This is an original JCO publication from 2007. Please visit the JCO website to access the full article.
Initial Hormonal Management of Androgen-Sensitive Metastatic, Recurrent, or Progressive Prostate Cancer
D. Andrew Loblaw, Katherine S. Virgo, Robert Nam, Mark R. Somerfield, Edgar Ben-Josef, David S. Mendelson, Richard Middleton, Stewart A. Sharp, Thomas J. Smith, James Talcott, Maryellen Taplin, Nicholas J. Vogelzang, James L. Wade III, Charles L. Bennett and Howard I. Scher
1. What Are the Standard Initial Treatment Options?
Bilateral orchiectomy or medical castration with luteinizing hormone–releasing hormone (LHRH) agonists are the recommended initial treatments for metastatic prostate cancer. A full discussion between practitioner and patient should occur to determine which is best for the patient. Diethylstibestrol should not be considered as a standard first-line treatment option and currently is no longer commercially available in North America.
2. Are Antiandrogens As Effective As Other Castration Therapies?
Nonsteroidal antiandrogen (NSAA) monotherapy may be discussed as an alternative, but steroidal antiandrogen (AA) monotherapy should not be offered.
3. Is Combined Androgen Blockade Better Than Castration Alone?
Combined androgen blockade (CAB) should be considered.
4. Does Early ADT Improve Outcomes Over Deferred Therapy?
For patients with metastatic or progressive prostate cancer, there is a moderate decrease (17%) in relative risk (RR) for prostate cancer–specific mortality, a moderate increase (15%) in RR for non–prostate cancer–specific mortality, and no overall survival advantage for immediate institution of ADT versus waiting until symptom onset for patients. Therefore, the Panel cannot make a strong recommendation for the early use of ADT. PSA kinetics and other metrics allow the identification of populations at high risk for prostate cancer–specific and overall mortality. Further studies must be completed to assess whether patients with adverse prognostic factors gain a survival advantage from immediate ADT. If a patient decides to wait until symptoms for ADT, he should have regular visits for monitoring. For patients with recurrent disease, clinical trials should be considered if available.
2007 literature update and discussion.
5. What Is the Role of Intermittent Androgen Blockade?
Currently, data are insufficient to support the use of intermittent androgen blockade outside of clinical trials.
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