# Localised prostate cancer, intermediate risk

Source: https://onco.cc/cancers/prostate-intermediate-risk/  
OnCo record `prostate-intermediate-risk` (Cancer). Data CC BY-NC 4.0, attribute "Data from OnCo (onco.cc)"; commercial use needs a licence.

## TL;DR

Intermediate-risk prostate cancer has Grade Group 2 or 3 disease, a PSA between 10 and 20 or a tumour that fills more of the gland. Surgery or radiotherapy cure most men; the favourable half can sometimes be watched, and the unfavourable half is given a few months of hormone therapy with radiotherapy.

## Summary

Intermediate-risk localised prostate cancer, in the NCCN scheme, has one or more of clinical stage T2b to T2c, Grade Group 2 or 3, or PSA 10 to 20 ng/mL, without high-risk features. It is split into favourable (one factor, Grade Group 1 or 2, under half of cores positive) and unfavourable (two or more factors, Grade Group 3, or more than half of cores positive), because the two behave differently. It is found by PSA, MRI and biopsy and staged clinically; bone scan and CT are reserved for unfavourable disease. Favourable disease is treated by radical prostatectomy, external beam radiotherapy or brachytherapy alone, and active surveillance is an option for selected men. Unfavourable disease is treated by prostatectomy with lymph node dissection, or radiotherapy with four to six months of androgen deprivation, or external beam radiotherapy plus a brachytherapy boost. CHHiP established 60 Gy in 20 fractions, HYPO-RT-PC showed seven fractions are equivalent, and PACE-B showed five stereotactic fractions match conventional radiotherapy at five years. Genomic classifiers and the ArteraAI pathology test are used to decide whether hormone therapy adds anything.

## Fields

- Kind: Cancer
- Last checked: 2026-09-25
- Also known as: Intermediate-risk prostate cancer; Favourable intermediate risk; Unfavourable intermediate risk; Grade Group 2 and 3 prostate cancer; Cambridge Prognostic Group 2; Cambridge Prognostic Group 3; CPG 2; CPG 3; CPG2 prostate cancer; CPG3 prostate cancer
- Tags: subtype-page
- Group: genitourinary
- Burden: About four in ten newly diagnosed localised prostate cancers; ten-year cancer-specific survival is above 95 percent with treatment.
- Subtypes: Favourable intermediate risk (one factor, Grade Group 1 or 2, under half of cores); Unfavourable intermediate risk (two or more factors, Grade Group 3, or more than half of cores); Localised acinar adenocarcinoma, Grade Group 2 or 3; Cribriform or intraductal pattern (behaves as unfavourable)
- Biomarkers: Gleason Grade Group 2 or 3; PSA 10 to 20 ng/mL; Percentage of positive cores; Cribriform or intraductal carcinoma; Decipher genomic classifier and ArteraAI Prostate for hormone therapy decisions

## Sections of this record

The page is a hub with ten sections in reading order; large sections have their own page. The same plan as JSON: https://onco.cc/api/v1/cancers/prostate-intermediate-risk/sections.json

- Overview (on the hub): The TL;DR, the family this cancer belongs to, the organ, who gets it and what the state of the art is. https://onco.cc/cancers/prostate-intermediate-risk/#overview [3 state-of-the-art points]
- Types and stages (on the hub): Anatomy, the subtypes and how they differ, how it is staged, and where advanced disease spreads. https://onco.cc/cancers/prostate-intermediate-risk/#what-it-is [4 subtypes]
- Symptoms and diagnosis (on the hub): How this cancer shows itself, how the diagnosis is confirmed, and the biomarkers clinicians test for. https://onco.cc/cancers/prostate-intermediate-risk/#finding-it [5 biomarkers]
- Treatment (on the hub): The standard of care by setting, the medicines, surgery and radiotherapy named in it, and the regimens behind them. https://onco.cc/cancers/prostate-intermediate-risk/#treating-it [3 settings, 3 decisions with options]
- Trials and papers (on the hub): Trials recruiting now, the landmark trials, the trials held by this cancer's subtypes, the key papers and what they mean, the latest literature, and the milestones year by year. https://onco.cc/cancers/prostate-intermediate-risk/#evidence [16 trials, 15 key papers, 5 milestones]
- Biology and targets (on the hub): The molecular landscape: the targets and how often each appears, the pathways, the mechanics stages and the preclinical models. https://onco.cc/cancers/prostate-intermediate-risk/#science [1 target]
- Countries and centres (own page): Cases by country, the UK and NHS pathway and other country lenses, the expert centres with trials on record, and the centres named on this cancer's subtypes. https://onco.cc/cancers/prostate-intermediate-risk/where-you-are/ [26 UK centres]
- Decisions and support (on the hub): The decisions you may face, the aids that walk through them, the warnings on record, the first sixty days and the questions to ask. https://onco.cc/cancers/prostate-intermediate-risk/#living-with-it [16 questions, 3 red cards, 1 decision aid]
- Pipeline and open problems (own page): Everything in development, the medicines held by this cancer's subtypes, the open problems and what is being done about them, the roadmaps, and what changed on this record. https://onco.cc/cancers/prostate-intermediate-risk/coming/ [3 medicines, 16 trials, 3 ideas, 3 open problems]
- Data (own page): Every connected record, the notes, the JSON, Markdown and RDF twins, and where the record came from and when it was checked. https://onco.cc/cancers/prostate-intermediate-risk/data/ [77 connected records, 2 notes]

