Updates in the Management of CRPC - Episode 6

Treating High-Risk Localized Prostate Cancer

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Multiple treatment options exist for patients with high-risk localized or advanced prostate cancer, moderator Raoul S. Concepcion, MD, states. Both the patient and his physician should agree upon the treatment approach utilized, which include active surveillance, prostatectomy, radiotherapy, and cryosurgery.

For a patient with high-risk, Gleason 8 or higher localized prostate cancer with a PSA over 20 ng/ml, the treatment decision is difficult and likely requires multiple modalities. In this situation, surgical intervention may miss extracapsullary extensions and seminal vesicle involvement, states Steven E. Finkelstein, MD. As a result, Finkelstein prefers to utilize upfront radiation therapy in combination with hormonal therapy rather than radical prostatectomy.

In recent years, the effectiveness of surgery has increased substantially while the associated side effects have decreased, states David Albala, MD. Regardless of the type of treatment utilized, it is important to follow the patient to determine if further treatment is required. The effectiveness of each approach emphasizes the need for multidisciplinary care. Prior to treatment, each patient should meet with a radiation, medical, and surgical oncologist, in order to determine the best treatment plan, Albala stresses.

At this point in time, the current treatments for patients with high-risk prostate cancer are not sufficient, Stephen J. Freedland, MD, believes. A single treatment is unlikely to cure a patient, requiring a multimodal treatment approach. The ultimate goal is to prevent castration-resistant prostate cancer from developing, Freedland notes. To accomplish this, patients are likely going to need surgery plus radiation with hormonal therapy.

If radiation therapy is utilized before surgery, there is still the potential to perform a salvage perineal prostatectomy, states E. David Crawford, MD. This approach is effective and does not require robotic surgery. It is important to separate treatment from any potential hype, Crawford notes. The focus should be on ensuring an optimal outcome for the patient.

Regardless of the treatment utilized, it is important that the procedure is carried out in a reputable, quality-drive environment, Finkelstein notes. Outcomes vary greatly based on the experience of the provider. Moreover, Finkelstein states, treatment should always be delivered in a multidisciplinary fashion.