The median age at diagnosis of prostate cancer is 67 years. Prostate cancer may be cured when localized, and it frequently responds to treatment when widespread. The rate of tumor growth varies from very slow to moderately rapid, and some patients may have prolonged survival even after the cancer has metastasized to distant sites, such as bone. The 5-year relative survival rate for men diagnosed in the United States from 2013 to 2019 with local or regional disease was greater than 99%, and the rate for distant disease was 34%; a 97% survival rate was observed for all stages combined. The approach to treatment is influenced by age and coexisting medical problems. Side effects of various forms of treatment should be considered in selecting appropriate management.

Many patients—especially those with localized tumors—may die of other illnesses without ever having suffered disability from prostate cancer, even if managed conservatively without an attempt at curative therapy. In part, these favorable outcomes are likely the result of widespread screening with the prostate-specific antigen (PSA) test, which can identify patients with asymptomatic tumors that have little or no lethal potential. There is a large number of these clinically indolent tumors, estimated to range from 30% to 70% of men older than 60 years, based on autopsy series of men dying of causes unrelated to prostate cancer.

Because diagnostic methods have changed over time, any analysis of survival after treatment of prostate cancer and comparison of the various treatment strategies is complicated by evidence of increasing diagnosis of nonlethal tumors. Nonrandomized comparisons of treatments may be confounded not only by patient selection factors but also by time trends.

For example, a population-based study in Sweden showed that, from 1960 to the late 1980s, before the use of PSA for screening purposes, long-term relative survival rates after the diagnosis of prostate cancer improved substantially as more sensitive methods of diagnosis were introduced. This occurred despite the use of watchful waiting or active surveillance or palliative hormonal treatment as the most common treatment strategies for localized prostate cancer during the entire era (150 radical prostatectomies per year were performed in Sweden during the late 1980s). The investigators estimated that, if all prostate cancers diagnosed between 1960 and 1964 were of the lethal variety, then at least 33% of cancers diagnosed between 1980 and 1984 were of the nonlethal variety. With the advent of PSA screening as the most common method of detection in the United States, the ability to diagnose nonlethal prostate cancers has further increased.

Another issue complicating comparisons of outcomes among nonconcurrent series of patients is the possibility of changes in criteria for the histological diagnosis of prostate cancer. This phenomenon creates a statistical artifact that can produce a false sense of therapeutic accomplishment and may also lead to more aggressive therapy.

Controversy exists about the value of screening, the most appropriate staging evaluation, and the optimal treatment of each stage of the disease.

Incidence and Mortality

Estimated new cases and deaths from prostate cancer in the United States in 2024:

• New cases: 299,010.
• Deaths: 35,250.

Anatomy

Screening

Screening for prostate cancer is controversial. In the United States, most prostate cancers are diagnosed because of screening, either with a PSA blood test or, less frequently, with a digital rectal examination. Randomized trials have yielded conflicting results. Systematic literature reviews and meta-analyses have reported no clear evidence that screening for prostate cancer decreases the risk of death from prostate cancer, or that the benefits outweigh the harms of screening.

For a detailed summary of evidence regarding the benefits and harms of screening for prostate cancer, see Prostate Cancer Screening.

Pathology

More than 95% of primary prostate cancers are adenocarcinomas. Prostate adenocarcinomas are frequently multifocal and heterogeneous in patterns of differentiation. Prostatic intraepithelial neoplasia (PIN) (noninvasive atypical epithelial cells within benign-appearing acini) is often present in association with prostatic adenocarcinoma. PIN is subdivided into low grade and high grade. The high-grade form may be a precursor of adenocarcinoma.

Several rare tumors account for the rest of the cases. These include the following:

• Small-cell tumors.
• Intralobular acinar carcinomas.
• Ductal carcinomas.
• Clear cell carcinomas.
• Mucinous carcinomas.

Gleason score

The histological grade of prostate adenocarcinomas is usually reported according to one of the variations of the Gleason scoring system, which provides a useful, albeit crude, adjunct to tumor staging in determining prognosis. The Gleason score is calculated based on the dominant histological grades, from grade 1 (well differentiated) to grade 5 (very poorly differentiated). The classical score is derived by adding the two most prevalent pattern grades, yielding a score ranging from 2 to 10. Because there is some evidence that the least-differentiated component of the specimen may provide independent prognostic information, the score is often provided by its separate components (e.g., Gleason score 3 + 4 = 7; or 4 + 3 = 7).

There is evidence that, over time, pathologists have tended to award higher Gleason scores to the same histological patterns, a phenomenon sometimes termed grade inflation. This phenomenon complicates comparisons of outcomes in current versus historical patient series. For example, prostate biopsies from a population-based cohort of 1,858 men diagnosed with prostate cancer from 1990 through 1992 were re-read in 2002 to 2004. The contemporary Gleason score readings were an average of 0.85 points higher (95% confidence interval, 0.79–0.91; P .001) than the same slides read a decade earlier. As a result, Gleason-score standardized prostate cancer mortality rates for these men were artifactually improved from 2.08 to 1.50 deaths per 100-person years—a 28% decrease even though overall outcomes were unchanged.

Molecular markers

A number of tumor markers are associated with the outcome of patients with prostate cancer, including the following:

• Markers of apoptosis including Bcl-2, Bax.
• Markers of proliferation rate, such as Ki67.
• TP53 mutation or expression.
• p27.
• E-cadherin.
• Microvessel density.
• DNA ploidy.
• p16.
• PTEN gene hypermethylation and allelic losses.

However, none of these has been prospectively validated, and they are not a part of the routine management of patients.

Clinical Presentation

In the United States, most prostate cancers are diagnosed as a result of screening; therefore, symptoms of cancer are infrequent at the time of diagnosis. Nevertheless, local growth of the tumor may produce symptoms of urinary obstruction such as:

• Decreased urinary stream.
• Urgency.
• Hesitancy.
• Nocturia.
• Incomplete bladder emptying.

These symptoms are nonspecific and more indicative of benign prostatic hyperplasia than cancer.

Although rare in the current era of widespread screening, prostate cancer may also present with symptoms of metastases, including bone pain, pathological fractures, or symptoms caused by bone marrow involvement.

Diagnostic Evaluation

Needle biopsy is the most common method used to diagnose prostate cancer. Most urologists now perform a transrectal biopsy using a bioptic gun with ultrasound guidance. Less frequently, a transperineal ultrasound-guided approach can be used in patients who may be at increased risk of complications from a transrectal approach. Over the years, there has been a trend toward taking eight to ten or more biopsy samples from several areas of the prostate with a consequent increased yield of cancer detection after an elevated PSA blood test.

The use of magnetic resonance imaging (MRI)−directed biopsy in the initial diagnostic evaluation of prostate cancer is also being studied, either as a replacement for, or in addition to, standard systematic prostate needle biopsies. The data have been reported primarily by experienced MRI radiologists and urologists in referral centers, and generalizability of results is uncertain. A multicenter randomized trial of 500 patients has shown that, in experienced hands, a multiparametric MRI-directed biopsy is more accurate than a transrectal-guided biopsy to detect clinically significant cancers. MRI led to the detection of more Gleason score (≥7) lesions and fewer Gleason score (7) lesions, with fewer biopsies overall. The data suggested that MRI-directed biopsy can replace standard transrectal-guided biopsies. However, a large, single-arm, single-center study of 2,103 men with MRI-visible lesions who underwent both MRI-directed biopsies and standard systematic prostate needle biopsies under ultrasound visualization suggested otherwise. In that study, MRI-directed biopsies alone led to misclassification of 8.8% of cancers defined as clinically significant (Gleason score 4 + 3 or higher) compared with the combination of both biopsy techniques. Both studies reported only on histology end points at the time of diagnosis, rather than health outcomes on follow-up.

Prophylactic antibiotics, especially fluoroquinolones, are often used before transrectal needle biopsies. There are reports of increasing rates of sepsis, particularly with fluoroquinolone-resistant E. coli, and hospitalization after the procedure. Therefore, men undergoing transrectal biopsy should be told to seek medical attention immediately if they experience fever after biopsy.

Prognostic Factors

The following factors influence the survival of patients with prostate cancer:

• Extent of tumor.
• Histological grade of tumor.
• Patient's age and health.
• Prostate-specific antigen (PSA) level.

For more information on survival rates, see Cancer Stat Facts: Prostate Cancer.

Extent of tumor

When the cancer is confined to the prostate gland, long-term prognosis is excellent. Patients with locally advanced cancer are not usually curable, but 5-year survival is still very good. If prostate cancer has spread to distant organs, current therapy will not cure it. Median survival is usually 1 to 3 years, and most of these patients will die of prostate cancer. Even in this group of patients, indolent clinical courses lasting for many years may be observed.

Histological grade of tumor

Poorly differentiated tumors are more likely to have metastasized before diagnosis and are associated with a poorer prognosis. The most commonly used method to report tumor differentiation is the Gleason score. For more information, see the Pathology section.

Patient's age and health

Any benefits of definitive local therapy with curative intent may take years to emerge. Therefore, therapy with curative intent is usually reserved for men with a sufficiently long life expectancy. For example, radical prostatectomy is often reserved for men with an estimated life expectancy of at least 10 years.

Prostate-specific antigen (PSA) level

PSA, an organ-specific marker, is often used as a tumor marker. The higher the level of PSA at baseline, the higher the risk of metastatic disease or subsequent disease progression. However, it is an imprecise marker of risk.

For example, baseline PSA and rate of PSA change were associated with subsequent metastasis or prostate cancer death in a cohort of 267 men with clinically localized prostate cancer who were managed by watchful waiting or active surveillance in the control arm of a randomized trial comparing radical prostatectomy with watchful waiting or active surveillance. Nevertheless, the accuracy of classifying men into groups whose cancer remained indolent versus those whose cancer progressed was poor at all examined cut points of PSA or PSA rate of change.

Serum acid phosphatase levels

Elevations of serum acid phosphatase are associated with poor prognosis in both localized and disseminated disease. However, serum acid phosphatase levels are not incorporated into the American Joint Committee on Cancer's (AJCC) staging system for prostate cancer.

Use of nomograms as a prognostic tool

Several nomograms have been developed to predict outcomes either before radical prostatectomy or after radical prostatectomy with intent to cure. Preoperative nomograms are based on clinical stage, PSA level, Gleason score, and the number of positive and negative prostate biopsy cores. One independently validated nomogram demonstrated increased accuracy in predicting biochemical recurrence-free survival by including preoperative plasma levels of transforming growth factor B1 and interleukin-6 soluble receptor.

