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Predicting the outcome of individual prostate adenocarcinoma can be challenging, especially for patients affected by intermediate or high risk, but localised disease. Natural histories of prostate cancers with similar stage and prognostic factors can differ significantly; and an ongoing debate surrounds the optimal treatment choice for men diagnosed with non-metastatic prostate cancer. A variety of effective therapeutic options are available to be used as a sole modality, or in combination, including surgery, external beam radiotherapy, brachytherapy, and endocrine manipulation. Although these treatments have been used routinely for more than 15 years, there is a paucity of data from randomised trials comparing their results. In addition, most treatment techniques have changed dramatically in the last two decades due to the ongoing healthcare technological revolution. The rapid proliferation of new and expensive therapeutic options (i.e. adaptive radiotherapy, focal ablation, etc.) promises to minimise treatment related side effects and improve local control, however, there is no uniform consensus. Treatment choice is based on the available prognostic factors and life expectancy, along with patient preference, toxicity profiles, the individual institution’s (and clinician’s) experience and resource availability. Unfortunately, our prognostic tools are still limited, as is our ability to precisely predict which subset of patients might benefit from more aggressive therapeutic combinations. Therefore, a significant number of patients receive unnecessary and expensive treatments, whilst others are denied highly technological procedures because of associated resource limitation. This paper aims to analyse the current evidence, cost-effectiveness and controversies, surrounding the nonsurgical treatment of localised prostate cancer, with a focus on radiation and endocrine therapies, and to discuss the role of magnetic resonance spectroscopy, as a decision tool for multimodality treatment design and prediction of response.
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