Carcinoma of the prostate: general concepts

The work of Huggins et al more than 40 years ago established the effectiveness of androgenic deprivation in the management of patients with disseminated prostatic cancer. The initial utilization of estrogens was considered appropriate until elevated cardiovascular risk was proven with higher doses. Orchidectomy continues to be an effective method of androgenic suppression, although disadvantages are seen to be its irreversible nature and possible psychologic impact on the patient. Luteinizing hormone-releasing hormone (LHRH) agonists can achieve plasma levels of testosterone similar to surgical castration with minimum inconvenience to the patient. Androgen antagonists act directly on the metabolism of the prostatic cell, obtaining a similar effect to that of castration, with maintenance of testosterone levels in the case of flutamide. The concept of total androgen blockade is one currently receiving attention. Although controversy still remains, it is thought that complete hormone blockade (for example, orchidectomy plus an anti-androgen) may improve survival.