Hormone therapy for prostate cancer: a topical perspective

Evolution of the roles proposed for antiandrogenic agents in prostatic disease has been rapid. Since the early suggestions by Labrie and his colleagues that the nonsteroidal antiandrogen flutamide could be used in combination with medical or surgical castration to provide superior care for patients with metastatic prostate cancer, and subsequent substantiation of the theory in a number of clinical trials, we have observed an increasing tendency to test the use of antiandrogens (alone or in combination with other interventions) earlier in the disease process. At least in part, this tendency is a consequence of our increased ability to detect prostate cancer earlier in the disease process. At the present time, flutamide is the only nonsteroidal antiandrogen available for the treatment of prostate cancer in general clinical practice in the United States. However, two other nonsteroidal antiandrogens currently await decisions on their efficacy and safety by the Food and Drug Administration: nilutamide and bicalutamide. Will either of these agents offer clinical benefits beyond those offered by flutamide? Will the safety, activity, and dosing profiles of the nonsteroidal antiandrogens allow us to use them to treat even earlier stages of prostate cancer and perhaps even prostatic intraepithelial dysplasia in patients at high risk of prostate cancer? What are the potential future roles for bicalutamide and other nonsteroidal antiandrogens in the management of prostatic disorders? This article will attempt to lay out the key questions that await definitive answers as we expand our understanding of the possible future roles for antiandrogens in the management of prostate cancer and related conditions.