Treatment depends on:
- Grade group
- Stage
- PSA
- Expected survival
- Patient preference
Low risk disease
For men with life expectancy above approximately 10 years, active surveillance is generally preferred.
Surveillance uses:
- PSA
- MRI
- Repeat biopsy according to protocol
Treatment begins if disease is reclassified rather than treating every Grade Group 1 tumour immediately. Long term cancer specific survival under appropriately selected active surveillance is excellent.
Localised intermediate risk disease
Curative options include:
- Radical prostatectomy
- External beam radiotherapy
- Brachytherapy in selected disease
Unfavourable intermediate disease treated with radiotherapy generally receives short term androgen deprivation for approximately 4 to 6 months.
High risk and locally advanced disease
Options include:
- Radical prostatectomy as part of multimodal treatment in selected men
- External beam radiotherapy plus long term ADT
- Additional systemic intensification in appropriate very high risk disease
Radical prostatectomy removes:
- Entire prostate
- Seminal vesicles
followed by vesicourethral anastomosis.
Important complications include:
- Urinary incontinence
- Erectile dysfunction
- Anastomotic stricture
- Lymphocele after lymph node dissection
Androgen deprivation
Options include:
- Bilateral orchiectomy
- LHRH agonist
- LHRH antagonist
LHRH agonists can cause an initial testosterone flare.
Where immediate suppression is essential, such as impending cord compression or major bladder outlet obstruction, use an LHRH antagonist or orchiectomy rather than allowing a flare.
Metastatic hormone sensitive disease
ADT alone is inadequate treatment for most fit patients.
Combine ADT with an androgen receptor pathway inhibitor such as:
Abiraterone 1000 mg orally once daily
plus
Prednisone or prednisolone approximately 5 mg once daily
or:
Enzalutamide 160 mg orally once daily
or another approved AR pathway agent.
Selected fit patients, particularly those with substantial metastatic burden, may receive triplet treatment incorporating docetaxel.
Metastatic castration resistant disease
Continue castration level androgen suppression.
Treatment is selected according to previous therapy and molecular profile and can include:
- Abiraterone
- Enzalutamide
- Docetaxel
- Cabazitaxel
- PARP inhibitor for appropriate HRR altered disease
- Lutetium PSMA radioligand therapy in selected PSMA positive disease
- Radium 223 for selected symptomatic bone predominant disease without visceral metastases
A standard docetaxel regimen is:
Docetaxel 75 mg/m² IV every 3 weeks
with appropriate steroid support, commonly up to 10 cycles in mCRPC.
Molecular testing for BRCA1, BRCA2 and other homologous recombination repair alterations increasingly affects advanced treatment selection.
