High risk prostate cancer is defined as PSA > 20 ng/mL or Gleason ≥8 or stage ≥T2c. Monotherapy alone is not good enough. The risk of prostate cancer death in these patients is 25% at 5 years. Multi-modality therapy must be used, and this can either be:
Traditionally most T3 disease was treated with combined primary radiotherapy and hormones. The proponents of surgery for high risk disease argue that it still allows adjuvant radiotherapy to be used depending on the pathologic result, or early salvage radiotherapy at time of biochemical recurrence. Also it allows for an initial period of freedom from hormones, and their associated side effects. In addition there is evidence that up to 40% of high risk prostate cancer is down-staged at final pathology. The proponents of primary radiotherapy with hormones argue that the oncological efficacy is the same with a better side effect profile and without the need to have an operation. There are several series that report on the success of surgery for high risk disease with 10 year PSA progression free rates of 35-55%, metastasis free survival rates of 84% and cancer specific survival rates of 88-95%.