Initial Treatment of Prostate Cancer, by Stage and Risk Group

The stage of your cancer is one of the most important factors in choosing the best way to treat it. Prostate cancer is staged based on the extent of the cancer (using T, N, and M categories) and the PSA level and Gleason score (Grade Group) when it is first diagnosed.

For prostate cancers that haven’t spread (stages I to III), doctors also use risk groups (based on how far the prostate tumor has grown, PSA level, grade, and prostate biopsy results) and sometimes special lab tests to help guide treatment options. Risk groups range from very low-risk to very high-risk. Cancers in the lower-risk groups have a smaller chance of growing and spreading compared to those in higher-risk groups.

Other factors, such as your age, overall health, life expectancy, and personal preferences are also important when looking at treatment options. This is especially true for early-stage cancers, where you might have several options.

You might want to ask which factors your doctor is considering when discussing your treatment options. There is also some variability in what different doctors consider to be “standard” options, so some doctors might recommend options different from those listed here.

Taking part in a clinical trial of newer treatments is also an option for many men with prostate cancer.

Very-low-risk group

These prostate cancers are very unlikely to grow and spread, even if they aren’t treated. For men whose cancers are in this group, active surveillance is typically recommended. (For men who have medical problems that might shorten their lifespan, observation, which is a less intense form of monitoring, might be an option as well.) This is because these tumors are unlikely to cause any harm, while treatments such as radiation and surgery can have side effects that can affect a man’s quality of life. If the cancer starts to show signs of growing at some point, treatments such as surgery or radiation can then be considered.

For men who aren’t comfortable with just monitoring the cancer and choose to start treatment right away, radiation therapy (external beam or brachytherapy) or surgery (radical prostatectomy) may be options.

Another option for some men who prefer to treat the cancer might be some type of focal therapy, such as cryotherapy or high-intensity focused ultrasound (HIFU). However, most expert groups don’t recommend these as a first treatment, unless surgery and radiation aren’t good options. This is mainly because there isn’t enough long-term data yet to show if these treatments are as effective as surgery or radiation.

If surgery is done and it finds concerning features in the cancer, your doctor might recommend external radiation therapy to the prostate bed (the area where the prostate was before it was removed), possibly along with hormone therapy.

Low-risk group

Most men whose prostate cancers are in the low-risk group will be offered active surveillance (or observation, for men who have other serious health issues that might affect their lifespan), since very few of these cancers will spread to distant parts of the body. If the cancer starts to show signs of growing at some point, treatments such as surgery or radiation can then be considered.

Other options, depending on a man’s preferences, might include radiation therapy (external beam or brachytherapy) or surgery (radical prostatectomy).

Another option for some men who prefer to treat the cancer might be some type of focal therapy, such as cryotherapy or high-intensity focused ultrasound (HIFU). However, most expert groups don’t recommend these as a first treatment, unless surgery and radiation aren’t good options. This is mainly because there isn’t enough long-term data yet to show if these treatments are as effective as surgery or radiation.

If surgery is done and it finds concerning features in the cancer, your doctor might recommend external radiation therapy to the prostate bed (the area where the prostate was before it was removed), possibly along with hormone therapy.

Favorable intermediate-risk group

These cancers are slightly more likely to grow and spread. Initial treatment options for men with these cancers might include:

• Active surveillance
• Surgery (radical prostatectomy, possibly with the removal of nearby lymph nodes)
• Radiation therapy (external beam or brachytherapy)

Another option for some men who prefer to treat the cancer might be some type of focal therapy, such as cryotherapy or high-intensity focused ultrasound (HIFU). However, most expert groups don’t recommend these as a first treatment, unless surgery and radiation aren’t good options. This is mainly because there isn’t enough long-term data yet to show if these treatments are as effective as surgery or radiation.

If surgery is done and it finds concerning features in the prostate cancer, your doctor might recommend external radiation therapy to the prostate bed (the area where the prostate was before it was removed), possibly along with hormone therapy. If cancer is found in the lymph nodes, hormone therapy might be recommended, possibly along with external radiation.

Men who have other serious medical problems that might affect their life span may choose a less aggressive first treatment such as radiation alone, or less intensive monitoring (observation).

