What would Peter Hoskin do? 
Rémi has node positive prostate cancer based on size criteria on CT imaging and consistent with high grade (Gleason 4+5) disease. There is no evidence of more distant metastatic disease. He is otherwise fit with a probable life expectancy >10 years but does have some urinary outflow symptoms. He should be offered radical treatment.
My choice would rest between A and D. Whilst a lymph node dissection would yield diagnostic information, the probability of nodal metastases is high given the size criteria. Combinations of surgery and radiotherapy in the pelvis undoubtedly increase morbidity following treatment. The EORTC and RTOG data show a clear survival advantage for ADT in this setting and for high grade disease a period of two years is recommended.
What is the role of docetaxel or abiraterone in this setting? He does not fulfil the criteria for CHAARTED or LATITUDE which studied patients with metastatic disease; STAMPEDE included node positive patients and showed a non-significant effect on patients with node positive only disease. Overall therefore the impact of docetaxel or abiraterone in this patient is not supported by current published data. Docetaxel would be associated with significant treatment-related toxicity.
As presented at ESTRO 38, there is level 1 evidence to show that in high risk disease combined external beam and brachytherapy has a superior biochemical control compared to external beam alone and hence, as a clinical oncologist for non-surgical treatment I would recommend D. It was also shown in this presentation that ADT may not be needed when brachytherapy is given, and if he had significant toxicity I would have a low threshold for reducing the period of treatment.
So what is the case for A? This would be an option and should be put to the patient for informed choice between this and option D. He should know that surgery in this setting may have a higher risk of erectile dysfunction and whilst it would resolve his outflow symptoms, he may have minor leakage of urine.
Want to challenge me? I’m happy to discuss these data in more detail during PROSCA on 23-24 October in Paris!