Contemporary management of prostate cancer with lethal potential.
Screening for prostate cancer by determining serum prostate-specific antigen (PSA) levels has resulted in a stage migration such that patients with high-risk disease are more likely to be candidates for curative local therapy. By combining serum PSA, clinical stage, and biopsy information--both Gleason score and volume of tumor in the biopsy cores--specimen pathologic stage and patient biochemical disease-free survival can be estimated. This information can help patients and clinicians understand the severity of disease and the need for multimodal therapy, often in the context of a clinical trial. While the mainstays of treatment for local disease control are radical prostatectomy and radiation therapy, systemic therapy must be considered as well. A randomized trial has shown a survival benefit for radical prostatectomy in patients with positive lymph nodes who undergo immediate adjuvant androgen deprivation. Clinical trials are needed to clarify whether adjuvant radiation therapy after surgery confers a survival benefit. PSA is a sensitive marker for follow-up after local treatment and has proven that conventional external-beam irradiation alone is inadequate treatment for high-risk disease. Fortunately, the technology of radiation delivery has been dramatically improved with tools such as three-dimensional conformal radiation, intensity-modulated radiation therapy, and high-dose-rate brachytherapy. The further contributions of pelvic irradiation and neoadjuvant, concurrent, and adjuvant androgen deprivation therapy have been defined in clinical trials. Future management of high-risk prostate cancer may be expanded by clinical trials evaluating neoadjuvant and/or adjuvant chemotherapy in combination with androgen deprivation.
Davis
John W
JW
Department of Urology, The Virginia Prostate Center of Eastern Virginia Medical School, Norfolk, Virginia, USA. jdhdavis@aol.com
Shaves
Mark E
ME
Schellhammer
Paul F
PF
D000726:Androgen Antagonists / Q000627:therapeutic use; D002986:Clinical Trials as Topic; D003131:Combined Modality Therapy; D006801:Humans; D008297:Male; D020360:Neoadjuvant Therapy; D009367:Neoplasm Staging; D011379:Prognosis; D017430:Prostate-Specific Antigen / Q000032:analysis*; D011471:Prostatic Neoplasms / Q000473:pathology / Q000532:radiotherapy* / Q000601:surgery*; D018714:Radiotherapy, Adjuvant; D012307:Risk Factors
D000726:Androgen Antagonists; D017430:Prostate-Specific Antigen