W e commend Sonpavde et al 1 on their review of neoadjuvant therapy prior to prostatectomy, which focused on neoadjuvant drug trials. The bulk of preoperative intervention trials for prostate cancer utilize neoadjuvant chemotherapy, but we would like to comment on the use of preoperative radiotherapy as an option in the setting of high-risk disease.
To our knowledge, only 1 published study of radical prostatectomy after neoadjuvant radiotherapy currently exists. 2 A protocol conducted in 1969 of 40 to 60 gray as a planned preoperative measure demonstrated minimal postoperative morbidity and excellent treatment results. Ten of 18 patients were continent upon discharge from the hospital and all were continent within 1 year. Two patients had no residual tumor at the time of surgery. With a mean follow-up of 54 months, 12 patients were alive with no evidence of disease.
Radiotherapy can be curative for patients with prostate cancer, with higher doses reported to be more effective. 3,4 Unfortunately, dose escalation is limited by the tolerance of nearby structures. The planned combination of radiation plus surgical removal of the prostate may act as the ultimate in dose escalation by completely removing the bulk of cancer while radiotherapy eliminates regional microscopic disease.
The authors did comment on the current phase 1/2 trial at Oregon Health Science University combining neoadjuvant docetaxel and radiotherapy. In addition to the chemotherapy trials referenced in the article by Sonpavde et al, 1 Duke University is also currently conducting a trial of preoperative radiotherapy without chemotherapy. Patients undergo prostate, seminal vesicle, and pelvic lymph node irradiation 4 to 8 weeks prior to prostatectomy. Early results have been promising.
In summary, we believe that neoadjuvant radiotherapy followed by prostatectomy is a treatment that may potentially improve outcomes for patients with high-risk prostate cancer. Both radiotherapy and chemotherapy trials are deserving of ongoing study through multidisciplinary efforts.