Intermediate-risk Prostate Cancer: Stratification and Management

Felix Preisser; Matthew R Cooperberg; Juanita Crook; Felix Feng; Markus Graefen; Pierre I Karakiewicz; Laurence Klotz; Rodolfo Montironi; Paul L Nguyen; Anthony V D'Amico

doi:10.1016/j.euo.2020.03.002

Intermediate-risk Prostate Cancer: Stratification and Management

Eur Urol Oncol. 2020 Jun;3(3):270-280. doi: 10.1016/j.euo.2020.03.002. Epub 2020 Apr 14.

Authors

Affiliations

¹ Department of Urology, University Hospital Frankfurt, Frankfurt, Germany. Electronic address: felix.preisser@kgu.de.
² Department of Urology, UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, CA, USA.
³ BCCA Center for the Southern Interior, University of British Columbia, Kelowna, BC, Canada.
⁴ Department of Radiation Oncology, UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, CA, USA.
⁵ Martini-Klinik Prostate Cancer Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany.
⁶ Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montreal Health Center, Montreal, Quebec, Canada.
⁷ Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada.
⁸ Section of Pathological Anatomy, Marche Polytechnic University, School of Medicine, United Hospitals, Ancona, Italy.
⁹ Department of Radiation Oncology, Brigham and Women's Hospital and Dana Farber Cancer Institute, Harvard Medical School, Boston, MA, USA.

PMID: 32303478
DOI: 10.1016/j.euo.2020.03.002

Abstract

Context: Intermediate-risk prostate cancer consists of a highly heterogeneous group of patients. Owing to this heterogeneity and variable prognoses, it is challenging to provide uniform treatment recommendations for men in this group.

Objective: To review the current literature regarding the best available evidence for stratification and treatment of intermediate-risk prostate cancer patients.

Evidence acquisition: We searched Medline and EMBASE, through September 2019 without year or language restriction, supplemented with hand search.

Evidence synthesis: Different treatment options with good long-term oncological outcomes are available for intermediate-risk prostate cancer patients. Best available evidence with long follow-up exists for radical prostatectomy and dose-escalated radiotherapy with short-term androgen deprivation. In favorable intermediate-risk patients, active surveillance and brachy-monotherapy also represent two valid treatment options. In carefully selected men, partial gland ablation represents a reasonable option. Patient preferences and comorbidities should also be considered.

Conclusions: Treatment options for intermediate-risk patients range from active surveillance to partial gland ablation, radical prostatectomy, and various radiotherapy methods. The best stratification and the optimal treatment remain controversial. Classification systems, such as the National Cancer Comprehensive Network guidelines, stratify this large cohort into subgroups with favorable or unfavorable disease, which may simplify treatment recommendations but still leave substantial variability within strata. Advanced imaging may further improve current stratification systems of intermediate-risk patients.

Patient summary: In this review, we assessed the current literature regarding the best available evidence for stratification and treatment of intermediate-risk prostate cancer patients.

Keywords: Active surveillance; Focal therapy; Prostate cancer; Radical prostatectomy; Radiotherapy.

Publication types

Review

MeSH terms

Humans
Male
Prostatic Neoplasms / classification*
Prostatic Neoplasms / pathology
Prostatic Neoplasms / therapy*
Risk Assessment