Postoperative nomograms add pathological findings, such as capsular invasion, surgical margins, seminal vesicle invasion, and lymph node involvement. The nomograms, however, were developed at academic centers and may not be as accurate when generalized to nonacademic hospitals, where most patients are treated. In addition, the nomograms use nonhealth (intermediate) outcomes, such as PSA rise or pathological surgical findings, and subjective end points, such as the physician's perceived need for additional therapy. In addition, the nomograms may be affected by changing methods of diagnosis or neoadjuvant therapy.

Follow-Up After Treatment

The optimal follow-up strategy for men treated for prostate cancer is uncertain. Men should be interviewed and examined for symptoms or signs of recurrent or progressing disease, as well as side effects of therapy that can be managed by changes in therapy. However, using surrogate end points for clinical decision-making is controversial, and the evidence that changing therapy based on such end points translates into clinical benefit is weak. Often, rates of PSA change are thought to be markers of tumor progression. However, even though a tumor marker or characteristic may be consistently associated with a high risk of prostate cancer progression or death, it may be a very poor predictor and of very limited utility in making therapeutic decisions.

Although the PSA test is nearly universally used to follow patients, the diversity of recommendations on the provision of follow-up care reflects the current lack of research evidence on which to base firm conclusions. A systematic review of international guidelines highlights the need for robust primary research to inform future evidence-based models of follow-up care for men with prostate cancer.

Preliminary data from a retrospective cohort of 8,669 patients with clinically localized prostate cancer treated with either radical prostatectomy or radiation therapy suggested that short posttreatment PSA doubling time (3 months in this study) fulfills some criteria as a surrogate end point for all-cause mortality and prostate cancer-specific mortality after surgery or radiation therapy.

Likewise, a retrospective analysis (SWOG-S9916 ) showed PSA declines of 20% to 40% (but not 50%) at 3 months and 30% or more at 2 months after initiation of chemotherapy for hormone-independent prostate cancer, and fulfilled several criteria of surrogacy for overall survival (OS).

These observations should be independently confirmed in prospective study designs and may not apply to patients treated with hormonal therapy. In addition, there are no standardized criteria of surrogacy or standardized cut points for adequacy of surrogate end points, even in prospective trials.

Follow-up after radical prostatectomy

After radical prostatectomy, a detectable PSA level identifies patients at elevated risk of local treatment failure or metastatic disease; however, a substantial proportion of patients with an elevated or rising PSA level after surgery remain clinically free of symptoms for extended periods. Biochemical evidence of failure on the basis of elevated or slowly rising PSA alone, therefore, may not be sufficient to initiate additional treatment.

For example, in a retrospective analysis of nearly 2,000 men who had undergone radical prostatectomy with curative intent and were followed for a mean of 5.3 years, 315 men (15%) demonstrated an abnormal PSA of 0.2 ng/mL or higher, which is considered evidence of biochemical recurrence. Among these 315 men, 103 (34%) developed clinical evidence of recurrence. The median time to the development of clinical metastasis after biochemical recurrence was 8 years. After the men developed metastatic disease, the median time to death was an additional 5 years.

Follow-up after radiation therapy

For patients treated with radiation therapy, the combination of clinical tumor stage, Gleason score, and pretreatment PSA level is often used to estimate the risk of relapse. As is the case after prostatectomy, PSA is often followed for signs of tumor recurrence after radiation therapy. After radiation therapy with curative intent, persistently elevated or rising PSA may be a prognostic factor for clinical disease recurrence; however, reported case series have used a variety of definitions of PSA failure. Criteria have been developed by the American Society for Therapeutic Radiology and Oncology Consensus Panel. It is difficult to base decisions about initiating additional therapy on biochemical failure alone. The implication of the various definitions of PSA failure for OS is not known, and, as in the surgical series, many biochemical relapses (rising PSA only) may not be clinically manifested in patients treated with radiation therapy.

Follow-up after hormonal therapy

After hormonal therapy, reduction of PSA to undetectable levels provides information regarding the duration of progression-free status; however, decreases in PSA of less than 80% may not be very predictive. Because PSA expression itself is under hormonal control, androgen deprivation therapy can decrease the serum level of PSA independent of tumor response. Clinicians, therefore, cannot rely solely on the serum PSA level to monitor a patient’s response to hormonal therapy; they must also follow clinical criteria.

Staging Tests

Most men are diagnosed with prostate cancer at an early clinical stage and do not have detectable metastases. Therefore, they generally do not have to undergo staging tests, such as a bone scan, computed tomography (CT), or magnetic resonance imaging (MRI). However, staging studies are done if there is clinical suspicion of metastasis, such as bone pain; local tumor spread beyond the prostate capsule; or a substantial risk of metastasis (prostate-specific antigen >20 ng/mL and Gleason score >7).

Tests used to determine stage include the following:

Serum prostate-specific antigen (PSA) level

Serum PSA can predict the results of radionuclide bone scans in newly diagnosed patients.

• In one series, only 2 of 852 patients (0.23%) with a PSA of less than 20 ng/mL had a positive bone scan in the absence of bone pain.
• In another series of 265 patients with prostate cancer, 0 of 23 patients with a PSA of less than 4 ng/mL had a positive bone scan, and 2 of 114 patients with a PSA of less than 10 ng/mL had a positive bone scan.

Magnetic resonance imaging (MRI)

Although MRI has been used to detect extracapsular extension of prostate cancer, a positive-predictive value of about 70% and considerable interobserver variation are problems that make its routine use in staging uncertain. Ultrasound and MRI, however, can reduce clinical understaging and thereby improve patient selection for local therapy. MRI with an endorectal coil appears to be more accurate for identification of organ-confined and extracapsular disease, especially when combined with spectroscopy. MRI is a poor tool for evaluating nodal disease.

MRI is more sensitive than radionuclide bone scans in the detection of bone metastases, but it is impractical for evaluating the entire skeletal system.

Positron emission tomography (PET)

It is becoming more common to use PET-CT with specific radionuclide tracers to stage prostate cancer. Several tracers have been tested and shown the ability to detect either lymph node or distant metastases in certain patients with prostate cancer.

68Ga-gozetotide and 18F-piflufolastat PET-CT

Prostate-specific membrane antigen (PSMA) is a transmembrane receptor expressed in high levels in prostate cancer. PSMA can be targeted for imaging with 68Ga-gozetotide and 18F-piflufolastat. These radionuclide tracers have been tested for the imaging of nodes and metastases in the initial staging of intermediate- and high-risk prostate cancer, as well as imaging of suspected posttreatment recurrent disease in patients with an elevated PSA.

A phase III trial included 764 patients with intermediate- or high-risk prostate cancer who underwent 68Ga-gozetotide PET-CT staging. The trial reported a sensitivity of 40% and a specificity of 95% in the detection of nodal disease as compared with PLND.

68Ga-gozetotide PET-CT was studied alongside CT and bone scan for the detection of metastatic disease in men with high-risk prostate cancer. Compared with conventional imaging, 68Ga-gozetotide PET-CT provided increased sensitivity (85% vs. 38%) and specificity (98% vs. 91%). 68Ga-gozetotide PET-CT was also evaluated to assess recurrent disease and showed a high positive predictive value (PPV) and detection rate. 68Ga-gozetotide also had better results than 18F-fluciclovine in that context.

18F-piflufolastat PET-CT had a sensitivity of 40% and a specificity of 98% in staging intermediate- or high-risk prostate cancer compared with PLND. For the detection of recurrent or metastatic prostate cancer in the context of increasing PSA, 18F-piflufolastat PET-CT had a sensitivity of 95.8% and a PPV of 81.9%.

Based on these data, the U.S. Food and Drug Administration (FDA) approved 68Ga-gozetotide and 18F-piflufolastat PET-CT for the initial staging of patients with prostate cancer and suspicion of metastatic disease, and for the evaluation of potential recurrence based on an elevated posttreatment PSA.

18F-fluciclovine PET-CT

18F-fluciclovine PET-CT showed low sensitivity but high specificity in the initial lymph nodal staging of intermediate- and high-risk prostate cancer, compared with PLND. Compared with conventional imaging, its specificity was similar, but sensitivity was higher for detection of extraprostatic disease.

18F-fluciclovine also detected more bone metastases and was more sensitive and specific than 99mTc-MDP bone scan.

The FDA approved 18F-fluciclovine PET-CT for the assessment of suspected recurrent disease in men with a rising posttreatment PSA.

Pelvic lymph node dissection (PLND)

PLND remains the most accurate method to assess metastasis to the pelvic nodes, and laparoscopic PLND has been shown to accurately assess pelvic nodes as effectively as an open procedure.

The determining factor in deciding whether any type of PLND is indicated is when definitive therapy may be altered. For example, radical prostatectomy is generally reserved for men without lymph node metastasis. Likewise, preoperative seminal vesicle biopsy may be useful in patients with palpable nodules who are being considered for radical prostatectomy (unless they have a low Gleason score) because seminal vesicle involvement could affect the choice of primary therapy and predicts for pelvic lymph node metastasis.

In patients with clinically localized (stage I or stage II) prostate cancer, Gleason pathological grade and enzymatic serum prostatic acid phosphatase values (even within normal range) predict the likelihood of capsular penetration, seminal vesicle invasion, or regional lymph node involvement. Analysis of a series of 166 patients with clinical stage I or stage II prostate cancer undergoing radical prostatectomy revealed an association between Gleason biopsy score and the risk of lymph node metastasis found at surgery. The risks of nodal metastasis for patients grouped according to their Gleason biopsy score was 2% for a Gleason score of 5, 13% for a Gleason score of 6, and 23% for a Gleason score of 8.

Having all patients undergo a PLND is debatable, but in patients undergoing a radical retropubic prostatectomy, nodal status is usually ascertained as a matter of course. Evidence is mounting that PLND is likely unnecessary in patients with a PSA less than 20 ng/mL and a low Gleason score who are undergoing radical perineal prostatectomy. This is especially true for patients whose malignancy was not palpable but detected on ultrasound.

Transrectal or transperineal biopsy

The most common means to establish a diagnosis and determine the Gleason score in cases of suspected prostate cancer is by needle biopsy. Most urologists now perform a transrectal biopsy using a bioptic gun with ultrasound guidance. Less frequently, a transperineal ultrasound-guided approach can be used for those patients who may be at increased risk of complications from a transrectal approach. Over the years, there has been a trend toward taking eight to ten or more biopsy samples from several areas of the prostate with a consequent increased yield of cancer detection after an elevated PSA blood test.

