High-risk prostate cancer is a heterogeneous disease that lacks clear consensus on its ideal management. Historically, non-surgical treatment was the preferred strategy, and several studies demonstrated improved survival among men with high-risk disease managed with the combination of radiotherapy and androgen deprivation therapy (ADT) compared with ADT alone. However, practice trends in the past 10-15 years have shown increased use of radical prostatectomy with pelvic lymph node dissection for primary management of high-risk, localized disease. Radical prostatectomy, as a primary monotherapy, offers the potential benefits of avoiding ADT, reducing rates of symptomatic local recurrence, enabling full pathological tumour staging and potentially reducing late adverse effects such as secondary malignancy compared with radiation therapy. Retrospective studies have reported wide variability in short-term (pathological) and long-term (oncological) outcomes of radical prostatectomy. Surgical monotherapy continues to be appropriate for selected patients, whereas in others the best treatment strategy probably involves a multimodal approach. Appropriate risk stratification utilizing clinical, pathological and potentially also genomic risk data is imperative in the initial management of men with prostate cancer. However, data from ongoing and planned prospective trials are needed to identify the optimal management strategy for men with high-risk, localized prostate cancer.
Nature reviews. Urology. 2020 Nov 10 [Epub ahead of print]
Lamont J Wilkins, Jeffrey J Tosoian, Debasish Sundi, Ashley E Ross, Dominic Grimberg, Eric A Klein, Brian F Chapin, Yaw A Nyame
Department of Urology, Glickman Urologic and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA., Department of Urology, University of Michigan, Ann Arbor, MI, USA., Department of Urology, Ohio State University Comprehensive Cancer Center, Columbus, OH, USA., Texas Urology Specialists, US Oncology Research, Mary Crowley Cancer Research, Dallas, TX, USA., Division of Urology, Duke University, Durham, NC, USA., Department of Urology, MD Anderson Cancer Center, Houston, TX, USA., Department of Urology, University of Washington Medical Center, Seattle, WA, USA. .