Initial therapy with radical prostatectomy for high risk localized prostate cancer.

Objective: This study provides a perspective on initial treatment in select patients with high risk, localized prostate cancer.

Methods: A select literature review was done with commentary on the philosophy of initial surgery followed by adjuvant or salvage therapies.

Results: Early detection and associated stage migration identify a cadre of men with unfavorable but apparently localized prostate cancer who historically would not have been viewed as appropriate candidates for radical prostatectomy. Decreased morbidity from radical prostatectomy and data demonstrating improved outcomes in some patients treated with multimodal therapy protocols provide a rationale for including radical prostatectomy as part of an aggressive treatment plan to achieve optimal local elimination of cancer. Data suggest that radical prostatectomy and adjuvant or possibly even salvage radiation therapy may provide the best elimination of large local cancers. Whether such an approach provides results that are better than or even as good as those of the common standard of radiation therapy plus androgen deprivation therapy remains to be seen and, if so, at what cost to the patient in terms of adverse effects. However, it is likely that optimal elimination of local disease is needed to achieve the maximum benefit from adjuvant systemic endocrine, chemotherapy or targeted treatments. In other words optimal local therapy may be necessary but not sufficient.

Conclusions: Initial radical prostatectomy may have a role for treating high risk localized prostate cancer.