Beyond Gleason score, pretreatment serum PSA, and stage at diagnosis, additional pathologic factors including percent positive biopsy cores, PSA density and velocity, length of core involvement by tumor, and presence of perineural invasion also portend prognostic significance.

Since the clinical behavior of prostate cancer might range from indolent to highly aggressive, prognostic assessment is important for predicting outcome and treatment selection. A number of prognostic schemes have been developed. The clinical grouping system developed by the National Comprehensive Cancer Network (NCCN) is summarized, in addition with suggested general risk-adapted treatment recommendations in Table 2. Localized prostate cancer can be treated with surgery, radiation therapy, or the combination of both. In addition, hormonal therapy plays a role in the treatment of locally advanced disease. For selected patients with very low- or low-risk disease, active surveillance may be a valid option. It should be noted that no randomized trial exists comparing modern radiation with prostatectomy techniques, and that oncologic outcomes for localized prostate cancer appear similar, when appropriate radiation doses are employed (Kupelian et al. 2004). In a recent large scale comprehensive review of the literature by Grimm et al. (2012) comparing risk stratified patients by treatment option and with long-term follow-up, the statistical analysis suggested that, in terms of biochemical-free progression, brachytherapy provides superior outcome in patients with low-risk disease. For intermediate-risk disease, the combination of EBRT and brachytherapy appears equivalent to brachytherapy alone. For high-risk patients combination therapies involving EBRT and brachytherapy plus or minus androgen deprivation therapy appear superior to more localized treatments such as seed implant alone, surgery alone or EBRT.