Prostate Cancer Treatment by Stage, Age and Fitness

Prostate cancer treatment depends on three things: the stage and risk group of the cancer, the man's fitness, and his life expectancy. Early disease is treated with curative intent by robotic radical prostatectomy or radiotherapy. Metastatic disease is suppressed with hormone therapy. Older or frail men with low risk disease and no symptoms may need no active treatment at all.

Dr. Anurag Puri, Additional Director Urology, Fortis Hospital, Shalimar Bagh, New Delhi, India, summarised his approach for international doctors by where the patient "lands up": confined to the prostate, spread locally, spread to the bones, or no longer responding to hormones. Each landing point has its own goal of treatment. This article sets out the options, the categories he uses to choose between them, and how age and frailty change the decision. It belongs to a series introduced by the guide to prostate cancer diagnosis and latest treatment guidelines; how the risk group itself is established is covered in prostate cancer risk stratification.

The treatment options available

Dr. Puri listed the modalities available:

• Watchful waiting: no treatment until symptoms appear, for older men with limited life expectancy.
• Active surveillance: close monitoring of low risk disease with a plan to treat if it progresses.
• Radical prostatectomy: removal of the entire prostate gland, today usually with robotic assistance.
• Radiotherapy: for early disease with curative intent, or as palliation for advanced disease.
• Androgen deprivation therapy (ADT): lowering testosterone, the male hormone on which most prostate cancers depend, either with injections (chemical castration) or by removing both testes (surgical castration, orchidectomy).
• Chemotherapy and newer hormonal agents: for disease that has become resistant to hormone therapy.

Watchful waiting and active surveillance are different strategies

The two terms are often confused, and the difference matters to patients.

Dr. Puri described watchful waiting as the answer to a question put to him before the session: "I'm a 70 or 80 year old person. Is there a treatment for me?" The first step is to see whether the man has symptoms. If he has none and a life expectancy under 10 years, treatment is deferred until symptoms develop. Active surveillance is a different proposition. It is for men with early, low risk disease, and it depends on reliable follow-up. If repeated testing shows the cancer increasing in size or progressing, treatment proceeds; otherwise the man stays under surveillance.

Prostate cancer treatment by stage: five categories

When doctors asked when to choose chemotherapy, radiotherapy, hormone therapy or prostatectomy, Dr. Puri set out five categories of patient, each with a different intent.

1. Early disease confined to the prostate: curative

If the cancer is limited to the prostate, without spread outside the gland, to the lymph nodes or to the bones, the intent is curative. The options are robotic radical prostatectomy or radiotherapy. Radical prostatectomy is mainly indicated for low and intermediate risk disease, and in selected high risk patients.

2. Locally advanced disease: surgery or radiotherapy plus hormones

If the cancer has spread somewhat outside the prostate but not through the body or the lymph nodes, robotic radical prostatectomy or radiotherapy can still be used. Radiotherapy is combined with androgen deprivation therapy; after surgery, hormones are added when the lymph nodes prove positive. Dr. Puri named bicalutamide, an oral anti-androgen, among the agents used alongside other androgen-depriving drugs.

3. Advanced local disease not suitable for surgery: less aggressive treatment

When the cancer has already spread to the surrounding organs and cannot be removed surgically, treatment becomes less aggressive: radiotherapy combined with long-term hormone deprivation.

4. Metastatic disease: suppressive, not curative

When the cancer has spread to the bones, the intent is no longer cure but suppression. Suppression is hormonal, either by surgical orchidectomy, in which both testes are removed, or by hormone-depleting injections given monthly or every three months. In men with urinary obstruction, Dr. Puri also opens the urinary channel so the bladder can empty, alongside the hormone treatment. Current EAU guidelines recommend adding an androgen receptor pathway inhibitor, such as abiraterone or enzalutamide, or docetaxel chemotherapy to hormone therapy for men with metastatic disease who are fit enough to receive them.

5. Hormone-resistant disease: chemotherapy and newer agents

Prostate cancer usually depends on testosterone, which is why lowering testosterone controls it. In some advanced cancers the disease escapes that control and continues to progress even after testosterone has been reduced. This is hormone-resistant prostate cancer, termed castration-resistant prostate cancer in guidelines. For these men, Dr. Puri adds chemotherapy such as docetaxel, or newer oral agents such as abiraterone and enzalutamide, which he described as among the latest advances in the field.

