This protocol addresses patients with high-risk localised prostate cancer — defined by ISUP grade group 4 or 5, a PSA above 20 ng/mL, or clinical stage cT2c — with no nodal involvement (cN0) and no distant metastasis (M0).
Patients with high-risk localised prostate cancer carry a substantially elevated risk of PSA failure, need for secondary therapy, metastatic progression, and prostate cancer-specific mortality compared to lower-risk disease stages.
Curative-intent treatment for this high-risk stage includes surgical resection with extended nodal dissection as part of a multimodal strategy, or radiotherapy combined with long-term hormonal therapy. Additional radiation modalities may be considered for appropriately selected patients. The full protocol specifies approach selection, sequencing, and any combination strategies.
Patients with high-risk PCa are at an increased risk of PSA failure, need for secondary therapy, metastatic progression and death from PCa.
When managed with noncurative intent, high-risk PCa is associated with 10-year and 15-year PCSM rates of 28.8 and 35.5%, respectively.
Radical prostatectomy is a standard option in selected patients with a low tumour volume, provided that the tumour is not fixed to the pelvic wall or there is no invasion of the urethral sphincter.
Offer RP to selected patients.
In patients undergoing a lymph node dissection you should perform an ePLND.
Offer intensity-modulated radiotherapy (IMRT)/volumetric modulated arc therapy (VMAT) plus image-guided radiotherapy (IGRT), with a total dose of 76–78 Gy or moderate hypofractionation (60 Gy/20 fx in four weeks or 70 Gy/28 fx in six weeks), in combination with long-term androgen deprivation therapy (ADT) (two to three years).
Offer patients with good urinary function IMRT/VMAT plus IGRT with brachytherapy boost (either high-dose rate or low-dose rate) in combination with long-term ADT (two to three years).
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