High risk prostate cancer: evolving definition and approach to management

Advances in the early detection and treatment of prostate cancer have progressed far beyond our ability to identify patients with high risk prostate cancer. In general, designation of high risk prostate cancer implies the presence of disease that is likely become progressive or lethal if not managed aggressively. Without proper risk stratification, there is a significant likelihood of both overtreatments of men with low risk disease and undertreatment for men with high risk cancer. The major issues surrounding the clinical management of high risk prostate cancer revolve around the definition of high risk disease as well as the benefits of multiple modality therapy. Over the years, numerous attempts have been made to develop risk assessment tools such as risk categories, scoring systems and nomograms, but a widely accepted definition is yet to be determined. The benefits of routine clinical utility of these risk assessment tools remain somewhat difficult to ascertain. We will discuss several multimodality therapeutic approaches, especially in combination with androgen ablation, to improve the outlook for men with high risk or locally advanced prostate cancer. This review focuses on the potential limitations of the risk assessment tools available to the clinicians and the approach to management of high risk prostate cancer.