What are the treatment protocols for very low risk and low risk of recurrence localized prostate cancer?

Updated: Dec 29, 2020
  • Author: Winston W Tan, MD, FACP; Chief Editor: E Jason Abel, MD  more...
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Answer

Answer

Very low risk of recurrence:

  • Patients with clinical stage T1c, Gleason score ≤6, PSA < 10 ng/mL, fewer than three positive prostate cores, ≤50% cancer in each core, and PSA density < 0.15 ng/mL, with a life expectancy ≤20 y, should be treated with active surveillance.

  • Active surveillance includes periodic PSA testing, digital rectal examination (DRE), and prostate biopsy. The optimal protocol for surveillance is still unknown, [1, 2, 3] but may include PSA as often as every 3 mo or at least every 6 mo, DRE as often as every 6 mo but at least every 12 mo, and repeat biopsy within 18 mo but as often as every 12 mo or if PSA and DRE change. [4, 5, 6]

  • For treatment recommendations for patients with a life expectancy ≥20 y, see initial therapy for Low Risk of Recurrence, below.

Low risk of recurrence:

  • Treatment for patients with clinical stage T1-T2a, Gleason score 2-6, PSA < 10 ng/mL, who have a life expectancy < 10 y includes observation, with continued monitoring until symptoms develop or are eminent, then initiation of palliative androgen deprivation therapy (ADT) [7]

  • Treatment for patients with a life expectancy ≥10y includes active surveillance or

  • Radical prostatectomy (RP) with or without pelvic lymph node dissection (PLND); RP is the standard therapy for localized prostate cancer, involving the removal of the prostate and seminal vesicles with or without pelvic lymph nodes; this may be done using either open or laparoscopic (robotic-assisted) technique [3, 8, 9]  or

  • External beam radiation therapy is a standard therapy for patients with localized disease; 3-dimensional (3D) techniques such as 3D conformal radiation treatment (3D-CRT) offer reduced toxicity and the use of higher doses; second-generation techniques, including intensity-modulated radiation therapy (IMRT), are also required, especially if doses ≥78 Gy are administered [10]

  • Radiation therapy doses of 75.6-79 Gy in conventional 36-41 Gy fractions to the prostate [10] with 3D-CRT/IMRT with daily image-guided radiotherapy (IGRT) or brachytherapy (recommended dose rate: 145 Gy for iodine-125 and 125 Gy for palladium-103): A study by Haverkort et al found that position verification using gold markers and reduced planning target volume margins yielded adequate treatment of the prostate and a lower rectal wall dose in patients treated with curative external beam radiotherapy [11]
  • Patients with low-risk cancer are not candidates for pelvic lymph node irradiation or androgen deprivation therapy (ADT) [12]


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