STEP 4: Treatment

Step 4 describes the optimal treatments for prostate cancer, the training and experience required of the treating clinicians and the health service characteristics required for optimal cancer care.

All health services must have clinical governance systems that meet the following integral requirements:

  • identifying safety and quality measures
  • monitoring and reporting on performance and outcomes
  • identifying areas for improvement in safety and quality (ACSQHC 2020).

Step 4 outlines the treatment options for prostate cancer. For detailed clinical information on treatment options refer to these resources:

The intent of treatment can be defined as one of the following:

  • curative
  • anti-cancer therapy to improve quality of life and/or longevity without expectation of cure
  • symptom palliation.

The treatment intent should be established in a multidisciplinary setting, documented in the patient’s medical record and conveyed to the patient and carer as appropriate.

The potential benefits need to be balanced against the morbidity and risks of treatment.

The lead clinician should discuss the advantages and disadvantages of each treatment and associated potential side effects with the patient and their carer or family before treatment consent is obtained and begins so the patient can make an informed decision. Supportive care services should also be considered during this decision-making process. Patients should be asked about their use of (current or intended) complementary therapies (see Appendix D).

Timeframes for starting treatment should be informed by evidence-based guidelines where they exist. The treatment team should recognise that shorter timeframes for appropriate consultations and treatment can promote a better experience for patients.

Initiate advance care planning discussions with patients before treatment begins (this could include appointing a substitute decision-maker and completing an advance care directive). Formally involving a palliative care team/service may benefit any patient, so it is important to know and respect each person’s preference (AHMAC 2011).

For any given patient, multiple lines and modalities of treatment might be required.

This may involve:

  • watchful waiting
  • active surveillance
  • surgery (radical prostatectomy)
  • radiation therapy by external beam radiation therapy (EBRT) and/or brachytherapy (Cancer Australia 2017a)
  • focal ablative therapies.

For most men having active curative treatment for their prostate cancer, there are several viable options for their treatment with similar long-term cancer outcomes. It is important that men are fully informed of their treatment options by the relevant trained specialists (radiation oncologist and urologist) as part of their decision making before initiating any treatment. Men should be strongly encouraged to have an opinion from both a radiation oncologist and a urologist.

Watchful waiting

Watchful waiting is appropriate in some patients, especially those with complex health issues who are not expected to live more than seven years (PCFA and CCA 2016). These patients should undergo regularly monitoring and symptoms should be treated if they arise. If the cancer progresses, it may be more appropriate that they receive palliative treatment rather than a treatment with a curative intent such as surgery or radiation therapy.

Active surveillance

Most men with low-risk prostate cancer will not die from their cancer. Men with low-risk prostate cancer should be offered the opportunity to be regularly monitored for signs of disease progression so curative treatment can be initiated if necessary (PCFA and CCA 2016). There is no universally accepted active surveillance protocol, but all are based on regular clinical monitoring (PSA/DRE) and interval tumour reassessment (repeat biopsy/MRI) (Klotz 2019).

Surgery (radical prostatectomy)

Patients with localised or locally advanced prostate cancer, with at least 10 years life expectancy and who have been assessed by a multidisciplinary team, may benefit from surgery.

Timeframe for starting treatment

Surgery should be conducted within three months of diagnosis or within 4 weeks if significant local symptoms are present.

Training and experience required of the surgeon

Fellow of the Royal Australian College of Surgeons or equivalent with adequate training and experience that enables institutional credentialing and agreed scope of practice in prostate cancer (ACSQHC 2015).

Documented evidence of the surgeon’s training and experience, including their specific (sub-specialty) experience with prostate cancer and procedures to be undertaken, should be available.

Health service characteristics

To provide safe and quality care for patients having surgery, health services should have these features:

  • critical care support
  • 24-hour medical staff availability
  • 24-hour operating room access and intensive care unit
  • diagnostic imaging
  • pathology
  • nuclear medicine imaging
  • specialist urology, continence nursing and physiotherapy support
  • support for managing common complications of surgery such as treating incontinence with artificial urinary sphincters or slings.

