Prostate Cancer: Treatment by Risk
Once you've classified the risk, treatment follows a logic: low-risk disease is often best NOT treated immediately, while intermediate and high-risk disease are treated with surgery or radiation ± hormones.
The big picture
Once you've classified the risk (previous lesson), treatment follows a logic: low-risk disease is often best NOT treated immediately (active surveillance spares men the harms of overtreatment), while intermediate and high-risk disease are treated with surgery or radiation ± hormones. The whole field turned on realising that many prostate cancers are indolent — so the art is matching the intensity of treatment to the aggressiveness of the cancer and the life expectancy of the man.
The framework: the options (active surveillance, watchful waiting, radical prostatectomy, radiotherapy ± ADT, ADT) → a chooser by risk group + life expectancy → advanced/metastatic disease.
Mechanism pathway
Tap any step to see why it happens.
Interactive — systemic therapy by class (EAU)
Diagnostic algorithm
Each step answers one question. Tap to expand.
Procedure chooser
Active surveillance
FitsMonitoring (PSA, exam, repeat MRI/biopsy) with curative treatment held in reserve if the cancer progresses. Preferred for most low-risk disease to avoid overtreating indolent cancer; may still be appropriate for selected favourable-intermediate men.
Radical prostatectomy (± PLND)
FitsRemove the whole prostate + seminal vesicles (open/laparoscopic/robotic); nerve-sparing where oncologically safe. An option for low/favourable-intermediate men who prefer or are unsuitable for surveillance; definitive for unfavourable-intermediate and high risk (often with pelvic lymph-node dissection in high-risk disease).
Radiotherapy ± ADT
FitsExternal beam (EBRT) or brachytherapy. An option in low/favourable-intermediate disease (± short-course ADT); given with ADT in unfavourable-intermediate and high risk — long-course ADT in high risk. Neoadjuvant/concurrent/adjuvant ADT improves higher-risk RT outcomes.
Watchful waiting
Less intensive observation with palliative intent (no curative treatment planned), for men with limited life expectancy where the cancer is unlikely to threaten them.
Focal therapy — NanoKnife / IRE (investigational)
FitsIrreversible electroporation (NanoKnife) — a NON-thermal focal ablation (short direct-current pulses → permanent membrane nanopores → cell death) that may better spare adjacent neurovascular bundles and the urethra. One of several focal modalities (alongside HIFU and cryotherapy); investigational — needs larger cohorts / longer follow-up, and is not a replacement for radical prostatectomy or radiotherapy in standard practice.
Life expectancy matters: don't aggressively treat a low-threat cancer in a man unlikely to live long enough to benefit. ADT is given with radiotherapy in higher-risk disease (short-course for intermediate, long-course for high). The verbatim guideline KEY is kept in the mechanism card above.
Board traps
Low-risk → active surveillance is preferred (avoid overtreating indolent cancer).
High-risk → aggressive multimodal therapy (RP + PLND, or RT + long-course ADT).
Radiotherapy for intermediate/high risk is given ± ADT (improves higher-risk outcomes).
Life expectancy drives intensity — watchful waiting for low-threat cancer in limited life expectancy.
mHSPC: ADT alone is no longer enough — intensify with ARPI ± docetaxel.
Rising PSA after definitive therapy = biochemical recurrence → restage (PSMA PET) + salvage.
Focal therapy: HIFU and cryotherapy are THERMAL; NanoKnife / irreversible electroporation (IRE) is NON-thermal (short DC pulses → permanent membrane nanopores → cell death) — its theoretical advantage is sparing connective tissue and adjacent structures (nerves, vessels, urethra) → better functional outcomes.
IRE/NanoKnife is focal therapy for selected localized disease and remains investigational (needs larger cohorts / longer follow-up) — not standard of care, not a replacement for RP or radiotherapy.