Transrectal ultrasound (TRUS)

TRUS may facilitate diagnosis by directing needle biopsy; however, ultrasound is operator dependent and does not assess lymph node size.

A prospective multi-institutional study of preoperative TRUS in men with clinically localized prostate cancer eligible for radical prostatectomy showed that TRUS was no better than digital rectal examination in predicting extracapsular tumor extension or seminal vesicle involvement.

Computed tomography (CT) scans

CT scans can detect grossly enlarged lymph nodes but poorly define intraprostatic features; therefore, it is not reliable for the staging of pelvic node disease when compared with surgical staging.

Technetium Tc 99m (99mTc)-methylene diphosphonate (MDP) bone scan

A 99mTc-MDP bone scan is the most widely used test for metastasis to the bone, which is the most common site of distant tumor spread.

Staging Systems

Historically, two systems have been in common use for the staging of prostate cancer.

• In 1975, the Jewett system (stage A through stage D) was described and has since been modified. This staging system is no longer in common use, but older studies and publications may refer to it.
• In 1997, the American Joint Committee on Cancer (AJCC) and the International Union Against Cancer adopted a revised TNM (tumor, node, metastasis) system, which used the same broad T-stage categories as the Jewett system but included subcategories of T stage, such as a stage to describe patients diagnosed through PSA screening. This revised TNM system more precisely stratifies newly diagnosed patients.

AJCC Stage Groupings and TNM Definitions

The AJCC has designated staging by TNM classification.

Local treatment modalities are associated with prolonged disease-free survival (DFS) for many patients with localized prostate cancer but are rarely curative in patients with locally extensive tumors. Because of clinical understaging using current diagnostic techniques, even when the cancer appears clinically localized to the prostate gland, some patients develop disseminated tumors after local therapy with surgery or radiation.

Treatment options for each stage of prostate cancer are presented in Table 6.

Table 6. Treatment Options by Stage for Prostate Cancer

Side effects of each of the treatment approaches are covered in the relevant sections below. Patient-reported adverse effects differ substantially across the options for management of clinically localized disease, with few direct comparisons, and include watchful waiting/active surveillance/active monitoring, radical prostatectomy, and radiation therapy. The differences in adverse effects can play an important role in patient choice among treatment options. Detailed comparisons of these effects have been reported in population-based cohort studies, albeit with relatively short follow-up times of 2 to 3 years.

Watchful Waiting or Active Surveillance/Active Monitoring

Asymptomatic patients of advanced age or with concomitant illness may warrant consideration of careful observation without immediate active treatment. Watch and wait, observation, expectant management, and active surveillance/active monitoring are terms indicating a strategy that does not employ immediate therapy with curative intent.

Watchful waiting and active surveillance/active monitoring are the most commonly used terms, and the literature does not always clearly distinguish them, making the interpretation of results difficult. The general concept of watchful waiting is patient follow-up with the application of palliative care as needed to alleviate symptoms of tumor progression. There is no planned attempt at curative therapy at any point in follow-up. For example, transurethral resection of the prostate (TURP) or hormonal therapy may be used to alleviate tumor-related urethral obstruction should there be local tumor growth; hormonal therapy or bone radiation might be used to alleviate pain from metastases. Radical prostatectomy has been compared with watchful waiting or active surveillance/active monitoring in men with early-stage disease (i.e., clinical stages T1b, T1c, or T2). For more information, see the Radical Prostatectomy section.

In contrast, the strategy behind active surveillance/active monitoring is to defer therapy for clinically localized disease but regularly follow the patient and initiate local therapy with curative intent if there are any signs of local tumor progression. The intention is to avoid the morbidity of therapy in men who have indolent or nonprogressive disease but preserve the ability to cure them should the tumor progress. Active surveillance/active monitoring often involves the following:

• Regular patient visits.
• Digital rectal examinations.
• Prostate-specific antigen (PSA) testing.
• Transrectal ultrasound (in some series).
• Transrectal needle biopsies (in some series).

Patient selection, testing intervals, and specific tests, as well as criteria for intervention, are arbitrary and not established in controlled trials.

In the United States, as in other settings with widespread PSA screening, the results of conservative management of localized prostate cancer are particularly favorable. In the aggregate, men managed by watchful waiting or active surveillance/active monitoring (using various criteria, depending upon the study) have had very favorable prostate–cancer-specific mortalities ranging from about 1% to 10% (with the most favorable rates in more recent series). Most men with screen-detected prostate cancer may, therefore, be candidates for active surveillance/active monitoring, with definitive therapy reserved for signs of tumor progression. This has been shown most clearly in the large Prostate Testing for Cancer Treatment (ProtecT ) randomized trial that compared active monitoring, radical prostatectomy, and radiation therapy. For more information, see the Radical Prostatectomy section.

For more information, see the Treatment of Stage II Prostate Cancer section.

Radical Prostatectomy

A radical prostatectomy is usually reserved for patients who:

• Are in good health and elect surgical intervention.
• Have tumor confined to the prostate gland (stage I and stage II).

Open prostatectomy can be performed by the perineal or retropubic approach. The perineal approach requires a separate incision for lymph node dissection. Laparoscopic lymphadenectomy is technically possible. Robot-assisted prostatectomy is an alternative to open prostatectomy and has become the most common technique in developed countries. In experienced hands, functional outcomes between open and robot-assisted prostatectomy appear very similar, at least in the short- to mid-term. In a randomized trial of 308 men suitable for prostatectomy, urinary, sexual, and bowel functional outcomes were similar between open retropubic and robotic surgeries at a median follow-up of 24 months. The sample size and duration of follow-up were too small to detect meaningful differences in cancer outcomes.

For small, well-differentiated nodules, the incidence of positive pelvic nodes is less than 20%, and pelvic node dissection may be omitted. With larger, less-differentiated tumors, a pelvic lymph node dissection is more important. In these cases, the value of open surgical or laparoscopic pelvic node dissection is not therapeutic, but it spares patients with positive nodes the morbidity of prostatectomy. Radical prostatectomy is usually not performed if a frozen-section evaluation of pelvic nodes reveals metastases; these patients should be considered for entry into existing clinical trials or receive radiation therapy to control local symptoms.

The role of preoperative (neoadjuvant) hormonal therapy is not established.

After radical prostatectomy, pathological evaluation stratifies tumor extent into the following classes:

• Margin-positive disease—The incidence of disease recurrence increases when the tumor margins are positive. Results of the outcome of patients with positive surgical margins have not been systematically reported.
• Specimen-confined disease—The incidence of disease recurrence increases when the tumor is not specimen-confined (extracapsular).
• Organ-confined disease—Patients with extraprostatic disease (not organ-confined) are suitable candidates for clinical trials of which the Radiation Therapy Oncology Group's (RTOG) RTOG-9601 trial (NCT00002874), was an example. These trials have included evaluation of postoperative radiation delivery, cytotoxic agents, and hormonal treatment using luteinizing hormone-releasing hormone (LH-RH) agonists and/or antiandrogens.

Radical prostatectomy compared with other treatment options

In 1993, a structured literature review of 144 papers was done in an attempt to compare the three primary treatment strategies for clinically localized prostate cancer:

The authors concluded that poor reporting and selection factors within all series precluded a valid comparison of efficacy for the three management strategies.

In a literature review of case series of patients with palpable, clinically localized disease, the authors found that 10-year prostate−cancer-specific survival rates were best in radical prostatectomy series (about 93%), worst in radiation therapy series (about 75%), and intermediate with deferred treatment (about 85%). Because it is highly unlikely that radiation therapy would worsen disease-specific survival, the most likely explanation is that selection factors affect choice of treatment. Such selection factors make comparisons of therapeutic strategies imprecise.

Radical prostatectomy has been compared with watchful waiting or active surveillance/active monitoring in men with early-stage disease (i.e., clinical stages T1b, T1c, or T2) in randomized trials, with conflicting results. The difference in results may be the result of differences in how the men were diagnosed with prostate cancer.

Evidence (radical prostatectomy vs. watchful waiting or active surveillance/active monitoring):

Complications of radical prostatectomy

Complications of radical prostatectomy include the following:

• Morbidity and mortality associated with general anesthesia and a major surgical procedure.
• Urinary incontinence and impotence.
• Penile shortening.
• Inguinal hernia.
• Fecal incontinence.

Functional outcomes of radical prostatectomy with respect to sexual, urinary, bowel function, and health-related quality of life (QOL), appear to be similar whether the procedure is open retropubic, laparoscopic, or robot-assisted radical prostatectomy.

Morbidity and mortality associated with radical prostatectomy

An analysis of Medicare records on 101,604 radical prostatectomies performed from 1991 to 1994 showed the following:

• A 30-day operative mortality rate of 0.5%.
• A rehospitalization rate of 4.5%.
• A major complication rate of 28.6%.

Over the study period, these rates decreased by 30%, 8%, and 12%, respectively.

Prostatectomies done at hospitals where fewer of the procedures were performed than those done at hospitals where more were performed were associated with the following:

• Higher rates of 30-day postoperative mortality.
• Major acute surgical complications.
• Longer hospital stays.
• Higher rates of rehospitalization.

Operative morbidity and mortality rates increase with age. Comorbidity, especially underlying cardiovascular disease and a history of stroke, accounts for a portion of the age-related increase in 30-day mortality.

In a cohort of all men with prostate cancer who underwent radical prostatectomy from 1990 to 1999 in Ontario, 75-year-old men with no comorbidities had a predicted 30-day mortality of 0.74%. Thirty-day surgical complication rates also depended more on comorbidity than age (i.e., about 5% vs. 40% for men with 0 vs. ≥4 underlying comorbid conditions, respectively).

Urinary incontinence and impotence

Urinary incontinence and impotence are complications that can result from radical prostatectomy and have been studied in multiple studies.

Evidence (urinary incontinence and impotence after radical prostatectomy):

Differences are often reported between population-based surveys and case series from individual centers. Reasons could include the following:

• Age differences among the populations.
• Surgical expertise at the major reporting centers.
• Patient selection factors.
• Publication bias of favorable series.
• Different methods of collecting information from patients.

Penile shortening

Case series of men who have undergone radical prostatectomy have shown shortening of penile length (by an average of 1–2 cm). The functional consequence of the shortening is not well studied, but it is noticeable to some men.

In a registry of men with rising PSA after initial treatment of clinically localized prostate cancer, 19 of 510 men (3.7%) who had undergone radical prostatectomy complained of reduced penile size. However, the data were based upon physician reporting of patients' complaints rather than direct patient questioning or before-and-after measurement of penile length. Also, the study sample was restricted to patients with known or suspected tumor recurrence, making generalization difficult.

