Contemporary management of locally advanced prostate cancer: a narrative review and expert perspective.

BACKGROUND: Locally advanced prostate cancer (PCa) encompasses a heterogeneous group of patients, including those with clinical stage T3–T4 disease and/or regional lymph node involvement (cN1), without distant metastases. While curative-intent treatment remains the goal in many cases, optimal management strategies are still subject to debate due to limited high-level evidence and variability in clinical guidelines. OBJECTIVE: This narrative review summarizes current treatment guidelines, appraises recent clinical evidence, and offers an expert perspective on contemporary management strategies for patients with locally advanced PCa. METHODS: A narrative review of international guidelines and recent clinical trials was conducted, focusing on the role of external beam radiotherapy (EBRT), androgen deprivation therapy (ADT), radical prostatectomy (RP), and systemic treatment intensification using androgen receptor pathway inhibitors (ARPIs) and chemotherapy. In addition, we highlight the impact of novel imaging modalities such as PSMA-PET/CT. RESULTS: The established standard of care remains EBRT combined with ADT, with the addition of abiraterone now recommended for selected high-risk cases. RP, although not yet supported by randomized trials, may provide oncological and functional benefits in carefully chosen patients and is increasingly being incorporated into multimodal treatment strategies. The role of intensified neoadjuvant or adjuvant systemic therapies, however, remains under investigation. CONCLUSION: Current management of locally advanced PCa requires individualized decision-making based on modern imaging modalities, patient characteristics, tumor biology, and available resources. While EBRT based multimodal concepts are mainly the preferred treatment, RP based multimodal concepts play an important role in selected cases. Emerging systemic therapies and advanced imaging may further refine treatment strategies in the near future.