Therapeutic options in locally defined or advanced prostate cancer

Objective: Critical discussion of the available therapeutic options in locally defined or advanced prostate cancer (PCa) in the absence of standards or guidelines. Methods: Medline-based survey of the pertinent literature. The therapeutic options are presented stage-by-stage. Results: Intracapsular PCa (T-1a-T2bN0M0) is preferably managed by radical prostatectomy; 'insignificant' cancers may be treated expectantly. The outcome of irradiation is not as predictable as radical surgery. The following points regarding treatment of locally advanced PCa are still under debate: neoadjuvant treatment is probably not as efficient as believed; technical refinements of radical prostatectomy may be helpful; in some instances, the value of adjuvant treatment is undecided. The efficacy of irradiation in conjunction with androgen deprivation probably equals the efficacy of surgery. No consensus can be found in the presence of positive lymph nodes, although single institutions achieve remarkable results with surgery plus androgen deprivation. Conclusion: Prognostic factors beside the clinical stages and grades should be incorporated in the treatment decision, and quality-of-life measurement should gain more importance when the treatment outcome is assessed.