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Localised prostate cancer
Localised prostate cancer is treated by risk group — PSA, ISUP grade group and T stage: low risk with active surveillance, intermediate with surgery or radiation plus short hormonal therapy when needed, and high with radiation plus long hormonal therapy or surgery.
Why it matters in the exam
Prostate cancer is among the frequent topics in the radiation and urology parts of the exam. Stems give PSA, Gleason score and clinical stage, and require assigning a risk group and choosing treatment, or ask about the definition of biochemical failure, salvage radiation after surgery, brachytherapy and the advantage of IMRT.
Many distractors rest on a wrong conversion of the Gleason score to a grade group — for example 4+3 versus 3+4 — or on confusing the definition of biochemical failure after surgery with the definition after radiation. It also helps to remember when germline genetic testing is recommended.
Key points
- The risk group is set by PSA, grade group and T stage.
- Low risk — active surveillance; intermediate — surgery or radiation; high — radiation with long hormonal therapy.
- Biochemical failure: after surgery PSA of 0.2 or more; after radiation nadir plus 2.
- Early salvage radiation is equivalent to routine adjuvant radiation and avoids overtreatment.
- IMRT and SBRT allow high doses with less rectal injury.
Summary table
| Risk group | Definition | Treatment |
|---|---|---|
| Low | T1–T2a, grade group 1 (3+3), PSA below 10 | Active surveillance with PSA, MRI and repeat biopsies |
| Favourable intermediate | One intermediate factor, grade group 1 to 2 | Surgery or radiation; active surveillance in selected cases |
| Unfavourable intermediate | 2 or more intermediate factors, grade group 3, or most biopsy cores positive | Surgery, or radiation with hormonal therapy for 4 to 6 months |
| High | T3a, grade group 4 to 5, or PSA above 20 | Radiation with hormonal therapy for 18 to 36 months, or radical surgery when suitable |
| Biochemical failure | After surgery: PSA of 0.2 or more on two tests; after radiation: nadir plus 2 | Early salvage radiation to the prostate bed, usually with hormonal therapy |
| Radiation methods | Hypofractionation 60 Gy in 20 fractions, SBRT of 36.25 Gy in 5 fractions, brachytherapy | IMRT lowers rectal and bladder dose; in brachytherapy the key metric is D90 |
| Side effects of local treatment | Surgery: urinary incontinence and impotence | Radiation: proctitis, cystitis and late impotence; hormonal therapy: hot flushes, osteoporosis and metabolic syndrome |
In the full version for subscribers
- A simple algorithm
- Memory aid
- Exam traps
- 5 review cards
- Enough for IMLE
The full version is open to subscribers of: Oncology, Urology, Medical licensing exam (IMLE), Family medicine.
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Sources
- NCCN Clinical Practice Guidelines in Oncology: Prostate Cancer, 2026 — Risk stratification and initial management
- EAU-EANM-ESTRO-ESUR-ISUP-SIOG Guidelines on Prostate Cancer, 2025 — Treatment of localised disease
- Gunderson and Tepper's Clinical Radiation Oncology, 5th ed. (2021) — Prostate cancer
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-06. The text may contain errors; when in doubt, check the source.