This document provides an overview and guidelines for the diagnosis and management of prostate cancer from the National Comprehensive Cancer Network. It discusses the classification, staging, diagnostic evaluation through PSA tests, biopsy and imaging. It covers management options including active surveillance, radical prostatectomy and their pre-operative preparation. Post-operative follow up, quality of life outcomes and recurrence are also reviewed based on latest evidence and guidelines.

1. Dr. Ali Mujtaba
(Resident Urology)
Department of Urology
SIUT , Karachi13-05-2020

2. TABLE OF CONTENTS
1. INTRODUCTION
2. CLASSIFICATION AND
STAGING SYSTEMS
3. DIAGNOSTIC EVALUATION
4. MANAGEMENT
5. RECURRENCE AND
PROGRESSION
6. FOLLOW-UP
7. QUALITY OF LIFE
OUTCOMES IN PROSTATE
CANCER
8. REFERENCES

3. } Prostate cancer (Pca) is the cancer starts inside
the cells of prostate gland, Almost all prostate
cancers are adenocarcinomas.
} Early-stage prostate cancers needs testosterone to
grow. As a result, treatment will often focus on
reducing /blocking the amount of testosterone.
According to The National Comprehensive Cancer
Network (NCCN)-Clinical Guideline for the
Treatment of Prostate Cancer

4. } Aims and scope
} Prostate Cancer (PCa) Guidelines Panel have prepared this
guidelines document to assist medical professionals in the evidence-
based management of PCa.
} Clinical guidelines present the best evidence available to the
experts but following guideline recommendations will not
necessarily result in the best outcome.
} Guidelines can never replace clinical expertise when making
treatment decisions for individual patients, but rather help to focus
decisions - also taking personal values and preferences/individual
circumstances of patients into account. Guidelines are not mandates
and do not purport to be a legal standard of care.

5. } Peripheral zone
} Central zone
} Transitional zone
The peripheral zone is almost
exclusively the site of origin
for carcinoma of the prostate.

6. } For each recommendation within the guidelines there is an accompanying
online strength rating form, the basis of which is a modified GRADE
methodology. These forms address a number of key elements namely:
} The overall quality of the evidence which exists for the recommendation,
references used in this text are graded according to a classification system
modified from the Oxford Centre for Evidence-Based Medicine Levels of
Evidence.
} The magnitude of the effect (individual or combined effects);
} The certainty of the results (precision, consistency, heterogeneity and other
statistical or study related factors);
} The balance between desirable and undesirable outcomes;
} The impact of patient values and preferences on the intervention;
} The certainty of those patient values and preferences.

7. } The strength of each recommendation is represented
by the words ‘strong’ or ‘weak’.
} The strength of each recommendation is determined
by the balance between desirable and undesirable
consequences of alternative management strategies,
the quality of the evidence (including certainty of
estimates) and, nature and variability of patient
values and preferences.

8. } Prostate cancer is the second most commonly
diagnosed cancer in men.
} Estimated 1.1 million diagnoses worldwide in 2012,
accounting for 15% of all cancers diagnosed
} Frequency of autopsy detected PCa is roughly the same
worldwide.
} A systematic review of autopsy studies reported a
prevalence of PCa at age < 30 years of 5% and
prevalence to 48-71% by age > 79 years.

9. } The incidence of PCa diagnosis varies widely between
different geographical areas, being highest in
Australia/New Zealand and Northern America.
} The incidence is low in Eastern and South Central Asia
(ASRs of 10.5 and 4.5, respectively), whilst rates in
Eastern and Southern Europe, which were low, have
showed a steady increase.

10. } Family history/genetics
} Family history and racial/ethnic background are associated
with an increased PCa incidence suggesting a genetic
predisposition.
} Only a small subpopulation of men with PCa (~9%) has true
hereditary disease.
} This is defined as three or more affected relatives or at least
two relatives who have developed early-onset PCa (< 55
years). Hereditary PCa is associated with a 6 to 7-year earlier
disease onset but the disease aggressiveness and clinical
course does not seem to differ in other ways.

