Debate 1: Radical Prostatectomy For the Right Patient With High-Risk Prostate Cancer

Prostate cancer is a heterogeneous disease with varying degrees of metastatic potential and responsiveness to treatment. Whether surgical removal or radiation therapy combined with androgen deprivation therapy (ADT) is the best initial course of treatment for those with 'high risk' features poses an enduring clinical dilemma. In the absence of an adequate randomized clinical trial to resolve this question, contemporary decision-making seeks to balance expected treatment effectiveness and health-related quality of life over the long time horizon expected by most facing this choice. In this article, we distill the following 5 evidence-based arguments that commonly motivate patients to select radical prostatectomy as initial treatment of 'high-risk' prostate cancer. The first is that surgery alone provides excellent long-term cancer control and disease-related survival. Second, radical prostatectomy provides definitive local and regional disease staging, serving as the backbone for multimodality treatment if needed. Third, the sequencing of surgery before radiation is viewed as preferable beca by preserving options for effective local salvage. Fourth, initial surgery successfully defers or avoids the adverse effects of long-term androgen deprivation therapy in a substantial proportion of patients. Lastly, fifth, prostatectomy offers manageable impacts on urinary and sexual function, minimizing risk of gastrointestinal toxicity or secondary malignancy, and averts local symptomatic progression in most.