An 89-year-old gentleman presented with severe urinary retention.
After careful discussion, his surgeon performed a radical prostatectomy. The final pathology showed pT3 prostate cancer, meaning that the cancer had extended beyond the prostate.
Naturally, this raised an important question:
“Should I start hormone treatment immediately to reduce the risk of the prostate cancer returning?”
The answer may be surprising.
Even though pT3 prostate cancer is considered a higher-risk finding, pT3 disease by itself does not automatically mean hormone treatment should start after surgery.
The same is true for several other concerning findings, including a positive surgical margin or a high Gleason score.
These findings increase the risk of recurrence, but they do not automatically prove that immediate hormone treatment will help an individual patient live longer.
Some personal details have been adjusted to protect patient confidentiality.
Who is this article for?
This article may be helpful if:
- you have recently had a radical prostatectomy;
- your pathology shows pT3 prostate cancer;
- your cancer has extended outside the prostate;
- the seminal vesicles are involved;
- your surgical margin is positive;
- your cancer is Gleason 8–10 or ISUP Grade Group 4–5;
- cancer has been found in the pelvic lymph nodes;
- ADT has been recommended after surgery; or
- you are considering radiotherapy, ADT or a newer androgen-receptor medicine.
The diamond answer
A high-risk pathology result does not automatically mean that hormone treatment should begin immediately.
The decision depends on the complete postoperative picture.
I would want to know:
- What is the PSA after surgery?
- Were lymph nodes involved?
- How many lymph nodes were positive?
- What was the Gleason score or Grade Group?
- Were the seminal vesicles involved?
- Were the surgical margins clear?
- Is radiotherapy being considered?
- What are the patient’s age, general health and life expectancy?
For men with pT3 but lymph-node-negative disease, ADT alone is generally not given routinely simply because the pathology looks high risk.
Cancer found in the lymph nodes changes the discussion considerably, but even then treatment should be individualised.
What is androgen deprivation therapy?
Most prostate cancers are stimulated by male hormones called androgens, particularly testosterone.
Androgen deprivation therapy, usually shortened to ADT, lowers testosterone or prevents it from stimulating prostate cancer cells.
Common ADT treatments include:
- leuprolide;
- goserelin;
- triptorelin;
- degarelix; and
- relugolix.
More intensive treatments targeting the androgen pathway include:
- apalutamide;
- enzalutamide;
- darolutamide; and
- abiraterone.
These drugs are extremely important in prostate cancer treatment.
However, that does not mean that every patient with an aggressive-looking pathology report should automatically receive them after surgery.
Which findings can look worrying after surgery?
A prostatectomy pathology report may contain terms such as:
- pT3 disease
- cancer extending outside the prostate
- seminal-vesicle involvement
- a positive surgical margin
- Gleason 8, 9 or 10 cancer
- ISUP Grade Group 4 or 5
- lymph-node involvement
Understandably, these findings can be frightening.
They tell us that the risk of recurrence may be higher than for a small cancer completely contained within the prostate.
But they do not all mean the same thing.
And they do not necessarily mean that surgery has failed.
What does pT3 actually mean?
pT3 prostate cancer means the tumour has extended beyond the prostate.
This may include:
- pT3a: extension outside the prostate; or
- pT3b: involvement of the seminal vesicles.
These findings increase recurrence risk.
However, some patients with pT3 disease will still have no detectable cancer after surgery.
That is why the next question is extremely important:
What happens to the PSA?
Why does PSA after surgery matter so much?
After the prostate has been removed, PSA would usually be expected to fall to a very low or undetectable level.
If the PSA becomes undetectable and stays that way, that is reassuring.
If PSA remains detectable or begins rising later, the possibility of remaining or recurrent prostate cancer becomes more important.
This is one reason I would not make a treatment decision from the word “pT3” alone.
The pathology and postoperative PSA need to be considered together.
Does a positive surgical margin mean I need ADT?
Not automatically.
A positive margin means prostate cancer cells were seen at the cut edge of the removed tissue.
This may increase the risk that microscopic cancer remains around the surgical area.
