The management of high risk prostate cancer

A major problem that urologists encounter is the recurrence of prostate cancer after local therapy or the failure of primary therapy. There is no consensus on the treatment of these groups of patients. The role of radiotherapy, hormonal therapy or chemotherapy must be defined.

A comprehensive literature review of the current management of recurrence after primary therapy in prostate cancer was performed using MEDLINE, a review of current urology and oncology journals, and abstracts from recent urology meetings. The data collected focused on the role of radiotherapy, hormonal therapy and chemotherapy in this setting.

Defining a high risk group of patients using Gleason score, seminal vesicle or pelvic lymph node involvement and prostate specific antigen recurrence time is important for treating the problem early in disease course. Adjuvant radiotherapy cannot offer a survival advantage but it provides longer biochemical recurrence-free survival. Early administration of salvage radiotherapy in adequate doses provides a success rate similar to that of adjuvant radiotherapy in patients with low prostate specific antigen. Although there is no good evidence that early androgen deprivation definitely prolongs patient survival, increased time to progression in addition to excellent palliation with early hormonal therapy was reported in the majority of trials. Early trials of the use of chemotherapy showed improved survival rates with adjuvant chemotherapy alone or with a combination of hormonal therapy, especially in patients with nonmetastatic disease.

Although analysis of current literature revealed that patients who have recurrence after primary therapy would benefit from radiotherapy, hormonal therapy, chemotherapy or a combination of therapies, additional prospective randomized studies are needed to support these findings.