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A structured debate: immediate versus deferred androgen suppression in prostate cancer-evidence for deferred
P C Walsh1, T L DeWeese, M A Eisenberger
1James Buchanan Brady Urological Institute and Departments of Urology and Oncology, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA.
Purpose:
We present a structured debate supporting the premise that immediate hormonal intervention has not been conclusively shown to provide a survival advantage in the management of advanced prostate cancer.
Materials And Methods:
The literature emphasizing randomized trials was reviewed. Recommendations are based solely on a demonstrated advantage in survival.
Results:
In patients with stage Tx Nx Mo or MI disease who did not receive other primary therapy there is no demonstrated survival advantage to immediate hormonal therapy. In men with positive lymph nodes who underwent radical prostatectomy a relatively small study showed a survival advantage in favor of immediate hormonal treatment compared to deferred treatment. This study did not reach the projected accrual of 240 patients and results have not been supported by other trials. In men with stages T2-4 Nx Mx disease who underwent primary treatment with radiotherapy a survival advantage for early hormonal therapy is primarily limited to high risk subgroups. In patients with biochemical relapse following primary treatment there are no trials.
Conclusions:
Because hormonal therapy is associated with the development of irreversible resistance in virtually all patients, it does not cure, there is usually a long interval from first prostate specific antigen elevation to the development of metastatic disease, and hormonal therapy has profound side effects and is expensive, delayed treatment is recommended in men with biochemical relapse following surgery or radiotherapy. Patients should be strongly encouraged to enter clinical trials to answer this question.