31st December 2024

Management of prostate cancer

Management of localised prostate cancer

Patients should undergo risk stratification taking into consideration their Gleason grade, PSA, TNM staging and life expectancy (determined by age and comorbidities).

There are two main radical (potentially curative) options which should be considered in patients with localised prostate cancer, particularly in those with greater life expectancy. All radical options carry a risk of loss of sexual function.

• Radical prostatectomy ± pelvic lymph node dissection
• Radical radiotherapy, either external beam or brachytherapy

Additional treatments include:

• Androgen deprivation therapy may also be offered to patients depending on risk stratification
• Docetaxel may be used in high risk cases, in conjunction with androgen deprivation. The most important side effect to be aware of is neutropenic sepsis

Those with low risk disease, or with a preference to postpone treatment, may be offered active surveillance during which they are monitored for signs of progression and radical treatment is initiated only once such signs arise:

• PSA every 3-4 months for the first year
• Digital rectal examination at 1 year
• Multi-parametric MRI at 12-18 months
• After the first year, PSA 6 monthly and rectal examination yearly

Contrast this to watchful waiting, which describes cases where a patient does not ever plan to go on to have curative treatment, either out of preference or due to poor performance status and therefore ineligibility. Usually an annual PSA is performed.

In both active surveillance and watchful waiting a rise in PSA or other abnormality triggers further investigation and/or MDT discussion.

Management of locally advanced prostate cancer

Patients with tumour fixation to or invasion of adjacent organs are considered curable but are at very high risk of recurrence and/or progression. If fit, they should be offered either:

• Radical prostatectomy with extended pelvic lymph node dissection; those with positive lymph nodes should be offered adjuvant radiotherapy or androgen-deprivation therapy;
• OR radical radiotherapy with long-term androgen-deprivation therapy.

Management of metastatic prostate cancer

Prostate cancer with distant metastases is not considered curable and treatment is aimed at controlling disease and maintaining quality of life. Both specialist urological services and palliative care should be involved from the outset to help with symptom control and holistic needs of the patient.

In hormone-naive patients, the first line is androgen-deprivation (hormone) therapy, also described as medical castration. This aims to reduce testosterone levels, helping to shrink the tumour and/or prevent further growth.

This may be followed by several lines of alternative systemic therapies in patients whose disease progresses despite effective castration, described as castration- or hormone-resistant prostate cancer. The details of this are beyond the scope of this chapter. Of note, however, are specific options for patients with bony metastases in hormone-resistant prostate cancer:

• Palliative radiotherapy, simple analgesia and IV bisphosphonates can help with bone pain. Bisphosphonates can also be used to treat hypercalcaemia of malignancy.
• Denosumab can be used to prevent skeletal-related events, including pathological fractures and metastatic cord compression.