Recovery of penile length to preoperative measurements within 1 to 2 years has been reported in some, but not all, case series in which men were followed longitudinally.

Inguinal hernia

Inguinal hernia has been reported as a complication of radical prostatectomy.

Evidence (inguinal hernia after radical prostatectomy):

Although the observations of increased rates of inguinal hernia after radical prostatectomy are consistent, it is conceivable that men with prostate cancer who are being followed carefully by urologists could have higher detection rates of hernia because of frequent examinations or diagnostic imaging (i.e., detection bias). Men should be made aware of this potential complication of prostatectomy.

Fecal incontinence

Radical prostatectomy may cause fecal incontinence, and the incidence may vary with surgical method.

Evidence (fecal incontinence after radical prostatectomy):

Radiation Therapy and Radiopharmaceutical Therapy

External-beam radiation therapy (EBRT)

Candidates for definitive radiation therapy must have a confirmed pathological diagnosis of cancer that is clinically confined to the prostate and/or surrounding tissues (stage I, stage II, and stage III). Staging laparotomy and lymph node dissection are not required.

Radiation therapy may be a good option for patients who are considered poor medical candidates for radical prostatectomy. These patients can be treated with an acceptably low complication rate if care is given to the delivery technique.

Long-term results with radiation therapy are dependent on stage and are associated with dosimetry of the radiation.

Evidence (EBRT):

For more information, see the Radical prostatectomy compared with other treatment options section.

Prophylactic radiation therapy to clinically or pathologically uninvolved pelvic lymph nodes does not appear to improve OS or prostate cancer-specific survival as was seen in the RTOG-7706 trial, for example.

Conventional versus hypofractionated EBRT

The more convenient schedules of hypofractionated radiation therapy (using fewer fractions at higher doses per fraction) appear to yield similar outcomes to conventional schedules of radiation, at least with respect to the intermediate outcomes of DFS and failure-free survival (low levels of evidence not known to translate into health outcomes), and early data on OS rates. However, hypofractionated radiation may incur more toxicity than standard doses, depending on the schedules used.

Evidence (conventional vs. hypofractionated EBRT):

Brachytherapy

Patients undergoing brachytherapy are often selected for favorable characteristics that include the following:

• Low Gleason score.
• Low PSA level.
• Stage T1 to T2 tumors.

More information and further study are required to better define the effects of modern interstitial brachytherapy on disease control and QOL and to determine the contribution of favorable patient selection to outcomes.

Information about ongoing clinical trials is available from the NCI website.

Radiopharmaceutical therapy

Alpha emitter radiation

Radium Ra 223 (223Ra) emits alpha particles (i.e., two protons and two neutrons bound together, identical to a helium nucleus) with a half-life of 11.4 days. It is administered intravenously and selectively taken up by newly formed bone stroma. The high-energy alpha particles have a short range of less than 100 mcM. 223Ra improved OS in patients with prostate cancer metastatic to bone. In a double-blind, randomized, controlled trial, 921 men with symptomatic castration-resistant prostate cancer, two or more metastases, and no known visceral metastases were randomly assigned in a 2:1 ratio to 223Ra versus placebo. 223Ra statistically significantly improved OS (median 14.9 months vs. 11.3 months), rate of symptomatic skeletal events (33% vs. 38%), and spinal cord compression (4% vs. 7%). With administration at a dose of 50kBq per kg body weight every 4 weeks for six injections, the side effects were similar to those of a placebo.

Complications of radiation therapy

Definitive EBRT can result in acute cystitis, proctitis, and enteritis. These conditions are generally reversible but may be chronic and rarely require surgical intervention.

A cross-sectional survey of patients with prostate cancer who had been treated in a managed care setting by radical prostatectomy, radiation therapy, or watchful waiting and active surveillance showed substantial sexual and urinary dysfunction in the radiation therapy group.

Radiation is also carcinogenic. EBRT for prostate cancer is associated with an increased risk of bladder and gastrointestinal cancer. Brachytherapy is associated with an increased risk of bladder cancer.

Reducing complications

Potency, in most cases, is preserved with radiation therapy in the short term but appears to diminish over time. Sildenafil citrate may be effective in the management of sexual dysfunction after radiation therapy in some men.

Evidence (reducing complications):

Morbidity may be reduced with the employment of sophisticated radiation therapy techniques—such as the use of linear accelerators—and careful simulation and treatment planning.

Evidence (3D conformal vs. conventional radiation therapy):

Radiation therapy can be delivered after an extraperitoneal lymph node dissection without an increase in complications if careful attention is paid to radiation technique. The treatment field should not include the area that contained the dissected pelvic nodes. Previous TURP is associated with an increased risk of stricture above that seen with radiation therapy alone, but, if radiation therapy is delayed 4 to 6 weeks after the TURP, the risk of stricture is lower. Pretreatment TURP to relieve obstructive symptoms has been associated with tumor dissemination; however, multivariable analysis in pathologically staged cases indicates that this may be due to a worse underlying prognosis of the cases that require TURP rather than the result of the procedure itself.

Comparison of complications from radiation therapy and from radical prostatectomy

In general, radical prostatectomy is associated with a higher rate of urinary incontinence and early sexual impotence but a lower rate of stool incontinence and rectal injury. However, over time, the differences in sexual impotence diminish because the risk rises with time since radiation. Many side effects of definitive local therapy for prostate cancer persist well beyond a decade after therapy, and urinary problems in addition to sexual impotence may worsen with age.

Evidence (complications of radical prostatectomy vs. radiation therapy):

Hormonal Therapy and Its Complications

Several different hormonal approaches are used in the management of various stages of prostate cancer.

These approaches include the following:

• Abiraterone acetate (added to androgen deprivation therapy ).
• Bilateral orchiectomy.
• Estrogen therapy.
• Luteinizing hormone-releasing hormone (LH-RH) agonist therapy.
• Antiandrogen therapy.
• ADT.
• Antiadrenal therapy.
  • Ketoconazole.
  • Aminoglutethimide.

Abiraterone acetate

Abiraterone acetate has been shown to improve OS when added to ADT in men with advanced prostate cancer who have castration-sensitive disease. Abiraterone acetate is generally well-tolerated; however, it is associated with an increase in the mineralocorticoid effects of grade 3 or 4 hypertension and hypokalemia compared with ADT alone. It may also be associated with a small increase in respiratory disorders.

Bilateral orchiectomy

Benefits of bilateral orchiectomy include the following:

• Ease of the procedure.
• Compliance.
• Immediacy in lowering testosterone levels.
• Low cost relative to the other forms of ADT.

Disadvantages of bilateral orchiectomy include the following:

• Psychological effects.
• Loss of libido.
• Less reversible impotence.
• Hot flashes.
• Osteoporosis.

Bilateral orchiectomy has also been associated with an elevated risk of coronary heart disease and myocardial infarction.

For more information, see Hot Flashes and Night Sweats.

Estrogen therapy

Estrogens at a dose of 3 mg qd of diethylstilbestrol (DES) will achieve castrate levels of testosterone. Like orchiectomy, estrogens may cause loss of libido and impotence. Estrogens also cause gynecomastia, and prophylactic low-dose radiation therapy to the breasts is given to prevent this complication.

DES is no longer manufactured or marketed in the United States and is seldom used today because of the risk of serious side effects, including myocardial infarction, cerebrovascular accidents, and pulmonary embolism.

Luteinizing hormone-releasing hormone (LH-RH) agonist therapy

LH-RH agonists, such as leuprolide, goserelin, and buserelin, lower testosterone to castrate levels. Like orchiectomy and estrogens, LH-RH agonists cause impotence, hot flashes, and loss of libido. Tumor flare reactions may occur transiently but can be prevented by antiandrogens or short-term estrogens at a low dose for several weeks.

There is some evidence that LH-RH agonists are associated with increased risk of cardiovascular morbidity or mortality, although the results are conflicting.

Evidence (LH-RH agonists and cardiovascular disease):

Antiandrogen therapy

Antiandrogen agents used in the treatment of prostate cancer include flutamide and bicalutamide. A systematic evidence review compared nonsteroidal antiandrogen monotherapy with surgical or medical castration from 11 randomized trials in 3,060 men with locally advanced, metastatic, or recurrent disease after local therapy. Use of nonsteroidal antiandrogens as monotherapy decreased OS and increased the rate of clinical progression and treatment failure.

The pure antiandrogen, flutamide, may cause diarrhea, breast tenderness, and nausea. Case reports show fatal and nonfatal liver toxic effects. For more information, see Gastrointestinal Complications.

Bicalutamide may cause nausea, breast tenderness, hot flashes, loss of libido, and impotence. For more information, see Nausea and Vomiting Related to Cancer Treatment and Hot Flashes and Night Sweats.

The steroidal antiandrogen, megestrol acetate, suppresses androgen production incompletely and is generally not used as initial therapy.

Additional studies that evaluate the effects of various hormone therapies on QOL are required.

ADT

A national Medicare survey of men who had undergone radical prostatectomy for prostate cancer and either had or had not undergone androgen depletion (either medically or surgically induced) showed a decrease with androgen depletion in all seven health-related QOL measures, including the following:

• Impact of cancer and treatment.
• Concern regarding body image.
• Mental health.
• General health.
• Activity.
• Worries about cancer and dying.
• Energy.

ADT can cause osteoporosis and bone fractures. In a population-based sample of 50,613 Medicare patients aged 66 years or older followed for a median of 5.1 years, men who had been treated with either a gonadotropin-releasing hormone (GnRH) or orchiectomy had a 19.4% bone fracture rate compared with 12.6% in men who had not received hormone deprivation therapy. The effect was similar in men whether or not they had metastatic bone disease.

The use of ADT may be associated with complaints of penile shortening, although the data are very limited. In a registry study of men with rising PSA after initial treatment of clinically localized prostate cancer treated with radiation therapy plus ADT, 6 of 225 men (2.7%) complained of reduced penile size. Of the 213 men treated with radiation therapy but no ADT, none complained of changes in penile size. However, the data were based upon physician reporting of patients' complaints rather than direct patient questioning or before-and-after measurement of penile length. Also, the study sample was restricted to patients with known or suspected tumor recurrence, making generalization difficult.

Placebo-controlled, randomized trials have shown that treatment of bone loss with bisphosphonates decreases the risk of bone fracture in men receiving ADT for prostate cancer (RR, 0.80 in a meta-analysis of 15 trials; 95% CI, 0.69–0.94). In the meta-analysis, zoledronate appeared to have the largest effect.