11. } Ancestry-specific risk loci have been identified and
genome wide association studies have identified more
than 100 common susceptibility loci contributing to the
risk for Pca.
} Of the underlying determinants of genomic diversity
and mechanisms between genetic and environmental
factors, much remains unknown. However, it is
accepted that men of African descent show a higher
incidence of PCa and generally have a more aggressive
course of disease.

12. } Germline mutations have also been increasingly identified
amongst men with non-hereditary PCa.
} In metastatic PCa patients an incidence of 11.8% germline
mutations was found in genes mediating DNA-repair
processes.
} Mutations were most commonly seen in
} BRCA2 (5.35%),
} ATM (1.6%),
} CHEK2 (1.9%),
} BRCA1 (0.9%),
} and PALB2 (0.4%).
} In 3,607 unselected PCa patients, 620 (17.2%) were found
to have a pathogenic germline variant

13. } Risk factors
} A wide variety of exogenous/environmental factors are
associated with the risk of developing PCa or as being
aetiologically important for the progression from latent to clinical
PCa .
} Japanese men have a lower PCa risk compared to men from the
Western world. However, as Japanese men move from Japan to
California, their risk of PCa increases, approaching that of
American men, implying a role of environmental or dietary
factors
} Metabolic syndrome (MetS)
MetS hypertension have been associated with a significantly
greater risk of PCa, but in contrast, having > 3 components of MetS
is associated with a reduced risk.

14. } Diabetes/metformin
} metformin users (but not other oral hypoglycaemic agents) were
found to be at a decreased risk of PCa diagnosis compared with
never-users.
} Cholesterol/statins
} An association between blood total cholesterol, high-density
lipoprotein cholesterol, low-density lipoprotein cholesterol levels
and the risk of either overall PCa or high-grade PCa .Results
from the REDUCE study also did not show a preventive effect of
statins on PCa risk .
} Obesity
} obesity was associated with lower risk of low-grade PCa but
increased risk of high-grade.
} Dietary factors
} The association between a wide variety of dietary factors and
Pca.

16. } Balding
} Gonorrhoea
} Night-shift work
} Smoking
} Cadmium (Cd),high Cd exposure and risk of PCa for
occupational exposure.
} Men positive for human papillomavirus-16.
} Vasectomy and, self-reported acne.
} Higher ejaculation frequency (> 21 times a month vs. 4 to 7
times) has been associated with a 20% lower risk of Pca.

18. } Classification
} The objective of a tumour classification system is to
combine patients with a similar clinical outcome.
} This allows for the design of clinical trials on
relatively homogeneous patient populations, the
comparison of clinical and pathological data obtained
from different hospitals across the world, and the
development of recommendations for the treatment of
these patient populations.

19. TNM staging system for prostate cancer

20. TNM staging system for prostate cancer

23. } Initial widespread aggressive screening in USA was
associated with a decrease in mortality.
} In 2012 the US Preventive Services Task Force
(USPSTF) released a recommendation against non-
selective PSA screening which was adopted in the 2013
AUA Guidelines.

25. Ø Prostate cancer is usually suspected on the basis of
DRE and/or PSA levels. Definitive diagnosis depends
on histopathological verification of adenocarcinoma in
prostate biopsy cores.
Digital rectal examination
} PCas are located in the peripheral zone and may be detected by
DRE when the volume is > 0.2 mL. In ~18% of cases, PCa is
detected by suspect DRE alone, irrespective of PSA level.
} A suspect DRE in patients with a PSA level < 2 ng/mL has a
positive predictive value (PPV) of 5-30% .
} An abnormal DRE is associated with an increased risk of a
higher ISUP grade and is an indication for biopsy

26. } Prostate-specific antigen
} The use of PSA as a serum marker has revolutionised
PCa diagnosis.
} Prostate-specific antigen is organ but not cancer
specific; therefore, it may be elevated in benign
prostatic hypertrophy (BPH), prostatitis and other non-
malignant conditions.

