Editing Management of Localized Prostate Cancer (section)

== Treatment by risk stratum==

=== AUA ===

* '''[https://pubmed.ncbi.nlm.nih.gov/23659877/ 2022 AUA Guidelines on Clinically Localized Prostate Cancer]'''
** <span style="color:#ff0000">'''Life expectancy ≤5 years'''</span>
*** '''<span style="color:#ff0000">Watchful waiting should be recommended</span>'''
****Minimum estimated life expectancy of 8-10 years in order for treatment to result in a reduction in the risk of death.
****Watchful waiting is appropriate for elderly patients or patients with significant comorbidities in whom competing risks of mortality are considerably greater than the risk of death from prostate cancer
***Watchful waiting does not involve routine cancer surveillance, but rather aims to deliver palliative therapy for relief of symptoms should they develop.
****The critical goal of watchful waiting is to maintain the patient’s QOL by avoiding treatment when prostate cancer is unlikely to cause mortality or significant morbidity. One of the principal aims of watchful waiting is avoidance of side effects from local treatment or ADT.
**<span style="color:#ff0000">'''Low-risk'''</span>
***'''<span style="color:#ff0000">Active surveillance should be recommended as the preferred management option </span>(Strong Recommendation; Evidence Level: Grade A).'''
****Select patients with low-risk disease may elect definitive local therapy after an informed discussion between clinician and patient. In particular, clinicians may offer immediate treatment to select patients who are fully informed as to all options and risks with low-risk prostate cancer such as those who
*****Have a high probability of disease risk reclassification on active surveillance (e.g., high-volume cancer, higher PSA density) OR
*****Other risk factors for harboring higher-risk disease (e.g., family history of lethal prostate cancer, germline mutation associated with adverse pathology).
****'''Patients electing to proceed with active surveillance should be informed of the importance of regular cancer surveillance to avoid missing the window of curability.'''
**<span style="color:#ff0000">'''Favorable, intermediate-risk'''</span>
***'''<span style="color:#ff0000">Options (3):</span>'''
***#'''<span style="color:#ff0000">Active surveillance</span>'''
***#'''<span style="color:#ff0000">Radical prostatectomy</span>'''
***#'''<span style="color:#ff0000">Radiation therapy (without ADT)</span>'''
***##'''<span style="color:#ff0000">Modalities (3):</span>'''
***###'''Dose-escalated hypofractionated external beam radiotherapy (EBRT) (moderate or ultra hypofractionation)''' 
***###'''Permanent low-dose rate (LDR) seed implant''' 
***###'''Temporary high-dose rate (HDR) prostate implant'''
***'''Patients with favorable intermediate-risk disease who may be considered for active surveillance include those with (3):'''
***#'''Low PSA density'''
***#'''Low tumor volume'''
***#'''Low percentage of Gleason pattern 4 disease on biopsy'''
**<span style="color:#ff0000">'''Unfavorable, intermediate-risk or high-risk AND life expectancy >10 years'''</span>
***'''<span style="color:#ff0000">Options (2):</span>'''
***#'''<span style="color:#ff0000">Radical prostatectomy</span>'''
***#'''<span style="color:#ff0000">Radiation therapy (with ADT)</span>'''
***#* '''<span style="color:#ff0000">Duration of ADT:</span>'''
***#**'''<span style="color:#ff0000">Unfavorable, intermediate-risk: 4-6 months</span>''' 
***#**'''<span style="color:#ff0000">High-risk: 18-36 months</span>'''
***#*'''<span style="color:#ff0000">Modalities (2):</span>'''
***#**'''Dose-escalated hypofractionated EBRT (moderate only for high-risk; use of ultra not specified for unfavorable, intermediate-risk)'''
***#**'''Combined EBRT + brachytherapy (LDR, HDR)'''
***#*'''<span style="color:#ff0000">If sufficiently high-risk disease (clinically node positive OR with 2 of 3 of the following criteria: clinical stage  ≥T3, PSA ≥ 40 ng/mL, or ≥ Gleason 8), treatment with radiation and ADT can include 2 years of concurrent abiraterone acetate plus prednisone as well.</span>'''