Original studyPrimary Intermittent Androgen Deprivation As Initial Therapy for Men with Newly Diagnosed Prostate Cancer
Introduction
In the early 1990s prostate cancer treatment options were limited to surgery and radiation therapy. During that time a number of men consulted us with an interest in avoiding surgery. They perceived radiation therapy as either too toxic or ineffective. Around 1992 we tested the idea of primary androgen deprivation (AD) in 24 men with newly diagnosed prostate cancer who had a follow-up sextant biopsy after 6 months of AD. Eighteen of the 24 men (75%) showed no residual cancer.1 Further experience with longer duration AD revealed that an undetectable PSA level was almost always reached and maintained. We later found, as did others, that AD could be stopped and restarted in an intermittent fashion.2
In men with localized prostate cancer treated with initial AD, treatment selection is a dynamic ongoing process that plays out over many years. Intermittent AD, because of its intrinsically open-ended nature, leads to multiple recurrent decision points regarding when to start or stop therapy and when to initiate definitive local therapy such as surgery or radiation. These clinical decisions are made by the patient in consultation with the physician, taking into account the pace of the disease and the impact of potential treatment-related side effects.
In the present study we report the 12-year outcome of a small group of men with early-stage prostate cancer eligible for local therapy but who elected to start AD as primary treatment.
Section snippets
Materials and Methods
Systematic and exhaustive review of > 1200 patient charts was performed at a medical oncology practice specializing in prostate cancer to identify all patients meeting the following entry criteria: (1) biopsy proven prostate cancer, (2) no previous surgery or radiation therapy, (3) clinical stage < T3, (4) treatment with initial AD for at least 9 months, (5) concomitant antiandrogen therapy continued for the duration of luteinizing hormone–releasing hormone (LHRH) agonist treatment, (6)
Results
After systematic review of all charts in the practice, 73 men were determined to be eligible for study inclusion. The median follow-up was 12.0 years. Patient characteristics are shown in Table 1. The median treatment time (duration of LHRH agonist therapy) of the initial cycle of AD was 15.9 months. The median treatment for subsequent cycles averaged 12 months. The number of men in each of the D'Amico3 risk categories (assigned retrospectively) was low risk, 15; intermediate risk, 38; high
Discussion
This observational report is most relevant when interpreted in the context of its times. For example, the risk of radiation toxicity was much higher in the past. In the 1990s, men with a strong antipathy against radical prostatectomy or radiation had few alternatives.
It should be reiterated that this is a purely descriptive study. It consists of a relatively small group of men evaluated retrospectively. Care and restraint are necessary before drawing unwarranted conclusions about the
Conclusion
Our small study provides some modest preliminary evidence that primary induction AD may be feasible in men with intermediate-risk prostate cancer who are otherwise eligible for local therapy and in men with high-risk disease who are of advanced age or have significant comorbidities. