Management

There are numerous strategies for treatment which depend on patient, tumour and treatment factors.

• Patient factors: Age, cormorbities, performance status, fitness for surgery, previous radiotherapy
• Tumour factors: Stage, grade, PSA level
• Treatment factors: Availability of treatment options (esp. brachytherapy)

The approaches include:

• Watchful waiting, used when patients are elderly or have significant comorbidities and it is thought that the prostate cancer is unlikely to impact on their life expectancy
• Active surveillance, used for very low risk prostate cancers in older patients. These patients are followed closely and offered treatment if their disease worsens
• Radical prostatectomy, which is commonly used in Australia. This is best suited for lower stage disease as the risk of positive margins and adjuvant radiotherapy (which increases complication rates) is significant with higher stage and grade disease.
• Radiotherapy, for which there are several options:
  • External beam radiotherapy, widely available but limited in dose escalation and with significant side effects (particularly rectum)
  • Low dose rate brachytherapy, which is only available in select centres and is not covered by Medicare. It is best suited for low grade/low stage disease and should have a favourable side effect profile.
  • High dose rate brachytherapy, which is used in conjunction with external beam radiotherapy to provide significant dose escalation. HDR brachytherapy alone is considered experimental and should only be used in clinical trials
• Androgen deprivation, which has a significant role in adjuvant therapy with radiotherapy and as systemic treatment for metastatic disease
• Cytotoxic therapy, which is only used for systemic disease when hormonal therapy has failed.

Low Risk

PSA < 10, Gleason < 7, organ confined

• Surgical resection
• LDR Seeds
• Active surveillance

Intermediate Risk

One of: PSA 10 - 20, Gleason 7

High Risk

PSA > 20, Gleason > 7, 2 or more intermediate risk factors, cT3

• External beam radiotherapy
• External beam radiotherapy with HDR brachytherapy boost

Adjuvant Therapy after Prostatectomy

Metastatic Disease

In Depth Topics

• a) Watchful Waiting
• b) Active Surveillance
• c) Radical Prostatectomy
• d) Radiotherapy
  • i) External Beam Radiotherapy
  • iii) - High Dose Rate Brachytherapy
  • ii) - Permanent Interstitial LDR Brachytherapy
• e) Androgen Deprivation Therapy
• Systemic Therapy

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Links

• 1. Prostate Cancer
  • Management
    • a) Watchful Waiting
    • b) Active Surveillance
    • c) Radical Prostatectomy
    • d) Radiotherapy
      • i) External Beam Radiotherapy
      • iii) - High Dose Rate Brachytherapy
      • ii) - Permanent Interstitial LDR Brachytherapy
    • e) Androgen Deprivation Therapy
    • Systemic Therapy