Prostate Cancer Treatment by Stage: From Watchful Waiting to Surgery

Yes, that's correct. Orchidectomy is a cost-effective, one-time procedure, and increasingly patients in developing countries are also getting health insurance that covers the ongoing medications, so when it comes to overall treatment, orchidectomy can even be considered superior in efficacy compared to injectable treatment, and there's no harm in doing it. However, losing a testicle is a point of real psychological impact for a man, so if a patient can afford it or the treatment is available, I would suggest androgen deprivation therapy via injections or medication as preferable — orchidectomy remains a well-suited procedure specifically for patients with stage 4 disease.

What you're describing is the androgen depletion syndrome — you have abolished testosterone, so the patient develops post-menopausal-type symptoms. In our practice, for patients who have undergone androgen deprivation, we educate them not to panic, start gabapentin and sometimes an anti-anxiety medication, and for central obesity and related issues advise calcium and vitamin D supplements, a high-protein, low-fat diet, regular exercise, and sunlight exposure, since bones become fragile and there is increased risk of coronary artery disease and hypertension. We sometimes also use denosumab if the patient is very incapacitated by hot flashes and sweating. You did the right thing for your patient — surgical castration is the most practical option where injectable androgen analogues or antagonists aren't reliably available.

False positivity of PSA is very common, so I would follow this patient regularly, first checking for infection. I would repeat the PSA after 6 weeks — if the high PSA was due to infection, a course of antibiotics should show a downward trend by then; if it doesn't trend down, you should have a high suspicion of prostate cancer. You can also check the free-to-total PSA ratio — if it's less than 25%, that supports the diagnosis. If the DRE is normal and there's no biopsy facility, you can follow the patient for a year and check PSA velocity — if it goes beyond 0.75 per year, refer to a centre with TRUS-guided biopsy or MRI facilities. With a PSA of 10-20, there is roughly a 10-30% chance of harbouring prostate cancer, so this should be investigated further rather than dismissed.

This is a sign of chronic prostatitis — patients with chronic infection in the prostate get calcium deposited in the glandular secretions over time, which is the mechanism behind the calcification. If the patient is asymptomatic and PSA is normal, I would not worry. If symptomatic, try medical management first, and only if that fails should you consider a surgical procedure. Prostatic calcification itself does not cause any harm — it is simply a telltale sign of chronic infection in the prostate.

In our country this facility is not widespread and is not yet widely accepted by the urology community here, though it is practised in the West by urologists, medical oncologists, and interventional radiologists. I would add that prostate cancer is usually slow-growing, but the prostate also has BPH growing alongside it, and patients with even locally advanced or oligometastatic disease often die from the obstructive mass effect of the prostate on the bladder neck and ureters rather than from the cancer itself — which is why, as a surgeon, I usually still consult even locally advanced or oligometastatic candidates for robotic radical prostatectomy, aiming for clear margins, early continence, and preserved erectile function.

A well-differentiated, low-grade tumour with a Gleason score of 3+3 in a younger patient can be managed with watchful waiting, or, after proper counselling, with robotic radical prostatectomy, brachytherapy or radiotherapy.

Stage 2 disease, with a higher Gleason score of 3+4 or 4+3, is generally treated directly with radiotherapy or radical prostatectomy rather than the more conservative brachytherapy option.

For stage 3 and locally advanced stage 4 disease, robotic radical prostatectomy is now commonly used because these patients face two distinct challenges: the cancer itself and the mechanical obstruction the enlarged prostate can cause as they grow older.

In a select group of younger patients with oligometastatic disease, meaning at least three spots of bone metastasis, a multimodality approach combining surgery, focused radiation and hormonal therapy is used to achieve the best possible results.