Optimization of the Radiation Management of High-Risk Prostate Cancer

Radiation and androgen-deprivation therapy (ADT) are mainstays of treatment for men with high-risk prostate cancer. High-risk disease is heterogeneous and subcategories of “favorable” high risk and very high risk can identify subgroups with particularly good or poor prognosis to help personalize treatment. Overall, randomized trials show that the combination of radiation and ADT improves survival when compared with either by itself. The optimum duration of ADT remains controversial, but for most healthy men with aggressive disease, approximately 2-3 years of ADT is well supported by the literature. The role of prophylactic pelvic nodal irradiation remains controversial, and there is an ongoing trial testing whether it improves overall survival. The use of brachytherapy boost appears to improve recurrence-free survival without yet improving survival, and may come at the cost of slightly higher toxicity. The addition of docetaxel to radiation and ADT may also improve failure-free survival, but a meta-analysis did not find that it improved overall survival. Retrospective data about the relative value of surgery vs radiation for high-risk disease have yielded varied conclusions and are ultimately hampered by the major issue of selection bias in retrospective series.