The use of ADT has also been associated with an increased risk of colorectal cancer.

Evidence (increased risk of colorectal cancer):

Antiadrenal therapy

Antiadrenal agents used in the treatment of prostate cancer include ketoconazole and aminoglutethimide. Long-term use of ketoconazole can result in impotence, pruritus, nail changes, and adrenal insufficiency. Aminoglutethimide commonly causes sedation and skin rashes. For more information, see Pruritus.

Cryosurgery

Cryosurgery, or cryotherapy, is under evaluation for the treatment of localized prostate cancer. It is a surgical technique that involves destruction of prostate cancer cells by intermittent freezing of the prostate with cryoprobes, followed by thawing.; There is limited evidence regarding its efficacy and safety compared with standard prostatectomy and radiation therapy, and the technique is evolving in an attempt to reduce local toxicity and normal tissue damage. The quality of evidence on efficacy is low, currently limited to case series of relatively small size, short follow-up, and surrogate outcomes of efficacy.

Serious toxic effects associated with cryosurgery include bladder outlet injury, urinary incontinence, sexual impotence, and rectal injury. Impotence is common, ranging from about 47% to 100%.

The frequency of other side effects and the probability of cancer control at 5 years' follow-up have varied among reporting centers, and series are small compared with surgery and radiation therapy. Other major complications include urethral sloughing, urinary fistula or stricture, and bladder neck obstruction.

Proton-Beam Therapy

There is interest in the use of proton-beam therapy for the treatment of prostate cancer. Although the dose distribution of this form of charged-particle radiation could theoretically improve the therapeutic ratio of prostate radiation, allowing for an increase in dose to the tumor without a substantial increase in side effects, no randomized controlled trials have been reported that compare its efficacy and toxicity with those of other forms of radiation therapy.

Photodynamic Therapy

Vascular-targeted photodynamic therapy using a photosensitizing agent has been tested in men with low-risk prostate cancer.

Neoadjuvant Hormonal Therapy

The role of neoadjuvant hormonal therapy is not established.

Bicalutamide

Bicalutamide has not been shown to improve OS in patients with localized or locally advanced prostate cancer.

Evidence (bicalutamide):

Information about ongoing clinical trials is available from the NCI website.

Overview

Stage I prostate cancer is defined by the American Joint Committee on Cancer's TNM (tumor, node, metastasis) classification system:

• cT1a–c, N0, M0, prostate-specific antigen (PSA) 10 ng/mL, Gleason ≤6.
• cT2a, N0, M0, PSA 10 ng/mL, Gleason ≤6.
• pT2, N0, M0, PSA 10 ng/mL, Gleason ≤6.

The frequency of clinically silent, nonmetastatic prostate cancer that can be found at autopsy greatly increases with age and may be as high as 50% to 60% in men aged 90 years and older. Undoubtedly, the incidental discovery of these occult cancers at prostatic surgery performed for other reasons accounts for the similar survival of men with stage I prostate cancer, compared with the normal male population, adjusted for age.

Many stage I cancers are well differentiated and only focally involve the gland (T1a, N0, M0); most require no treatment other than careful follow-up.

In younger patients (aged 50–60 years) whose expected survival is long, treatment should be considered. Radical prostatectomy, external-beam radiation therapy (EBRT), interstitial implantation of radioisotopes, and watchful waiting and active surveillance/active monitoring yield apparently similar survival rates in noncontrolled, selected series. The decision to treat should be made in the context of the patient’s age, associated medical illnesses, and personal desires.

Treatment Options for Stage I Prostate Cancer

Treatment options for patients with stage I prostate cancer include the following:

Watchful waiting or active surveillance/active monitoring

Asymptomatic patients of advanced age or with concomitant illness may warrant consideration of careful observation without immediate active treatment. Watch and wait, observation, expectant management, and active surveillance/active monitoring are terms indicating a strategy that does not employ immediate therapy with curative intent. For more information, see the Watchful Waiting or Active Surveillance/Active Monitoring section.

Evidence (observation with delayed hormonal therapy):

Radical prostatectomy

Radical prostatectomy, usually with pelvic lymphadenectomy (with or without the nerve-sparing technique designed to preserve potency) is the most commonly applied therapy with curative intent. Radical prostatectomy may be difficult after a transurethral resection of the prostate (TURP).

Because about 40% to 50% of men with clinically organ-confined disease are found to have pathological extension beyond the prostate capsule or surgical margins, the role of postprostatectomy adjuvant radiation therapy has been studied.

Consideration may also be given to postoperative radiation therapy (PORT) for patients who are found to have seminal vesicle invasion by tumor at the time of prostatectomy or who have a detectable level of PSA more than 3 weeks after surgery. Because duration of follow-up in available studies is still relatively short, the value of PORT has not been determined; however, PORT does reduce local recurrence. Careful treatment planning is necessary to avoid morbidity.

Evidence (radical prostatectomy followed by radiation therapy):

Radical prostatectomy has been compared with watchful waiting or active surveillance/active monitoring. For more information, see the Radical prostatectomy compared with other treatment options section.

Evidence (radical prostatectomy compared with watchful waiting):

External-beam radiation therapy (EBRT)

EBRT is another treatment option used with curative intent. Definitive radiation therapy should be delayed 4 to 6 weeks after TURP to reduce the incidence of stricture. Adjuvant hormonal therapy should be considered for patients with bulky T2b to T2c tumors.

Evidence (EBRT with or without adjuvant hormonal therapy):

Interstitial implantation of radioisotopes

Interstitial implantation of radioisotopes (i.e., iodine I 125 , palladium, and iridium Ir 192) done through a transperineal technique with either ultrasound or computed-tomography guidance, is being used in patients with T1 or T2a tumors. Short-term results in these patients are similar to those for radical prostatectomy or EBRT.;

Factors for consideration in the use of interstitial implants include the following:

• The implant is performed as outpatient surgery.
• The rate of maintenance of sexual potency with interstitial implants has been reported to be 86% to 92%. In contrast, rates of maintenance of sexual potency with radical prostatectomy were 10% to 40% and 40% to 60% with EBRT.
• Typical side effects from interstitial implants that subside with time include urinary tract frequency, urgency, and less commonly, urinary retention.
• Rectal ulceration may also be seen. In one series, a 10% 2-year actuarial genitourinary grade 2 complication rate and a 12% risk of rectal ulceration were seen. This risk decreased with increased operator experience and modification of the implant technique.

Long-term follow-up of these patients is necessary to assess treatment efficacy and side effects.

Retropubic freehand implantation with 125I has been associated with an increased local failure and complication rate and is now rarely done.

Photodynamic therapy

Vascular-targeted photodynamic therapy using a photosensitizing agent has been tested in men with low-risk prostate cancer. In the CLIN1001 PCM301 (NCT01310894) randomized trial, 413 men with low-risk cancer (tumor stage T1–T2c, PSA ≤10 ng/mL, generally Gleason score 3 + 3) were randomly assigned in an open-label trial to receive either the photosensitizing agent, padeliporfin (4 mg/kg intravenously over 10 minutes, and optical fibers inserted into the target area of the prostate, then activated by 753 nm laser light at 150 mW/cm for 22 minutes 15 seconds), or active surveillance. Median time to local disease progression was 28.3 months for patients who received padeliporfin and 14.1 months for patients who were assigned to active surveillance (HR, 0.34; 95% CI, 0.24–0.46; P .0001). However, the appropriate population for photodynamic therapy may be quite narrow, as it may overtreat men with very low-risk disease and undertreat men with higher-risk disease.

Overview

Stage II prostate cancer is defined by the American Joint Committee on Cancer's TNM (tumor, node, metastasis) classification system:

Stage IIA

• cT1a–c, N0, M0, prostate-specific antigen (PSA) ≥10 20 ng/mL, Gleason ≤6.
• cT2a, N0, M0, PSA ≥10 20 ng/mL, Gleason ≤6.
• pT2, N0, M0, PSA ≥10 20 ng/mL, Gleason ≤6.
• cT2b–c, N0, M0, PSA 20 ng/mL, Gleason ≤6.

Stage IIB

• T1–2, N0, M0, PSA 20 ng/mL, Gleason 7.

Stage IIC

• T1–2, N0, M0, PSA 20, Gleason 7 or 8.

Radical prostatectomy, external-beam radiation therapy (EBRT), and interstitial implantation of radioisotopes are each employed in the treatment of stage II prostate cancer with apparently similar therapeutic effects. Radical prostatectomy and radiation therapy yield apparently similar survival rates with as many as 10 years of follow-up. For well-selected patients, radical prostatectomy is associated with a 15-year survival comparable with an age-matched population without prostate cancer. Unfortunately, randomized comparative trials of these treatment methods with prolonged follow-up are lacking.

Patients with a small, palpable cancer (T2a, N0, and M0) fare better than patients in whom the disease involves both sides of the gland (T2c, N0, and M0). Patients proven free of node metastases by pelvic lymphadenectomy fare better than patients in whom this staging procedure is not performed; however, this is the result of selection of patients who have a more favorable prognosis.

Side effects of the various forms of therapy—including impotence, incontinence, and bowel injury—should be considered in determining the type of treatment to employ.

Prostate-specific antigen (PSA) changes as markers of tumor progression

Often, changes in PSA are thought to be markers of tumor progression. Even though a tumor marker or characteristic may be consistently associated with a high risk of prostate cancer progression or death, it may be a very poor predictor of very limited utility in making therapeutic decisions.

Baseline PSA and rate of PSA change were associated with subsequent metastasis or prostate cancer death in a cohort of 267 men with clinically localized prostate cancer who were managed by watchful waiting or active surveillance in the control arm of a randomized trial comparing radical prostatectomy with watchful waiting. Nevertheless, the accuracy of classifying men into groups whose cancer remained indolent versus those whose cancer progressed was poor at all examined cut points of PSA or PSA rate of change.

Bisphosphonates and risk of bone metastases

Patients with locally advanced nonmetastatic disease (T2–T4, N0–N1, and M0) are at risk of developing bone metastases. Bisphosphonates are being studied as a strategy to decrease this risk.

Evidence (bisphosphonates and risk of bone metastases):

Treatment Options for Stage II Prostate Cancer

Treatment options for patients with stage II prostate cancer include the following:

Patients with stage II prostate cancer are candidates for clinical trials, including trials of neoadjuvant hormonal therapy followed by radical prostatectomy.

Watchful waiting or active surveillance/active monitoring

Asymptomatic patients of advanced age or with concomitant illness may warrant consideration of careful observation without immediate active treatment. Watch and wait, observation, expectant management, and active surveillance/active monitoring are terms indicating a strategy that does not employ immediate therapy with curative intent. For more information, see the Treatment Option Overview for Prostate Cancer section.

Evidence (observation with delayed hormonal therapy):

Radical prostatectomy

Radical prostatectomy, usually with pelvic lymphadenectomy (with or without the nerve-sparing technique designed to preserve potency) is the most commonly applied therapy with curative intent. Radical prostatectomy may be difficult after a transurethral resection of the prostate (TURP).

Because about 40% to 50% of men with clinically organ-confined disease are found to have pathological extension beyond the prostate capsule or surgical margins, the role of postprostatectomy adjuvant radiation therapy has been studied.

Consideration may also be given to postoperative radiation therapy (PORT) for patients who are found to have seminal vesicle invasion by tumor at the time of prostatectomy or who have a detectable level of PSA more than 3 weeks after surgery. Because the duration of follow-up in available studies is relatively short, the value of PORT has not been determined; however, PORT does reduce local recurrence. Careful treatment planning is necessary to avoid morbidity.

Evidence (radical prostatectomy followed by radiation therapy):

Evidence (radical prostatectomy compared directly with watchful waiting/active surveillance/active monitoring and/or external-beam radiation therapy):

External-beam radiation therapy (EBRT) with or without hormonal therapy

EBRT is another treatment option often used with curative intent. Definitive radiation therapy should be delayed 4 to 6 weeks after TURP to reduce the incidence of stricture. Adjuvant hormonal therapy should be considered for patients with bulky T2b to T2c tumors.

The role of adjuvant hormonal therapy in patients with locally advanced disease has been analyzed by the Agency for Health Care Policy and Research (now the Agency for Healthcare Research and Quality). Most patients had more advanced disease, but patients with bulky T2b to T2c tumors were included in the studies that were re-evaluating the role of adjuvant hormonal therapy in patients with locally advanced disease.

Evidence (EBRT with or without adjuvant hormonal therapy):

Interstitial implantation of radioisotopes

Interstitial implantation of radioisotopes (i.e., iodine I 125 , palladium, and iridium), using a transperineal technique with either ultrasound or computed tomography guidance, is being done in patients with T1 or T2a tumors. Short-term results in these patients are similar to those for radical prostatectomy or EBRT.;

Factors for consideration in the use of interstitial implants include the following:

• The implant is performed as outpatient surgery.
• The rate of maintenance of sexual potency with interstitial implants has been reported to be 86% to 92%. In contrast, rates of maintenance of sexual potency with radical prostatectomy were 10% to 40% and 40% to 60% with EBRT.
• Typical side effects from interstitial implants that are seen in most patients but subside with time include urinary tract frequency, urgency, and less commonly, urinary retention.
• Rectal ulceration may also be seen. In one series, a 10% 2-year actuarial genitourinary grade 2 complication rate and a 12% risk of rectal ulceration were seen. This risk decreased with increased operator experience and modification of the implant technique.

Long-term follow-up of these patients is necessary to assess treatment efficacy and side effects.

Retropubic freehand implantation with 125I has been associated with an increased local failure and complication rate and is now rarely done.

Ultrasound-guided percutaneous cryosurgery

Cryosurgery is a surgical technique that involves destruction of prostate cancer cells by intermittent freezing of the prostate with cryoprobes followed by thawing.; Cryosurgery is less well established than standard prostatectomy, and long-term outcomes are not as well established as with prostatectomy or radiation therapy. Serious toxic effects include:

• Bladder outlet injury.
• Urinary incontinence.
• Sexual impotence.
• Rectal injury.

The frequency of other side effects and the probability of cancer control at 5 years' follow-up have varied among reporting centers, and series are small compared with surgery and radiation therapy.

High-intensity focused ultrasound

High-intensity focused ultrasound has been reported in case series to produce good local disease control. However, it has not been directly compared with more standard therapies, and experience with it is more limited.

Proton-beam radiation therapy

There is growing interest in the use of proton-beam radiation therapy for the treatment of prostate cancer. Although the dose distribution of this form of charged-particle radiation has the potential to improve the therapeutic ratio of prostate radiation, allowing for an increase in dose to the tumor without a substantial increase in side effects, no randomized controlled trials have been reported that compare its efficacy and toxicity with those of other forms of radiation therapy.

Photodynamic therapy

Vascular-targeted photodynamic therapy using a photosensitizing agent has been tested in men with low-risk prostate cancer. In the CLIN1001 PCM301 (NCT01310894) randomized trial, 413 men with low-risk cancer (tumor stage T1–T2c, PSA ≤10 ng/mL, generally Gleason score 3 + 3) were randomly assigned in an open-label trial to receive either the photosensitizing agent, padeliporfin (4 mg/kg IV over 10 minutes, and optical fibers inserted into the target area of the prostate, then activated by 753 nm laser light at 150 mW/cm for 22 minutes 15 seconds), or active surveillance. Median time to local disease progression was 28.3 months for patients who received padeliporfin and 14.1 months for patients who were assigned to active surveillance (HR, 0.34; 95% CI, 0.24–0.46; P .0001). However, the appropriate population for photodynamic therapy may be quite narrow, as it may overtreat men with very low-risk disease and undertreat men with higher-risk disease.

Overview

Stage III prostate cancer is defined by the American Joint Committee on Cancer's TNM (tumor, node, metastasis) classification system:

Stage IIIA

• T1–2, N0, M0, prostate-specific antigen (PSA) ≥20, Gleason ≤6–8.

Stage IIIB

• T3–4, N0, M0, any PSA, Gleason ≤6–8.

Stage IIIC

• Any T, N0, M0, any PSA, Gleason 9 or 10.

Extraprostatic extension with microscopic bladder neck invasion (T4) is included with T3a.

External-beam radiation therapy (EBRT), interstitial implantation of radioisotopes, and radical prostatectomy are used to treat stage III prostate cancer. Prognosis is greatly affected by whether regional lymph nodes are evaluated and proven not to be involved.

EBRT using a linear accelerator is the most common treatment for patients with stage III prostate cancer, and large series support its success in achieving local disease control and disease-free survival (DFS). The results of radical prostatectomy in stage III patients are greatly inferior compared with results in patients with stage II cancer. Interstitial implantation of radioisotopes is technically difficult in large tumors.

The patient’s symptoms related to cancer, age, and coexisting medical illnesses should be considered before deciding on a therapeutic plan. In a series of 372 patients treated with radiation therapy and followed for 20 years, 47% eventually died of prostate cancer, but 44% died of intercurrent illnesses without evidence of prostate cancer.

Treatment Options for Stage III Prostate Cancer

Treatment options for patients with stage III prostate cancer include the following:

External-beam radiation therapy (EBRT) with or without hormonal therapy

EBRT alone, luteinizing hormone-releasing hormone (LH-RH) agonist, or orchiectomy, in addition to EBRT, should be considered. Definitive radiation therapy should be delayed until 4 to 6 weeks after transurethral resection to reduce the incidence of stricture.

Hormonal therapy should be considered in conjunction with radiation therapy especially in men who do not have underlying moderate or severe comorbidities. Several studies have investigated its use in patients with locally advanced disease.

Evidence (EBRT with or without hormonal therapy):

Hormonal manipulations (with or without radiation therapy)

Hormonal manipulations (orchiectomy or LH-RH agonists) may be used in the treatment of stage III prostate cancer.

Some data suggest that the efficacy of orchiectomy or LH-RH agonists may be enhanced by the addition of abiraterone acetate in men with locally advanced tumors. In the randomized, open-label, STAMPEDE trial (NCT00268476) trial, 1,917 men (about 95% newly diagnosed; about 50% had metastatic disease and about 50% had locally advanced or node-positive disease) were treated with ADT alone or ADT plus abiraterone acetate (1,000 mg PO qd) and prednisolone (5 mg PO qd). Local radiation therapy was mandated after 6 to 9 months for men with node-negative nonmetastatic disease and optional for those with node-positive nonmetastatic disease. Hormone therapy was curtailed at 2 years or until progression. Radiation therapy was planned in about 40% of the study participants.

• With a median follow-up of 40 months, the 3-year OS rate was 83% in the abiraterone study group compared with 76% in the ADT-only study group (HRdeath, 0.63; 95% CI, 0.52–0.76; P .001). Although there was no clear evidence of heterogeneity in relative treatment differences in metastatic disease versus nonmetastatic disease, absolute differences were much smaller in men with nonmetastatic disease and not statistically significant, perhaps because of the short follow-up (HRdeath, 0.75; 95% CI, 0.49–1.18).
• The main additional differences in toxicity associated with abiraterone compared with ADT alone were hypertension (5% vs. 1%), mild increase in blood aminotransferase levels (6% vs. 1%), and respiratory disorders (5% vs. 2%).

Antiandrogen monotherapy has also been evaluated in men with locally advanced prostate cancer as an alternative to castration.

Evidence (nonsteroidal antiandrogen monotherapy vs. surgical or medical castration):

Evidence (orchiectomy vs. LH-RH agonist):

Immediate versus deferred hormonal therapy

In patients who are not candidates for or who are unwilling to undergo radical prostatectomy or radiation therapy, immediate hormonal therapy has been compared with deferred treatment (i.e., watchful waiting or active surveillance/active monitoring with hormonal therapy at progression).

Evidence (immediate vs. deferred hormonal therapy):

Continuous versus intermittent hormonal therapy

When used as the primary therapy for patients with stage III or stage IV prostate cancer, androgen suppression with hormonal therapy is usually given continuously until there is disease progression. Some investigators have proposed intermittent androgen suppression as a strategy to attain maximal tumor cytoreduction followed by a period without therapy to allow tumor repopulation by hormone-sensitive cells. Theoretically, this strategy might provide tumor hormone responsiveness for a longer period. An animal model suggested that intermittent androgen deprivation (IAD) could prolong the duration of androgen dependence of hormone-sensitive tumors.

Evidence (continuous vs. intermittent hormonal therapy):

Radical prostatectomy with or without EBRT

Radical prostatectomy may be used with or without EBRT (in highly selected patients). Because about 40% to 50% of men with clinically organ-confined disease are found to have pathological extension beyond the prostate capsule or surgical margins, the role of postprostatectomy adjuvant radiation therapy has been studied.

