Prostate cancer risk grading Unlike the TNM staging commonly used for other tumors, prostate cancer has its own dedicated risk grading criteria. This is based on early findings that T-stage, GS score, and PSA value are all factors that affect the prognosis of prostate cancer, and therefore define a risk grading for prostate cancer and use it to guide treatment. According to the NCCN guidelines, limited-stage high-risk prostate cancer is defined as meeting one or more of T3a or GS8-10 or PSA >20ng/ml, and for those with only one high-risk factor is called single high-risk. Very high-risk cases are defined as meeting one or more of T3b-4 or a primary GS of 5 or a stitch count of GS 8-10 >4. Preferred treatment for high-risk prostate cancer Surgery and radiation therapy are both radical treatments for high-risk prostate cancer, and which modality should be preferred depends on survival data. No prospective studies comparing surgery and radiotherapy have been reported, and there are more retrospective studies, but the vast majority of retrospective studies have generally enrolled cases in the radiotherapy group at a later stage than the surgery group, and even so, several retrospective studies have shown no significant differences in biochemical recurrence-free survival, distant metastasis-free survival, disease-specific survival, or overall survival rates for high-risk prostate cancer treated with radical radiotherapy versus after radical surgery. Data from Zelefsky et al. at Memorial Sloan-Kettering Oncology Center showed that even though patients in the radiotherapy group were staged significantly later than those in the surgery group, the 5-year biochemical recurrence-free survival rates were 80% and 84% for the radiotherapy and surgery groups, respectively, and the 8-year distant metastasis-free survival rates were 93% and 97%, respectively. The 10-year tumor-specific survival rates were 88% in the radiotherapy group, 92% in the radiotherapy + endocrine therapy group, and 92% in the surgery group, and the 10-year overall survival rates were 67% in the radiotherapy group and 77% in the surgery group, and more than 60% of patients in the surgery group received adjuvant radiotherapy or endocrine therapy. Therefore, the US NCCN guidelines recommend radiotherapy combined with endocrine therapy as the first choice for limited-stage high-risk and very high-risk prostate cancer (Class 1 evidence). The development of radiation therapy technology has further improved the efficacy and reduced the toxicity of radiation therapy for prostate cancer in the past decades. The efficacy of the treatment is improved while the urinary and rectal reactions are significantly reduced. In recent years, image-guided radiotherapy and real-time image-guided technology have been gradually introduced to further improve the accuracy of treatment. At the same time, surgical techniques are also improving, especially robotic-assisted lumpectomy, which is being gradually introduced. Because of the long survival period of prostate cancer, the 10-year disease-specific survival rate can reach more than 95%, so the long-term survival data we get now are mostly using the past techniques and low doses, while the survival results of new techniques need a long follow-up to be seen. Respecting patients’ wishes and individualized comprehensive treatment plan Prostate cancer is a tumor that progresses slowly and even for high-risk patients, life expectancy is long. Therefore, when deciding what treatment should be chosen first for high-risk patients, we need to fully explain to patients the possible complications and adverse effects of various treatments and respect patients’ own treatment wishes. The common toxic side effects of radiotherapy include urinary symptoms such as urinary frequency and urgency, rectal reactions such as increased frequency of stool, and a feeling of falling, but these acute symptoms are reversible and mostly recover in about 3 weeks after radiotherapy. Late urinary and rectal reactions of grade 3 and above, which affect patients’ quality of life, have gradually decreased with the application of new techniques, to about 5% in IMRT and less than 1% in image-guided techniques, and there are few urinary strictures and long-term pus and blood stools, which were common in the past. The main complication of surgery is urinary and fecal incontinence, which in severe cases significantly affects daily life. The high-risk group is currently the most controversial group in terms of the choice of treatment options for each stage of prostate cancer. The current risk grouping criteria only include T-stage, GS score and PSA value. In the future, we need to work together to discover more biomarkers at the genetic and molecular levels to guide treatment and prognosis, and to achieve individualized treatment according to the current treatment model for breast cancer.