Counseling the patient with regional metastasis of prostate cancer

Treatment options for all stages of prostate cancer are a source of considerable debate; patients with regional nodal metastases have been advised to undergo a wide range of therapies from observation with delayed endocrine treatment to an aggressive combination of radical prostatectomy (RP), radiation therapy (RT), and hormonal treatment.

In the absence of reliable data to confirm the wisest choice, a clinician must counsel the patient based on treatment morbidity, the best estimate of efficacy, and an appreciation of the patient's individual desires regarding treatment. Patients with minimal microscopic nodal metastases treated with RP are destined to have relapses ultimately, but the development of metastases may take 5-10 years even with no additional therapy. Immediate hormonal treatment combined with RP currently is used more commonly, and a subgroup of patients have remained disease-free for more than 10 years. Local morbidity can occur as a consequence of RP or RT or, later in the disease course, secondary to progressive growth of the cancer in the prostate. Finally, the ability to detect nodal metastases with minimal morbidity is available using laparoscopic pelvic lymphadenectomy. Thus, more emphasis may be placed on defining nodal status before definitive therapy.

Historically, nodal status was used to define whether the patient was eligible for aggressive local therapy; the presence of positive lymph node metastases disqualified a patient to receive RP or RT. In the future, nodal status may not define local therapy but instead may determine whether the patient receives adjuvant hormonal therapy or not. This more aggressive approach has gained acceptance because of the lowered morbidity of both RP or RT and the extended disease-free survival in at least a segment of the patient population. Because patients initially often select the form of local therapy best suited for them, this approach respects this initial decision by offering additional psychologic support in the long term.