Radiation therapy (by external beam radiation therapy and/or brachytherapy)

A number of patients may benefit from radiation therapy with EBRT and/or brachytherapy:

  • those with localised/locally advanced prostate cancer who have at least a 10-year life expectancy or have symptomatic disease
  • those with locally advanced disease who may benefit from multimodal therapy
  • those patients with a rising/persistent PSA or established local recurrence without evidence of metastatic disease following radical prostatectomy
  • those who have limited bone metastases – these patients may still benefit from radiation therapy to the prostate gland (Parker et al. 2018) to improve survival.

Some patients will receive neoadjuvant/adjuvant hormones with radiation therapy.

Timeframe for starting treatment

Treatment should begin within three months of the diagnosis or within four weeks if significant local symptoms are present.

Training and experience required of the appropriate specialists

The radiation oncologist should be a Fellow of the Royal Australian and New Zealand College of Radiologists, or equivalent, with adequate training and experience, and institutional cross-credentialing and agreed scope of practice in prostate cancer (ACSQHC 2015).

The training and experience of the radiation oncologist should be documented.

Health service unit characteristics

To provide safe and quality care for patients having radiation therapy, health services should have these features:

  • suitably trained brachytherapy staff where appropriate
  • access to allied health
  • linear accelerator (LINAC) capable of image-guided radiation therapy (IGRT)
  • dedicated CT planning
  • access to MRI and PET imaging
  • automatic record-verify of all radiation treatments delivered
  • a treatment planning system
  • trained medical physicists, radiation therapists and nurses with radiation therapy experience
  • access to equipment and staff for inserting fiducial markers before beginning radiation therapy
  • coordination for combined therapy with systemic therapy, especially where facilities are not co-located
  • participation in Australian Clinical Dosimetry Service audits
  • an incident management system linked with a quality management system.

Every patient presenting with metastatic disease should be referred to a medical oncologist and discussed at an MDM before starting therapy unless it is an emergency.

Androgen deprivation therapy

ADT is the standard treatment for men with advanced prostate cancer. There is little survival benefit related to initiating ADT treatment early (rather than later). Therefore, the timing of ADT treatment initiation is often related to balancing the risk of significant side effects of ADT (many of which increase over time) against the unwanted effects of the disease. When ADT therapy is indicated it can be initiated by any lead clinician after an appropriate multidisciplinary team discussion unless it is an emergency.

Clinicians prescribing ADT (including general practitioners and clinical practice nurses) should be trained in its administration and be knowledgeable about the long-term side effects of ADT. Side effects should be monitored through regular patient reviews.

Other systemic therapy

For patients with metastatic disease, cytotoxic chemotherapy, novel androgen receptor signalling inhibitors, bisphosphonates and RANK ligand inhibitors may be of benefit.

Depending on both patient and disease factors, an upfront combination of systemic agents (e.g. docetaxel chemotherapy or androgen receptor signalling inhibitors and ADT) may result in more significant survival benefits than treatment sequencing.

Consideration should be given to the metabolic, cardiovascular and bone health of the patient and preventative measures instituted as appropriate. There should be a clear understanding with the care team as to who will undertake monitoring (the general practitioner, oncologist, urologist or radiation oncologist).

Timeframes for starting treatment

Treatment should begin within three months of the diagnosis if asymptomatic, or within four weeks if symptomatic or extensive metastatic disease is present on imaging.

Training and experience required of the appropriate specialists

Medical oncologists must have training and experience of this standard:

  • Fellow of the Royal Australian College of Physicians (or equivalent)
  • adequate training and experience that enables institutional credentialing and agreed scope of practice within this area (ACSQHC 2015).

Cancer nurses should have accredited training in these areas:

  • anti-cancer treatment administration
  • specialised nursing care for patients undergoing cancer treatments, including side effects and symptom management
  • the handling and disposal of cytotoxic waste (ACSQHC 2020).

Systemic therapy should be prepared by a pharmacist whose background includes this experience:

  • adequate training in systemic therapy medication, including dosing calculations according to protocols, formulations and/or preparation.

In a setting where no medical oncologist is locally available (e.g. regional or remote areas), some components of less complex therapies may be delivered by a general practitioner or nurse with training and experience that enables credentialing and agreed scope of practice within this area. This should be in accordance with a detailed treatment plan or agreed protocol, and with communication as agreed with the medical oncologist or as clinically required.

