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What Is Intermediate Risk Prostate Cancer

Pretreatment Evaluation Of Patients With Intermediate

Intermediate-Risk Prostate Cancer Treatment – MUSC Hollings

In addition to routine history and physical examination, including a digital rectal examination, serum PSA, and serum testosterone, radiographical imaging of the abdomen and pelvis using computed tomography or magnetic resonance imaging should be obtained to assist in the evaluation of the extent of primary disease. Although the likelihood of bone metastases is low in men with intermediate-risk prostate cancer, bone scan may be appropriate for patients in whom there is high suspicion for metastatic disease based on laboratory, imaging, or clinical findings .

While CT imaging of the pelvis is the current standard, T2 MRI is superior to CT as it provides adequate soft tissue resolution to delineate the anatomy of the prostate, seminal vesicles, neurovascular bundles, and pelvic floor. MRI offers the ability to detect disease within and adjacent to the prostate gland that is not as easily visualized on CT . MRI, if obtained, can be fused to treatment planning CTs, allowing improved accuracy in contour definition of target and normal tissue volumes . This may result in improved clinical outcomes by decreasing normal tissue toxicity . MRI and magnetic resonance spectroscopy may have a role in the evaluation of tumor response to external beam radiation therapy and prostate brachytherapy .

The Risks Of Active Surveillance For Men With Intermediate

  • By Charlie Schmidt, Editor, Harvard Medical School Annual Report on Prostate Diseases

Men diagnosed with slow-growing prostate tumors that likely wont be harmful during their lifetimes can often avoid immediate treatment. Instead, they can have their tumor monitored using a strategy called active surveillance. With this approach, doctors perform periodic checks for tumor progression and start treatment only if the cancer begins to metastasize, or spread. Active surveillance has become popular worldwide, but doctors still debate which groups of men can safely use this strategy. Some doctors offer it only to men with the lowest risk of cancer progression. Others say that men with intermediate-risk prostate cancer can also make good candidates.

A new study now shows that intermediate-risk tumors are more likely to metastasize on active surveillance than initially expected. Most men do fine on surveillance, but we have detected a higher risk of metastasis among intermediate-risk patients over the long term, said Dr. Laurence Klotz, director of the active surveillance program at the University of Torontos Sunnybrook Health Sciences Centre, where the study was based.

When Is Brachytherapy Alone The Right Choice

For a patient with disease that is confined to the prostate and not too aggressive, brachytherapy alone is a good option. With the use of sophisticated real-time computer-based planning, we can use brachytherapy to deliver radiation in an extraordinarily precise way, with minimal exposure to the surrounding normal tissues. It is also convenient for the patient as it is done in an outpatient setting and most people are able to get back to work the next day.

But brachytherapy is not right for everyone. For some patients with less-aggressive disease, a watch-and-wait approach would also be very reasonable. At MSK, our philosophy is that when the disease is caught very early meaning a low PSA level, or nonaggressive disease as reflected by a Gleason score of 6 with evidence of cancer in only a few of the biopsy samples and no evidence from the MRI of a significant amount of disease then it would be very appropriate to do active surveillance and hold off on treatment.

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Active Surveillance And Focal Therapy For Low

Laurence Klotz

Division of Urology, Sunnybrook Health Sciences Centre, University of Toronto, Canada

Correspondence to:

Keywords: Active surveillance focal therapy low risk prostate cancer minimally invasive conservative management biomarkers

Submitted Jun 01, 2015. Accepted for publication Jun 05, 2015.

doi: 10.3978/j.issn.2223-4683.2015.06.03

Medical Research Council Rt01 Trial


This trial sought to evaluate whether NHT combined with dose-escalated RT would improve cancer control as measured by biochemical progression-free survival, freedom from local progression, metastasis-free survival, and overall survival, without a prohibitive increase in treatment-associated toxicity compared with NHT followed by standard dose RT. This is the largest randomized prospective dose-escalation trial, and the only one to prescribe NHT uniformly to all patients.

A total of 843 men with stage T1bT3a, N0, M0 prostate cancer, and serum PSA of less than 50 ng/ml first received between 3 and 6 months of NHT and were randomly assigned to receive 64 Gy over 32 fractions in 6.5 weeks or 74 Gy over 37 fractions in 7.5 weeks.