Evidence (radical prostatectomy with or without EBRT):

Watchful waiting or active surveillance/active monitoring

Careful observation without further immediate treatment may be used in the treatment of stage III prostate cancer.

Asymptomatic patients of advanced age or with concomitant illness may warrant consideration of careful observation without immediate active treatment. Watch and wait, observation, expectant management, and active surveillance/active monitoring are terms indicating a strategy that does not employ immediate therapy with curative intent. For more information, see the Treatment Option Overview for Prostate Cancer section.

Treatment of Symptoms

Because many stage III patients have urinary symptoms, control of symptoms is an important consideration in treatment. The following modalities may be used to improve local control of disease and subsequent symptoms:

• Radiation therapy.
• Hormonal manipulation.
• Palliative surgery (transurethral resection of the prostate ).
• Interstitial implantation combined with EBRT.
• Alternative forms of radiation therapy (under clinical evaluation).
• Ultrasound-guided percutaneous cryosurgery (under clinical evaluation).

Radiation therapy

Radiation therapy may be used. EBRT designed to decrease exposure of normal tissues using methods such as computed tomography–based 3-dimensional conformal radiation therapy treatment planning is under clinical evaluation.

Hormonal manipulation

Hormonal manipulations effectively used as initial therapy for prostate cancer include the following:

• Orchiectomy.
• Leuprolide or other LH-RH agonists (e.g., goserelin) in daily or depot preparations. These agents may be associated with tumor flare.
• Estrogens (diethylstilbestrol is no longer available in the United States).
• Nonsteroidal antiandrogens (e.g., flutamide, nilutamide, and bicalutamide) or steroidal antiandrogen (e.g., cyproterone acetate).

A meta-analysis of randomized trials comparing various hormonal monotherapies in men with stage III or stage IV prostate cancer (predominantly stage IV) came to the following conclusions:

• The OS at 2 years using any of the LH-RH agonists was similar to treatment with orchiectomy or 3 mg qd of DES (HR, 1.26; 95% CI, 0.92–1.39).
• Survival rates at 2 years were similar or worse with nonsteroidal antiandrogens compared with orchiectomy (HR, 1.22; 95% CI, 0.99–1.50).
• Treatment withdrawals, used as a surrogate for adverse effects, occurred less with LH-RH agonists (0%–4%) than with nonsteroidal antiandrogens (4%–10%).

Interstitial implantation combined with EBRT

Interstitial implantation combined with EBRT is being used in selected T3 patients, but little information is available.

Alternative forms of radiation therapy

Alternative forms of radiation therapy are being employed in clinical trials.

• A randomized trial from the RTOG reported improved local control and survival with mixed-beam (neutron/photon) radiation therapy compared with standard photon radiation therapy.
• A subsequent randomized study from the same group compared fast-neutron radiation therapy with standard photon radiation therapy. Local-regional control was improved with neutron treatment, but no difference in OS was seen, although follow-up was shorter in this trial. Fewer complications were seen with the use of a multileaf collimator.

Proton-beam radiation therapy is also under investigation.

Ultrasound-guided percutaneous cryosurgery

Ultrasound-guided percutaneous cryosurgery is under clinical evaluation.

Cryosurgery is a surgical technique under development that involves destruction of prostate cancer cells by intermittent freezing of the prostate with cryoprobes, followed by thawing.; ; Cryosurgery is less well established than standard prostatectomy, and long-term outcomes are not as well established as with prostatectomy or radiation therapy. Serious toxic effects include bladder outlet injury, urinary incontinence, sexual impotence, and rectal injury. The technique of cryosurgery is under development. Impotence is common. The frequency of other side effects and the probability of cancer control after 5 years of follow-up have varied among reporting centers, and series are small compared with surgery and radiation therapy.

Overview

Stage IV prostate cancer is defined by the American Joint Committee on Cancer's TNM (tumor, node, metastasis) classification system:

Stage IVA

• Any T, N1, M0, any prostate-specific antigen (PSA), any Gleason.

Stage IVB

• Any T, N0, M1, any PSA, any Gleason.

Extraprostatic extension with microscopic bladder neck invasion (T4) is included with T3a.

Treatment selection depends on the following factors:

• Age.
• Coexisting medical illnesses.
• Symptoms.
• The presence of distant metastases (most often bone) or regional lymph node involvement only.

The most common symptoms originate from the urinary tract or from bone metastases. Palliation of symptoms from the urinary tract with transurethral resection of the prostate (TURP) or radiation therapy and palliation of symptoms from bone metastases with radiation therapy or hormonal therapy are an important part of the management of these patients. Bisphosphonates may also be used for the management of bone metastases.

Treatment Options for Stage IV Prostate Cancer

Treatment options for patients with stage IV prostate cancer include the following:

Hormonal manipulations

Hormonal treatment is the mainstay of therapy for metastatic prostate cancer. Cure is rarely, if ever, possible, but striking subjective or objective responses to treatment occur in most patients. The cornerstone of hormonal therapy for prostate cancer is medical or surgical castration to stop the production of testosterone by the testes. This is commonly referred to as androgen deprivation therapy (ADT) and can be achieved with bilateral orchiectomy or with administration of gonadotropin-releasing hormone (GnRH) agonists or antagonists. The most effective purely hormonal approach employs a combination of ADT and one of the following agents:

• Abiraterone acetate, an inhibitor of cytochrome P450c17, a critical enzyme in androgen biosynthesis.
• Apalutamide, an androgen receptor antagonist.
• Enzalutamide, an androgen receptor antagonist.

Randomized controlled trials have reported that combination therapy with any one of these drugs plus ADT results in longer overall survival than does ADT alone.

Hormonal manipulations effectively used as initial therapy for prostate cancer include the following:

• Orchiectomy alone or with an androgen blocker as seen in the Southwest Oncology Group (SWOG-8894) trial.
• Luteinizing hormone-releasing hormone (LH-RH) agonists, such as leuprolide in daily or depot preparations. These agents may be associated with tumor flare when used alone; therefore, the initial concomitant use of antiandrogens should be considered in the presence of liver pain, ureteral obstruction, or impending spinal cord compression.
• Leuprolide plus flutamide; however, the addition of an antiandrogen to leuprolide has not been clearly shown in a meta-analysis to improve survival.
• Estrogens (diethylstilboestrol , chlorotrianisene, ethinyl estradiol, conjugated estrogens-USP and DES-diphosphate). DES is no longer commercially available in the United States.

In some series, pretreatment levels of PSA were inversely correlated with progression-free duration in patients with metastatic prostate cancer who received hormonal therapy. After hormonal therapy is initiated, a PSA reduction to beneath a detectable level provides information regarding the duration of progression-free status; however, decreases in PSA of less than 80% may not be very predictive.

Orchiectomy and estrogens yield similar results, and selection of one or the other depends on patient preference and the morbidity of expected side effects. Estrogens are associated with the development or exacerbation of cardiovascular disease, especially in high doses. DES at a dose of 1 mg qd is not associated with cardiovascular complications as frequent as those found at higher doses; however, the use of DES has decreased because of cardiovascular toxic effects.

The psychological implications of orchiectomy are objectionable to many patients, and many will choose an alternative therapy if effective. Combined orchiectomy and estrogens are not indicated to be superior to either treatment administered alone.

A large proportion of men experience hot flushes after bilateral orchiectomy or treatment with LH-RH agonists. These hot flashes can persist for years. Varying levels of success in the management of these symptoms have been reported with DES, clonidine, cyproterone acetate, or medroxyprogesterone acetate.

After tumor progression on one form of hormonal manipulation, an objective tumor response to any other form is uncommon. Some studies, however, suggest that withdrawal of flutamide (with or without aminoglutethimide administration) is associated with a decline in PSA and that one may need to monitor for this response before initiating new therapy. Low-dose prednisone may palliate symptoms in about 33% of cases. Newer hormonal approaches, such as inhibition of androgen receptors, have been shown to improve OS and quality of life (QOL) after tumor progression despite ADT. For more information, see the Treatment of Recurrent or Hormone-Resistant Prostate Cancer section.

Immediate versus deferred hormonal therapy

Some patients may be asymptomatic and careful observation without further immediate therapy may be appropriate.

Evidence (immediate vs. deferred hormonal therapy):

Luteinizing hormone-releasing hormone (LH-RH) agonists or antiandrogens

Approaches using LH-RH agonists or antiandrogens in patients with stage IV prostate cancer have produced response rates similar to other hormonal treatments.

Evidence (LH-RH agonists or antiandrogens):

Maximal androgen blockade (MAB)

On the basis that the adrenal glands continue to produce androgens after surgical or medical castration, case series studies were performed in which antiandrogen therapy was added to castration. Promising results from the case series led to widespread use of the strategy, known as MAB or total androgen blockade. Subsequent randomized controlled trials, however, cast doubt on the efficacy of adding an antiandrogen to castration.

Evidence (MAB):

Continuous versus intermittent hormonal therapy

When used as the primary therapy for patients with stage III or stage IV prostate cancer, androgen suppression with hormonal therapy is often given continuously until there is disease progression. Another option is intermittent androgen suppression as a strategy to attain maximal tumor cytoreduction followed by a period without therapy to allow treatment-free periods. It was proposed that this strategy might provide tumor hormone responsiveness for a longer period. An animal model suggested that intermittent androgen deprivation (IAD) could prolong the duration of androgen dependence of hormone-sensitive tumors. However, randomized controlled trials in humans have failed to support the hypothesis that IAD would delay the development of castration-resistant disease. If there are benefits from IAD, they appear to be in the realm of physical and sexual functioning.

Evidence (continuous vs. intermittent hormonal therapy):

Hormonal manipulations with chemotherapy

The addition of chemotherapy has been shown in randomized trials to improve OS compared with ADT alone, with efficacy that appears to be comparable with hormonal therapy, which includes ADT plus abiraterone acetate. However, the two approaches have not been directly compared in a randomized study.

The addition of docetaxel has been tested in combination with long-term hormone therapy in the first-line management of metastatic prostate cancer and has been shown to improve results more than hormone therapy alone. A systematic evidence review and meta-analysis of randomized trials in hormone-sensitive metastatic prostate cancer summarizes these data.

Evidence (hormonal manipulations with chemotherapy):

Bisphosphonates

In addition to hormonal therapy, adjuvant treatment with bisphosphonates has been tested.

