Treatment will depend on the location, extent of recurrent or metastatic disease, previous management and the patient’s preferences. Accordingly, imaging may be important to define these parameters. When the identification of metastatic disease is deemed likely to change management, PSMA PET/CT is generally recommended as a preferred imaging investigation (Fendler et al. 2019).

In managing men with prostate cancer, treatment may include these options:

• surgery
• radiation therapy
• ADT
• cytotoxic chemotherapy (e.g. docetaxel)
• novel androgen receptor signalling inhibitors (e.g. enzalutamide or abiraterone)
• radionuclides (e.g. radium 223)
• supportive therapies such as bisphosphonates or RANK ligand inhibitors to manage bone metastatic disease or ADT-induced osteoporosis.

In the case of a rising PSA post-prostatectomy or a defined local recurrence (in the absence of metastatic disease), patients should be referred to a radiation oncologist to consider curative intent, salvage pelvic radiation therapy. All patients with metastatic prostate cancer should be reviewed, if possible, by a medical oncologist prior to or soon after starting ADT to assess their suitability for combination treatment. Patients who go on to develop metastatic castration resistant disease should be offered a referral to a medical oncologist to discuss whether other systemic treatments are appropriate. Patients with local symptoms should also be referred to a radiation oncologist to consider the benefit of palliative radiation therapy for symptom control.

The potential goals of treatment should be discussed, respecting the patient’s cultural values. Wherever possible, written information should be provided.

Encourage early referral to clinical trials or accepting an invitation to participate in research.