Is neoadjuvant hormonal therapy before radical prostatectomy indicated?

Despite the success of surgical monotherapy in treating patients with organ-confined disease, nearly half of all patients undergoing radical prostatectomy will be pathologically upstaged on evaluation of the operative specimen. One possible means of improving the proportion of patients with organ-confined disease and cancer-negative margins at surgery is implementing neoadjuvant androgen deprivation therapy. Studies evaluating the use of neoadjuvant hormonal therapy (NHT) before radical prostatectomy will be reviewed, and outcomes will be discussed.

Review of the past and recent literature regarding the use and role of NHT before radical prostatectomy was performed. In particular, special attention was paid to the seven prospective, randomized studies that have been reported in the literature. In addition, review of other pertinent and appropriate texts and journals regarding the impact of hormonal therapy on histopathological evaluation and outcomes was performed.

Upon review of the prospective, randomized, clinical trials of NHT before radical prostatectomy, there remains no clear evidence that NHT improves disease-free survival for any stage of prostate cancer. Although positive surgical margins appear to be reduced for patients with clinical stage T2 disease only, significance and validity of such an end point remain uncertain. In addition, the use of NHT appears to come with a significant cost with regard to financial expense, patient morbidity, and possibly increased surgical difficulty.

The routine use of NHT before radical prostatectomy is not justified, and only in controlled investigational trials should its use be considered.