27. } No standards defined for measuring PSA It is a
continuous parameter, with higher levels indicating
greater likelihood of PCa.
} Many men may harbour PCa despite having low serum
PSA
} PSA density; The higher the PSA density, the more likely
it is that the PCa is clinically significant
Risk of PCa in relation to low PSA values

28. } PSA velocity and doubling time
} There are two methods of measuring PSA kinetics:
• PSA velocity (PSAV): absolute annual increase in
serum PSA (ng/mL/year)
• PSA doubling time (PSA-DT): which measures the
exponential increase in serum PSA over time.
Prostate specific antigen velocity and PSA-DT may have
a prognostic role in treating PCa but have limited
diagnostic use because of background noise

30. } Urine tests:
} PCA3 marker/SelectMDX/Mi Prostate score
(MiPS)/ExoDX Prostate cancer gene 3 (PCA3) is a prostate-
specific, non-coding microRNA (mRNA) biomarker that is
detectable in urine sediments obtained after three strokes of
prostatic massage during DRE.
The commercially available Progensa urine test for PCA3 is
superior to total and percent-free PSA for the detection of PCa
in men with elevated PSA as it shows significant increases in
the area under the receiver-operator characteristic curve
(AUC) for positive biopsies.

31. } TRUS
Guide prostatic biopsies and other prostate-directed
interventions.
} Endorectal magnetic resonance imaging (MRI)
Accuracy of endorectal MRI varies from 51% to 92%.

32. } Axial imaging
CT
MRI
} Bone scan
To role out prostate cancer metastasis
} Antibody imaging
FDA approved for initial staging and recurrent disease.

35. } Repeat biopsy after previously negative biopsy
The indications for repeat biopsy are:
• Rising and/or persistently elevated PSA
• Suspicious DRE, 5-30% PCa risk
•Atypical small acinar proliferation (i.e. atypical glands
suspicious for cancer), 31-40% PCa risk on repeat
• Extensive (multiple biopsy sites, i.e. > 3) high-grade
prostatic intraepithelial neoplasia (HGPIN), ~30% PCa risk
• A few atypical glands immediately adjacent to high-grade
prostatic intraepithelial neoplasia (i.e. PINATYP), ~50% PCa
risk
• Intraductal carcinoma as a solitary finding, > 90% risk of
associated high-grade PCa
• Positive multiparametric MRI (mpMRI) findings

37. } Diagnostic criteria include features;
} pathognomonic of cancer
} major and minor features favouring cancer and features
against cancer.
} Ancillary staining and additional (deeper) sections
should be considered

38. } A prostate biopsy that does not contain glandular tissue
should be reported as diagnostically inadequate.
} Mandatory elements to be reported for a carcinoma-
positive prostate biopsy are:
} • Type of carcinoma;
} • Primary and secondary/worst Gleason grade (per biopsy
site and global);
} • Percentage high-grade carcinoma (global);
} • Extent of carcinoma (in mm or percentage) (at least per
biopsy site);
} EPE, seminal vesicle invasion, LVI, intraductal
carcinoma/cribriform pattern, peri-neural invasion;
} • ISUP grade (global).

