Treatment of prostate cancer

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Treatment of Prostate Cancer: Current Approaches and Emerging Therapies

Screening and Diagnosis of Prostate Cancer

Prostate cancer (PCa) is typically diagnosed through a combination of prostate-specific antigen (PSA) testing and digital rectal examination, followed by a confirmatory prostate biopsy . Systematic prostate biopsies under ultrasound guidance and local anesthesia are the preferred diagnostic method. The European Association of Urology (EAU) guidelines recommend individualized screening in consultation with a physician due to insufficient evidence to support widespread population-based PSA screening.

Localized Prostate Cancer Treatment Options

Active Surveillance and Watchful Waiting

For men with low-risk, localized PCa, active surveillance is a viable option, especially for those with a long life expectancy. This approach involves regular monitoring and intervening only if the disease shows signs of progression . Watchful waiting is an alternative for men with locally advanced PCa who do not require immediate local treatment, offering equivalent oncologic efficacy to androgen-deprivation therapy (ADT).

Radical Prostatectomy and Radiation Therapy

Radical prostatectomy (RP) is recommended for patients with localized disease and a long life expectancy, with nerve-sparing RP being the preferred approach for organ-confined disease . Radiation therapy (RT) is another primary treatment option, with external beam radiotherapy (EBRT) and brachytherapy being common modalities. Higher RT doses (≥74 Gy for low-risk and 78 Gy for intermediate- or high-risk PCa) have been shown to improve outcomes .

Focal Therapy

Focal therapy aims to treat only the part of the prostate containing the index lesion, preserving quality of life by minimizing side effects. Techniques include cryoablation, high-intensity focused ultrasound, and photodynamic therapy, among others. These minimally invasive procedures have shown good functional outcomes and intermediate-term oncological control.

Advanced and Metastatic Prostate Cancer Treatment

Androgen Deprivation Therapy (ADT)

ADT remains a cornerstone for treating advanced PCa, particularly for high-risk locally or systemically advanced disease. It can be combined with other treatments such as RT for better outcomes . For men with castration-resistant prostate cancer (CRPC), newer systemic agents have been approved, including AR-targeted therapies and chemotherapy .

Chemotherapy and Novel Agents

Chemotherapy, often combined with ADT, is used for systemic relapse or metastatic disease. Novel agents like the poly(ADP-ribose) polymerase (PARP) inhibitor olaparib have shown promise in prolonging survival .

Immunotherapy

Immunotherapy is an emerging field in PCa treatment. Sipuleucel-T is the only FDA-approved immunotherapy for PCa, showing survival benefits in certain patients. Other immunotherapies, including checkpoint inhibitors like ipilimumab and PSMA-targeted treatments, are under investigation.

Multimodal Treatment Approaches

For high-risk localized or locally advanced PCa, combining treatments such as RP with postoperative RT or EBRT with long-term ADT has shown superior outcomes. Multimodal approaches are recommended to maximize oncological control while managing side effects .

Conclusion

The treatment landscape for prostate cancer is rapidly evolving, with a range of options available depending on the stage and risk profile of the disease. From active surveillance and focal therapies for localized PCa to multimodal approaches and novel systemic agents for advanced disease, personalized treatment plans are essential for optimizing patient outcomes. Ongoing research continues to refine these strategies and explore new therapeutic avenues.