Evolution of therapeutic approaches with luteinizing hormone-releasing hormone agonists in 2003

The role of hormone therapy in the current era of widespread testing for prostate-specific antigen (PSA) continues to evolve. Although still used in patients with metastatic disease, the most common uses of luteinizing hormone-releasing hormone (LHRH) agonist therapy are in the adjuvant and neoadjuvant settings with radiotherapy and sometimes with radical prostatectomy, as well as in the treatment of PSA-only recurrence. Immediate (adjuvant) hormone therapy after prostatectomy may provide a survival advantage relative to deferred treatment in high-risk patients, whereas the survival benefit of adjuvant therapy with radiation is clearer. Combined androgen blockade with an LHRH agonist and a nonsteroidal antiandrogen provides a very modest but statistically significant survival benefit relative to LHRH agonist monotherapy in patients with metastatic disease, but it has not been proved in those with less advanced disease. Intermittent hormone therapy appears to be effective in maintaining disease control for several years, but randomized studies are needed to determine if survival is at least equivalent to continuous therapy. Finally, LHRH agonist therapy is commonly used in the setting of biochemical or PSA-only recurrence. However, there are no randomized controlled trials to prove a survival benefit over observation. In summary, hormone therapy now plays a more important role at earlier stages of disease, consistent with the changing epidemiology of prostate cancer. Additional studies are needed, however, to define how to optimally use hormone therapy across various patient types.