Surgery or radiation: what is the optimal management for locally advanced prostate cancer?

To date, randomized trials comparing radiotherapy to surgery for adenocarcinoma of the prostate are few. Lacking, are randomized comparisons between treatment modalities for the patient with high-risk locally advanced disease. Hence, there is a need to determine which approach offers superior results in these patients who comprise a significant proportion of those dying of prostate cancer. In this short review we highlight key studies that may provide interim answers while awaiting definitive results from randomized studies.

A MEDLINE literature review was performed of studies evaluating current treatment modalities for high-risk (TNM stage >T2b, PSA>10, Gleason > or =8) prostate cancer. Publications from 1975 to present were searched using the keywords: prostate cancer, locally advanced prostate cancer, high-risk prostate cancer, prostatectomy, external beam radiation, brachytherapy, and PSA-doubling time.

Comparisons of different treatment modalities are difficult due to many factors, from uncertainties in clinical staging to the questionable equivalence of PSA failure. However, the general consensus is that low dose rate brachytherapy monotherapy is not ideal for high-risk patients. There are several options for combination therapy which show moderately good survival results. Because of the lack of prospective randomized trials comparing these approaches, matched analyses with uniform patient treatment and pathological review may provide an interim answer.

The optimal management for patients with locally advanced prostate cancer is unclear. While randomized clinical trials will eventually shed light on this question, interim solutions may provide some answers in the short term.