What Is the Treatment of Localised Prostate Cancer — Unfavourable Intermediate Risk (ISUP Grade Group 2–3)?
This protocol covers first-line management for men with localised prostate cancer that meets unfavourable intermediate-risk criteria: ISUP grade group 2 with ≥10% pattern 4, ISUP grade group 3, or multiple intermediate-risk factors. Active surveillance is not appropriate for this risk classification.
Clinical Scenario
Localised prostate cancer, unfavourable intermediate-risk — defined as ISUP grade group 2 with ≥10% pattern 4, ISUP grade group 3, or the presence of multiple intermediate-risk factors. Patients with ISUP grade group 3 disease should be excluded from active surveillance protocols.
Treatment Approach (Partial Overview)
Evidence-based treatment for this risk group centres on definitive local therapy — either surgical removal or radiation-based approaches, with certain patients eligible for a combination strategy that includes a brachytherapy boost alongside short-term hormonal therapy.
Complete regimen options, eligibility criteria, sequencing, and clinical decision points are available in the full structured protocol.
Treatment Goals
Clinical targets include undetectable serum PSA following surgical treatment, and achievement of an optimal PSA nadir following radiotherapy.
References
- Patients with ISUP GG 3 disease should be excluded from AS protocols.
- Trimodality therapy with IMRT plus BT boost and short-term ADT can be considered for NCCN-unfavourable intermediate-risk PCa.
- Offer RP to patients with a life expectancy of > ten years.
- 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 short-term androgen deprivation therapy (ADT) (four to six months).
- Offer LDR brachytherapy boost combined with IMRT/VMAT plus IGRT to patients with good urinary function and NCCN unfavourable intermediate-risk disease, in combination with short-term ADT (four to six months).
- Offer high-dose rate brachytherapy boost combined with IMRT/VMAT plus IGRT to patients with good urinary function and NCCN unfavourable intermediate-risk disease in combination with short-term ADT (four to six months).
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