Prostate cancer, high-risk localised

Typical sequence for High-risk localised disease; durations are protocol values (cycle counts and lengths, fraction schedules, guideline follow-up intervals), not averages of real patients. Your team's plan will differ in detail.

Phase by phase

1. 1. Diagnosis and staging

   weeks 0-8

   PSA, MRI-targeted biopsy with Gleason grading, and a PSMA PET-CT, which replaced bone scan and CT for staging (proPSMA).

   MRIPSMA PET
   Source
   Decision: Radiotherapy with hormone therapy, or radical prostatectomy?

   • Radiotherapy + 18-36 months ADT (+ abiraterone if very high risk)
   • Radical prostatectomy with node dissection, then radiotherapy if PSA rises or margins are involved
2. 2. Androgen deprivation therapy

   weeks 4-160

   GnRH agonist or antagonist injections for 18-36 months, starting before radiotherapy.

   ⟳Leuprolide (leuprorelin) and GnRH agonists⟳DegarelixAndrogen deprivation & AR pathway inhibitors
   Source
3. 3. Radiotherapy

   weeks 4-12 (alongside the previous phase)

   External beam radiotherapy to the prostate (and pelvic nodes) in 20 fractions over 4 weeks, or 5 fractions of stereotactic radiotherapy; brachytherapy boost in some centres. Radical prostatectomy is the surgical alternative.

   IMRT / IGRT (modern external beam)SBRT / SABR (stereotactic radiotherapy)Brachytherapy
   Source
4. 4. Abiraterone (very high risk)

   weeks 4-108 (alongside the previous phase)

   Two years of abiraterone with prednisolone alongside ADT improved survival in STAMPEDE for node-positive or very high-risk disease.

   ⟳Abiraterone acetate
   Source
5. 5. PSA surveillance

   from week 108, continues for years

   PSA every 6-12 months for at least 5 years then yearly; testosterone recovery after ADT; bone health monitoring.

   Source

Sources

• https://doi.org/10.1016/S0140-6736(20)30314-7
• https://doi.org/10.1016/S0140-6736(21)02437-5
• https://www.nccn.org/guidelines/category_1