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Living with cancer·Standard of care

Localised prostate cancer, very low and low 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.

Early / localised

Very low and low risk, preferred

2 options

Active surveillance with PSA every six months, MRI and repeat biopsy; treatment only on progression to Grade Group 2 or more.

Guideline
NCCN Guidelines: Prostate Cancer
The options, in plain words
Active surveillanceStandard of care

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)
Multiparametric prostate MRI (PI-RADS)Standard of care

Multiparametric prostate MRI combines three scan sequences, scored 1 to 5 under PI-RADS, and is done before a first biopsy in men with a raised PSA. Needles go to suspicious areas and men with a negative scan can often avoid biopsy altogether, but about one in ten clinically significant cancers is missed.

  • Fewer and better-targeted biopsies
  • Reduces overdiagnosis
Also referenced:PSA (prostate-specific antigen)Gleason score / Grade Group
The evidence behind it
  • ProtecTPhase 3NCT0204417220161,643 peopleevidence 64
    Tests Active surveillance
    PSA-detected localised prostate cancer: active monitoring vs prostatectomy vs 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.

    • 15-year prostate-cancer mortality 3.1% (monitoring), 2.2% (surgery), 2.9% (radiotherapy); no significant difference.
    Prostate-cancer-specific mortality at 15 years (%): Active monitoring 3.1 (n=545) vs Prostatectomy 2.2 (n=553) vs Radiotherapy 2.9 (n=545) · source
The main trade-offs on record
Active surveillance
  • Anxiety and adherence
  • Repeat biopsies
  • Under-used outside high-income countries
Multiparametric prostate MRI (PI-RADS)
  • Reader variability
  • Misses ~10% of significant cancers
Questions to ask about this decision
  1. Between Active surveillance and Multiparametric prostate MRI (PI-RADS), 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 ProtecT, 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 low and low risk, preferred), which of the standard options do you recommend and why?
    Why: Guideline options include: Active surveillance with PSA every six months, MRI and repeat biopsy; treatment only on progression to Grade Group 2 or more.
  7. How do the results of ProtecT 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

Low risk, men who prefer treatment

4 options

Radical prostatectomy, moderately hypofractionated external beam radiotherapy, five-fraction stereotactic radiotherapy or brachytherapy, without hormone therapy.

Guideline
NCCN Guidelines: Prostate Cancer
The options, in plain words
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
Hypofractionated radiotherapyEstablished

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
SBRT / SABR (stereotactic radiotherapy)Standard of care

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
BrachytherapyStandard of care

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

  • Highest conformality
  • Short treatment
The evidence behind it
  • CHHiPPhase 320163,216 peopleevidence 71
    Tests Hypofractionated radiotherapy
    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)
  • PACE-BPhase 3NCT015842582024874 peopleevidence 68
    Tests Hypofractionated radiotherapy, SBRT / SABR (stereotactic radiotherapy)
    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)
The main trade-offs on record
Robotic & minimally invasive surgery
  • Cost
  • Loss of haptic feedback
  • Not superior for every indication
Hypofractionated radiotherapy
  • Long-term follow-up still accruing for the shortest schedules
  • Not suitable where large volumes of normal tissue are treated
  • Requires precise setup
SBRT / SABR (stereotactic radiotherapy)
  • Size and location limits
  • Late toxicity near central airways
Brachytherapy
  • Invasive
  • Declining expertise in some regions
Questions to ask about this decision
  1. 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.
  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 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.
  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 (low risk, men who prefer treatment), which of the standard options do you recommend and why?
    Why: Guideline options include: Radical prostatectomy, moderately hypofractionated external beam radiotherapy, five-fraction stereotactic radiotherapy or brachytherapy, without hormone therapy.
  7. 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.

3 optionsCompare side by side →

MRI before biopsy and targeted plus systematic cores; genomic classifiers or AI pathology to refine surveillance decisions.

The options, in plain words
Multiparametric prostate MRI (PI-RADS)Standard of care

Multiparametric prostate MRI combines three scan sequences, scored 1 to 5 under PI-RADS, and is done before a first biopsy in men with a raised PSA. Needles go to suspicious areas and men with a negative scan can often avoid biopsy altogether, but about one in ten clinically significant cancers is missed.

  • Fewer and better-targeted biopsies
  • Reduces overdiagnosis
Decipher ProstateEstablishedGene-expression genomic classifier

A 22-gene test on the biopsy or surgical specimen that predicts spread and death, used to decide on surveillance or adding hormone therapy.

ArteraAI ProstateApprovedAI digital pathology prognostic/predictive test

The first AI tool cleared by the FDA to predict both prognosis and treatment benefit from a routine biopsy slide, in prostate cancer.

The evidence behind it
The main trade-offs on record
Multiparametric prostate MRI (PI-RADS)
  • Reader variability
  • Misses ~10% of significant cancers
Questions to ask about this decision
  1. Between Multiparametric prostate MRI (PI-RADS), Decipher Prostate and ArteraAI Prostate, 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 PRECISION, 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. For my situation (diagnosis), which of the standard options do you recommend and why?
    Why: Guideline options include: MRI before biopsy and targeted plus systematic cores; genomic classifiers or AI pathology to refine surveillance decisions.
  6. Am I a candidate for Decipher Prostate, ArteraAI Prostate, and what side effects should I expect?
    Why: Knowing the expected toxicities helps you plan work, family, and supportive care.
  7. How do the results of PRECISION 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.

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.