39. } Histopathology of radical prostatectomy specimens, Processing of
radical prostatectomy specimens and Histopathological examination
of RP specimens describes;
} Pathological stage,
} Histopathological type,
} Grade and surgical margins of PCa.
} It is recommended that RP specimens are totally embedded, to
enable assessment of cancer location, multifocality and
heterogeneity. For cost-effectiveness, partial embedding may also be
considered, particularly for prostates > 60 g.
} The most widely accepted method includes complete embedding of
the posterior prostate, and a single mid-anterior left and right
section. Compared with total embedding, partial embedding
detected 98% of PCa with an ISUP grade > 2 with accurate staging
in 96% of cases

40. Radical prostatectomy specimen report;
The pathology report provides essential information on the
prognostic characteristics relevant for clinical decision-making

45. } The International SIOG PCa Working Group recommends
that treatment for senior adults should be based on a
systematic evaluation of health status using the G8
(Geriatric 8) screening tool.
} Healthy patients with a G8 score > 14 or vulnerable patients
with reversible impairment after resolution of their geriatric
problems should receive the same treatment as younger
patients. Frail patients with irreversible impairment should
receive adapted treatment. Patients who are too ill should
receive only palliative treatment.
} Patients with a G8 score < 14 should undergo a full geriatric
evaluation as this score is associated with 3-year mortality,
assessing comorbidity, nutritional status, and cognitive and
physical functions, to determine if the impairment is
reversible.

49. } Deferred treatment (active surveillance/watchful waiting)
In localised disease a life expectancy of at least 10 years is
considered mandatory for any benefit from local treatment.
Active surveillance aims to avoid unnecessary treatment in men
with clinically localised PCa who do not require immediate
treatment, but at the same time achieve the correct timing for
curative treatment in those who eventually do.
Patients remain under close surveillance through structured
surveillance programmes with regular follow-up, and curative
treatment is prompted by predefined thresholds indicative of
potentially lifethreatening disease which is still potentially curable,
while considering individual life expectancy.

52. } The goal of RP by any approach is the eradication of
cancer, while whenever possible, preserving pelvic
organ function.
} The procedure involves removing the entire prostate
with its capsule intact and seminal vesicles, followed
by undertaking vesico-urethral anastomosis.

54. } Pre-operative preparation;
} Pre-operative patient education
} Peri-operative education
} Pre-operative patient-specific 3D printed prostate models to optimise
patient-centred care.
} Pre-operative pelvic floor exercises; Although many patients who have
undergone RP will experience a return to urinary continence [405],
temporary urinary incontinence is common early after surgery, reducing
quality of life.
} Pre-operative pelvic floor exercises (PFE), with or without biofeedback,
have been used with the aim of reducing this early post-operative
incontinence. A systematic review and meta-analysis of the effect of pre-
RP PFE on post-operative urinary incontinence showed a significant
improvement in incontinence rates at 3 months post-op.
} Pre-operative PFE may therefore provide some benefit, however the
analysis was hampered by the variety of PFE regimens and a lack of
consensus on the definition of incontinence.

55. } Prophylactic antibiotics
} Prophylactic antibiotics should be used; however no high-level
evidence is available to recommend specific prophylactic
antibiotics prior to RP (See EAU Urological Infections
Guidelines).
} In addition, as the susceptibility of bacterial pathogens and
antibiotic availability varies worldwide, any use of
prophylactic antibiotics should adhere to local guidelines.

56. } Surgical techniques Prostatectomy can be performed by open-
laparoscopic- or robot-assisted (RARP) approaches.
} Most recently, RARP was introduced using the da Vinci
Surgical System® by Binder in 2002.
} This technology combined the minimally-invasive advantages
of laparoscopic RP with improved surgeon ergonomics and
greater technical ease of suture reconstruction of the vesico-
urethral anastomosis, and has now become the preferred
minimally-invasive approach, where the equipment is
available.

57. } Robotic anterior versus Retzius-sparing dissection Robot-
assisted RP has typically been performed via the anterior
approach, first dropping the bladder to expose the space of
Retzius.
} However, recently the posterior approach (Retzius-sparing - RS-
RARP) has gained favour following two RCTs showing
improved early post-operative continence.
} RS-RARP; This approach commences dissection posteriorly at
the pouch of Douglas, first dissecting the seminal vesicles and
progressing caudally behind the prostate. All of the anterior
support structures are avoided, giving rise to the hypothetical
mechanism for improved early post-operative continence.
Retzius-sparing-RARP thus offers the same potential advantage
as the open perineal approach, but without disturbance of the
perineal musculature.
} Both RCTs were single-surgeon studies comparing post-
operative continence in RS-RARP vs. traditional anterior
dissection RARP in men with low- to intermediate-risk Pca.