## Standard of care

- Favourable intermediate risk: Radical prostatectomy, external beam radiotherapy (moderate or ultra-hypofractionated) or brachytherapy alone; active surveillance for selected men with low volume Grade Group 2 disease. ([Robotic & minimally invasive surgery](https://onco.cc/technologies/robotic-surgery/), [Hypofractionated radiotherapy](https://onco.cc/technologies/hypofractionated-radiotherapy/), [SBRT / SABR (stereotactic radiotherapy)](https://onco.cc/technologies/sbrt/), [Brachytherapy](https://onco.cc/technologies/brachytherapy/), [Active surveillance](https://onco.cc/technologies/active-surveillance/), [CHHiP](https://onco.cc/trials/chhip/), [PACE-B](https://onco.cc/trials/pace-b/))
- Unfavourable intermediate risk: Radical prostatectomy with pelvic lymph node dissection, or external beam radiotherapy with four to six months of androgen deprivation, or external beam plus brachytherapy boost. ([Robotic & minimally invasive surgery](https://onco.cc/technologies/robotic-surgery/), [Androgen deprivation & AR pathway inhibitors](https://onco.cc/technologies/androgen-deprivation/), [Leuprolide (leuprorelin) and GnRH agonists](https://onco.cc/drugs/leuprolide/), [Brachytherapy](https://onco.cc/technologies/brachytherapy/), [IMRT / IGRT (modern external beam)](https://onco.cc/technologies/imrt-igrt/), [HYPO-RT-PC](https://onco.cc/trials/hypo-rt-pc/))
- Deciding on hormone therapy: ArteraAI Prostate predicts benefit from short-course androgen deprivation with radiotherapy; Decipher stratifies risk. ([ArteraAI Prostate](https://onco.cc/drugs/artera-ai-prostate/), [Decipher Prostate](https://onco.cc/drugs/decipher-prostate/), [Digital pathology & AI](https://onco.cc/technologies/digital-pathology-ai/))

## State of the art

- Radiotherapy has shrunk from eight weeks to one to two, with the same control and side effects.
- The favourable and unfavourable split lets half of these men avoid hormone therapy.
- AI pathology trained on trial specimens now tells which men gain from hormone therapy.

## Open problems

- Whether favourable intermediate risk can be safely watched in the long term.
- How to select men for hormone therapy without giving it to everyone in the unfavourable group.
- Cribriform and intraductal patterns are prognostic but not yet in the risk groups.

## Notes

- What this page is called in the NHS: Cambridge Prognostic Groups 2 and 3, the two halves of intermediate risk. NICE NG131 1.2.15 defines group 2 as Gleason 3+4=7 (grade group 2) or PSA 10 to 20, at stage T1 to T2, and group 3 as Gleason 3+4=7 and PSA 10 to 20 and stage T1 to T2, or Gleason 4+3=7 (grade group 3) at stage T1 to T2. The split exists because the old three-tier model could not tell 3+4 from 4+3. The treatment differs across the line: in CPG 2 active surveillance, radical prostatectomy and radical radiotherapy are offered as a choice (1.3.9); in CPG 3 radical treatment is offered and active surveillance is only considered for people who choose not to have it (1.3.10). Radiotherapy is combined with six months of androgen deprivation from CPG 2 upwards (1.3.28 and the radical radiotherapy recommendations).
- Within these two groups, two things on the pathology report move a man towards treatment rather than surveillance: the percentage of Gleason pattern 4, a core reporting item in UK core biopsies since October 2024, and the presence of invasive cribriform or intraductal carcinoma, which both ISUP and the Genitourinary Pathology Society treat as a reason to exclude a man from active surveillance.