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What Is Your Prostate Cancer Stage

Your prostate cancer stage is set after testing. Stage describes if the tumor was detected or felt during the digital rectal exam. The prostate cancer stage also indicates whether or not the cancer may have spread to lymph nodes or other organs. Clinical stage is based on all information available prior to any treatment and designated by the TNM system as shown below.

Arent Nomograms More Predictive Of Prognosis

Nomograms are mathematical models used to attempt to individualize prognosis for individual patients. They use the PSA, stage and grade to predict results of various treatments. But nomograms are only as good as the data that is entered into them. For example, the current MSKCC nomogram for brachytherapy is VERY outdated. It includes patients Dr. Grimm treated from 1988-1990, but not his more recent patients with modern techniques. This data is incorrectly compared to updated surgical data. It is well recognized that within all treatment regimens the results have improved over the past 15 years primarily because the patients are diagnosed earlier and that the treatments are improved. Dr. Steven Frank at MD Anderson reported on the expected results of the MSKCC nomogram for brachytherapy compared to modern brachytherapy results and found the nomogram extremely inaccurate. Article

Thus, using the current MSKCC nomogram to compare surgical versus brachytherapy outcomes is extremely misleading. Therefore, rather than using a dated nomogram to decide on treatment, instead, look at modern results. Prostate Cancer Results Study Group

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Radiation Therapy For Prostate Cancer

Radiation therapy for prostate cancer involves the use of high-energy beams or radioactive seeds to eliminate tumors, provided by specialty doctors in the fields of urologic oncology and radiation oncology. Early-stage prostate cancer can often be successfully treated with a non-surgical option such as prostate radiation therapy. At UCLA, the most common types of radiation therapy offered for men with prostate cancer are brachytherapy, external beam radiation therapy, image-guided radiation therapy , and stereotactic radiotherapy.

Prostate Cancer Stage Rating System

Choosing a Treatment for Intermediate Risk Prostate Cancer | Prostate Cancer Staging Guide
T1 Cancer present, but not detectable in DRE or on imaging.

T1a Found incidentally, Less than 5 percent of sample malignant and low-grade.

T1b Found incidentally, More than 5 percent of sample malignant and/or not low-grade.

T1c PSA elevated, not palpable, found in needle biopsy.

T2 Tumor is palpable in DRE organ confined.

T2a Confined to half or less than half in one of the prostates two lobes.

T2b Confined to more than one half of one lobe of gland but not both.

T2c The tumor is in both lobes but within the prostatic capsule.

T3 Locally extensive cancer.

T3a Penetration of prostate capsule on one or both sides.

T3b Invasion into the seminal vesicle.

T4 Tumor extension to other organs.

T4a Cancer that has invaded the bladder neck and/or rectum and/or external urinary sphincter.

T4b Cancer that involves other areas near the prostate.

N Lymph node involvement.

NO No cancer detected in the lymph nodes.

N1 Cancer spread to one or more lymph nodes measuring less than 2cm.

N2 Cancer spread to one or more lymph nodes measuring 2-5cm.

N3 Cancer spread to one or more lymph nodes measuring more than 5cm.

M Metastasis to distant sites other than lymph nodes .

MO Cancer that is confined to the prostate, surrounding tissues and pelvic lymph nodes.

M1 Cancer that has spread beyond the pelvic area to bones, lungs, etc.


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Treatment Of Unfavorable Intermediate Risk Prostate Cancer

Biographies:Related Content:Read the Full Video Transcript

Ashley Ross: Hi, I’m Ashley Ross speaking for UroToday. I’m a urologist at Northwestern at the AUA 2022. This year. We had some interesting discussions around the use of decipher in unfavorable, intermediate risk, prostate cancer. Genomics has played a larger role in our practices as urologists. Particularly at initial diagnosis. For a while, we were using its prognostic ability to help guide us on decisions regarding active surveillance or active treatment for men with localized prostate cancer, mostly in the low and favorable intermediate risk space. They published some retrospective, an analysis of prospective randomized data in the RTOG 0126 trial. And this was with intermediate risk patients getting radiation for their prostate cancer. Many of which were unfavorable, intermediate risk patients. And they showed that you could use a genomic classifier to stratify those patients into low risk or into high risk categories. And by that stratification determine whether or not they would have benefit from adding androgen deprivation therapy to their treatment. In those studies men without androgen deprivation therapy, who were genomic high risk had metastasis rates of about 20%.

