For years there remains this terrible hidden question, does an androgen blockade (ADT) provide any survival advantage to men with early advanced prostate cancer?
We do know that ADT will have a significant negative impact on ones life, this is guaranteed. We do know that if we go on a blockade our life will change. We do know that we will become impotent, suffer hot flashes, grow larger breasts, and maybe suffer with cognitive issues. We also might hasten the onset of serious, potentially fatal illnesses, like diabetes and heart disease.
But, we don’t know if this treatment will extend our life if we have early advanced disease! So, why do we do it? I cannot answer that question, but I is one we need to ask our doctors and ourselves.
Why after all these years of using ADT cannot we answer this simple question? It seems pretty basic to me. It makes no sense that we don’t know this answer, but we continue to expose ourselves to this ghastly treatment. Why?
In the United Kingdom there was a randomized trial that did demonstrated a slight impact of immediate versus deferred hormone suppression in men with advanced prostate cancer . The majority of men had non- metastatic but locally advanced disease (55%) at the time of randomization. The men in the deferred treatment group were given ADT when they experienced clinically significant disease progression.
The major finding from this study was that all events (disease progression) occurred more rapidly in the men in the deferred treatment group: progression from M0 to M1 disease, development of pain,
need of transuretheral resection for local progression, patho-logical fractures, spinal cord compression, ureteral obstruction and development of visceral metastases.
There have been some additional studies that have come to similar conclusions, ADT does not show evidence that it extends survival in men with early advanced disease, but it does delay disease progression.
No study to date has demonstrated an overall cancer survival advantage to early androgen therapy versus delayed therapy administered at the time of clinical or symptomatic spread. Early hormonal therapy will provide the patient with a longer interval free of progression of the cancer but, ultimately, there does not appear to be an actual survival advantage. While a longer interval free of cancer sounds advantageous, this benefit should be weighed against the side effect of androgen withdrawal.
So, do you wait for evidence of survival benefit. When should androgen or testosterone withdrawal therapy (ADT) begin? Should the treatment begin when metastatic disease is first detected or should it start only when you become symptomatic (i.e.: bone pain, weight loss)?
It is just another of the many questions we face having advanced prostate cancer. However, before starting ADT doctors should be required to explain the current state of affairs and let a man decide himself instead of just starting the therapy as usually happens.
The Medical Research Council Prostate Cancer Working Party
Investigators Group. Immediate versus deferred treatment for
advanced prostatic cancer: initial results of the Medical Research
Council Trial. Br J Urol 1997; 79: 235–246.
Joel T Nowak, MA, MSW