Management of high-risk prostate cancer: surgery or radiotherapy with hormonal treatment

Among the different treatment options recommended for high-risk prostate cancer (HRPC), radical prostatectomy (RP) is recognized along with radiotherapy, but its role is still controversial in monotherapy and difficult to evaluate in combined treatments. The results of clinical trials combining an external radiotherapy with a long-term androgen deprivation in locally advanced tumours sustain the principle of a multidisciplinary management in HRPC. Clinical and histological data associated with the MRI assessment remain essential and enhance the preoperative multidisciplinary decision, especially regarding nodal and distant metastases. An enlarged RP with an extended pelvic lymphadenectomy can be considered a viable alternative to radiotherapy and hormonal therapy. Morbidity of the procedure is similar to RP for organ-confined tumours, despite more erectile dysfunction due to non-sparing RP is observed in most of the cases. Oncological results of recent studies show 10-year and 15-year specific survival rates to be around 85% and 75% respectively, similar to those with hormonoradiotherapy. For high-risk and locally advanced prostate cancers, combined androgen deprivation and radiotherapy improved progression-free survival and overall survival. Local control is always necessary, but some patients will benefit from local aggressive treatment (surgery, postoperative radiotherapy or high dose radiotherapy), some may have a shorter adjuvant treatment, and probably some will need an intensification of general therapy: optimization of these approaches need further randomized trials. To cite this journal: Oncologie 14 (2012).