Dr Stephen Freedland outlines the currently available, NCCN-recommended treatment options for patients with high-risk, clinically localized prostate cancer, and the clinical challenges he faces during the treatment decision-making process.
Stephen J. Freedland, MD: What are the treatment options for high-risk clinically localized prostate cancer? This is a tumor that’s at high risk. We don’t put numbers behind it, but it’s at high risk for spreading and causing harm. Left untreated, it will kill the patient. These are tumors we want to treat. Sometimes we get into older men. Hopefully, we’ve gone through that decision-making. For that analogy of a 95-year-old on oxygen, I don’t necessarily care if they have some high-risk tumor, but this is someone young enough and healthy enough. We’ve screened. We’ve biopsied. We’ve found this is a high-grade tumor.
In general, the options are surgery or radiation therapy. If they have 1 small spot in one location, there’s some thought of focal therapy. It’s not guideline concordant, and people are hesitant. Rightly so, because with high-grade disease, that’s potentially lethal disease. You want to match the aggressiveness of the tumor with the aggressiveness of our treatments. That’s the goal we’re always doing in prostate cancer: to treat the aggressive tumors aggressively and the nonaggressive tumors nonaggressively. For high risk, it could be surgery or radiation. Surgery is typically robotic-assisted laparoscopic prostatectomy. There are still some people doing open surgery. If you have the skill set, it doesn’t matter which surgical approach you do. The vast majority in the United States are robotically done.
Although there are clinical trials questioning this, we don’t add any systemic therapy to the surgery. You go straight to surgery. We usually wait about 6 weeks and let the inflammation from the biopsy resolve. We do the surgery. We see what we find, and then we decide if they need radiation afterward. Usually, we’ll wait for the PSA [prostate specific antigen] to rise. Typically, we don’t immediately do what we call adjuvant radiation. There’s still some debate about that, but most people don’t based on some well-designed clinical trials. Maybe we add hormones down the road. That’s 1 path.
The other path is radiation therapy. That could either be external beam radiation or a combination of external beam with brachytherapy. Most people are getting external beam alone. With high-risk disease, you add hormonal therapy, which suppresses the testosterone, shrinks the tumor, and works synergistically with the radiation. There are data that hormonal therapy plus radiation improves overall survival relative to radiation alone. The duration of hormonal therapy is hotly debated, but for real high-risk disease, a lot of people would say it’s a 2- to 3-year mark. In my practice, with that level of granularity, I have the radiation oncologist making those decisions. We have some wonderful people at our institution to manage that.
Transcript edited for clarity.