Addressing the needs of the high-risk prostate cancer patient

Abstract

For prostate cancer patients with a substantial risk of posttherapy progression, managing the disease with a risk-stratified approach and multimodal therapy is an evolving concept. Through an analysis of prostate-specific antigen (PSA) level, biopsy Gleason score, and clinical stage, investigators have been able to define low-, intermediate-, and high-risk disease in terms of the risk of progression after definitive local therapy. High-risk features include a PSA level greater than 20 ng/mL, a Gleason score of 8 to 10 or a clinical stage of T2c or higher. Because high-risk men treated by surgery or radiation therapy are at increased risk of progression and death from prostate cancer over the ensuing decade, various strategies have been used to improve their rates of disease-free progression and overall survival. Radiation therapy combined with hormonal therapy, radical prostatectomy combined with hormonal therapy or adjuvant radiation, and other approaches, such as chemo-hormonal therapy, are either under study or have been supported in randomized clinical trials. This review summarizes the current standard approaches to treating the man with high-risk disease.

Figure 1

Prostate-specific antigen (PSA)-based outcomes of low- and high-risk men with localized prostate cancer. RP, radical prostatectomy. Adapted with permission from D'Amico et al.

Figure 2

Changes in risk stratification in patients with newly diagnosed prostate cancer diagnosed in the “PSA era.” Reproduced with permission from Cooperberg et al.

Figure 3

Results of adjuvant radiation therapy in a group of high-risk men with postoperative prostate-specific antigen (PSA) levels of less than 0.2 ng/mL and matched controls followed with observation. bNED, biochemical nonevidence of disease. Reproduced with permission from Valicenti et al.

Figure 4

Results of Radiation Therapy Oncology Group study 9413. High-risk patients who received whole-pelvic radiation therapy (WP-RT), including prostate and lymph nodes, along with neoadjuvant hormonal therapy (NHT) had improved prostate-specific antigen recurrence rates compared with the other groups. PO-RT, prostate-only radiation therapy; AHT, adjuvant hormonal therapy. Reproduced with permission from Roach et al.