Katie Murray: Thank you.

Dr Mark Scholz Award Winning Prostate Oncologist Examines The New England Journal Of Medicine’s Prostate Study

News provided by

LOS ANGELES, CA, UNITED STATES, January 10, 2023 / — Dr. Mark Scholz, award winning prostate oncologist, values this study and believes much was to come of it. “Unnecessary diagnosis of harmless variants of prostate cancer occurs in 100,000 men annually in the US, often leading to mutilating surgery and impotence,” states Scholz. “The PSA blood test, which is a component of a mans annual physical exam, is often blamed for the overdiagnosis of prostate cancer, but the #1 culprit is an outdated and somewhat brutal procedure called the Template Prostate Biopsy, which consists of randomly jabbing the prostate a dozen times through the rectum with a large-bore needle to extract tissue samples.”

The most important finding of the study was that there was a 50% reduction in the diagnosis of clinically insignificant prostate cancer in men who underwent MRI screening as compared with men who underwent Template biopsy. Clinically significant cancer that was missed by MRI only occurred in 10 participants. and all cases were of intermediate risk and involved mainly low-volume disease that was managed with active surveillance.

The avoidance of Template biopsy in favor of MRI-directed targeted biopsy for screening and early detection in persons with elevated PSA levels reduced the risk of overdiagnosis by half at the cost of delaying detection of intermediate-risk tumors in a small proportion of patients.

Aurora DeRose

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Who Remained Prostate Cancer Free

Intermediate Risk patients experience a wider range of results and approaches due to the risk of disease beyond the prostate. When selecting a course of action, consultations are recommended with a urologist or surgeon, radiation oncologist and medical oncologist. Different treatments have different results and side effects. It is important to understand the potential impact each treatment can have on your quality of life after treatment.

Intermediate Risk patients are at a higher risk for cancer relapse or recurrence than Low Risk patients. That means patients in this risk group are more likely to have their cancer return following initial treatment, which may require additional treatment. To understand how effective the treatment or combination of treatments, are in keeping patients in remission, Doctors perform periodic monitoring or testing PSA levels, following treatment. It is very unlikely that the cancer will ever return, if you remain in remission for 10-15 years after prostate cancer treatment. Click on Get the Study, to obtain your copy of Foundations work. Share this Study with your Doctor as you select your treatment plan.

Intermediate Risk is any of the following:

PSA greater than 10 less than 20

Gleason Score is 7

How to Use the Graph
About the Data

Options For Treating Intermediate Risk Prostate Cancer


Finding out you or a loved one has been diagnosed with prostate cancer can be a scary thing to hear. The first thing many men ask is, what does this mean, and is my prostate cancer curable. Before I delve into treatment options with men, I like to discuss the specific risk group they belong to.

While many cancers are described as stage 1, 2, 3, or 4 cancers, localized prostate cancers are more typically described as low risk, intermediate risk, or high risk. Furthermore, many physicians group patients into sub-groups within each of these categories. These risk category groups are used to determine both how aggressive your prostate cancer is and what the best treatment may entail. Your specific risk group of prostate cancer is determined by a combination of factors, including, but not limited to, the PSA blood test value and the Gleason score determined by the prostate biopsy. This article will further discuss treatments for intermediate risk prostate cancer, specifically.

The Prostate Cancer Foundation has a nice, simple guide and video describing the prostate cancer risk groups here.

One of the best large studies to show the results of prostate brachytherapy in this population of men is NRG/RTOG 0232, a large randomized trial that included 588 men. In this trial, men with intermediate risk prostate cancer were randomized to 2 different treatments

The theory was that the combination therapy may increase the overall cure rate

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What Is A Risk Group

Evaluating the results of treatment can be done in multiple ways. Patient can be evaluated using a single characteristic such as the stage, the grade or the PSA. For example, all Stage T1c patients could be evaluated. However, the problem with this is that favorable prognosis patients can be lumped in with poorer prognosis patients. For example if your cancer was staged T1c and has a low grade, you wouldnt want patients with high grade included in the analysis. You want to know how patients like you do after treatment.Multiple studies have indicated that patients with slightly different characteristics can be organized into groups that have similar outcomess. For example a Low Risk patient with a T1c, Gleason Score 6 cancer and a PSA of 5 will behave very similarly to a patient with a T2a, Gleason Score 6 and PSA of 8. By grouping patients with similar results, large numbers of patients can be analyzed for the results of a treatment. By grouping these patients, we are able to compare the success of any treatment regimen.

