The introduction of more sensitive imaging (i.e. PSMA PET) has resulted in a stage migration and increased diagnosis of cN1 disease in high risk prostate cancer (patients who would have previously had negative conventional imaging).
EAU guidelines:
- No high level comparative evidence for locally advanced prostate cancer – a local treatment combined with systemic treatment provides the best outcome
- EBRT + ADT has been shown to have survival benefit for high risk disease vs ADT alone
- Comparative oncological effectiveness of RP as part of multi-modal treatment vs upfront EBRT/ADT for locally advanced prostate cancer unknown
- SPCG-15 trial recruiting
- Management of cN1M0 mainly based on long term ADT combined with a local treatment
- Retrospective evidence suggests an overall and cancer specific survival benefit with local treatment + ADT, compared to ADT alone
- Offer RP + ePLND to selected patients as part of multi-modal therapy
- Offer EBRT + ADT to locally advanced disease, +/- a brachytherapy boost (either HDR or LDR) if good urinary function
- Offer patients with cN1 disease a local treatment + ADT
STAMPEDE:
- 1974 men with high risk locally advanced or nodal M0 disease, or relapse after primary therapy
- De novo disease included 2 of – PSA > 40, cN1, cT3/4, Gleason 8+
- ADT vs ADT/abi vs ADT/abi/enza, with radiation therapy
- Radiation therapy to prostate + nodes, plus ADT 3 years, plus 2 years abiraterone showed improved OS and MFS compared to radiation and ADT alone
In summary:
No high level evidence comparing RP vs XRT for high risk or nodal disease.
For high risk N0 – surgery reasonable option accepting high risk of failure requiring further treatment. XRT with ADT proven option over ADT alone.
For N1 – RP + ePLND can be considered as part of likely multi-modal treatment as per EAU guidelines. However no high level evidence confirming benefit vs XRT/ADT alone, which is a very well accepted option. Consider adding abiraterone as per STAMPEDE, although not funded.