title: Treatment of patients with high risk localized prostate cancer: results from cancer of the prostate strategic urological research endeavor (CaPSURE).
abstract: OBJECTIVE
  Pretreatment risk assessment models facilitate more appropriate selection of treatment for prostate cancer. However, men with high risk disease remain a challenge with significant potential for primary treatment failure. We characterize patterns of treatment for high risk prostate cancer in a community based cohort.
  
  
  METHODS
  In the Cancer of the Prostate Strategic Urological Research Endeavor (CaPSURE) database, a longitudinal disease registry of men with prostate cancer, we identified those with nonmetastatic, high risk disease based on T stage, tumor grade and serum prostate specific antigen (PSA). Differences in primary treatment, and the use of neoadjuvant and adjuvant therapy in patients at low, intermediate and high risk were assessed. In the high risk cohort predictors of the type of primary treatment, and the use of neoadjuvant and adjuvant androgen therapy were identified.
  
  
  RESULTS
  Of the cancers 34%, 40% and 26% were low, intermediate and high risk, respectively. Differences in primary treatment type among the 3 risk groups were statistically significant (p <0.0001) with increasing external beam radiation therapy and androgen deprivation, and decreased surgery, brachytherapy and surveillance in men with high risk cancers. In this group older age, higher PSA and nonprivate insurance were associated with decreased use of radical prostatectomy. More than half of the men at high risk receiving radiation therapy also received androgen deprivation, which was significantly higher than in the low and intermediate risk groups (p <0.0001). Factors associated with androgen deprivation in high risk disease were primary therapy, PSA, Gleason sum, T stage, body mass index, insurance status and ethnicity. PSA and Gleason sum were the primary determinants of adjuvant radiation after prostatectomy.
  
  
  CONCLUSIONS
  Men with high risk but nonmetastatic prostate cancer are more likely to receive radiation therapy as well as androgen deprivation with the latter as primary therapy or in conjunction with local treatment. These data stress the importance of pretreatment risk stratification, education regarding appropriate combinations of local and systemic therapies, and the consideration of novel clinical trials in patients at higher risk.
authors.affiliation: Department of Urology, Program in Urologic Oncology, Urologic Outcomes Research Group, University of California-San Francisco Cancer Center, University of California-San Francisco, San Francisco, California 94115-1711, USA. mmeng@urol.ucsf.edu
authors.forename: Maxwell V
authors.initials: MV
authors.lastname: Meng
authors.forename: Eric P
authors.initials: EP
authors.lastname: Elkin
authors.forename: David M
authors.initials: DM
authors.lastname: Latini
authors.forename: Janeen
authors.initials: J
authors.lastname: Duchane
authors.forename: Peter R
authors.initials: PR
authors.lastname: Carroll
mesh_terms: D000368:Aged; D006801:Humans; D008297:Male; D011471:Prostatic Neoplasms / Q000453:epidemiology / Q000628:therapy*; D012042:Registries; D012306:Risk; D012307:Risk Factors