High risk prostate cancer carries a higher likelihood of spreading beyond the prostate. However, new advances in treatment can help reduce the recurrence rate as well as extend life.

High risk prostate cancer isn’t just a medical diagnosis — it’s a call to action. This aggressive form of the disease means there’s a higher risk that the cancer will grow quickly, spread beyond the prostate, or come back after treatment. But thanks to major medical advances, people with this form of cancer now have access to multiple effective treatment options. Some of these can help extend survival and reduce the risk of recurrence.

This article answers some of the most frequently asked questions about the best treatments for high risk prostate cancer.

Doctors classify prostate cancer into risk groups based on how likely it is to grow and spread.

“High-risk prostate cancer refers to cancer that has a higher likelihood of growing quickly, spreading outside the prostate, or recurring after treatment,” says Martina Ambardjieva, MD and urologist at Dr Telx. She also points out that there are different subtypes based on clinical stage, which include the following:

  • localized high risk (confined to the prostate or just beyond)
  • locally advanced high risk (extending to surrounding tissues or lymph nodes)
  • metastatic (spread to distant organs or bones)

There isn’t a one-size-fits-all treatment for high risk prostate cancer. Your doctor will look at your overall health, risks, type of cancer, and other personal factors before recommending treatment. However, a combination of therapies tends to work best.

“The best treatment depends on patient-specific factors, but combined approaches (radiotherapy plus long-term androgen deprivation therapy) are often preferred for improved control in high risk cases,” Ambardjieva explains.

Some of the best treatments include:

  • radical prostatectomy (surgical removal of the prostate, often combined with radiotherapy or hormone therapy)
  • external beam radiotherapy (EBRT) combined with long-term androgen deprivation therapy (ADT)
  • brachytherapy in combination with EBRT for selected patients

The combination of radiation and hormone therapy is a common course of action because it’s quite effective. However, older adults with prostate cancer or those with other medical issues may choose a less aggressive form of treatment due to potential complications.

A prostatectomy is the surgical removal of the prostate gland and sometimes the nearby lymph nodes. Doctors want to remove the cancer from the body, and in some instances, when it has spread to the lymph nodes, the surgeon will also remove those to stop it from spreading to other parts of the body. Your doctor may follow up surgery with hormone and radiation therapy, depending on your personal health and risk factors.

Androgens (dihydrotestosterone, or DHT, and testosterone) assist cancer cells, so stopping them from doing so helps shrink the cancer or stop it from growing. Long-term androgen deprivation therapy (ADT) blocks androgens, so the cancer cells are less likely to grow. For individuals with a high risk of prostate cancer, doctors may prescribe hormone therapy with radiation, before radiation, or if it has spread.

There are three types of radiation for high risk prostate patients: EBRT, internal radiation (brachytherapy), and injectable medication with radiation (radiopharmaceuticals). In EBRT, a machine focuses beams of radiation on the prostate gland. In people with high risk prostate cancer, this can help ease bone pain or treat cancer that has spread. Although conventional radiation therapy may require several weeks with five treatments per week, hypofractionated radiation therapy reduces treatment time by delivering slightly higher doses over a shorter period, eliminating the need for weeks of radiation therapy.

Technology advancements in cancer treatments have helped make treatment safer and more effective. For example, long-term ADT shows better outcomes than short-term ADT, so it has now become the standard treatment. In addition, image-guided radiation helps medical professionals see the prostate for more targeted care, maximizing treatment while decreasing possible toxicity.

Brachytherapy, also called internal radiation, interstitial radiation therapy, or seed implantation, is where a doctor places tiny radiation seeds (about the size of a grain of rice) into your prostate. If you are a high risk individual, your doctor will typically offer brachytherapy only in combination with external radiation.

Injectable medication, also called radiopharmaceuticals, can treat high risk prostate cancer. Your doctor may prescribe Xofigo (radium-223), Quadramet (samarium-153), or Metastron (strontium-89) if the disease has spread to your bones. Other medications (177Lu-PSMA-617 or Pluvicto) target prostate-specific membrane antigen (PSMA), a protein found in prostate cancer cells. A PSMA PET scan can indicate if your prostate cancer cells contain PSMA.

Radiation can irritate your bladder or rectum and cause other symptoms, including:

  • diarrhea
  • rectum or urinary leakage
  • bloody stool or urine
  • a loss of urinary control
  • fatigue
  • erectile dysfunction
  • lymphedema (excess fluid in legs or groin)

Brachytherapy (seed implantation) can also cause bowel, urinary, and erection problems like:

  • diarrhea
  • rectal pain
  • bleeding
  • burning
  • frequent urination
  • erectile dysfunction

Most of the time, these symptoms will go away on their own.

The side effects of radiopharmaceuticals include:

  • dry mouth
  • nausea
  • fatigue
  • decreased appetite
  • constipation
  • weakness
  • kidney damage
  • paleness
  • shortness of breath
  • bruising or bleeding easily
  • increased infection risk

It’s crucial to drink lots of water when taking a radiopharmaceutical to reduce the risk of kidney damage.

“Early detection and proper risk stratification are essential to avoid overtreatment or undertreatment,” says Ambardjieva. If you have a family history of prostate cancer or the BRCA1/2 mutation, this could increase your risk of aggressive disease, so your doctor may recommend genetic testing. Talk with your medical professionals about your individual risks and treatment options so you can get the best treatment for high risk prostate cancer.