In the issue of January , Hsu et al presented interesting data on 200 cT3a prostate cancers treated with radical prostatectomy by the same well-trained team. Despite 78.5% of patients harbouring a Gleason score 7, with a 4 + 3 subscore for half of them, 59.5% remain free of biochemical recurrence at 5 yr. More than 50% are free at 10 yr. In contrast to physicians who disclaim the curative role of local treatments in such high-risk situations, the only factor at the origin of biochemical recurrence in multivariate analysis is the presence of positive surgical margins (HR: 2.73 [1.69–4.40]; p < 0.001). Considering the clinical control, initial tumor volume remains the most important prognostic factor. This observation fit well in the general rules of oncology, but again, despite a mean initial tumor volume as high as 7 ml, disease control could be achieved for more than half the patients. Surgery remains thus the easiest way to demonstrate the importance of local control of a disease while highlighting the potential benefit of high radiation doses of 74–80 Gy in this pathology.
Unfortunately, the 33.5% rate of positive margins is over the accepted risk of 15%; therefore, surgeons recommend generally to not try to obviate this in daily practice. So radiation treatments that extend the curative efficacy far from the prostate capsule are more often recommended. Moreover, brachytherapy components that can deliver 150% of the prescribed dose to at least 50% of the clinical target volume consist more in ablative treatments, approaching the philosophy of surgery. Likewise, in locally advanced cancers, a recent paper compared surgery and high ablative radiation doses combining external radiotherapy and a brachytherapy boost in a matched pairs analysis . If surgery achieved biochemical control rates of 55% at 5 yr, high radiation doses achieved 73% control (p = 0.01). As for surgery, such higher control rates were recently reported to improve the overall survival  C.E. Vargas, A.A. Martinez and T.P. Boike et al., High dose irradiation for prostate cancer via a high dose rate brachytherapy boost: results of a phase I to II study, Int J Radiat Oncol Biol Phys 66 (2006), pp. 416–423. Article | PDF (186 K) | View Record in Scopus | Cited By in Scopus (23).
If surgery and very high radiation doses both have a place in the treatment of T3 prostate cancer, radiation therapy can be extremely toxic in patients with urinary obstructive syndromes or other predisposing factors of toxicity such as smoking habits or the presence of diabetes or compromised vascular status. In these patients, surgery and adjuvant modest radiation doses should certainly be investigated prospectively despite the discomfort linked to the length of such combined treatments and the higher risk of urinary incontinence. In the other situations, high radiation doses remain an easier alternative.