The Natural History And Molecular Biology Of Low Grade Prostate Cancer

Prostate cancer develops with age in the majority of men, including those from all races and regions. In Caucasians, the chance of harboring prostate cancer is approximately the same as ones age thirty percent of men in their 30s, 40% in their 40s, 80% in their 80s . Most of these are microfoci and low grade, particularly in younger men. The high prevalence of microfocal prostate cancer has been confirmed in autopsy studies of Caucasians, Asians, and other ethnic groups going back more than 50 years. A recent autopsy study in Japanese and Russian men who died of other causes showed that overall 35% of both groups had prostate cancer, and 50% of the cancers in Japanese men aged > 70 were Gleason score 7 or above .

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Validating This New Classification System

In order to validate the new classification system, the same authors retrospectively reviewed 1,024 men with intermediate-risk prostate cancer who underwent definitive DERT, defined as 81 Gy. They evaluated biochemical recurrencefree survival, incidence of distant metastasis, and PCSM in patients classified as FIR or UIR. They also examined the effect of ADT on the aforementioned endpoints. The investigators reported that primary Gleason pattern 4 , percent positive biopsy cores 50% , and multiple intermediate-risk factors were all significant predictors of increased distant metastasis in multivariate analyses. Primary Gleason pattern 4 and percent positive biopsy cores 50% both independently predicted an increased PCSM. They also reported that men with UIR disease had inferior biochemical recurrencefree survival , distant metastasis , and PCSM compared with those with FIR disease, despite the fact that UIR patients were more likely to receive ADT . Interestingly, they also found no difference in outcome between FIR patients and 511 low-risk patients treated with radiation doses of at least 81 Gy in terms of biochemical recurrencefree survival , distant metastasis , or PCSM .

Focal Therapy For Prostate Cancer

Active Surveillance in Favorable Intermediate-Risk Prostate Cancer

With recent advances in MRI and targeted biopsy, we are better able to locate the exact area of prostate cancer. Men who do not have an enlarged prostate, who have prostate cancer that is detected only in a single region of the prostate and have intermediate grade cancer can be a candidate for focal therapy. This type of therapy treats only the cancerous tissue and spares the normal prostate, thereby preserving urinary and sexual function

Here at UCLA we commonly use cryotherapy or HIFU to focally treat prostate cancer. Given that this is a relatively new form of treatment, we have established rigorous post-treatment protocols using MRI and biopsies to ensure that the cancer has been adequately treated.

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Surgeon Dr Daniel Costa Associate Professor Of Radiology At Ut Southwestern Medical Center Tells Keras Sam Baker The New Procedure Uses Ultrasound To Destroy Tumors In The Prostate

How does the procedure work?

A probe is placed in the urethra. They read through. Sits right in the middle of the prostate. This is all done under real-time MRI guidance so we can see where the heat has been delivered to make sure that the cancer is properly treated. And we don’t want to cause any damage to areas such as the nerves responsible for sexual function, or the bladder and the sphincter responsible for urinary function.

Why use ultrasound?

We don’t have to make an incision. So there is no cutting, no wound, and there is no blood loss.

We know that exposing certain tissues for a certain period of time, for a certain temperature will result in permanent cell death. And that is true for cancerous tissues and non-cancerous tissues.

Who’s the prime candidate for the ultrasound approach?

The typical patient is a patient that has what we call intermediate-risk prostate cancer. Prostate cancers are graded on a one to five scale, with one being the least aggressive, and five being the most aggressive. The intermediate risk is grades two and three. So that’s one of the conditions.

The other condition is the patient’s prostate. And where the cancer is located has to be within a certain distance, three centimeters from where the probe sits. So that is one of the reasons why it’s important for patients interested in this treatment option to be vetted by somebody familiar with prostate imaging.

At what point does surgery become necessary?



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