Adjuvant and neoadjuvant hormonal therapy for prostate cancer

Many men with early stage prostate cancer suffer relapse and/or die of their disease despite potentially curative surgery or radiotherapy. Early hormonal therapies are being combined with these local therapies, with the aim of facilitating local control and improving survival. In the surgical setting, neoadjuvant hormonal therapy reduces the rate of positive margins and extracapsular penetration, but most studies have failed to demonstrate an advantage with respect to biochemical progression. Further studies are needed to clarify the role of adjuvant therapy in surgical patients. In the radiotherapy setting, neoadjuvant hormonal therapy improves local control, although survival data is not available, and can be considered for stage T2b disease or higher. Adjuvant luteinizing hormone-releasing hormone (LH-RH) agonists improve both local control and survival after radiotherapy and should be offered to all patients. Currently, the LH-RH agonists are the drugs of choice for adjuvant therapy, whereas combined androgen blockade has generally been used as neoadjuvant therapy. Monotherapy with a nonsteroidal antiandrogen has considerable potential in both settings. Areas for future studies include appropriate endpoints for clinical studies, comparative drug efficacy and the effect of treatment on quality of life.