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.