Evidence (bisphosphonates):

Bisphosphonates and decreasing risk of bone metastases

Patients with locally advanced nonmetastatic disease (T2–T4, N0–N1, and M0) are at risk of developing bone metastases, and bisphosphonates are being studied as a strategy to decrease this risk. However, a placebo-controlled randomized trial (MRC-PR04) of a 5-year regimen of the first-generation bisphosphonate clodronate in high oral doses (2,080 mg qd) had no favorable impact on either time to symptomatic bone metastasis or survival.

External-beam radiation therapy (EBRT) with or without hormonal therapy

EBRT may be used for attempted cure in highly selected stage M0 patients. Definitive radiation therapy should be delayed 4 to 6 weeks after TURP to reduce incidence of stricture.

Hormonal therapy should be considered in addition to EBRT.

Evidence (radiation therapy with or without hormonal therapy):

Palliative radiation therapy

A single fraction of 8 Gy has been shown to have similar benefits on bone pain relief and QOL as multiple fractions (3 Gy × 10) as was evidenced in the RTOG-9714 trial (NCT00003162).; For more information, see Cancer Pain.

Palliative surgery with transurethral resection of the prostate (TURP)

Transurethral resection of the prostate may be useful in relieving urinary obstruction as part of palliative care in advanced prostate cancer.

Watchful waiting or active surveillance/active monitoring

Careful observation without further immediate treatment (in selected asymptomatic patients).

Radical prostatectomy with immediate orchiectomy

An uncontrolled, retrospective review of a large series of patients with any T, N1–3, M0 disease treated at the Mayo Clinic with concurrent radical prostatectomy and orchiectomy was associated with intervals to local and distant progression; however, increase in OS has not been demonstrated. Patient selection factors make such study designs difficult to interpret.

Overview

In recurrent or hormone-resistant prostate cancer, the selection of further treatment depends on many factors, including the following:

• Previous treatment.
• Site of recurrence.
• Coexistent illnesses.
• Individual patient considerations.

Definitive radiation therapy can be given to patients with disease that fails only locally after prostatectomy. A randomized trial (RTOG-9601 ) has shown improved overall survival (OS) and prostate–cancer-specific survival with the addition of high-dose bicalutamide to radiation therapy compared with radiation therapy alone in men with locally recurrent prostate cancer after radical prostatectomy.

• In the trial, 760 men who were initially treated with radical prostatectomy for tumor stage T2 or T3, and who had a detectable prostate-specific antigen (PSA) level of 0.2 to 4.0 ng/mL, but no evidence of metastases, were randomly assigned to receive radiation (64.8 Gy over 36 fractions) and either bicalutamide (150 mg PO qd) or placebo for 24 months. The median interval from surgery to PSA detectability was 1.4 years and from surgery to randomization was 2.1 years. Median follow-up was 13 years.
• Actuarial OS at 12 years was 76.3% in the bicalutamide group versus 71.3% in the placebo group (P = .04; hazard ratio , 0.77; 95% confidence interval , 0.59–0.99).
• Prostate–cancer-specific mortality at 12 years was 5.8% (bicalutamide) versus 13.4% (placebo), (HR, 0.49; 95% CI, 0.32–0.74; P .001).
• Most treatment-related toxicities were similar between the two groups, except for gynecomastia, which occurred in 69.7% of the men on bicalutamide versus 10.9% of those on placebo. This side effect may be mitigated by prophylactic breast irradiation, which was not used in this study because of the double-blinded design.

Some patients with a local recurrence after definitive radiation therapy can be salvaged with prostatectomy; however, only about 10% of patients treated initially with radiation therapy will have local relapse only. In these patients, prolonged disease control is often possible with hormonal therapy, with median cancer-specific survival of 6 years after local failure.

Cryosurgical ablation of recurrence after radiation therapy is associated frequently with a high complication rate. This technique is still undergoing clinical evaluation.

Hormonal therapy is used to manage most relapsing patients with disseminated disease who initially received locoregional therapy with surgery or radiation therapy. For more information, see the Treatment Options for Stage IV Prostate Cancer section.

Immediate Versus Deferred Hormonal Therapy

For more information on the use of immediate hormonal therapy (bicalutamide or luteinizing hormone-releasing hormone agonists) plus radiation in the setting of locally recurrent prostate cancer after radical prostatectomy, see the Treatment Option Overview for Prostate Cancer section.

PSA is often used to monitor patients after initial therapy with curative intent, and elevated or rising PSA is a common trigger for additional therapy even in asymptomatic men. Despite how common the situation is, it is not clear whether additional treatments given because of rising PSA in asymptomatic men with prostate cancer increase OS. The quality of evidence is limited.

Hormonal Therapy for Recurring Disease

Continuous versus intermittent hormonal therapy

Most men who are treated for recurrence after initial local therapy are asymptomatic, and the recurrence is detected by a rising PSA. It is possible that intermittent androgen deprivation (IAD) therapy can be used as an alternative to continuous ADT (CAD) to improve QOL and decrease the amount of time during which the patient experiences the side effects of hormonal therapy, without decreasing the survival rate.

Nonsteroidal antiandrogen monotherapy versus surgical or medical castration

A systematic evidence review compared nonsteroidal antiandrogen monotherapy with surgical or medical castration from 11 randomized trials in 3,060 men with locally advanced, metastatic, or recurrent disease after local therapy. The use of nonsteroidal antiandrogens as monotherapy decreased OS and increased the rate of clinical progression and treatment failure.

Hormonal approaches

As noted above, studies have shown that chemotherapy with docetaxel or cabazitaxel and immunotherapy with sipuleucel-T can prolong OS in patients with hormone-resistant metastatic prostate cancer. Nevertheless, hormonal therapy has also been shown to improve survival even in men who have progressed after other forms of hormonal therapy as well as chemotherapy. Some forms of hormonal therapy are effective in the management of metastatic hormone–refractory prostate cancer.

Because there are no head-to-head comparisons, there are no trials to help decide which of these agents should be used first or in what sequence they should be used.

Even among patients with metastatic hormone-refractory prostate cancer, some heterogeneity is found in prognosis and in retained hormone sensitivity. In such patients who have symptomatic bone disease, several factors are associated with worsened prognosis: poor performance status, elevated alkaline phosphatase, abnormal serum creatinine, and short (1 year) previous response to hormonal therapy. The absolute level of PSA at the initiation of therapy in relapsed or hormone-refractory patients has not shown prognostic significance.

Some patients whose disease has progressed on combined androgen blockade can respond to a variety of second-line hormonal therapies. Aminoglutethimide, hydrocortisone, flutamide withdrawal, progesterone, ketoconazole, and combinations of these therapies have produced PSA responses in 14% to 60% of patients treated and have also produced clinical responses of 0% to 25% when assessed. The duration of these PSA responses has ranged from 2 to 4 months. Survival rates are similar whether ketoconazole plus hydrocortisone is initiated at the same time as antiandrogen (e.g., flutamide, bicalutamide, or nilutamide) withdrawal or when PSA has risen after an initial trial of antiandrogen withdrawal, as seen in the CLB-9583 trial (NCT00002760), for example. There are conflicting data on whether PSA changes in men undergoing chemotherapy are predictive of survival.

Patients treated with either luteinizing-hormone agonists or estrogens as primary therapy are generally maintained with castrate levels of testosterone. One study from the Eastern Cooperative Oncology Group (ECOG) showed that a superior survival resulted when patients were maintained on primary androgen deprivation; however, another study from SWOG (formerly the Southwest Oncology Group) did not show an advantage to continued androgen blockade.

Evidence (hormonal approaches for castration-resistant progressive disease with no previous chemotherapy):

Evidence (hormonal approaches for progressive disease with previous chemotherapy):

Prevention of bone metastases

Painful bone metastases can be a major problem for patients with prostate cancer. Many strategies have been studied for palliation, including the following:

• External-beam radiation therapy (EBRT).
• Bone-seeking radionuclides (strontium chloride Sr 89 ).
• Denosumab (a monoclonal antibody that inhibits osteoclast function).
• Pain medication.
• Corticosteroids.
• Bisphosphonates.

For more information, see Cancer Pain.

Evidence (palliation for bone metastases using radiation therapy):

Evidence (palliation for bone metastases using strontium chloride):

The use of radioisotopes such as 89Sr has been effective as palliative treatment of some patients with osteoblastic metastases. As a single agent, 89Sr has been reported to decrease bone pain in 80% of patients treated.

Evidence (palliation or prevention of bone metastases using denosumab):

Treatment Options for Recurrent Prostate Cancer

Treatment options for patients with recurrent prostate cancer include the following:

• Hormone therapy.
• Chemotherapy for hormone-resistant prostate cancer.
• Immunotherapy.
• Radiopharmaceutical therapy.
• Poly (ADP-ribose) polymerase (PARP) inhibitors for men with prostate cancer and BRCA1, BRCA2, and/or ATM mutations.

Chemotherapy for hormone-resistant prostate cancer

Evidence (chemotherapy for hormone-resistant prostate cancer):

Other chemotherapy regimens reported to produce subjective improvement in symptoms and reduction in PSA level include the following:;

• Paclitaxel.
• Estramustine/etoposide.
• Estramustine/vinblastine.
• Estramustine/paclitaxel.

A study suggests that patients whose tumors exhibit neuroendocrine differentiation are more responsive to chemotherapy.

Immunotherapy

Sipuleucel-T, an active cellular immunotherapy, has been shown to increase OS in patients with hormone-refractory metastatic prostate cancer. Sipuleucel-T consists of autologous peripheral blood mononuclear cells that have been exposed ex vivo to a recombinant fusion protein (PA2024) composed of prostatic acid phosphatase fused to granulocyte-macrophage colony-stimulating factor.

Side effects are generally consistent with cytokine release and include chills, fever, headache, myalgia, sweating, and influenza-like symptoms, usually within the first 24 hours of infusion. No increase in autoimmune disorders or secondary malignancies has been noted.

Evidence (immunotherapy):

Low-dose prednisone may palliate symptoms in some patients.

Evidence (low-dose prednisone for palliation):

Ongoing clinical trials continue to explore the value of chemotherapy for these patients.

Radiopharmaceutical therapy

Alpha emitter radiation

Radium Ra 223 (223Ra) emits alpha particles (i.e., two protons and two neutrons bound together, identical to a helium nucleus) with a half-life of 11.4 days. It is administered by IV and selectively taken up by newly formed bone stroma. The high-energy alpha particles have a short range of 100 mcM. 223Ra improved OS in patients with prostate cancer metastatic to the bone.

Evidence (alpha emitter radiation):

PARP inhibitors for men with prostate cancer and BRCA1, BRCA2, and/or ATM mutations

Olaparib

Evidence (olaparib):