**Localized prostate cancer**

The lack of evidence regarding the effectiveness of treatment options for clinically localised prostate cancer continues to impact on clinical decision-making. The two such options are radical prostatectomy (RP) and active surveillance (AS). (44)

For the majority of men with favorable-risk localized disease, older than 65, surveillance will be an attractive option that avoids adverse effects of treatment(45). But the existing trials,

Radical Prostatectomy in High Risk Prostate Cancer 139

An alternative to patients risk-grouping with similar but not identical risk features is use of multivariable models such as nomograms. These models incorporate data from all risk factors relevant to the probability of treatment failure and proportionately weigh their

Eastham et al. demonstrate that high-risk patients were more likely to exhibit adverse pathologic features and to have biochemical progression. Nevertheless, roughly one-third of high-risk patients (22% to 63%, depending on the definition) had organ-confined cancers and roughly half (41% to 74%) remained progression-free 10 years after surgery alone. These results confirm that current definitions of high risk disease are unreliable in identifying

Men with high-volume lesions or high-stage yet clinically localized disease must receive multimodal therapy. More advances will require concerted efforts through clinical trials. (45) Neoadjuvant Androgen Deprivation Therapy may indeed provide no additional benefit over surgery alone for patients with clinically localized prostate cancer. Recent studies have demonstrated the feasibility of neoadjuvant chemotherapy prior to RP in patients with highrisk prostate cancer. (17). If such a strategy was shown to be effective, future clinical practice could be altered significantly. A randomized phase 3 clinical trial, CALGB 90203, is currently investigating whether neoadjuvant chemo-hormonal therapy followed by RP

relative contribution in order to calculate a risk score. (48)

patients who cannot be cured by local therapy. (48)

2. Trying to decrease prostate cancer progression 3. To increase metastatic disease free interval

**3.4 Actual treatment in high risk prostate cancer** 



should be based on the best available clinical evidence. (49)

with clinically localized, high-risk prostate cancer. (50)

1. To offer a radical treatment

4. To provide a proper quality of life.

Actually, the optimal treatment are:

men treated with RP.

either RP or RT.

**3.3 Objectives of treatment in high risk prostate cancer**  The actual objectives of the treatment of high prostate cancer are:

reduces the risk of biochemical recurrence when compared to RP alone.

There is no consensus regarding the optimal treatment of men with high-risk PCa.

Surgery is showing good results, but decisions on whether to elect surgery as local therapy

On the other hand, it has been recently assessed the effect of RP and RT on the rate of distant metastases in patients with clinically localized prostate cancer on the study from Memorial Sloan Kettering Cancer Center comparing patients whom underwent surgery versus radiotherapy (50). Patients with clinical stages T1c-T3b prostate cancer treated with intensity-modulated RT (81 Gy) from 1998 to 2002 were compared with similar cohort of

This study, showed that patients with higher-risk disease, treated with RP had a lower risk of metastatic progression and prostate cancer-specific death, than men treated with RT. The metastatic progression is infrequent in men with low-risk prostate cancer, treated with

These results, despite being from retrospective review of patients treated at a single institution, certainly suggest that RP should be considered as a treatment option in men

provide insufficient evidence to allow confident statements to be made about the relative beneficial and harmful effects of RP and AS for patients with localised prostate cancer.(44) Klotz L et al. assure that active surveillance with treatment reserved for evidence of rapid PSA progression or increase in tumor volume or grade is associated with about a 3% risk of prostate cancer death at 10 years. (46)

### **Advanced prostate cancer**

In the other hand, patients with prostate cancer continue to present with metastatic disease or to relapse following initial hormone therapy; for these men, the optimal combination and sequencing of new medical treatments must be defined. (45)

#### **High risk prostate cancer**

For these patients, (T2c-T3-T4 or PSA >20 or Gleason score ≥8) it is very important to give information about the different treatment options, and trying to adequate them to their live expectancy and quality of live.

Urologist, traditionally recommended radiotherapy or androgen deprivation therapy over RP, not because oncologic outcomes were better with radiotherapy, but because incontinence and impotence rates with RP were higher, and cure rates was discouraging. (47)

Actually, RP and radiotherapy have potential benefits and cumulative toxicities that must be matched to disease characteristics and patient expectations in selecting a treatment course. (48)
