Multimodal Therapy for Patients with High-Grade, High-Risk Prostate Cancer with Long-Term Followup
Jason Gee, MD; John Libertino, MD; Kaitlin Schuster, RA
Emerson Hospital, Concord, MA
BACKGROUND: High-risk prostate cancer requires a multimodal approach to treatment. Surgery has played an increasing role for these patients although long-term follow-up and experience with neoadjuvant therapy, a basic tenet of cancer treatment, remains limited. Here we report our experience with neoadjuvant hormonal ablation followed by surgery and postoperative radiation with greater than 20-year follow-up.
METHODS: From 1990-2012, 82 patients with clinically organ-confined prostate cancer underwent multimodal therapy (MMT) consisting of neoadjuvant hormonal ablation followed by radical retropubic prostatectomy and postoperative radiation. High-risk prostate cancer was defined preoperatively as a Gleason Score 8-10 or PSA>20. Patients with negative surgical margins were observed initially and treated with salvage XRT in the instance of recurrence. Adjuvant and salvage CSS were compared. Median follow-up for these patients is 10 years, ranging from 6 to 29 years.
RESULTS: The MMT protocol was well tolerated in all 82 patients with no treatment-related discontinuation of therapy. Final surgical pathology revealed stage pT3-T4 in 58/82 (71%), nodal involvement in 7/82 (9%). Distant metastatic disease was identified in 10/82 patients (12%). Cancer-specific survival for patients undergoing MMT at 10, 15 and 20 years was 78/82 (95%) and 77 /82 (94%) and 77/82 (94%) respectively. Overall survival at 10, 15 and 20 years was 68/82 (83%) and 66/82 (80%) and 60/82 (73%) respectively. Biochemical recurrence was lower at 61/82 (74%) and 51/82 (62%) and 35/82 (43%) at 10, 15 and 20 years respectively. Of 58/82 (71%) patients with Gleason 8-10 cancers, cancer-specific survival for patients undergoing MMT at 10, 15 and 20 years was 54/58 (93%). Overall survival at 10, 15 and 20 years was 47/58 (81%), 46/58 (79%), and 42/58 (72%) respectively. Freedom from biochemical recurrence was at 38/58 (66%), 33/58 (57%) and 24/58 (41%) at 10, 15 and 20 years respectively.
CONCLUSIONS: The MMT protocol for high-risk prostate cancer consisting of neoadjuvant hormonal therapy followed by surgery and post-operative radiation is an effective treatment strategy with excellent cancer-specific survival. Recurrence occurring primarily as a rising PSA as opposed to distant metastatic disease suggests limited morbidity as well among patients treated with this protocol. 
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