Localised prostate cancer, intermediate risk: the decisions you may face
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.
Favourable intermediate risk
Radical prostatectomy, external beam radiotherapy (moderate or ultra-hypofractionated) or brachytherapy alone; active surveillance for selected men with low volume Grade Group 2 disease.
Surgeons operate through small incisions using robotic arms with tremor-free precision and 3D vision.
- Precision, shorter stay
- Enables complex minimally invasive resections
Fewer, larger daily doses instead of the classic five to seven weeks of small ones. Large trials in breast and prostate cancer showed the same control with the same or fewer late effects and far less time in hospital.
- One to three weeks instead of five to seven
- Same cancer control in randomised trials
- Frees machine capacity
Stereotactic body radiotherapy converges multiple beams with sub-millimetre accuracy to deliver tumour-destroying doses in one to five outpatient sessions, doing the job of surgery for inoperable early lung cancer and for metastases in liver, spine and brain. Tumour size and location limit its use, and late toxicity is a concern near the central airways.
- Ablative doses with minimal recovery
- Outpatient
Brachytherapy places a radioactive source directly inside or next to the tumour.
- Highest conformality
- Short treatment
For low-risk prostate cancer, monitoring with PSA, MRI, and repeat biopsy instead of treating, because most such cancers never cause harm.
- Avoids incontinence and erectile dysfunction of treatment in men who would never be harmed
- Level-1 evidence of safety (ProtecT)
- Localised prostate cancer: 60 Gy in 20 fractions or 57 Gy in 19 versus 74 Gy in 37 fractions, all with IMRT
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 biochemical or clinical failure-free survival 90.6% (60 Gy in 20) vs 88.3% (74 Gy in 37), non-inferior.
Biochemical or clinical failure-free survival at 5 years (%): 60 Gy in 20 fractions 90.6 (n=1074) vs 74 Gy in 37 fractions 88.3 (n=1065) - Low- and intermediate-risk prostate cancer: stereotactic body radiotherapy in five fractions versus conventional or moderately hypofractionated radiotherapy
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 biochemical or clinical failure-free 95.8% (SBRT) vs 94.6% (conventional), non-inferior.
Freedom from biochemical or clinical failure at 5 years (%): SBRT 36.25 Gy in 5 95.8 (n=433) vs Conventional radiotherapy 94.6 (n=441)
- Cost
- Loss of haptic feedback
- Not superior for every indication
- Long-term follow-up still accruing for the shortest schedules
- Not suitable where large volumes of normal tissue are treated
- Requires precise setup
- Size and location limits
- Late toxicity near central airways
- Invasive
- Declining expertise in some regions
- Anxiety and adherence
- Repeat biopsies
- Under-used outside high-income countries
- Between Robotic & minimally invasive surgery, Hypofractionated radiotherapy, SBRT / SABR (stereotactic radiotherapy) 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.
- 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.
- How closely do I match the people in CHHiP and PACE-B, 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.
- 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.
- 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.
- For my situation (favourable intermediate risk), which of the standard options do you recommend and why?Why: Guideline options include: Radical prostatectomy, external beam radiotherapy (moderate or ultra-hypofractionated) or brachytherapy alone; active surveillance for selected men with low volume Grade Group 2 disease.
- How do the results of CHHiP and PACE-B 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.
Unfavourable intermediate risk
Radical prostatectomy with pelvic lymph node dissection, or external beam radiotherapy with four to six months of androgen deprivation, or external beam plus brachytherapy boost.
Surgeons operate through small incisions using robotic arms with tremor-free precision and 3D vision.
- Precision, shorter stay
- Enables complex minimally invasive resections
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 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.
Brachytherapy places a radioactive source directly inside or next to the tumour.
- Highest conformality
- Short treatment
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
- 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)
- Cost
- Loss of haptic feedback
- Not superior for every indication
- Metabolic and bone toxicity; castration resistance inevitable in metastatic disease
- Invasive
- Declining expertise in some regions
- Low-dose bath to normal tissue
- Motion management
- Between Robotic & minimally invasive surgery, 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.
- 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.
- 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.
- 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.
- 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.
- For my situation (unfavourable intermediate risk), which of the standard options do you recommend and why?Why: Guideline options include: Radical prostatectomy with pelvic lymph node dissection, or external beam radiotherapy with four to six months of androgen deprivation, or external beam plus brachytherapy boost.
- Am I a candidate for Leuprolide (leuprorelin) and GnRH agonists, and what side effects should I expect?Why: Knowing the expected toxicities helps you plan work, family, and supportive care.
- 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.
Deciding on hormone therapy
ArteraAI Prostate predicts benefit from short-course androgen deprivation with radiotherapy; Decipher stratifies risk.
The first AI tool cleared by the FDA to predict both prognosis and treatment benefit from a routine biopsy slide, in prostate cancer.
A 22-gene test on the biopsy or surgical specimen that predicts spread and death, used to decide on surveillance or adding hormone therapy.
Scanning microscope slides and letting software measure things a pathologist cannot see, including predictions of who will benefit from a treatment.
- Cheap biomarker from routine slides
- Consistent scoring (Ki-67, TILs, HER2)
No trial record is attached to this row yet. The trials tab lists what is recruiting and the landmark trials for this cancer.
- Scanner and stain domain shift
- Explainability
- Regulatory pathways for updates
- Between ArteraAI Prostate, Decipher Prostate and Digital pathology & AI, 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.
- 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.
- 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.
- For my situation (deciding on hormone therapy), which of the standard options do you recommend and why?Why: Guideline options include: ArteraAI Prostate predicts benefit from short-course androgen deprivation with radiotherapy; Decipher stratifies risk.
- Am I a candidate for ArteraAI Prostate, Decipher Prostate, and what side effects should I expect?Why: Knowing the expected toxicities helps you plan work, family, and supportive care.
Add these to your appointment list, or take the full question set for this cancer.