Management of locally advanced (nonmetastatic) prostate cancer.

Abstract

Locally advanced prostate cancer is decreasing because of stage migration with prostate-specific antigen (PSA) testing. The natural history of these tumors reflects a significant risk of morbidity and mortality from local and metastatic disease progression. The balance of risks and benefits of treatments need to be discussed carefully with men and their families, ideally using a shared decision-making approach. The aim of treatment is to eradicate the primary malignancy with the lowest risk of local or systemic relapse, and minimal morbidity from side effects or complications. While radiation therapy combined with hormonal therapy has traditionally been preferred, there is increasing evidence that radical prostatectomy offers a number of advantages as the primary treatment with the option of adjuvant or salvage radiation therapy for true local multimodal treatment. Older age groups of patients with relatively low PSA who are not fit for curative intent treatments appear to have little benefit with early hormone treatment, therefore, watchful waiting may be the most appropriate option in the first instance. The value of treatment of the primary malignancy in the presence of metastatic disease is uncertain and under investigation.