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Living with cancer·Standard of care

Localised prostate cancer, high and very high risk: the decisions you may face

Cancer page →Second-opinion finder →

3 treatment settings, 3 with more than one named option. Each section lays out the options the standard of care names, what each is for, the trials behind them with their recorded results, the side effects and cautions on record, and questions to ask. Built from the cancer page's standard-of-care rows; nothing here is advice for your case.

7 optionsCompare side by side →

External beam radiotherapy to prostate and pelvic nodes with 18 to 36 months of androgen deprivation, with or without brachytherapy boost; or radical prostatectomy with extended lymph node dissection.

Guideline
NCCN Guidelines: Prostate Cancer
The options, in plain words
IMRT / IGRT (modern external beam)Standard of care

IMRT and IGRT shape the radiation beam to the tumour's outline from multiple angles and check the patient's position with a scan before every session, so surrounding organs receive less dose. Fewer, larger doses are now standard in breast and prostate cancer, but a low-dose bath still spreads across normal tissue.

  • Conformal dose, fewer side effects
  • Hypofractionation saves visits
Androgen deprivation & AR pathway inhibitorsStandard of care

Androgen deprivation lowers testosterone or blocks its receptor, and has been the foundation of prostate cancer treatment since 1941 (Nobel Prize 1966).

  • Prolonged disease control
Leuprolide (leuprorelin) and GnRH agonistsApprovedGnRH agonist depot

Leuprolide is the injectable that shuts off testosterone production, the foundation of hormone therapy for prostate cancer since the 1980s; it is also used for ovarian suppression in premenopausal breast cancer.

DegarelixApprovedGnRH antagonist depot

An injectable hormone blocker for prostate cancer that lowers testosterone within days without the initial surge caused by agonists.

RelugolixApprovedOral GnRH antagonist

Relugolix is the first hormone-suppressing pill for prostate cancer, working within days and wearing off quickly when stopped.

BrachytherapyStandard of care

Brachytherapy places a radioactive source directly inside or next to the tumour.

  • Highest conformality
  • Short treatment
Robotic & minimally invasive surgeryStandard of care

Surgeons operate through small incisions using robotic arms with tremor-free precision and 3D vision.

  • Precision, shorter stay
  • Enables complex minimally invasive resections
The evidence behind it
  • HYPO-RT-PCPhase 320191,200 peopleevidence 68
    Intermediate- and high-risk prostate cancer: 42.7 Gy in seven fractions over two and a half weeks versus 78 Gy in 39 fractions
    Show survival figures (1)

    Averages across everyone diagnosed, often years ago. Your stage, subtype, age, fitness and the treatment you receive matter more than the average, and the numbers are improving quickly.

    • 5-year failure-free survival 84% in both arms, non-inferior.
    Failure-free survival at 5 years (%): 42.7 Gy in 7 fractions 84 (n=598) vs 78 Gy in 39 fractions 84 (n=602)
The main trade-offs on record
IMRT / IGRT (modern external beam)
  • Low-dose bath to normal tissue
  • Motion management
Androgen deprivation & AR pathway inhibitors
  • Metabolic and bone toxicity; castration resistance inevitable in metastatic disease
Brachytherapy
  • Invasive
  • Declining expertise in some regions
Robotic & minimally invasive surgery
  • Cost
  • Loss of haptic feedback
  • Not superior for every indication
Questions to ask about this decision
  1. Between IMRT / IGRT (modern external beam), Androgen deprivation & AR pathway inhibitors, Leuprolide (leuprorelin) and GnRH agonists and the other options, which do you recommend for me, and what about my case would make you choose differently?
    Why: Guidelines list several reasonable options; the choice turns on details of your tumour, your health and your priorities.
  2. What is each option trying to achieve: cure, long control, or relief of symptoms, and over what time?
    Why: The aim shapes how much side effect and disruption is worth accepting.
  3. How closely do I match the people in HYPO-RT-PC, and does that change what the results mean for me?
    Why: Trial populations are selected; age, fitness, prior treatment and biomarkers all affect how far results carry.
  4. What happens if I delay, or decline this step for now? Is the decision reversible?
    Why: Some decisions can wait for a second opinion or a trial slot; others cannot. Knowing which is part of the choice.
  5. Does your recommendation follow the current guideline (NCCN Guidelines: Prostate Cancer), and if it departs from it, why?
    Why: Departures from guidelines are sometimes right for an individual; they should be explained.
  6. For my situation (high risk), which of the standard options do you recommend and why?
    Why: Guideline options include: External beam radiotherapy to prostate and pelvic nodes with 18 to 36 months of androgen deprivation, with or without brachytherapy boost; or radical prostatectomy with extended lymph node dissection.
  7. Am I a candidate for Leuprolide (leuprorelin) and GnRH agonists, Degarelix, Relugolix, and what side effects should I expect?
    Why: Knowing the expected toxicities helps you plan work, family, and supportive care.
  8. How do the results of HYPO-RT-PC apply to someone like me?
    Why: Trial populations differ from individual patients; ask how closely you match.

Add these to your appointment list, or take the full question set for this cancer.

Early / localised

Very high risk and node-positive

2 options

Radiotherapy plus androgen deprivation with two years of abiraterone (STAMPEDE); PSMA PET staging before treatment.

Guideline
NCCN Guidelines: Prostate Cancer
The options, in plain words
Abiraterone acetateApprovedSmall-molecule CYP17A1 inhibitor

Abiraterone is a pill that shuts down testosterone production everywhere, including inside the tumour. Discovered at the Institute of Cancer Research, now generic and used from the first metastatic diagnosis.

PSMA PETStandard of care

A prostate-cancer-specific PET scan that finds spread far earlier than CT or bone scan, and tells you whether a matched radioactive drug will work.

