Controversies in the therapy of high-risk prostate cancer. Radiotherapy

For patients with high-risk prostate cancer there is currently no predefined standard treatment. In terms of curative treatment there are two alternatives: primary radiotherapy plus androgen deprivation therapy (ADT) and radical prostatectomy with pelvic lymph node dissection. Presentation and evaluation of the evidence for the current role of radiotherapy (with and without medication). Using the search terms listed in the full text a literature search covering the last 5 years was performed. Regarding primary therapy of high-risk prostate cancer randomized trials comparing radiotherapy plus ADT versus either radiotherapy or ADT alone demonstrated a significant benefit for the combined treatment with respect to all endpoints. There are no randomized controlled trials available comparing surgery and radiotherapy. The current evidence is limited to retrospective and mostly single institution studies (level of evidence 3-4) but sometimes with large patient cohorts. Modern dose escalated radiotherapy in combination with ADT yields very good results in terms of relapse-free survival and toxicity that is superior to radical prostatectomy alone, especially when considering patients older than 70 years. In patients younger than 60 years and in combination with adjuvant or salvage radiotherapy there are no clear treatment recommendations. For patients with high-risk prostate cancer only an interdisciplinary counseling with urologists and radiation oncologists can provide an individually optimized therapy sequence.