Unfavorable intermediate-risk group

Initial treatment options for men with cancers in this risk group might include:

• Surgery (radical prostatectomy, along with the removal of nearby lymph nodes)
• External radiation therapy plus hormone therapy
• External radiation plus brachytherapy (possibly along with hormone therapy)

If surgery is done and it finds concerning features in the prostate cancer, your doctor might recommend external radiation therapy to the prostate bed (the area where the prostate was before it was removed), possibly along with hormone therapy. If cancer is found in the lymph nodes, hormone therapy might be recommended, possibly along with external radiation.

Men who have other serious medical problems that might affect their lifespan may choose a less aggressive first treatment such as radiation therapy (possibly with hormone therapy), or less intensive monitoring (observation).

High- or very-high-risk group

For men with cancers that are at high or very high risk of growing and spreading, treatment options might include:

• Radiation therapy (external beam radiation, either alone or with brachytherapy) along with hormone therapy (typically for 1 to 3 years). For cancers in the very-high-risk group, the newer hormone drug abiraterone is often included as well.
• Surgery (radical prostatectomy, along with the removal of nearby lymph nodes)

If surgery is done and it finds concerning features in the prostate cancer, your doctor might recommend external radiation therapy to the prostate bed (the area where the prostate was before it was removed), possibly along with hormone therapy. If cancer is found in the lymph nodes, hormone therapy might be recommended, possibly along with external radiation.

Men who have other serious medical problems that might affect their lifespan may choose a less aggressive first treatment, such as external radiation therapy or hormone therapy, or less intensive monitoring (observation).

Stage IV

Stage IVA cancers have already spread to nearby lymph nodes (but not to distant parts of the body) when the cancer is first found. For men who don’t have other serious medical problems that might affect their life span or who are having symptoms from the cancer, options include:

• External beam radiation treatment with hormone therapy (which often includes the newer hormone drug abiraterone)
• Hormone therapy (which might include abiraterone)
• Surgery (radical prostatectomy, along with the removal of nearby lymph nodes), only in men who are most likely to benefit from it

If surgery is done and it finds concerning features in the prostate cancer, your doctor might recommend external radiation therapy to the prostate bed (the area where the prostate was before it was removed), possibly along with hormone therapy. If cancer is found in the lymph nodes, hormone therapy might be recommended, possibly along with external radiation.

Men who have other serious medical problems that might affect their life span and who aren’t having symptoms may choose a less aggressive first treatment such as hormone therapy, or less intensive monitoring (observation).

Stage IVB cancers have spread to distant organs such as the bones when the cancer is found. Most stage IVB cancers can’t be cured, but they are treatable. The goals of treatment are to keep the cancer under control for as long as possible and to improve a man’s quality of life. Initial treatment options may include:

• Hormone therapy (which typically includes a newer hormone drug, such as abiraterone, apalutamide, or enzalutamide)
• Hormone therapy (which typically includes a newer hormone drug, such as abiraterone or darolutamide) along with chemotherapy (usually docetaxel), especially if there is a lot of cancer in the body
• Hormone therapy with external beam radiation to the tumor in the prostate
• Surgery (TURP) to relieve symptoms, such as bleeding or urinary obstruction
• Observation (for those who are older or have other serious health issues and do not have major symptoms from the cancer)
• Taking part in a clinical trial of newer treatments

Treatment of stage IV prostate cancer may also include treatments to help prevent or relieve symptoms, such as pain from bone metastases. This can be done with external radiation (including stereotactic body radiation therapy, or SBRT) or with drugs like denosumab (Xgeva), a bisphosphonate such as zoledronic acid (Zometa), or a radiopharmaceutical such as radium-223, strontium-89, or samarium-153.

Prostate cancer that has spread or come back

The options above are for the initial treatment of different risk groups and stages of prostate cancer. But if the cancer continues to grow and spread or if it comes back, other treatments might be options, such as immunotherapy, targeted drug therapy, chemotherapy, or other forms of hormone therapy. (See Treating Prostate Cancer That Doesn’t Go Away or Comes Back After Treatment.)