59. } Several RCTs have analysed the impact of neoadjuvant ADT before
RP, most of them using a 3-month period. Neoadjuvant ADT is
associated with a decreased rate of pT3 (downstaging), decreased
positive margins, and a lower incidence of positive LNs. These
benefits are greater with increased treatment duration (up to 8
months).
} However, since neither the PSA relapse-free survival nor CSS were
shown to improve, neoadjuvant ADT should not be considered as
standard clinical practice. One recent RCT compared neoadjuvant
luteinising hormone-releasing hormone (LHRH) alone vs. LHRH plus
abiraterone plus prednisone prior to RP in 65 localised high-risk PCa
patients.
} Patients in the combination arm were found to have both significantly
lower tumour volume and significantly lower BCR at > 4 years
follow-up (p = 0.0014).
} Further supportive evidence is required before recommending
combination neoadjuvant therapy including abiraterone prior to RP.

60. } Radiotherapy Intensity-modulated radiotherapy
(IMRT), with or without image-guided radiotherapy
(IGRT), is the gold standard for EBRT.

61. } Intensity-modulated external-beam radiotherapy and volumetric
arc external-beam radiotherapy (VMAT)
} Intensity-modulated external-beam radiotherapy and VMAT employ dynamic multileaf
collimators, which automatically and continuously adapt to the contours of the target
volume seen by each beam.
} The advantage of VMAT over IMRT is shorter treatment times, generally two to three
minutes. Both techniques allow for a more complex distribution of the dose to be
delivered within the treatment field and provide concave isodose curves, which are
particularly useful as a means of sparing the rectum.
} Radiotherapy treatment planning for IMRT and VMAT differs from that used in
conventional EBRT, requiring a computer system capable of ‘inverse planning’, and the
appropriate physics expertise. Treatment plans must conform to pre-specified dose
constraints to critical organs at risk of normal tissue damage, and a formal quality
assurance process should be routine. With dose escalation using IMRT, organ
movement becomes a critical issue, in terms of both tumour control and treatment
toxicity. Evolving techniques will therefore combine IMRT with some form of
imageguided radiotherapy (IGRT), in which organ movement can be visualised and
corrected for in real time, although the optimum means of achieving this is still unclear.
} Tomotherapy is another technique for the delivery of IMRT, using a linear accelerator
mounted on a ring gantry that rotates as the patient is delivered through the centre of
the ring, analogous to spiral CT scanning.

62. } Dose escalation
} Several RCTs have shown that dose escalation (range 74-
80 Gy) has a significant impact on 5-year biochemical
relapse. The best evidence of an OS benefit for patients
with intermediate- or high-risk PCa, but not with low-risk
PCa, comes from a non-randomised but well conducted
propensity-matched retrospective analysis of the U.S.
} National Cancer Database covering a total of 42,481
patients. In everyday practice, a minimum dose of > 74 Gy
is recommended for EBRT plus HT, with no different
recommendations according to the patient’s risk group. If
IMRT and IGRT are used for dose escalation, rates of
severe late side-effects (> grade 3) for the rectum are 2-3%
and for the GU tract 2-5%.

63. } Hypofractionation (HFX)
} Fractionated RT utilises differences in the DNA repair capacity
of normal and tumour tissue and slowly proliferating cells are
very sensitive to an increased dose per fraction.
} Hypofractionation (HFX) has the added advantage of being
more convenient for the patient at with lower cost. Moderate
HFX is defined as RT with 2.5-4 Gy/fx.
} Several studies report on moderate HFX applied in various
techniques and, in part, also including HT.
} A systematic review concludes that studies on moderate HFX
(2.5-4 Gy/fx) delivered with conventional three-dimensional
conformal radiotherapy (3D-CRT)/ IMRT have sufficient
follow-up to support the safety of this therapy, but long-term
efficacy data are still lacking Ultra-HFX has been defined as
radiotherapy with > 3.4 Gy per fraction. It requires IGRT and
stereotactic body radiotherapy (SBRT).

