The patient, disease status, and treatment options for prostate cancer: stages D1 and D2

The treatment of choice for disseminated prostate cancer remains endocrine manipulation, either bilateral orchiectomy or exogenous estrogens. The recommended dose of diethylstilbestrol is 1 mg tid. Unanswered questions include: When should endocrine manipulation be instituted for the patient with advanced prostatic cancer? At the time of diagnosis, when clinical symptoms occur, or not at all? With few exceptions those patients relapsing after initial endocrine manipulation do not respond to successive attempts at further endocrine therapy. Much of the confusion in this regard relates to the variable response criteria used, more often subjective than objective. Since the polyclonal theory of prostatic cancer is attractive, its logical extension is the evaluation of combinations of treatments including both endocrine manipulation and cytotoxic agents. Because the currently available antiandrogens and luteinizing hormone-releasing hormone agonists have mechanisms of action different from conventional estrogens or bilateral orchiectomy, they too may have a role in the multimodal treatment of advanced prostatic cancer. Therapy for stage D1 prostatic cancer implies that information is available either from pelvic lymphadenectomy or from fine-needle aspiration cytology related to abnormal findings on CT scanning, lymphangiography, or excretory urography. Some evidence exists supporting the case of potential cure by radical prostatectomy when pelvic nodal involvement is minimal. Other options include standard external beam irradiation therapy, endocrine therapy with transurethral prostatic resection, and finally, observation until distant metastases occur. Because of the increased risk of distant metastases in patients with stage D1 prostatic cancer, adjuvant chemotherapy programs are rational with clinical trials now in progress.