What is Curative-Intent Therapy in Prostate Cancer?
Curative-intent therapy refers to treatment aimed at complete eradication of prostate cancer with the goal of achieving long-term disease-free survival and potential cure, as opposed to palliative treatment that only manages symptoms. 1
Definition and Core Concept
Curative-intent therapy encompasses treatments designed to eliminate all detectable cancer with the expectation of preventing disease progression and cancer-related death. 1 This contrasts fundamentally with palliative approaches where treatment is initiated only when symptoms develop and the goal is symptom relief rather than cure. 1
Primary Curative Treatment Modalities
For a patient with PSA 17 ng/mL and PI-RADS 5 peripheral zone lesion (indicating high-risk localized disease), curative-intent options include:
Radical Prostatectomy
- Radical prostatectomy with extended pelvic lymph node dissection is the only treatment proven in randomized trials to improve overall survival and cancer-specific survival compared to watchful waiting. 1
- This patient requires extended bilateral lymph node dissection given the high-risk features (PSA >20 ng/mL threshold approaching, PI-RADS 5 lesion). 1
- Ten-year cancer-specific survival reaches 83-92% for high-risk patients treated with radical prostatectomy in multimodal approaches. 1
Definitive Radiation Therapy
- External beam radiation therapy (minimum 75.6-78 Gy) combined with long-term androgen deprivation therapy for 2-3 years provides superior survival outcomes for high-risk disease. 2
- Dose escalation to at least 75.6-78 Gy using 3D-CRT or IMRT with daily image guidance is required for curative intent. 2
- Pelvic lymph node radiation (45 Gy) should be included for locally advanced disease. 2
Patient Selection Criteria for Curative Intent
Curative-intent therapy is appropriate when:
- Life expectancy exceeds 10 years 1
- Disease is clinically localized or locally advanced without distant metastases 1
- Tumor is not fixed to surrounding structures and does not invade the urethral sphincter 1
- Patient accepts the risks of treatment-related side effects (incontinence, erectile dysfunction) in exchange for potential cure 1
When Curative Intent is NOT Appropriate
Patients with locally advanced disease who are not candidates for curative-intent treatment should be managed with watchful waiting, where treatment starts only when symptoms develop. 1 This applies when:
- Life expectancy is less than 10 years due to comorbidities 1
- Documented metastatic disease is present 1
- Clinical parameters suggest too small a chance for cure to justify treatment toxicity 1
Monitoring After Curative Treatment
Following curative-intent therapy, PSA becomes the primary surveillance tool:
- After radical prostatectomy: biochemical recurrence is defined as confirmed PSA >0.2 ng/mL 1
- After radiation therapy: biochemical recurrence is defined as PSA rise ≥2 ng/mL above nadir 1, 2
- PSA recurrence occurs in approximately 30-40% of patients treated with curative intent 1
Salvage Curative-Intent Options
When biochemical recurrence occurs after initial curative treatment, salvage therapy with curative intent may still be possible:
- Salvage radiation therapy after radical prostatectomy should be initiated early (PSA <1.0 ng/mL) for best outcomes, with 6-year biochemical progression-free survival of 48%. 1
- The goal remains complete disease eradication rather than symptom palliation. 1
Critical Distinction from Palliative Therapy
The fundamental difference is outcome expectation: curative-intent therapy aims for complete cancer elimination and long-term survival, accepting significant treatment-related toxicity. 1 Palliative therapy (such as hormonal therapy for metastatic disease) aims only to relieve symptoms and improve quality of life, with no expectation of cure. 1