64. } The combination of RT with LHRH ADT has
definitively proven its superiority compared with RT
alone followed by deferred ADT on relapse.
} The main message is that for intermediate risk a short
duration of around 6 months is optimal, while a longer
one, around 3 years, is needed for high-risk patients.

65. } Proton beam therapy
} Proton beams are an attractive alternative to photon-beam RT for PCa,
as they deposit almost all their radiation dose at the end of the
particle’s path in tissue (the Bragg peak), in contrast to photons, which
deposit radiation along their path. There is also a very sharp fall-off
for proton beams beyond their deposition depth, meaning that critical
normal tissues beyond this depth could be effectively spared. In
contrast, photon beams continue to deposit energy until they leave the
body, including an exit dose.
} Unequivocal information that shows an advantage of protons over
IMRT photon therapy is still not available.
} Studies from the SEER database and from Harvard describing toxicity
and patient-reported outcomes do not point to an inherent superiority
for protons. In terms of longer-term gastrointestinal (GI) toxicity,
proton therapy might even be inferior to IMRT.
} A RCT comparing equivalent doses of proton-beam therapy with
IMRT is underway. Meanwhile, proton therapy must be regarded as a
promising, but experimental, alternative to photon-beam therapy.

66. } Low-dose rate (LDR) brachytherapy Low-dose rate
brachytherapy uses radioactive seeds permanently
implanted into the prostate
} High-dose rate brachytherapy High-dose rate (HDR)
brachytherapy uses a radioactive source temporarily
introduced into the prostate to deliver radiation

67. } Types of hormonal therapy
Androgen deprivation can be achieved by either
suppressing the secretion of testicular androgens or
inhibiting the action of circulating androgens at the level
of their receptor. These two methods can be combined to
achieve what has been known as complete (or maximal or
total) androgen blockade (CAB) using the old fashioned
anti-androgens.

68. } Testosterone-lowering therapy (castration)
} Current methods have shown that the mean value after
surgical castration is 15 ng/Dl. Therefore, a more
appropriate level should be defined as < 20 ng/dL (1
nmol/L).
} This definition is important as better results are
repeatedly observed with lower testosterone levels
compared to 50 ng/dL.
} However, the castrate level considered by the
regulatory authorities and in clinical trials addressing
castration in PCa is still the historical < 50 ng/dL (1.7
mmol/L).

69. } Bilateral orchiectomy
} Bilateral orchiectomy, or subcapsular pulpectomy, is
still considered the primary treatment modality for
ADT.
} It is a simple, cheap and virtually complication-free
surgical procedure. It is easily performed under local
anaesthesia and it is the quickest way to achieve a
castration level, which is usually reached within less
than twelve hours.
} It is irreversible and therefore does not allow for
intermittent treatment

71. } Oestrogens
} Treatment with oestrogens results in testosterone
suppression and is not associated with bone loss.
} Early studies tested oral diethylstilboestrol (DES) at
several doses. Due to severe side-effects, especially
thromboembolic complications, even at lower doses
these drugs are not considered as standard first-line
treatment.

72. } Anti-androgen therapy is usually continued for 4 weeks but
neither the timing nor the duration of anti-androgen therapy
are based on strong evidence.
} Chronic exposure to LHRH agonists results in the down-
regulation of LHRH-receptors, suppressing LH and FSH
secretion and therefore testosterone production. A castration
level is usually obtained within 2 to 4 weeks.
} Although there is no formal direct comparison between the
various compounds, they are considered to be equally
effective. No survival difference with orchiectomy has been
reported, despite the lack of high quality trials.