  • Detects recurrence at PSA <0.5 ng/mL
  • Theranostic gatekeeper
The evidence behind it
  • STAMPEDEPhase platformNCT00268476201611,992 peopleevidence 80
    Tests Abiraterone acetate
    Multi-arm multi-stage platform in men starting long-term hormone therapy for high-risk locally advanced or metastatic prostate cancer: docetaxel, zoledronic acid, celecoxib, abiraterone, radiotherapy to the prostate, abiraterone with enzalutamide, metformin and transdermal oestradiol added to ADT and compared with ADT alone

    Abiraterone + ADT: OS HR 0.63 in mHSPC; docetaxel + ADT: OS HR 0.78. Prostate radiotherapy improved survival in low-volume metastatic disease; abiraterone improved survival in high-risk non-metastatic disease; enzalutamide added to abiraterone, zoledronic acid, celecoxib and metformin did not improve survival.

  • proPSMAPhase 3ANZCTR126170000053582020302 peopleevidence 75
    Tests PSMA PET
    High-risk localised prostate cancer staging: PSMA PET/CT vs CT + bone scan

    Accuracy 92% vs 65%.

    Accuracy for pelvic nodal or distant metastases (AUC) (%): PSMA PET/CT 92 (n=150) vs CT + bone scan 65 (n=152) · source
The main trade-offs on record
Abiraterone acetateall recorded rates →
  • Take on an empty stomach: food raises exposure up to tenfold and increases toxicity. Prednisone 5 mg covers mineralocorticoid excess.
  • Reduce to 250 mg daily in moderate impairment; avoid in severe.
PSMA PET
  • PSMA-negative disease in ~10%
  • Uptake in ganglia, salivary glands
Questions to ask about this decision
  1. Between Abiraterone acetate and PSMA PET, which do you recommend for me, and what about my case would make you choose differently?
    Why: Guidelines list several reasonable options; the choice turns on details of your tumour, your health and your priorities.
  2. What is each option trying to achieve: cure, long control, or relief of symptoms, and over what time?
    Why: The aim shapes how much side effect and disruption is worth accepting.
  3. How closely do I match the people in STAMPEDE and proPSMA, and does that change what the results mean for me?
    Why: Trial populations are selected; age, fitness, prior treatment and biomarkers all affect how far results carry.
  4. What happens if I delay, or decline this step for now? Is the decision reversible?
    Why: Some decisions can wait for a second opinion or a trial slot; others cannot. Knowing which is part of the choice.
  5. Does your recommendation follow the current guideline (NCCN Guidelines: Prostate Cancer), and if it departs from it, why?
    Why: Departures from guidelines are sometimes right for an individual; they should be explained.
  6. For my situation (very high risk and node-positive), which of the standard options do you recommend and why?
    Why: Guideline options include: Radiotherapy plus androgen deprivation with two years of abiraterone (STAMPEDE); PSMA PET staging before treatment.
  7. Am I a candidate for Abiraterone acetate, and what side effects should I expect?
    Why: Knowing the expected toxicities helps you plan work, family, and supportive care.
  8. How do the results of STAMPEDE and proPSMA apply to someone like me?
    Why: Trial populations differ from individual patients; ask how closely you match.

Add these to your appointment list, or take the full question set for this cancer.

Other settings

After prostatectomy with adverse pathology

2 options

Adjuvant or early salvage radiotherapy guided by PSA, with hormone therapy for higher-risk features.

The options, in plain words
IMRT / IGRT (modern external beam)Standard of care

IMRT and IGRT shape the radiation beam to the tumour's outline from multiple angles and check the patient's position with a scan before every session, so surrounding organs receive less dose. Fewer, larger doses are now standard in breast and prostate cancer, but a low-dose bath still spreads across normal tissue.

  • Conformal dose, fewer side effects
  • Hypofractionation saves visits
Androgen deprivation & AR pathway inhibitorsStandard of care

Androgen deprivation lowers testosterone or blocks its receptor, and has been the foundation of prostate cancer treatment since 1941 (Nobel Prize 1966).

  • Prolonged disease control
Also referenced:PSA (prostate-specific antigen)Biochemical recurrence (BCR)
The evidence behind it

No trial record is attached to this row yet. The trials tab lists what is recruiting and the landmark trials for this cancer.

The main trade-offs on record
IMRT / IGRT (modern external beam)
  • Low-dose bath to normal tissue
  • Motion management
Androgen deprivation & AR pathway inhibitors
  • Metabolic and bone toxicity; castration resistance inevitable in metastatic disease
Questions to ask about this decision
  1. Between IMRT / IGRT (modern external beam) and Androgen deprivation & AR pathway inhibitors, which do you recommend for me, and what about my case would make you choose differently?
    Why: Guidelines list several reasonable options; the choice turns on details of your tumour, your health and your priorities.
  2. What is each option trying to achieve: cure, long control, or relief of symptoms, and over what time?
    Why: The aim shapes how much side effect and disruption is worth accepting.
  3. What happens if I delay, or decline this step for now? Is the decision reversible?
    Why: Some decisions can wait for a second opinion or a trial slot; others cannot. Knowing which is part of the choice.
  4. For my situation (after prostatectomy with adverse pathology), which of the standard options do you recommend and why?
    Why: Guideline options include: Adjuvant or early salvage radiotherapy guided by PSA, with hormone therapy for higher-risk features.

Add these to your appointment list, or take the full question set for this cancer.

How to read this page. Options and results come from OnCo records with their sources; the settings are the standard-of-care rows on the cancer page, and the lines of therapy are on the sequencing grid. Where a setting names one path, the choice is usually about timing, trials and where to be treated: see expert centres. OnCo is orientation, not medical advice.