But a positive surgical margin is not, by itself, an automatic indication for systemic hormone treatment.
Depending on the PSA and other features, radiotherapy may become an important part of the discussion.
Why don’t we treat every high-risk patient immediately?
It can seem logical to think:
“If the cancer looks aggressive, why not treat it immediately just in case?”
The problem is that ADT affects normal tissues throughout the body as well as prostate cancer.
Possible side effects include:
- hot flushes;
- fatigue;
- loss of sexual function;
- reduced muscle mass and strength;
- weight gain;
- changes in blood sugar and metabolism;
- loss of bone density;
- increased fracture risk;
- mood changes;
- possible changes in memory or concentration; and
- possible cardiovascular effects in some patients.
These risks become particularly important in older patients.
So the important question is not simply:
“Does this cancer look aggressive?”
It is:
“Is there enough evidence that starting systemic treatment now will provide meaningful benefit for this particular patient?”
What if cancer is found in the lymph nodes?
This is an important difference.
Cancer found in the pelvic lymph nodes after prostatectomy is called pathologically node-positive or pN1 prostate cancer.
A landmark randomised study included 98 men whose prostate cancer had reached the lymph nodes after surgery.
The men were assigned either immediate hormonal treatment or observation until the disease progressed.
After approximately seven years of follow-up:
- 7 of 47 men receiving immediate hormone treatment had died;
- compared with 18 of 51 men whose hormonal treatment was initially delayed.
Longer follow-up continued to support a benefit from earlier treatment in this population.
This remains important evidence that some men with node-positive prostate cancer can benefit from early ADT.
But there is an important qualification.
This was a relatively small trial conducted many years ago, and many participants had more extensive lymph-node disease than some patients diagnosed today.
Does every patient with positive lymph nodes need immediate ADT?
Not necessarily.
Modern management is more individualised.
Current European guidance describes several possible approaches after surgery for pN1 disease, including:
- ADT;
- ADT combined with radiotherapy; or
- observation in carefully selected patients.
Observation may be considered in selected men who have undergone an extended lymph-node dissection, have two or fewer positive lymph nodes and an undetectable PSA after surgery.
That means one very small cancer deposit in one lymph node is not necessarily the same situation as several extensively involved lymph nodes.
The number of involved nodes, PSA and other pathological features all matter.
Is hormone treatment usually given with radiotherapy?
Frequently, yes.
When postoperative treatment is required, ADT is often discussed together with radiotherapy because the treatments perform different roles.
Radiotherapy can treat microscopic cancer that may remain around the prostate bed or pelvis.
ADT acts throughout the body against hormone-sensitive prostate cancer cells.
For some men with a rising PSA after surgery and higher-risk features, ADT may improve outcomes when added to salvage radiotherapy.
The important point is that postoperative treatment is often not simply:
“ADT or no ADT?”
The real decision may be between:
- PSA monitoring;
- radiotherapy alone;
- radiotherapy plus ADT;
- systemic treatment; or
- a carefully selected combination.
| Approach | What it does | When it may be considered |
| PSA monitoring | Watches for evidence of recurrence | When PSA is undetectable and immediate treatment may not be needed |
| Radiotherapy | Treats microscopic cancer that may remain around the prostate bed or pelvis | Selected patients with postoperative risk factors or a rising PSA |
| ADT | Suppresses hormone-sensitive prostate cancer cells throughout the body | Selected higher-risk or node-positive situations |
| Radiotherapy + ADT | Combines local and systemic treatment | Some patients with biochemical recurrence or higher-risk features |
| Intensified androgen treatment | Adds medicines such as apalutamide to ADT | Selected high-risk settings; not routine after every adverse pathology result |
Can ADT ever be given without radiotherapy?
Yes.
There are situations where systemic hormone treatment may be used without radiotherapy, particularly when:
- there is significant lymph-node-positive disease;
- radiotherapy is not suitable;
- the patient chooses not to receive radiotherapy; or
- the treating team believes systemic disease risk is the dominant concern.
