[Primary Tumour Treatment in Patients with Metastatic Prostate Cancer]

Prostate cancer (PCa) with distant metastasis at diagnosis (M1) is associated with an unfavourable prognosis. Therefore, according to current treatment guidelines, local treatment (radical prostatectomy or irradiation of the prostate gland) is not recommended in men with M1 disease. However, M1 patients inevitably develop castration-resistant disease progression leading to local complications in half of men. Hence, local treatment, if reconcilable with a good quality of life, would have the potential to prevent future local symptoms. Furthermore, evolving data from genomic studies suggest that local treatment might have the potential to reduce further spread of lethal cancer clones by eliminating the primary tumour or nodal metastasis. This leads to the experimental concept of cytoreductive preventative local treatment. According to large US-American and German cancer registries, there is a growing body of evidence pointing towards a survival benefit for M1 patients who receive local treatment in combination with systemic therapy. These data provide the basis to generate the hypothesis of a better response to systemic tumour therapy in metastatic prostate cancer, which would be the rationale for prospective randomised trials, but would not suffice for a treatment recommendation to be given. While there is a dynamic paradigm shift in the systemic treatment of hormone-naive M1 prostate cancer, local treatment for primary tumours will only have a chance to be established in this indication if prospective randomised trials are successfully completed.