## Sources

- Wikipedia: https://en.wikipedia.org/wiki/Prostate_cancer_staging
- Wikipedia: https://en.wikipedia.org/wiki/Prostate_cancer_staging
- NCCN Guidelines: Prostate Cancer: https://www.nccn.org/guidelines/guidelines-detail?category=1&id=1459
- NICE NG131: prostate cancer, diagnosis and management (recommendations, including the Cambridge Prognostic Group table at 1.2.15): https://www.nice.org.uk/guidance/ng131/chapter/Recommendations
- Royal College of Pathologists G084: dataset for histopathology reports for prostatic carcinoma, version 4, October 2024: https://www.rcpath.org/static/8cc88604-2c8d-4df4-a99542df41c102af/G084-dataset-for-histopathology-reports-for-prostatic-carcinoma.pdf

## Connected records

- cancers: [Biochemical recurrence of prostate cancer](https://onco.cc/cancers/prostate-bcr/), [Ductal adenocarcinoma of the prostate](https://onco.cc/cancers/prostate-ductal-adenocarcinoma/), [Localised prostate cancer, high and very high risk](https://onco.cc/cancers/prostate-high-risk/), [Localised prostate cancer, very low and low risk](https://onco.cc/cancers/prostate-low-risk/), [Prostate cancer](https://onco.cc/cancers/prostate/)
- terms: [Cambridge Prognostic Group (CPG 1 to 5)](https://onco.cc/terms/cambridge-prognostic-group/), [Choosing treatment for localised prostate cancer: what each option costs](https://onco.cc/terms/prostate-treatment-choice-localised/), [Cribriform growth pattern in prostate cancer](https://onco.cc/terms/cribriform-prostate-cancer/), [Focal and tissue-preserving treatment of prostate cancer](https://onco.cc/terms/prostate-focal-therapy/), [Gleason score / Grade Group](https://onco.cc/terms/gleason-grade-group/), [How many radiotherapy visits: the prostate fractionation trials](https://onco.cc/terms/prostate-radiotherapy-fractionation/), [Intraductal carcinoma of the prostate (IDC-P)](https://onco.cc/terms/intraductal-carcinoma-prostate/), [Lead time, and lead-time bias](https://onco.cc/terms/lead-time-bias/), [Number needed to screen (and number needed to diagnose)](https://onco.cc/terms/number-needed-to-screen/), [Other-cause mortality](https://onco.cc/terms/other-cause-mortality/), [Overtreatment](https://onco.cc/terms/overtreatment/), [Percentage of Gleason pattern 4](https://onco.cc/terms/percentage-gleason-pattern-4/), [PI-RADS (Prostate Imaging Reporting and Data System)](https://onco.cc/terms/pi-rads/), [Polygenic risk score (PRS)](https://onco.cc/terms/polygenic-risk-score/), [Template mapping biopsy (transperineal template prostate mapping)](https://onco.cc/terms/template-mapping-biopsy/), [TNM staging for prostate cancer, and what changed in the 9th edition](https://onco.cc/terms/tnm-prostate-cancer/), [Whole-mount pathology](https://onco.cc/terms/whole-mount-pathology/)
- key papers: [Association of Black race with prostate cancer-specific and other-cause mortality](https://onco.cc/key-papers/paper-dess-black-race-prostate-mortality-jama-oncol-2019/), [CHHiP: conventional versus hypofractionated high-dose intensity-modulated radiotherapy for prostate cancer](https://onco.cc/key-papers/paper-chhip-lancet-oncol-2016/), [D'Amico risk groups: biochemical outcome after radical prostatectomy, external beam radiotherapy or brachytherapy](https://onco.cc/key-papers/paper-damico-risk-groups-jama-1998/), [Detection of individual prostate cancer foci via multiparametric magnetic resonance imaging](https://onco.cc/key-papers/paper-johnson-mpmri-individual-foci-eur-urol-2019/), [ERSPC: screening and prostate cancer mortality in a randomised European study](https://onco.cc/key-papers/paper-schroder-erspc-screening-mortality-nejm-2009/), [Measurement of prostate-specific antigen in serum as a screening test for prostate cancer](https://onco.cc/key-papers/paper-catalona-psa-screening-test-nejm-1991/), [PIVOT: follow-up of prostatectomy versus observation for early prostate cancer](https://onco.cc/key-papers/paper-wilt-pivot-prostatectomy-observation-nejm-2017/), [PLCO: mortality results from a randomised prostate cancer screening trial](https://onco.cc/key-papers/paper-andriole-plco-prostate-screening-nejm-2009/), [PROMIS: diagnostic accuracy of multiparametric MRI and TRUS biopsy in prostate cancer](https://onco.cc/key-papers/paper-ahmed-promis-multiparametric-mri-lancet-2017/), [Prostate-specific antigen