Standard Prostate Cancer Treatment in 2026: What Is the Right Answer?

For prostate cancer, there is no single "gold standard"—the standard is choosing among active surveillance, surgery, radiation therapy, and hormone therapy based on the risk group (low, intermediate, high, or metastatic).

Key Takeaways

• Korea's 5-year relative survival rate for prostate cancer is 96.9%, up 37.7 percentage points from patients diagnosed in 1993–1995 (National Cancer Registration Statistics 2019–2023, National Cancer Center Korea).
• Low-risk disease is one of the rare cancers for which active surveillance—watching at set intervals without treatment—is a standard option.
• For intermediate-risk disease, both surgery and radiation therapy are standard; the choice often comes down to differences in the nature of side effects rather than differences in outcomes.
• For high-risk or locally advanced disease, the standard is either surgery plus lymph node removal followed by additional radiation, or radiation combined with several years of hormone therapy.
• For metastatic disease, the standard has become combining hormone therapy from the start with anti-androgen agents and/or chemotherapy.

Why isn't there a single "gold standard" treatment?

• Prostate cancer often progresses slowly, so entirely different treatments become standard depending on the risk group. Treatment decisions are not based on stage alone but on a risk group formed by combining PSA level, Gleason score (Grade Group 1 through 5), and stage—along with age, life expectancy, and coexisting conditions.
• The Gleason score is calculated by scoring two patterns of how different cancer cells look from normal tissue on biopsy and adding them together; this is then organized into Grade Groups 1 through 5. A higher Grade Group is considered more aggressive cancer.
• So the accurate answer to "which is better, surgery or heavy-ion therapy?" isn't which one is "better"—it's which one is "right" for the individual case.

How does the standard treatment differ by risk group?

• For low-risk disease (low PSA, lowest Grade Group, cancer confined to a small area within the prostate), active surveillance using PSA, MRI, and repeat biopsy as needed is the standard. Treatment begins only if signs of progression appear.
• For intermediate-risk disease, both radical prostatectomy and radiation therapy are standard. If radiation is chosen, a short course of hormone therapy may be added depending on the case.
• For high-risk or locally advanced disease, pelvic lymph nodes are also removed during surgery, and radiation is added afterward depending on surgical findings. If radiation is chosen instead, several years of hormone therapy is part of the standard.
• For metastatic disease, hormone therapy is the backbone of treatment, and the standard has become combining it from the outset with stronger anti-androgen agents or chemotherapy. If hormone therapy stops working, other drug classes, chemotherapy, or PSMA-targeted radioligand therapy are considered.

What is the sequence from diagnosis to treatment direction?

• Step 1: If a PSA blood test is elevated or a digital rectal exam finds an abnormality, a prostate MRI is done first.
• Step 2: If the MRI shows a suspicious area, an MRI-fusion biopsy targeting that spot yields the Gleason score and Grade Group.
• Step 3: MRI is used to check for invasion of the prostate capsule, and if the risk group is high, a bone scan or PSMA PET is used to check for metastasis.
• Step 4: PSA, Grade Group, and stage are combined to determine the risk group, and together with age, life expectancy, and coexisting conditions, a direction is chosen among active surveillance, surgery, radiation therapy, and hormone therapy.
• Step 5: After treatment, PSA is measured at set intervals to check for recurrence.

FAQ — Which is better, surgery or radiation (including heavy-ion therapy)?

It's not about which is better, but which is right for you. Robotic radical prostatectomy is widely used for localized prostate cancer surgery and is known to be favorable for nerve preservation, typically requiring 5–7 days of hospitalization. Heavy-ion therapy has been available in Korea since 2023 and, for localized prostate cancer, is typically completed in about 12 sessions; whether it can be used depends on prior radiation history, presence of an artificial hip joint, and bowel/bladder condition. Either way, the choice is made based on age, risk group, priorities regarding urinary incontinence and sexual function, and urinary status.

FAQ — Can it still be treated if it has spread to the bone?

Metastatic prostate cancer can often be controlled for a long time with hormone therapy as the backbone. Combining drugs from the start has become the standard, alongside bone-protecting agents and radiation therapy to reduce pain. However, this stage is not aimed at cure, and the duration of control varies by individual.

Sources and Notes

• This article was written based on the National Cancer Registration Statistics 2019–2023 (Korea Central Cancer Registry, National Cancer Center), U.S. SEER 2016–2022, the National Cancer Information Center, and NCCN patient guidelines.
• This content is provided for general medical information purposes only, and actual diagnosis, treatment methods, and outcomes may vary depending on individual conditions. Accurate diagnosis and treatment should always be determined through consultation with a medical professional.