Prostate cancer patients with high risk features of lymph node spread and micrometastatic disease are generally treated with more aggressive local therapy often in combination with long- term androgen deprivation therapy. Some patients who are at extremely high risk of micrometastatic disease, treatment with systemic therapy alone is often considered without local therapy. For information on treating early stage prostate cancer, refer to the article on Prostate Cancer Treatments.
High Risk Prostate Cancer
Combined EBRT with Brachytherapy
A combination of external-beam radiation therapy (EBRT) and brachytherapy is considered to be suitable treatment option for patients with higher-risk prostate cancer. A high-dose rate temporary brachytherapy is sometimes preferred in the combination therapies. Read more on EBRT and brachytherapy under Prostate Cancer Treatments.
Androgen Deprivation Therapy (ADT) and Radiation Therapy
Pelvic radiation therapy can be safely combined with neoadjuvant and concurrent ADT providing better results and is recommended for patients with locally advanced prostate cancer. Neoadjuvant ADT for 3 to 4 months before radiotherapy reduces the size of prostate and also acts like a radiosensitizer, thereby improving the effectiveness of the EBRT. ADT can also be continued as a long term adjuvant therapy to improve overall survival. Read more on radiation therapy under Prostate Cancer Treatments.
Radical Prostatectomy with Adjuvant Radiotherapy
High-risk patients who underwent radical prostatectomy but have positive margins, seminal vesicle involvement or detectable PSA are given adjuvant radiotherapy. This approach has shown to improve PSA progression-free survival and reduces the risk of a local recurrence.
Neoadjuvant ADT with Radical Prostatectomy
Neoadjuvant ADT significantly reduces positive margin rates and lymph node invasion. The combined approach outcome is significantly better than surgery alone.
Prostate Cancer Recurrence
Almost half of the men treated surgically or with radiation therapy show signs of recurrence and the most important sign being the rise in PSA levels. If the PSA is detectable after primary therapy, it either suggests the presence of cancer cells locally or at a metastatic site. Patients with a rise in PSA levels within 5 years following primary treatment are more likelyto experience a recurrence of the cancer. The chances of recurrence also depend on the clinical stage, Gleason score, and serum PSA level before the surgery.
Patients with signs of recurrence following radical prostatectomy may be treated with salvage radiotherapy which is potentially curative. Patients who fail to respond to radiation therapy may be considered for salvage radical prostatectomy. Other options for the patients include salvage cryotherapy, or brachytherapy. This can help in local control of disease and improve PSA progression-free survival. Patients who cannot be considered for definitive salvage therapies can be considered for ADT or surveillance (wait-and-watch approach). Treatment with ADT prolongs the time for progression in patients with PSA recurrence. The median time to development of metastases is about 12 years after the starting of ADT.