Senior Director & Unit Head, Urology, Kidney Transplant, Uro-Oncology, Robotic Surgery, Max Hospital, Gurugram
Part 8 of 11 in Prostate Cancer: Diagnosis and Management
Choosing a Treatment: Risk-Based Options From Active Surveillance to Surgery
September 6, 2026
Dr. Amit Goel called prostate cancer treatment planning one of the more difficult exercises in oncology, precisely because so many variables have to be weighed together: the stage of disease, the patient's age and life expectancy, the biopsy and Gleason score, and the patient's individual risk factors. There is no single answer that applies to every diagnosis.
Risk Categorisation Comes First
Before choosing a treatment, Dr. Goel's team runs a formal risk assessment, using tools such as the D'Amico risk scheme or the CAPRA score, which factor in age, PSA at diagnosis, Gleason score, clinical stage and the proportion of positive biopsy cores. That score sorts a patient into low, intermediate or high-risk disease, and the treatment options that follow differ meaningfully by category.
What the Evidence Shows
For low-risk, localised disease, randomised trials show radiotherapy and surgery produce broadly equal disease-free and overall survival, so either is a reasonable choice. For intermediate or higher-risk localised disease, surgery has the edge: a recent meta-analysis comparing radical prostatectomy against radiotherapy for high-risk disease found similar cancer-specific survival between the two, but a clear overall survival advantage for surgery. Patients with locally advanced or metastatic disease start on androgen deprivation therapy, moving to further hormonal, chemotherapy or bone-directed treatment as the disease progresses.
Managing Bone Disease and Comorbidities
For patients with advanced disease and bone involvement, treatment expands to painkillers, steroids and bone-strengthening therapy. Dr. Goel singled out lutetium-177 PSMA radioligand therapy as an option that works well even in patients with significant comorbidities and widespread, painful bone metastasis, where more invasive options aren't practical.
This article is based on a Jivo Masterclass session conducted by Dr. Amit Goel, Director and Head of Unit, Renal Transplant, Uro-oncology, Urology and Robotic Surgery, Max Hospital, Gurugram, India. The article has been summarised with the assistance of an AI tool from the original masterclass recording. Watch the full Masterclass recording
This guide is based on a live Jivo Masterclass: Dr. Amit Goel taught doctors across Africa on April 20, 2025.
FROM THE LIVE Q&A
Moderator
What is the management of metastatic prostate cancer?
Dr. Amit Goel
It depends on where the metastasis is. Bilateral orchidectomy is still a valid option for patients who don't want to spend money on ongoing hormone injections, and it works about as well as hormone therapy. For bone metastasis with pain or fracture risk, bone-strengthening injections and radiotherapy to the affected bone are added. Once the disease becomes castration-resistant, treatment moves to stronger anti-androgens such as abiraterone or enzalutamide, chemotherapy for visceral metastasis, and increasingly immunotherapy.
Frequently Asked Questions
What are the survival chances after surgical treatment for a patient with prostate adenocarcinoma, and is there a possibility of recurrence?▼
Surgery is offered specifically in patients where the goal is cure. But every patient needs lifelong follow-up, with PSA testing every three to six months, because recurrence can and does happen. Nobody can promise a patient that surgery guarantees no recurrence. That possibility is exactly what the word cancer is telling us.
What is the average cost of robotic surgery for prostate cancer?▼
Approximately 8,700 US dollars, which is the total cost of the robotic surgery.
What is the management of metastatic prostate cancer?▼
It depends on where the metastasis is. Bilateral orchidectomy is still a valid option for patients who don't want to spend money on ongoing hormone injections, and it works about as well as hormone therapy. For bone metastasis with pain or fracture risk, bone-strengthening injections and radiotherapy to the affected bone are added. Once the disease becomes castration-resistant, treatment moves to stronger anti-androgens such as abiraterone or enzalutamide, chemotherapy for visceral metastasis, and increasingly immunotherapy.
How is a patient's prostate cancer risk category decided?▼
Tools such as the D'Amico risk scheme or CAPRA score combine age, PSA level, Gleason score and clinical stage to sort a diagnosis into low, intermediate or high-risk disease.
Is surgery or radiotherapy better for prostate cancer?▼
For low-risk disease, trials show broadly equal survival between surgery and radiotherapy. For intermediate or high-risk disease, surgery shows a clearer overall survival advantage.
In This Series: Prostate Cancer: Diagnosis and Management
- 1.Diagnosis and Management of Prostate Cancer
- 2.Prostate Cancer Risk Factors and Why Men of African Descent Face the Highest Risk
- 3.Recognizing Prostate Cancer: From Early Symptoms to Advanced and Metastatic Disease
- 4.How Prostate Cancer Is Diagnosed: PSA Testing and Digital Rectal Examination
- 5.Prostate Biopsy: TRUS-Guided and MRI Fusion Techniques
- 6.The Gleason Score: Grading Prostate Cancer and What It Means for Treatment
- 7.Staging Prostate Cancer: TNM Classification and PSMA PET Scans
- 8.Choosing a Treatment: Risk-Based Options From Active Surveillance to Surgery
- 9.Robotic, Laparoscopic and Open Radical Prostatectomy: Comparing the Evidence
- 10.The Retzius-Sparing Technique: Protecting Continence and Erectile Function After Surgery
- 11.Managing Metastatic and Castration-Resistant Prostate Cancer