The role of surgery in high‐risk localised prostate cancer

Abstract

The optimal management of high‐risk localised prostate cancer is a major challenge for urologists and oncologists. It is clear that multimodal therapy including radical local treatment is needed in these men to achieve the best outcomes. External beam radiotherapy (EBRT) is an essential component of therapy either as a primary or adjuvant treatment. However, the role of radical prostatectomy (RP) is more controversial. Both methods are currently valid therapy options. There have been many individual studies of EBRT and RP in high‐risk disease, but no good quality large prospective randomized trials. In EBRT, combination with neoadjuvant plus long‐term adjuvant androgen‐deprivation therapy (ADT) has been conclusively shown to improve outcomes and is widely considered the standard of care. However, the role of RP has achieved recent prominence with several important studies. Published data from prospective randomized trials in patients after RP have shown that in men with adverse pathological features at surgery, the addition of adjuvant RT improves biochemical‐free and progression‐free survival. More recently, studies from large‐volume centres comparing EBRT and RP have provided intriguing suggestions of better outcomes with RP as the primary treatment. An important question therefore, is which of the two methods provides the best outcome in men with localised high‐risk disease. Crucially, does the combination of RP and selective adjuvant EBRT provide clinically significant better outcomes compared with EBRT alone? In this review we discuss the current evidence for the role of RP for high‐risk localised prostate cancer and define the parameters and urgent need for a prospective trial to test the role of surgery for this group of patients.

Molecular markers to guide primary radical treatment selection in localized prostate cancer

“…Recent refinements in surgical techniques using robotics have led to resurgence in the popularity of this modality to treat localized prostate cancer [9]. Recent work has shown that the addition of adjuvant local EBRT can improve the outcomes from surgery particularly when an aggressive or advanced tumor has been found at pathology or where the surgical resection is incomplete [27,28].…”

“…Where studied, it has been mainly in advanced disease where different chemotherapy or small molecule-based treatments are being considered in individualized therapy [4][5][6]. In primary prostate cancer, there is no chemotherapy or small molecule therapies that are used in treatment and none has been shown to work [7][8][9]. Instead, the key issue in individualized therapy for these patients is the selection between radical prostatectomy (RP) and radiotherapy-based treatments and, in particular, radical external beam radiotherapy (EBRT).…”

“…Instead, the key issue in individualized therapy for these patients is the selection between radical prostatectomy (RP) and radiotherapy-based treatments and, in particular, radical external beam radiotherapy (EBRT). To date, in terms of primary radical therapy, there is no good evidence that one form of treatment is any better than another for an individual patient in terms of disease progression, cancer-specific and overall disease survival [2,3,9]. Currently, there is no reliable method to predict therapy response at the time of diagnosis.…”

Multi-transcript profiling in archival diagnostic prostate cancer needle biopsies to evaluate biomarkers in non-surgically treated men

“…Clinical prostate cancer can be effectively treated by different modalities including surgery and external beam radiotherapy (EBRT) [1, 2]. There is currently no way of accurately predicting which therapy is best for an individual patient who may be otherwise eligible for both modalities [2, 3].…”

High resolution ultrasound features of prostatic rib metastasis: A prospective feasibility study with implication in the high-risk prostate cancer patient

“…Although controversial, the advent of prostate cancer screening has led to an increased diagnosis of the cancer at earlier stages resulting in high cure rates for those who have organ-confined disease. For men whose prostate specific antigen is >20 ng/ml, Gleason ≥8, or have clinical T3 or T4 disease (high risk), a staging whole body bone scan is recommended to evaluate for osseous metastasis [2,3]. Unfortunately, given the high sensitivity of bone scintigraphy, areas of increased technetium-99 m-MDP uptake are often found and may be related to trauma, degenerative disease, infection, or healing bone which complicates the staging for osseous metastasis [4].…”