One of the largest and most controversial issues for the treatment of advanced prostate cancer is the value of androgen-deprivation therapy (ADT). Most doctors use ADT as their pivotal initial treatment in the management of locally advanced and metastatic prostate cancer (PCa). But, the grand question is does it extend survival?
Verhagen, etal. reviewed the available randomized studies of ADT (orchiectomy or luteinising hormone-releasing hormone analogues) in the treatment of PCa—both immediate and deferred/adjuvant studies—to elucidate a possible interaction between local treatment and ADT.
1- They found that studies of immediate versus deferred ADT without local treatment consistently showed only limited benefit for overall survival (OS; hazard ratio [HR]: 0.90; 95% confidence interval [CI], 0.83–0.97) and cancer-specific survival (CSS; HR: 0.79; 95% CI, 0.71–0.89).
2- In contrast, ADT as an adjuvant to radiation therapy in men with high-risk localized disease or locally advanced disease was associated with substantial OS and CSS benefits.
3- A similar benefit was seen in men with proven systemic disease (node-positive men after radical prostatectomy).
4- Overall, the data suggest a clinically important survival benefit (HR for OS: 0.69; 95% CI, 0.61–0.79) when a local treatment has been applied to the primary tumor.
They concluded that:
1- There is an interaction between local treatment and in men with advanced and aggressive disease who are at a high risk to die from PCa and who are treated for their primary tumor with curative intent, immediate and sustained ADT improves OS and CSS significantly.
2- The local therapy in T3 and/or lymph node–positive disease is an essential part of the optimal treatment.
3- However, this intensive treatment is unnecessary in a substantial number of men with T3 and/or N1 disease with a slow natural history or high competing death risk.
Take Home Message
Local therapy of the prostate (radiation or radical prostatectomy) appears to influence the efficacy of androgen-deprivation therapy. Local therapy is an essential part of the optimal treatment in T3 and/or lymph node–positive disease.
European Urology – Published online 27 May 2010, pages 261 – 269 Volume 58, issue 2, pages e19-e28, August 2010; Paul C.M.S. Verhagen, Fritz H. Schröder, Laurence Collette, Chris H. Bangma.
Joel T. Nowak, M.A., M.S.W.
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