Carlos G. Arcangeli, MD & Mark A. Rosen, MD

Adult and Pediatric Urology

Treatment of High-Risk Localized Prostate Cancer

What is high-risk localized prostate cancer?

High-risk localized prostate cancer is cancer that appears to be contained in the prostate, but has a high probability that there may already be microscopic spread of cancer. Our best x-ray tests cannot find microscopic cancer cells that are outside the prostate, but we know from experience that certain patients have a higher risk of microscopic spread of cancer cells and eventual recurrence of the cancer. These patients have a higher chance of eventual symptoms or death from prostate cancer. Patients with two or more of the following cancer features are considered to have high-risk prostate cancers:

Men with high-risk prostate cancer who have 10 or more years of life ahead of them need aggressive treatment to increase their chances of cancer cure.

What is the best way to treat high-risk localized prostate cancer?

There is no one treatment for high-risk localized prostate cancer that has been proven to be the best treatment. It is clear, however, that most patients with high-risk prostate cancer require more than one type of treatment to increase the chance of cure. The concept of multi-modality treatment is common for many other types of cancer, including breast cancer in women. Which combination of treatments is”best” is not clear at this time, and the best combination of treatments may depend on the extent of the cancer, and also on the patients urinary symptoms, prostate size, and general medical health. Some of the more common combinations of treatments used for high-risk localized prostate cancers are described below.

Surgery and External Beam Radiation

Surgery to remove the entire prostate, called laparoscopic prostatectomy followed by external beam radiation is a common approach for men with high-risk localized prostate cancer. Men who choose this combination undergo surgery, recovery for seveal months, and then undergo daily external radiation treatments to the pelvic area for 7-8 weeks. Some patients may also take hormonal therapy for some length of time after surgery. There is some preliminary evidence that surgery to remove the prostate improves the long-term survival of men with high-risk localized prostate cancer compared to men who don’t have the prostate removed.

There are a number of potential advantages of initial surgery for high-risk localized prostate cancer. In some cases, examination of the prostate after it has been removed shows that the cancer is contained in the prostate, and these men may be able to avoid radiation treatments. Surgery will usually prevent local recurrence of the cancer in the future, which can cause urinary bleeding, difficulty urinating, or obstruction of the kidneys.

Disadvantages of initial surgery include the risks of surgery, which include a small risk of urinary incontinence and a high chance of impotence. In most cases, surgery for high-risk localized prostate cancer involves wide excision of the tissues around the prostate, including the nerves that cause erections.

Radiation and Hormonal Therapy

There are a number of studies that show that the combination of radiation treatments and hormonal therapy increases the chance for cancer cure compared to radiation treatments alone for men with high-risk localized prostate cancer. Men usually start hormonal therapy 2-3 months before radiation treatments and continue the hormonal therapy for 12-36 months after the radiation treatment is finished.

Advantages of this approach include the fact that men can avoid the risks of surgery. Some men may feel that they do not want to take the risks of surgery, including incontinence, if they will need to have radiation treatments afterwards anyway. Disadvantages of this approach include the possibility of local recurrence of prostate cancer in the prostate because the prostate has not been removed. Recurrence of cancer in the prostate can caused bothersome urinary symptoms, bleeding, or urinary obstruction. Hormonal therapy can also cause bothersome side effects, including hot flashes, decreased sex drive, and osteoporosis.

The role of chemotherapy

At the present time chemotherapy for prostate cancer treatment is used for men with advanced prostate cancer who have recurrent cancer after using hormonal therapy. There are experimental trials of surgery and chemotherapy, or radiation treatment and chemotherapy, but these are not the standard of care at this time

Conclusion

Your urologist and radiation oncologist can give you advice about the best combination of treatments for your individual case. There is no consensus on the “best” treatment for high-risk localized prostate cancer, but prostate cancer experts agree that aggressive, combined treatment has the best chance of curing high-risk localized prostate cancer.

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