiation therapy and morbidity and disease control in localized prostate cancer. JAMA 2012; 307:1611.
- Sanda MG, Dunn RL, Michalski J, et al. Quality of life and satisfaction with outcome among prostate-cancer survivors. N Engl J Med 2008; 358:1250.
- Nag S, Beyer D, Friedland J, et al. American Brachytherapy Society (ABS) recommendations for transperineal permanent brachytherapy of prostate cancer. Int J Radiat Oncol Biol Phys 1999; 44:789.
- Thompson I, Thrasher JB, Aus G, et al. Guideline for the management of clinically localized prostate cancer: 2007 update. J Urol 2007; 177:2106.
- Kittel JA, Reddy CA, Smith KL, et al. Long-Term Efficacy and Toxicity of Low-Dose-Rate ¹²⁵I Prostate Brachytherapy as Monotherapy in Low-, Intermediate-, and High-Risk Prostate Cancer. Int J Radiat Oncol Biol Phys 2015; 92:884.
- Cookson MS, Aus G, Burnett AL, et al. Variation in the definition of biochemical recurrence in patients treated for localized prostate cancer: the American Urological Association Prostate Guidelines for Localized Prostate Cancer Update Panel report and recommendations for a standard in the reporting of surgical outcomes. J Urol 2007; 177:540.
- Kawakami J, Cowan JE, Elkin EP, et al. Androgen-deprivation therapy as primary treatment for localized prostate cancer: data from Cancer of the Prostate Strategic Urologic Research Endeavor (CaPSURE). Cancer 2006; 106:1708.
- Sammon JD, Abdollah F, Reznor G, et al. Patterns of Declining Use and the Adverse Effect of Primary Androgen Deprivation on All-cause Mortality in Elderly Men with Prostate Cancer. Eur Urol 2015; 68:32.
- Cullen J, Zhao J, Chen Y, et al. Overall survival among prostate cancer patients treated with primary androgen deprivation therapy versus expectant management (abstract). Data presented at the 3rd annual ASCO Prostate Cancer Symposium, Orlando, Florida, February 22-24, 2007.
- Iversen P, McLeod DG, See WA, et al. Antiandrogen monotherapy in patients with localized or locally advanced prostate cancer: final results from the bicalutamide Early Prostate Cancer programme at a median follow-up of 9.7 years. BJU Int 2010; 105:1074.
- Hamdy FC, Donovan JL, Lane JA, et al. 10-Year Outcomes after Monitoring, Surgery, or Radiotherapy for Localized Prostate Cancer. N Engl J Med 2016; 375:1415.
- Donovan JL, Hamdy FC, Lane JA, et al. Patient-Reported Outcomes after Monitoring, Surgery, or Radiotherapy for Prostate Cancer. N Engl J Med 2016; 375:1425.
- Boorjian SA, Karnes RJ, Rangel LJ, et al. Mayo Clinic validation of the D'amico risk group classification for predicting survival following radical prostatectomy. J Urol 2008; 179:1354.
- Eggener SE, Scardino PT, Walsh PC, et al. Predicting 15-year prostate cancer specific mortality after radical prostatectomy. J Urol 2011; 185:869.
- Mullins JK, Feng Z, Trock BJ, et al. The impact of anatomical radical retropubic prostatectomy on cancer control: the 30-year anniversary. J Urol 2012; 188:2219.
- Moschini M, Sharma V, Zattoni F, et al. Natural History of Clinical Recurrence Patterns of Lymph Node-Positive Prostate Cancer After Radical Prostatectomy. Eur Urol 2016; 69:135.
- Zelefsky MJ, Yamada Y, Fuks Z, et al. Long-term results of conformal radiotherapy for prostate cancer: impact of dose escalation on biochemical tumor control and distant metastases-free survival outcomes. Int J Radiat Oncol Biol Phys 2008; 71:1028.
- Zelefsky MJ, Kuban DA, Levy LB, et al. Multi-institutional analysis of long-term outcome for stages T1-T2 prostate cancer treated with permanent seed implantation. Int J Radiat Oncol Biol Phys 2007; 67:327.
- Hauswald H, Kamrava MR, Fallon JM, et al. High-Dose-Rate Monotherapy for Localized Prostate Cancer: 10-Year Results. Int J Radiat Oncol Biol Phys 2016; 94:667.
- Jarosek SL, Virnig BA, Chu H, Elliott SP. Propensity-weighted long-term risk of urinary adverse events after prostate cancer surgery, radiation, or both. Eur Urol 2015; 67:273.
- Laviana AA, Ilg AM, Veruttipong D, et al. Utilizing time-driven activity-based costing to understand the short- and long-term costs of treating localized, low-risk prostate cancer. Cancer 2016; 122:447.
- Wiegel T, Stöckle M, Bartkowiak D. PREFEREnce-based randomized evaluation of treatment modalities in low or early intermediate-risk prostate cancer. Eur Urol 2015; 67:1.
- Barocas DA, Alvarez J, Resnick MJ, et al. Association Between Radiation Therapy, Surgery, or Observation for Localized Prostate Cancer and Patient-Reported Outcomes After 3 Years. JAMA 2017; 317:1126.
- Chen RC, Basak R, Meyer AM, et al. Association Between Choice of Radical Prostatectomy, External Beam Radiotherapy, Brachytherapy, or Active Surveillance and Patient-Reported Quality of Life Among Men With Localized Prostate Cancer. JAMA 2017; 317:1141.
- Lardas M, Liew M, van den Bergh RC, et al. Quality of Life Outcomes after Primary Treatment for Clinically Localised Prostate Cancer: A Systematic Review. Eur Urol 2017.
- RISK STRATIFICATION
- TREATMENT APPROACHES
- Active surveillance
- Radiation therapy
- - External beam RT
- - Brachytherapy
- Patient selection
- Radical prostatectomy
- - Localized disease
- - Pathologic T3, margin positive disease, and microscopic lymph node involvement
- - Complications
- Urinary incontinence
- Erectile dysfunction
- Other approaches
- - Ablation therapy
- - Androgen deprivation therapy alone
- - Antiandrogen monotherapy
- Radical prostatectomy
- External beam RT
- CHOICE OF THERAPY
- ProtecT trial
- Quality of life
- POST-TREATMENT SURVEILLANCE
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS