Management of locally advanced prostatic carcinoma

There is no universally accepted definition of locally advanced prostate cancer. It covers a spectrum of disease from a tumour that has spread through the capsule of the prostate (T3a) to large T4 cancers that may be invading the bladder or rectum or have spread to pelvic lymph nodes.

Cancer Research UK define "locally advanced prostate cancer" :

• using TNM staging system locally advanced prostate cancer is the same as one of the following:
  • T3, N0, M0
  • T4, N0, M0
  • Any T, N1, M0

The managment options include:

• systemic treatment
  • neoadjuvant and concurrent luteinising hormone-releasing hormone agonist (LHRHa) therapy is recommended for 3 to 6 months in men receiving radical radiotherapy for locally advanced prostate cancer (1)
  • adjuvant hormonal therapy in addition to radical prostatectomy is not recommended, even in men with margin-positive disease, other than in the context of a clinical trial (1,4)
  • adjuvant hormonal therapy is recommended for a minimum of 2 years in men receiving radical radiotherapy for locally advanced prostate cancer who have a Gleason score of >= 8 (1)
    
  • bisphosphonates should not be used for the prevention of bone metastases in men with prostate cancer (1,4)
    
    
• radiotherapy
  • clinical oncologists should consider pelvic radiotherapy in men with locally advanced prostate cancer who have a > 15% risk of pelvic lymph node involvement and who are to receive neoadjuvant hormonal therapy and radical radiotherapy
  • immediate post-operative radiotherapy after radical prostatectomy is not routinely recommended, even in men with margin-positive disease, other than in the context of a clinical trial (1,4)
  • high-intensity focused ultrasound and cryotherapy are not recommended for men with locally advanced prostate cancer other than in the context of controlled clinical trials comparing their use with established interventions (1,4)
  • a clinical trial revealed that, in patients with locally advanced or high-risk local prostate cancer, addition of local radiotherapy to endocrine treatment halved the 10-year prostate-cancer-specific mortality, and substantially decreased overall mortality with fully acceptable risk of side-effects compared with endocrine treatment alone (2)

NICE updated guidance suggests (5):

Open Image in Modal

Notes (3):

• treatment options for locally recurrent prostate cancer after radiotherapy are limited and include salvage radical prostatectomy, salvage cryotherapy and salvage brachytherapy
• clinical oncologists should consider pelvic radiotherapy in men with locally advanced prostate cancer who have a higher than 15% risk of pelvic lymph node involvement and who are to receive neoadjuvant hormonal therapy and radical radiotherapy (4)

Reference:

• NICE (February 2008).Prostate cancer Diagnosis and treatment
• Widmark A et al. Endocrine treatment, with or without radiotherapy, in locally advanced prostate cancer (SPCG-7/SFUO-3): an open randomised phase III trial.Lancet. 2009 Jan 24;373(9660):301-8.
• NICE (May 2005).Cryotherapy for recurrent prostate cancer
• NICE (January 2014). Prostate cancer: diagnosis and treatment
• NICE (May 2019). Prostate cancer: diagnosis and treatment