The training and experience of the appropriate specialist should be documented.

Health service characteristics

To provide safe and quality care for patients having systemic therapy, health services should have these features:

  • a clearly defined path to emergency care and advice after hours
  • access to diagnostic pathology including basic haematology and biochemistry, and imaging
  • cytotoxic drugs prepared in a pharmacy with appropriate facilities
  • occupational health and safety guidelines regarding handling of cytotoxic drugs, including preparation, waste procedures and spill kits (eviQ 2019)
  • guidelines and protocols to deliver treatment safely (including dealing with extravasation of drugs)
  • coordination for combined therapy with radiation therapy, especially where facilities are not co-located
  • appropriate molecular pathology access

Multiple agents are being developed and will be considered in the systemic treatment of these patients.

Therapies that show promise for treatment of prostate cancer include novel hormonal and targeted therapies, immunotherapies, combination therapies and radiopharmaceuticals (Sonnenburg & Morgans 2018).

For certain classes of drugs under investigation (e.g. PARP inhibitors), germline or somatic genomic testing (e.g. defects in genes involved in DNA repair) may help predict the patient’s treatment response.

Theranostics is an emerging treatment using radioactive substances that are taken into sites of prostate cancer spread, enabling high doses of radiation to be delivered to tumour sites. Examples are radioactive molecule lutetium-177 (Lu-177) labelled to a small molecule targeting prostate-specific membrane antigen (PSMA) and radium 223.

Radiation therapy is also emerging as an additional promising treatment for patients with oligometastatic prostate cancer. There are multiple ongoing trials evaluating the benefit of metastasis-directed therapy using conventional and stereotactic body radiation therapy (SBRT) to treat patients with oligometastatic or oligoprogressive disease (Palma et al. 2019). The rationale for metastasis-directed therapy is to either delay the need for additional systemic therapies or to use in combination with systemic therapies to further improve progression-free survival.

The key principle for precision medicine is prompt and clinically oriented communication and coordination with an accredited laboratory and pathologist. Tissue analysis is integral for access to emerging therapies and, as such, tissue specimens should be treated carefully to enable additional histopathological or molecular diagnostic tests in certain scenarios.

Early referral to palliative care can improve the quality of life for people with cancer and in some cases may be associated with survival benefits (Haines 2011; Temel at al. 2010; Zimmermann et al. 2014). This is particularly true for cancers with poor prognosis.

Interdisciplinary palliative care can improve symptom management and enhance the wellbeing of men with metastatic prostate cancer (Cancer Council Australia Advanced Prostate Cancer Guidelines Working Party 2010).

The lead clinician should ensure patients receive timely and appropriate referral to palliative care services. Referral should be based on need rather than prognosis. Emphasise the value of palliative care in improving symptom management and quality of life to patients and their carers.

The ‘Dying to Talk’ resource may help health professionals when initiating discussions with patients about future care needs (see ‘More information’). Ensure that carers and families receive information, support and guidance about their role in palliative care (Palliative Care Australia 2018).

Patients, with support from their family or carer and treating team, should be encouraged to consider appointing a substitute decision-maker and to complete an advance care directive.

Refer to Step 6 for a more detailed description of managing patients with recurrent, residual or metastatic disease.

More information

These online resources are useful:

The team should support the patient to participate in research or clinical trials where available and appropriate. Many emerging treatments are only available on clinical trials that may require referral to certain trial centres.

For more information visit the Cancer Australia website.

The Pathfinder Prostate Cancer Research Register is a national online register for men interested in participating in research into improving the health and lives of people post-prostate cancer treatment. For more information visit the register’s website.

See validated screening tools mentioned in Principle 4 ‘Supportive care’.

