Initial Treatment of Prostate Cancer, by Stage and Risk Group

The stage of your cancer is one of the most important factors in choosing the best way to treat it. Prostate cancer is staged based on the extent (how much the cancer has spread) of the cancer (using T, N, and M categories) and the PSA level and Gleason score (Grade Group) when it is first diagnosed.

For prostate cancers that haven't spread (stages I to III), doctors also use risk groups (based on how far the prostate tumor has grown, PSA level, grade group, and prostate biopsy results) to help determine if more tests should be done and to help guide treatment options. Risk groups range from very-low-risk to very-high-risk, with cancers in the lower risk groups having a smaller chance of growing and spreading compared to those in higher risk groups.

Other factors, such as your age, overall health, life expectancy, and personal preferences are also taken into account when looking at treatment options. In fact, many doctors determine a man’s possible treatment options based not just on the stage, but on the risk of cancer coming back (recurrence) after the initial treatment and on the man’s life expectancy.

You might want to ask your doctor what factors he or she is considering when discussing your treatment options. Some doctors might recommend options that are different from those listed here.Taking part in a clinical trial of newer treatments is also an option for many men with prostate cancer.

Very-low-risk group

For men in this group without any other serious health problems that may limit their lifespan, active surveillance is often recommended because these tumors are unlikely to harm the patient, while radiation and surgery can have side effects that can change a man’s quality of life.

For men who wish to start treatment, radiation therapy (external beam or brachytherapy) or radical prostatectomy may be options.

For men who have medical problems that might shorten their lifespan, observation is another possibility. 

Low-risk group

Most men whose prostate cancers are in the low-risk group and who don’t have serious health issues will be offered active surveillance since very few of these cancers will spread to distant sites. Other options, depending on your preferences, include radiation therapy (external beam or brachytherapy) or radical prostatectomy. If the findings after surgery show that the cancer has features that make it more likely to come back, then the following treatments might be considered:

• External beam radiation to the prostate bed (the area where the prostate gland used to rest before it was removed) with or without androgen deprivation therapy (ADT) OR
• Close follow-up of the PSA levels with the plan to consider radiation treatment when the PSA level starts to go up.

Observation is often a good option for men whose cancer is not causing any symptoms and who have other serious health problems. 

Intermediate-risk group

Radiation therapy (external beam or brachytherapy), often with ADT, is an option for men in this group.

A radical prostatectomy with pelvic lymph node dissection (PLND) is also an option. Depending on the findings from surgery, treatments that might be discussed include:

• External beam radiation therapy with or without ADT if the cancer is found in the lymph nodes or if it has features that make it more likely to come back (recur)
• Close follow-up of the PSA level with the plan to consider radiation treatment when the PSA level starts to rise.

Active surveillance is an option for people in this group whose cancers have favorable features. But people with intermediate-risk prostate cancers with favorable features that are under active surveillance should keep in mind that there is a slightly higher risk of the cancer spreading compared to getting radiation treatment or radical prostatectomy with PLND as the initial therapy.

Men who have other serious medical problems may choose less aggressive treatment such as radiation alone or observation.

High-risk group

People with cancer in this group might be offered:

• Radiation therapy (external beam with brachytherapy OR external beam radiation alone) along with ADT for 1 to 3 years.
• Radical prostatectomy with PLND. If cancer is found in the lymph nodes taken during surgery or if it has features that make it more likely to come back (recur), ADT with or without radiation might be recommended. In some cases, instead of radiation or ADT therapy, watching the PSA closely after surgery might be considered with the plan to consider ADT with or without radiation treatment when the PSA level rises.

For men with other serious health problems and symptoms from their prostate cancer, ADT alone might be a good choice. For men with no symptoms from the cancer and who have major health issues, ADT alone, external beam radiation therapy alone, or observation are options.

Very-high-risk group

Treatment options for people in this group include:

• External beam radiation therapy (with or without brachytherapy) along with ADT for 1 to 3 years. Sometimes, the chemotherapy drug docetaxel or the hormone drug abiraterone might be added to radiation plus ADT.
• Radical prostatectomy with PLND (especially for younger men). If cancer is found in the lymph nodes taken during surgery, ADT with or without external beam radiation treatment might be given. Radiation therapy with or without ADT might be recommended if the cancer is not found in the lymph nodes but does have features that make it more likely to come back (recur). In some cases, instead of radiation or ADT therapy, watching the PSA level closely after surgery might be done with the plan to consider ADT with or without radiation treatment when the PSA level rises.

For men with no symptoms from the cancer but who have major health issues, treatment options include ADT alone, external beam radiation therapy alone, or observation.

Stage IVA

Stage IVA cancers have spread to nearby lymph nodes but not to distant sites. For men who are healthy enough to get treatment or have symptoms from the cancer, options include:

• External beam radiation treatment with ADT(with or without abiraterone)
• ADT with or without abiraterone
• Radical prostatectomy with PLND. If cancer is found in the lymph nodes taken during surgery or it has features that make it more likely to come back (recur), ADT with or without external beam radiation treatment might be given. In some cases, instead of radiation or ADT therapy, watching the PSA closely after surgery might be done with the plan to consider ADT with or without radiation treatment when the PSA level starts to go up.

For men with Stage IVA cancer without symptoms or with other serious health problems, observation or ADT alone might be recommended.

Stage IVB

Stage IVB cancers have spread to distant organs such as the bones. Most stage IVB cancers can’t be cured, but are treatable. The goals of treatment are to keep the cancer under control for as long as possible and to improve a man’s quality of life.

Initial treatment options may include:

• ADT with abiraterone
• ADT with apalutamide
• ADT with chemotherapy, specifically docetaxel
• ADT with enzalutamide
• ADT with external beam radiation to the tumor in the prostate
• ADT alone
• Surgery (TURP) to relieve symptoms such as bleeding or urinary obstruction
• Treatments aimed at painful bone metastases, such as external radiation
• Denosumab (Xgeva), a bisphosphonate like zoledronic acid (Zometa), external radiation aimed at bones, or a radiopharmaceutical such as radium-223, strontium-89, or samarium-153
• Observation (for those who are older or have other serious health issues and do not have major symptoms from the cancer)
• Taking part in a clinical trial of newer treatments

Treatment of stage IV prostate cancer may also include treatments to help prevent or relieve symptoms such as pain from bone metastases with drugs like denosumab (Xgeva), a bisphosphonate like zoledronic acid (Zometa), or a radiopharmaceutical such as radium-223, strontium-89, or samarium-153.

The options above are for the initial treatment of prostate cancer at different risk groups and stages. But if these treatments aren’t working (the cancer continues to grow and spread) or if the cancer comes back, other treatments might be used, such as immunotherapy or chemotherapy. (See Treating Prostate Cancer That Doesn’t Go Away or Comes Back After Treatment.)