However, for a patient with pT3 but lymph-node-negative disease, ADT alone would generally not be considered routine postoperative treatment simply because pT3 disease was found.
What about newer prostate cancer drugs?
This is an important and rapidly developing area.
Medicines such as apalutamide, enzalutamide, darolutamide and abiraterone block the androgen pathway more intensively than conventional ADT alone.
These medicines already have major roles in several settings in advanced prostate cancer.
The question is whether they should also be used earlier in selected high-risk patients around the time of surgery.
What did the PROTEUS trial show?
The PROTEUS trial, published in 2026, studied 2,109 men with high-risk localised or locally advanced prostate cancer.
This is important:
PROTEUS was not simply a trial where apalutamide was started after an unexpected pT3 pathology result.
Treatment began before surgery.
Patients received ADT for approximately six months before prostatectomy and six months afterward.
Half also received apalutamide.
At five years:
- approximately 78 in every 100 patients receiving apalutamide plus ADT were alive without distant metastasis;
- compared with approximately 74 in every 100 receiving ADT alone.
In statistical terms, adding apalutamide reduced the relative risk of distant metastasis or death by approximately 20%.
There was also more treatment toxicity.
Serious grade 3 or 4 adverse events occurred in approximately:
- 40 in every 100 patients receiving apalutamide; and
- 31 in every 100 patients in the comparison group.
These results are important, but longer follow-up is required to determine the final effect on overall survival.
Does PROTEUS mean everyone with high-risk pathology should receive apalutamide?
No.
This is one of the most important distinctions for patients to understand.
PROTEUS tested a planned perioperative strategy in patients already recognised as having high-risk disease before surgery.
It does not prove that every patient who unexpectedly receives a pathology report showing pT3 disease, a positive margin or a high Gleason score should immediately start apalutamide.
PROTEUS studied men with high-risk localised or locally advanced disease identified before surgery. How this approach should be applied to an individual patient requires consideration of the specific clinical setting.
What does this mean for my 89-year-old patient?
For this gentleman, the finding of pT3 disease alone would not make me automatically recommend ADT.
I would want to review:
- His postoperative PSA
Has it become undetectable, or does PSA remain detectable? - His lymph nodes
Were they negative? Was one node involved, or were several involved? - His complete pathology
What was the Grade Group? Were the seminal vesicles involved? Were the margins positive? - Whether radiotherapy is appropriate
Would postoperative or salvage radiotherapy provide meaningful benefit? - His overall health
At 89, heart health, bone strength, muscle function, independence and other medical conditions are highly relevant. - His likely benefit from treatment
Is the expected reduction in prostate-cancer risk large enough to justify the burden of ADT?
In some older patients, the potential side effects of hormone treatment may outweigh a modest or uncertain cancer benefit.
In selected patients, avoiding or delaying treatment may therefore represent appropriate treatment selection rather than undertreatment.
What would I usually consider?
For an individual patient after prostatectomy, I would want clear answers to a few questions:
- What was the final pT stage?
- What was the Gleason score or Grade Group?
- Were the margins positive?
- Were the seminal vesicles involved?
- Were lymph nodes removed?
- How many lymph nodes were positive?
- Has the PSA become undetectable?
- If PSA is detectable or rising, how quickly is it changing?
- Would salvage radiotherapy be appropriate?
- Would adding ADT to radiotherapy provide meaningful benefit?
- How long would ADT need to continue?
- What are the patient’s cardiovascular, metabolic and bone-health risks?
- Does a newer androgen-receptor treatment genuinely apply to this clinical situation?
- Would monitoring be reasonable?
The goal is not simply to give the most aggressive treatment.
It is to choose the treatment most likely to provide meaningful benefit for that particular patient.
What surprised me?
A prostatectomy pathology report can sound alarming.
Words such as pT3 disease, positive surgical margin, seminal-vesicle involvement or Gleason 9 cancer understandably make patients feel that further treatment must begin immediately.
But these findings do not all mean the same thing.
A patient with pT3 disease, negative lymph nodes and an undetectable PSA may face a very different decision from someone with several positive lymph nodes or a PSA that remains detectable after surgery.