A number of specific challenges and needs may arise for patients at this time:

  • assistance for dealing with emotional and psychological issues, including body image concerns, fatigue, quitting smoking, traumatic experiences, existential anxiety, treatment phobias, anxiety/depression, interpersonal problems and sexuality concerns
  • mood lability or depression as a result of ADT, which may benefit from referral to a psychologist or consideration of mood-stabilising medication
  • erectile and ejaculation dysfunction and impotence as a result of treatment, which may require referral to a medical specialist and/or nurse practitioner skilled in counselling in this area
  • urinary dysfunction, including urinary incontinence, requiring pads, referral to a continence nurse and/or pelvic floor physiotherapist
  • bowel dysfunction or rectal bleeding, which may require referral for endoscopic evaluation and dietitian review
  • weight gain and fluid retention, and fatigue and loss of muscle mass as a result of ADT, which may require referral to a dietitian for review and referral to an exercise physiologist or physiotherapist for an individualised exercise program
  • assistance with managing complex medication regimens, multiple medications, assessment of side effects and assistance with difficulties swallowing medications – referral to a pharmacist may be required
  • potential isolation from normal support networks, particularly for rural patients who are staying away from home for treatment
  • decline in mobility or functional status as a result of treatment
  • assistance with beginning or resuming regular exercise with referral to an exercise physiologist or physiotherapist (COSA 2018; Hayes et al. 2019).

Early involvement of general practitioners may lead to improved cancer survivorship care following acute treatment. General practitioners can address many supportive care needs through good communication and clear guidance from the specialist team (Emery 2014).

Patients, carers and families may have these additional issues and needs:

  • financial issues related to loss of income (through reduced capacity to work or loss of work) and additional expenses as a result of illness or treatment
  • advance care planning, which may involve appointing a substitute decision-maker and completing an advance care directive
  • legal issues (completing a will, care of dependent children) or making an insurance, superannuation or social security claim on the basis of terminal illness or permanent disability.

Cancer Council’s 13 11 20 information and support line can assist with information and referral to local support services.

For more information on supportive care and needs that may arise for different population groups, see Appendices A and B, and special population groups.

Rehabilitation may be required at any point of the care pathway. If it is required before treatment, it is referred to as prehabilitation (see section 3.6.1).

All members of the multidisciplinary team have an important role in promoting rehabilitation. Team members may include occupational therapists, speech pathologists, dietitians, social workers, psychologists, physiotherapists, exercise physiologists and rehabilitation specialists.

To maximise the safety and therapeutic effect of exercise for people with cancer, all team members should recommend that people with cancer work towards achieving, and then maintaining, recommended levels of exercise and physical activity as per relevant guidelines. Exercise should be prescribed and delivered under the direction of an accredited exercise physiologist or physiotherapist with experience in cancer care (Vardy et al. 2019). The focus of intervention from these health professionals is tailoring evidence-based exercise recommendations to the individual patient’s needs and abilities, with a focus on the patient transitioning to ongoing self-managed exercise.

Other issues that may need to be dealt with include managing cancer-related fatigue, improving physical endurance, achieving independence in daily tasks, optimising nutritional intake, returning to work and ongoing adjustment to cancer and its sequels. Referrals to dietitians, psychosocial support, return-to-work programs and community support organisations can help in managing these issues.

The lead or nominated clinician should take responsibility for these tasks:

  • discussing treatment options with patients and carers, including the treatment intent and expected outcomes, and providing a written version of the plan and any referrals
  • providing patients and carers with information about the possible side effects of treatment, managing symptoms between active treatments, how to access care, self-management strategies and emergency contacts
  • encouraging patients to use question prompt lists and audio recordings, and to have a support person present to aid informed decision making
  • initiating a discussion about advance care planning and involving carers or family if the patient wishes

The general practitioner plays an important role in coordinating care for patients, including helping to manage side effects and other comorbidities, and offering support when patients have questions or worries. For most patients, simultaneous care provided by their general practitioner is very important.

The lead clinician, in discussion with the patient’s general practitioner, should consider these points:

  • the general practitioner’s role in symptom management, supportive care and referral to local services
  • using a chronic disease management plan and mental health care management plan
  • how to ensure regular and timely two-way communication about:
    • the treatment plan, including intent and potential side effects
    • supportive and palliative care requirements
    • the patient’s prognosis and their understanding of this
    • enrolment in research or clinical trials
    • changes in treatment or medications
    • the presence of an advance care directive or appointment of a substitute decision-maker
    • recommendations from the multidisciplinary team.
More information

Refer to Principle 6 ‘Communication’ for communication skills training programs and resources.