Many methods exist to define high-risk
prostate cancer. These include clinical stage, serum PSA, and pathological features such as Gleason score and the number of positive biopsies. Partin tables are widely used to stratify patients according to risk of adverse pathological features at surgery, and to identify those more likely to remain free of recurrent disease following surgery. The priority in most patients with localized
prostate cancer remains the selection of a treatment that will provide them with the best chance for cure. While treatment-related morbidity is an important issue, we believe that side effects of surgery or
radiation therapy are not increased in patients with high-risk
cancer. Results from a small number of population studies indicate a highly significant improvement in disease-specific survival for radical
prostatectomy compared to
radiotherapy, and it appears that this difference may become more pronounced as the grade of the
cancer increases. While acknowledging the need for
adjuvant radiotherapy and/or hormonal
therapy, we suggest that radical
prostatectomy may offer a better primary treatment option for patients with high-grade
cancer. However, urologists must be prepared for higher failure rates when performing this surgery in patients with high-risk disease compared to those with low-risk disease.