Significance of neoadjuvant therapy before radical prostatectomy

Neoadjuvant therapy before radical prostatectomy should increase survival in patients. This is necessary especially in patients with adverse prognostic factors for locally advanced disease, because in this stage radical prostatectomy as the only treatment results in a significantly reduced rate of progression-free survival. The aim of neo-adjuvant therapy protocols is to increase local tumor control because of possible downstaging effects of the tumor and to improve systemic control because of elimination of circulating tumor cells and possible micrometastases. This review discusses the present and future aspects of neoadjuvant therapies in detail. The neoadjuvant hormonal therapy prior to radical prostatectomy results in a significant downstaging that does not translate into prolonged disease-free survival. This observation was made for short-term (3 months) and long-term (8 months) hormonal therapy. Therefore, neoadjuvant hormonal therapy has only a cosmetic effect on the pathological results and should not be advocated any more. Newer protocols have shown that neoadjuvant chemotherapy or hormone chemotherapy is feasible. The results obtained in non-randomized trials with small numbers of patients do not allow analyzing the efficacy of these protocols. Theoretically, neoadjuvant chemotherapy, especially a taxane-based protocol, which has shown efficacy in hormone-refractory disease, could improve disease outcome. Clinical trials are underway to prove this hypothesis. In the future, new therapeutic strategies could also be used in the neoadjuvant setting. It can only be speculated if antibody protocols or gene therapy will be used in this respect. In conclusion, there is no standard neoadjuvant protocol prior to radical prostatectomy. Whether chemotherapy will set a new standard for care has to be elucidated by the ongoing clinical trials.