Radiotherapy as primary treatment modality.

The proper management of prostate cancer is dependent on appropriate risk categorization, based on pretreatment prostate-specific antigen (PSA), clinical stage and Gleason score (GS). The use of radiotherapy in low-risk (T1-T2a, PSA < 10 ng/ml and GS <or= 6) and intermediate-risk (T1/T2, PSA < 20 ng/ml and GS <or= 7) disease is well established, with comparable results to surgery in the era of modern radiation therapy. However, cancer-related outcomes in some radiotherapy patients might still be improved with the use of adjuvant hormonal therapy. There is presently no clear evidence to support its use in low-risk patients and benefits in intermediate-risk patients need to be elucidated in the era of dose-escalated radiation therapy. Hypofractionated radiotherapy using biologically equivalent doses also has the potential to improve the therapeutic index, given the low alpha / beta ratio of prostate cancer, and to reduce overall treatment time, but the most advantageous regimen needs to be determined. In patients with high-risk disease (T3-T4, PSA > 20 ng/ml or GS >or=6 8), radiation with hormones has become the standard treatment. The issues that remain focus on determining the optimal duration of hormones, assessing the use of locoregional dose escalation and determining the possible benefit from adjuvant chemotherapy.