Prostate cancer staging

Characeristics of low local disease

Means patient is in Gleason group 1 and or PSA <10

local disease low risk

• Less than 10 years left: Observation 

• Greater than 10 years left: Active Surveillance, EBRT, Radiotherapy 

Difference between favorable intermediate and unfavorable intermediate

Favorable risk: Group II, <50 percent biopsy cores positive, PSA between 10-20

Unfavorable risk: Group III, >50% biopsy cores +, PSA between 10-20

local disease intermediate favorable risk

Less than 10 years survival: Observation 

Greater than 10 years survival:

• Active surveillance

• Radiotherapy

• Radical prostatectomy

local disease unfavorable risk

• Less than 10 years survival:

  • Observation

  • radiotherapy + Active surveillance 

• >10 year survival:

  • Radioprosectomy

  • radiotherapy+ androgen deprivation(4-6 months)

Characteristics of local high risk

PSA between 20-40%

local high risk

Observation or Radiotherapy with or without androgen deprivation 

Characteristics of local very high risk

PSA >40

local very high risk

• Radiotherapy + androgen deprivation(12-36 months)→preferred 

• Radiotherapy + androgen deprivation(24 months)+ abiraterone(for very high risk) 

regional disease

<5 years survival: observation

>5 years survival:

• Radiotherapy

• androgen deprivation(24 months)

• abiraterone

Castrate sensitive non-metastatic

Monitoring or AD

castrate sensitive metastatic

• Continue ADT +  Abiraterone

• Enzalutamide or Apalutamide or Darolutamide ± Docetaxel x 6 cycle

Characteristic of castrative resistant

tester one <50ng/mL with disease progression

castrate resistant recurrent

• Androgen deprivation therapy plus

  • PSADT ≤ 10 months: Apalutamide or Darolutamide or Enzalutamide or other secondary therapy

  • PSADT > 10 months: Monitoring or other secondary therapy

castrate resistant metastatic

• Continue ADT plus:

  • Abiraterone (category 1)

  • Darolutamide (category 1)

  • Enzalutamide (category 1)