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Localised high-risk prostate cancer (Cambridge Prognostic Group 4) — MSRA MCQ

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HardProstate CancerLocalised high-risk prostate cancer (Cambridge Prognostic Group 4)MSRA

A 68-year-old man has newly diagnosed prostate adenocarcinoma. He is fit for curative treatment and has no major comorbidity. Multiparametric MRI shows organ-confined disease (cT2c) with no nodal or distant metastases. Targeted biopsy shows Gleason score 4+4=8 (grade group 4) adenocarcinoma. PSA is 14 micrograms/L. Following discussion with the urological cancer MDT, he prefers non-surgical radical treatment. Which management plan is most appropriate?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: A — Offer radical external beam radiotherapy with androgen deprivation therapy for 6 months, and discuss continuing androgen deprivation therapy for up to 3 years

Explanation lettering: D = shown as B · E = shown as C · C = shown as D · B = shown as E

This man has Cambridge Prognostic Group (CPG) 4 prostate cancer because a Gleason score of 8 alone meets CPG 4 criteria, despite a PSA below 20 micrograms/L and organ-confined T2 disease. He is fit for, and wishes to pursue, non-surgical curative treatment. NICE recommends radical radiotherapy combined with androgen deprivation therapy (ADT) for CPG 2–5 disease. ADT should be given for 6 months before, during or after external beam radiotherapy; for CPG 4 or 5 disease, continuing ADT for up to 3 years should also be considered after discussion of benefits and harms. B is incomplete because CPG 4 status requires consideration of prolonged ADT, not automatic cessation at 6 months. C omits ADT, which should accompany radical radiotherapy in this risk group. D is inappropriate because brachytherapy alone should not be offered for CPG 4 or 5 disease, although a brachytherapy boost alongside external beam radiotherapy may be considered. E is inappropriate because active surveillance should not be offered for CPG 4 or 5 localised or locally advanced prostate cancer.

Reference: NICE NG131: Prostate cancer: diagnosis and management — risk stratification and localised/locally advanced treatment recommendations (Last updated 15 December 2021) — https://www.nice.org.uk/guidance/ng131/chapter/Recommendations NICE NG131: Prostate cancer: diagnosis and management — radical radiotherapy and androgen deprivation therapy recommendations (Last updated 15 December 2021) — https://www.nice.org.uk/guidance/ng131/chapter/Recommendations