Early versus late androgen deprivation therapy in metastatic disease

Patients presenting with metastatic prostatic cancer can be categorized into 3 groups. At present, most patients seen with metastases are those identified as having lymph-node disease when being assessed for curative therapy. The second group consists of patients with a high level of prostate-specific antigen, without symptoms, who are found incidentally to have asymptomatic bone metastases or metastases in soft tissue. The third group, who previously comprised about half of patients presenting with metastatic prostate cancer, are those presenting with painful metastases. There can be little doubt that most urologists will treat the second and third group of patients with hormone therapy at the outset. The question is whether the mere presence of lymph-node metastases or painless bony or soft tissue metastases justifies the side effects of long-term hormone therapy. A number of studies have shown a benefit in progression-free survival in the treatment of patients with lymph-node disease. Only 1 study has shown an advantage in overall survival. All studies of hormone therapy in asymptomatic and symptomatic metastatic disease have shown that serious complications of the disease can be avoided by offering hormonal therapy when the diagnosis is established. With the new generation of antiandrogens, differentiation therapies, and possibly alpha-reductase inhibitors, hormone therapy causes many fewer side effects than in the past and can be tolerated for longer periods of time. An aim of early hormonal therapy and its justification is a possible improvement in the quality of life of patients with metastatic prostate carcinoma, whose quantity of life cannot be lengthened.