Men with locally advanced prostate cancer (that has not spread elsewhere) and who receive radiotherapy (RT) on top of their androgen deprivation therapy (ADT) have greater overall survival compared with men on ADT alone.

The advantages of combined treatment should be discussed with all men with this condition, concludes an article published by The Lancet and written Dr Padraig Warde, Radiation Medicine Program, Princess Margaret Hospital, Toronto, ON, Canada, Matthew R Sydes , MRC Clinical Trials Unit, London, UK, and Dr Malcolm Mason, Cardiff University School of Medicine, UK, and colleagues.

This trial, the first that has been adequately powered to compare these two treatment strategies, assessed patients with locally advanced (T3 or T4) prostate cancer (n=1057); or organ-confined disease (T2) with either a prostate-specific antigen (PSA) concentration more than 40 ng/mL (n=119) or PSA concentration more than 20 ng/mL and a Gleason score of 8 or higher (n=25)Patients were randomly assigned to receive lifelong ADT and RT, or ADT only.

A total of 1205 patients were randomly assigned (602 in the ADT only group and 603 in the ADT and RT group); median follow-up was 6·0 years. At the time of analysis, a total of 320 patients had died, 175 in the ADT only group and 145 in the ADT and RT group. The addition of RT to ADT improved overall survival at 7 years (74% ADT/RT vs 66% ADT). Serious long-term genitourinary or gastrointestinal toxicity from RT was uncommon, and low numbers of serious adverse events were recorded in each group.

The authors say: "This trial provides convincing evidence that local control of disease in the prostate improves survival in patients with locally advanced prostate cancer."

They conclude: "Our findings suggest that the benefits of the combination of ADT and RT should be discussed with all patients considering a curative treatment approach."

In a linked Comment, Dr Matthew R Cooperberg, Department of Urology, University of California, San Francisco, CA, USA, says: "This study has provided the strongest evidence to date that androgen deprivation therapy alone for men with high-risk prostate cancer is not adequate. These patients require an aggressive, multimodal approach incorporating prostate-directed local therapy. However, the crucial question—whether the optimum initial strategy should include radiation combined with androgen deprivation therapy, or surgery followed by selective radiation on the basis of pathological findings and early biochemical outcomes—is still open. The definitive answer will only come through trials of men with high-risk disease randomly assigned to receive surgery or radiation as an initial treatment."

Source: The Lancet