Prostate Cancer: Management

Key points

• Localised prostate cancer: treatment depends on risk category, age, comorbidity, life expectancy and preference. Options include active surveillance for appropriate low/intermediate-risk disease, radical prostatectomy or radical radiotherapy for suitable higher-risk disease; watchful waiting is appropriate for selected men with limited life expectancy.
• Locally advanced prostate cancer: radical radiotherapy is generally combined with androgen-deprivation therapy when curative treatment is appropriate. Radical prostatectomy may be considered in selected men as part of multimodality treatment; it should not be presented as a universal equivalent alternative to radiotherapy + ADT.
• Androgen deprivation: LHRH/GnRH agonists such as goserelin cause an initial testosterone flare, so short-term anti-androgen cover may be used when clinically indicated. GnRH antagonists such as degarelix or relugolix avoid the flare. Bilateral orchidectomy is an alternative form of ADT.
• Metastatic hormone-sensitive prostate cancer: ADT is the backbone, and current NICE guidance supports treatment intensification with agents such as docetaxel, abiraterone, enzalutamide, apalutamide or darolutamide according to disease characteristics, suitability and current technology-appraisal criteria.
• Castration-resistant prostate cancer: treatment is individualised according to prior therapy, symptoms, metastases and biomarkers. Options can include docetaxel/cabazitaxel, abiraterone or enzalutamide in appropriate settings, radiopharmaceuticals such as radium-223 for selected symptomatic bone-predominant disease, and PARP inhibitors for eligible homologous-recombination-repair mutations. Bone health should be actively managed.
• MRCP discriminator: localised low-risk disease → active surveillance may be appropriate; high-risk/localised or locally advanced → radical treatment; metastatic hormone-sensitive disease → ADT + treatment intensification.
• Current update: NICE now includes newer intensification options such as darolutamide and updated abiraterone recommendations; do not rely on the old ADT-alone model.