[First line therapy in the treatment of metastatic prostate cancer]

Hormonal therapy has been the main treatment for advanced prostate cancer for the past six decades. Maximum androgen blockade (MAB), combination therapy with castration and antiandrogens, has been compared with castration monotherapy since the late 1980s. However, the results of the different trials have been conflicting. Recently published meta-analyses have revealed that MAB with non-steroidal antiandrogens is slightly superior to monotherapy (surgical or medical castration) in the treatment of advanced prostate cancer, and that MAB has more adverse effects. The question of whether the modest survival advantage of MAB balances with the increase in adverse effects should be investigated. Some studies indicated that the survival of metastatic prostate cancer patients treated with immediate therapy was similar to that of men in whom treatment was delayed. Hormonal therapy has side effects and is costly, and delayed treatment may be beneficial to elderly men with silent metastasis. Intermittent hormonal therapy is a controversial approach to management of advanced prostate cancer, although laboratory data suggest that intermittent androgen deprivation may prolong the duration of androgen dependence. Intermittent hormonal therapy for patients with metastatic prostate cancer needs to be assessed in a randomized trial to determine the effect on overall survival and quality of life. Our results in a randomized clinical trial of chemo-endocrine therapy versus endocrine therapy alone suggested that the addition of chemotherapy (cisplatin plus pirarubicin) to initial endocrine therapy might be beneficial to patients with advanced prostate cancer, especially an aggressive form of prostate cancer. However, chemo-endocrine therapy should be considered an experimental approach at present.