73. } Luteinising-hormone-releasing hormone antagonists
} Luteinising-hormone releasing hormone antagonists
immediately bind to LHRH receptors, leading to a
rapid decrease in LH, FSH and testosterone levels
without any flare. The practical shortcoming of these
compounds is the lack of a long-acting depot
formulation with, so far, only monthly formulations
being available.
} Degarelix is a LHRH antagonist. The standard dosage
is 240 mg in the first month, followed by monthly
injections of 80 mg

74. } Anti-androgens
These oral compounds are classified according to their
chemical structure as:
• steroidal, e.g. cyproterone acetate (CPA), megestrol
acetate and medroxyprogesterone acetate;
• non-steroidal or pure, e.g. nilutamide, flutamide and
bicalutamide.

75. } Cryotherapy
} Cryotherapy uses freezing techniques to induce cell death by dehydration resulting
in protein denaturation, direct rupture of cellular membranes by ice crystals and
vascular stasis and microthrombi, resulting in stagnation of the microcirculation with
consecutive ischaemic apoptosis.
} Freezing of the prostate is ensured by the placement of 17 gauge cryo-needles under
TRUS guidance, placement of thermosensors at the level of the external sphincter
and rectal wall, and insertion of a urethral warmer. Two freeze-thaw cycles are used
under TRUS guidance, resulting in a temperature of -40°C in the mid-gland and at
the neurovascular bundle.
} Currently, third and fourth generation cryotherapy devices are mainly used. Since its
inception, cryotherapy has been used for whole-gland treatment in PCa either as a
primary or salvage treatment option. The main adverse effects of cryosurgery are
ED (18%), urinary incontinence (2-20%), urethral sloughing (0-38%), rectal pain
and bleeding (3%) and recto-urethral fistula formation (0-6%) . There is a lack of
prospective comparative data regarding oncological outcomes of whole-gland
cryosurgery as a curative treatment option for men with localised PCa, with most
studies being non-comparative single-arm case series with short follow-up periods.

76. } High-intensity focused ultrasound
} High-intensity focused ultrasound consists of focused US
waves, emitted from a transducer, that cause tissue damage by
mechanical and thermal effects as well as by cavitation.
} The goal of HIFU is to heat malignant tissues above 65°C so
that it is destroyed by coagulative necrosis. High-intensity
focused US is performed under general or spinal anaesthesia,
with the patient lying in the lateral or supine position.
} Disadvantages of HIFU include difficulty in achieving complete
ablation of the prostate, especially in glands larger than 40 mL,
and in targeting cancers in the anterior zone of the prostate.
Similar to cryosurgery, the lack of any long-term prospective
comparative data on oncological outcomes prevents whole-
gland HIFU from being considered as a reasonable alternative to
the established curative treatment options.

77. } Focal therapy
Treating only the tumor while sparing the normal prostate and
surrounding structures
Methods for focal therapy

79. } Treatment of low-risk disease
} Active surveillance (AS)
} The main risk for men with low-risk disease is over-
treatment and therefore AS should be considered for all
such patients.

81. Guidelines for the treatment of intermediate-risk disease

82. Guidelines for radical treatment of high-risk localised disease

83. Guidelines for radical treatment of locally-advanced disease

84. } Adjuvant treatment after radical prostatectomy
} Adjuvant treatment additional to the primary or initial
therapy with the aim of decreasing the risk of relapse.

88. } Between 5 and 20% of men continue to have detectable
or persistent PSA after RP (when defined in the
majority of studies as detectable post-RP PSA of > 0.1
ng/mL within 4 to 8 weeks of surgery).
} It may result from persistent local disease, pre-existing
metastases or residual benign prostate tissue.

90. } Between 27% and 53% of all patients
undergoing RP or RT develop a rising PSA
(PSA recurrence).