as a serum marker for adenocarcinoma of the prostate](https://onco.cc/key-papers/paper-stamey-psa-serum-marker-nejm-1987/), [ProtecT: 10-year outcomes after monitoring, surgery or radiotherapy for localised prostate cancer](https://onco.cc/key-papers/paper-protect-nejm-2016/), [ProtecT: fifteen-year outcomes after monitoring, surgery or radiotherapy for prostate cancer](https://onco.cc/key-papers/paper-protect-15-year-nejm-2023/), [RTOG 9408: radiotherapy with short-term androgen deprivation for localised prostate cancer](https://onco.cc/key-papers/paper-rtog-9408-short-term-adt-jones-nejm-2011/), [SPCG-4: radical prostatectomy or watchful waiting in prostate cancer, 29-year follow-up](https://onco.cc/key-papers/paper-bill-axelson-spcg-4-29-year-nejm-2018/), [USPSTF 2018: screening for prostate cancer, recommendation statement (grade C at 55 to 69, grade D at 70 and over)](https://onco.cc/key-papers/paper-uspstf-prostate-screening-jama-2018/)
- trials: [A Biomarker Study in Men With Localized Prostate Cancer Treated With Aglatimagene Besadenovec](https://onco.cc/trials/nct07332000/), [ASCENDE-RT](https://onco.cc/trials/ascende-rt/), [CHHiP](https://onco.cc/trials/chhip/), [DART 01/05 GICOR](https://onco.cc/trials/dart-01-05-gicor/), [EORTC 22991](https://onco.cc/trials/eortc-22991/), [ERSPC (European Randomized Study of Screening for Prostate Cancer)](https://onco.cc/trials/erspc/), [HYPO-RT-PC](https://onco.cc/trials/hypo-rt-pc/), [PACE-B](https://onco.cc/trials/pace-b/), [PIVOT (Prostate Cancer Intervention Versus Observation Trial)](https://onco.cc/trials/pivot/), [PROFIT (Prostate Fractionated Irradiation Trial)](https://onco.cc/trials/profit-trial/), [PROMIS](https://onco.cc/trials/promis/), [ProtecT](https://onco.cc/trials/protect/), [Radiation Therapy With or Without Androgen-Deprivation Therapy in Treating Patients With Prostate Cancer](https://onco.cc/trials/nct00936390/), [RTOG 94-08](https://onco.cc/trials/rtog-9408/), [SPCG-4 (Scandinavian Prostate Cancer Group Study 4)](https://onco.cc/trials/spcg-4/), [Study of the Efficacy, Safety and Quality of Life After TOOKAD® Soluble (VTP) for Intermediate Risk Prostate Cancer](https://onco.cc/trials/nct03315754/)
- drugs: [ArteraAI Prostate](https://onco.cc/drugs/artera-ai-prostate/), [Decipher Prostate](https://onco.cc/drugs/decipher-prostate/), [Leuprolide (leuprorelin) and GnRH agonists](https://onco.cc/drugs/leuprolide/)
- technologies: [Active surveillance](https://onco.cc/technologies/active-surveillance/), [Androgen deprivation & AR pathway inhibitors](https://onco.cc/technologies/androgen-deprivation/), [Brachytherapy](https://onco.cc/technologies/brachytherapy/), [Digital pathology & AI](https://onco.cc/technologies/digital-pathology-ai/), [Hypofractionated radiotherapy](https://onco.cc/technologies/hypofractionated-radiotherapy/), [IMRT / IGRT (modern external beam)](https://onco.cc/technologies/imrt-igrt/), [Robotic & minimally invasive surgery](https://onco.cc/technologies/robotic-surgery/), [SBRT / SABR (stereotactic radiotherapy)](https://onco.cc/technologies/sbrt/)
- roadmaps: [Prostate cancer roadmap: from Huggins and the discovery that a cancer can depend on a hormone, through the PSA epidemic and what it cost, the androgen receptor drugs, the DNA repair subset and PSMA, to a 2032 registry watch](https://onco.cc/roadmaps/prostate-roadmap/)
- ideas: [Judge a prostate screening programme on metastatic presentation, not on incidence or mortality](https://onco.cc/ideas/idea-prostate-metastatic-presentation-as-the-screening-endpoint/), [Publish a per-lesion miss rate for every prostate MRI service before it is allowed to guide focal treatment](https://onco.cc/ideas/idea-prostate-per-lesion-mri-audit-before-focal-treatment/), [Report death from other causes as an outcome of the prostate cancer service, split by deprivation and ethnicity](https://onco.cc/ideas/idea-prostate-other-cause-mortality-as-a-reported-service-outcome/)
- people: [Caroline Moore](https://onco.cc/people/caroline-moore/), [David Dearnaley](https://onco.cc/people/david-dearnaley/), [Jenny Donovan](https://onco.cc/people/jenny-donovan/), [Nicholas van As](https://onco.cc/people/nicholas-van-as/)

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JSON: https://onco.cc/api/v1/entities/prostate-intermediate-risk.json