Localized Prostate Cancer: Treatment Options

 

Am Fam Physician. 2018 Jun 15;97(12):798-805.

  Patient information: See related handout on prostate cancer.

Author disclosure: No relevant financial affiliations.

In the United States, prostate cancer will be diagnosed in one out of seven men in his lifetime. Most cases are localized, and only one in 39 men will die from the disease. Prostate cancer is most often detected using serum prostate-specific antigen testing. The National Comprehensive Cancer Network guidelines use four main factors to stratify risk of disease progression or recurrence and to determine the recommended treatment: clinical stage, pathologic grade, prostate-specific antigen level, and comorbidity-adjusted life expectancy. Radical prostatectomy or external beam radiation therapy should be considered for patients with high-risk prostate cancer regardless of comorbidity-adjusted life expectancy. These treatments are almost equivalent in effectiveness but have different adverse effect profiles. Patients who undergo radical prostatectomy are more likely to experience urinary incontinence and trouble obtaining or sustaining an erection compared with patients who opt for radiation therapy. Brachytherapy is an option for patients with low-risk disease and some patients with intermediate- risk disease. Active surveillance is an option for patients with low-risk and very low-risk disease. With active surveillance, patients are closely followed and undergo invasive treatments only if the cancer progresses. Prostate cancer progression may be indicated by an increase in the pathologic grade, a significant rise in serum prostate-specific antigen level, or an abnormality on digital rectal examination.

Prostate cancer is the third most common cause of cancer-related death in U.S. men, with an estimated 161,000 cases and 26,700 deaths in 2017.1,2 In the United States, prostate cancer will be diagnosed in one out of seven men in his lifetime. However, most cases are localized, and only one in 39 men will die from the disease.3 Prostate cancer incidence and mortality are higher in black men.3

WHAT IS NEW ON THIS TOPIC

The 2014 International Society of Urological Pathology consensus conference established the Gleason grade group system. Gleason grade group 1 is associated with lower risk.

A randomized controlled trial of 1,643 men with clinically localized prostate cancer found no difference in prostate cancer–specific mortality among active surveillance, radical prostatectomy, and external beam radiation therapy over 10 years. Surgery and radiation therapy were associated with lower incidences of disease progression than active surveillance.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Recommended treatment options for localized prostate cancer, including active surveillance, are based on clinical stage, pathologic grade, prostate-specific antigen level, and comorbidity-adjusted life expectancy.

C

15

Radical prostatectomy or external beam radiation therapy should be considered for patients with high-risk localized prostate cancer regardless of comorbidity-adjusted life expectancy.

C

15

Brachytherapy is an option for patients with low-risk or intermediate-risk prostate cancer.

B

15, 26

Active surveillance is an option for patients with low-risk or very low-risk prostate cancer.

C

8, 15, 34


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Recommended treatment options for localized prostate cancer, including active surveillance, are based on clinical stage, pathologic grade, prostate-specific antigen level, and comorbidity-adjusted life expectancy.

C

15

Radical prostatectomy or external beam radiation therapy should be considered for patients with high-risk localized prostate cancer regardless of comorbidity-adjusted life expectancy.

C

15

Brachytherapy is an option for patients with low-risk or intermediate-risk prostate cancer.

B

15, 26

Active surveillance is an option for patients with low-risk or very low-risk prostate cancer.

C

8, 15, 34


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

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BEST PRACTICES IN UROLOGY

Recommendations from the Choosing Wisely Campaign
RecommendationSponsoring organization

Do not initiate management of low-risk prostate cancer without discussing active surveillance.

American Society for Radiation Oncology

Do not obtain a computed tomography scan of the pelvis for asymptomatic men with low-risk

The Authors

show all author info

STEPHEN BRAWLEY, MD, PhD, is an assistant professor in the Department of Family Medicine at Eastern Virginia Medical School, Portsmouth....

RAVINDER MOHAN, MD, PhD, is an associate professor in the Department of Family Medicine at Eastern Virginia Medical School.

CHRISTOPHER D. NEIN, MD, is a second-year resident in the Department of Family Medicine at Eastern Virginia Medical School.

Address correspondence to Stephen Brawley, MD, PhD, Eastern Virginia Medical School, 3640 High St., Portsmouth, VA 23707 (e-mail: brawlesc@evms.edu). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

References

show all references

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