Treatment of advanced and metastatic disease, including newer systemic therapies, is covered in more depth in advanced prostate cancer treatment by Dr. Yajvender Pratap Singh Rana.

Robotic radical prostatectomy: indications and results

Robotic assistance is the main advance in prostate cancer surgery over the open operation that was previously standard. Dr. Puri's rationale is functional: with modern robotic systems, men achieve very good urinary continence, holding urine well after surgery, and may also keep their erections.

Asked which stages robotic surgery is used for, he answered that it is used for low and intermediate risk disease and can be done for high risk disease. In high risk disease the lymph nodes decide. If they are positive, he does not perform radical surgery. If they are negative, he performs robotic surgery together with an extended lymph node dissection, in which a wider field of pelvic lymph nodes is removed for staging and control.

Is prostate surgery safe?

One doctor relayed a common fear that many men die after a prostate operation. Dr. Puri called this a completely misplaced notion. Most prostate operations are done for benign enlargement (BPH); they are now endoscopic, performed through the urethra without an incision, and patients go home with little morbidity. Even for cancer, robotic radical prostatectomy usually requires a hospital stay of about three days, and the patient is typically fit to fly home within two to three weeks without a catheter. For patients considering treatment abroad, indicative costs are listed under robotic radical prostatectomy cost, radiotherapy cost, chemotherapy cost and TURP cost.

Prostate cancer treatment for older men: age is not the only barrier

Several questions concerned older patients, and Dr. Puri's answers form a consistent rule: chronological age matters less than fitness, life expectancy and symptoms.

A fit man in his seventies

Asked which operation is ideal for a 74-year-old man, he replied that age is not the only barrier. If the man has a lower metabolic age, is fit and mobile, has no other medical conditions, has a life expectancy of more than 10 years and has disease limited to the prostate, robotic surgery can still be offered.

A frail older man

If the man is frail, struggles to look after himself and does not have a long life expectancy, treatment is tapered to his needs. If he cannot empty his bladder, the urinary passage is opened up, and hormone ablation is added.

Men over 80

It is not true that men over 80 have no treatment. Dr. Puri's point was different: most men between 80 and 90 carry some focus of prostate cancer, yet most die of other causes, and in many the cancer never becomes a clinical disease. In this age group, treatment is sometimes avoided when the man has no symptoms and the disease is low risk and controlled.

A frail patient who cannot tolerate chemotherapy

A doctor described a very weak, frail man with prostate cancer who could not take chemotherapy and was on no medication. Dr. Puri's advice was to step back. In prostate cancer, chemotherapy is not the first modality but the last. The first is hormone ablation, either with hormone-ablating injections or by orchidectomy. Chemotherapy has its own side effects and can leave a frail man worse than before. The priority is to stage the disease and confirm whether the initial hormonal treatments have been offered, rather than going straight to chemotherapy.

Other options and questions raised

High-intensity focused ultrasound (HIFU)

HIFU, which destroys prostate tissue with focused ultrasound energy, can be offered to men who are unfit for major surgery. Dr. Puri was clear that it is not the standard of care and is not widely used.

Hydrocele during treatment

A hydrocele, a collection of fluid around the testis, is very uncommon in prostate cancer, and Dr. Puri noted that it can arise from malignancy near the testis. While cancer treatment is ongoing and the hydrocele is not large, his advice is to manage it conservatively rather than add a major operation, and to correct it surgically only if it becomes large enough to need symptomatic relief.

Outcomes: what patients can expect

Survival depends on the stage and the risk parameters: the PSA level, the Gleason score and the clinical stage. Dr. Puri described localised, low risk disease as curable with a very good prognosis. Even in metastatic disease, appropriate treatment gives a life expectancy considerably longer than in other cancers at stage four. Every stage requires some form of treatment, and the earlier a man is treated, the better his cure rate and life expectancy.

The questions doctors asked about individual patients during the session are collected on the Live Discussion page, and Dr. Puri's profile is at Dr. Anurag Puri. A detailed account of the robotic operation itself is available in robotic radical prostatectomy: a complete guide, and the wider field is covered on the urology and oncology specialty hubs.