The pathology tells us about risk.
The postoperative PSA, lymph-node findings and the patient’s overall health help determine what should happen next.
Key takeaways
- pT3 disease, a positive surgical margin or a high Gleason score do not automatically mean that ADT should start immediately after surgery.
- Postoperative PSA and whether cancer has reached the lymph nodes are important factors when deciding whether further treatment is needed.
- If further treatment is required, radiotherapy, ADT or a combination may be considered depending on the PSA, pathology, lymph-node involvement and individual patient factors.
- The PROTEUS trial showed improved metastasis-free survival with apalutamide plus ADT given before and after surgery in high-risk patients, but these results should not automatically be applied to every adverse prostatectomy result.
Key evidence
- Taplin ME, Gleave M, Shore ND, et al. Perioperative apalutamide in high-risk localized prostate cancer. N Engl J Med. 2026;395(6):546-560. doi:10.1056/NEJMoa2603878
- European Association of Urology. EAU Guidelines on Prostate Cancer. Published 2026. Accessed September 28, 2026. https://uroweb.org/guidelines/prostate-cancer
- Messing EM, Manola J, Sarosdy M, Wilding G, Crawford ED, Trump D. Immediate hormonal therapy compared with observation after radical prostatectomy and pelvic lymphadenectomy in men with node-positive prostate cancer. N Engl J Med. 1999;341(24):1781-1788. doi:10.1056/NEJM199912093412401
- Messing EM, Manola J, Yao J, et al. Immediate versus deferred androgen deprivation treatment in patients with node-positive prostate cancer after radical prostatectomy and pelvic lymphadenectomy. Lancet Oncol. 2006;7(6):472-479. doi:10.1016/S1470-2045(06)70700-8
- Morgan TM, Boorjian SA, Buyyounouski MK, et al. Salvage therapy for prostate cancer: AUA/ASTRO/SUO guideline part I: introduction and treatment decision-making at the time of suspected biochemical recurrence after radical prostatectomy. J Urol. 2024;211(4):509-517. doi:10.1097/JU.0000000000003892
Frequently asked questions (FAQs)
Does every pT3 prostate cancer need hormone treatment?
No. pT3 disease increases the risk of recurrence, but it does not automatically mean that immediate ADT is required. The postoperative PSA, lymph-node findings and other pathological features also matter.
Does a positive surgical margin mean I need ADT?
Not necessarily. A positive margin increases the risk of recurrence, but it is not by itself an indication for immediate systemic hormone treatment. Radiotherapy may be more relevant in some patients.
What if cancer is found in my lymph nodes?
Lymph-node involvement makes additional treatment more likely to be considered. Depending on the number of involved nodes, postoperative PSA and other risk factors, options may include ADT, ADT with radiotherapy or observation in carefully selected patients.
Can ADT be given without radiotherapy?
Yes. ADT may be used without radiotherapy in some situations, particularly in node-positive disease or when radiotherapy is unsuitable. However, ADT alone is not routinely required simply because pT3 disease has been found.
Should I start apalutamide after a high-risk prostatectomy result?
Not automatically. PROTEUS studied a planned treatment strategy in which apalutamide and ADT were started before surgery and continued afterward. The results should not be interpreted as meaning that every patient with pT3 disease, a positive margin or a high Gleason score should start apalutamide after surgery.
About Dr Dilanka De Silva
Dr Dilanka De Silva is a Melbourne-based Medical Oncologist and Cancer Genetics Physician with experience in precision oncology, prostate cancer treatment, hereditary cancer assessment and complex cancer second opinions.
He completed fellowship training at Memorial Sloan Kettering Cancer Center in New York and reviews Australian and international patients through Sloan Maccallum Cancer Care, including patients from Sri Lanka, the Maldives, Indonesia and the Philippines.
Dr Dilanka De Silva
MBBS, MRCP(UK), MRCP(UK SCE Oncology), FRACP, PhD
Medical Oncologist & Cancer Genetics Physician
Memorial Sloan Kettering Cancer Center Fellow (New York, USA)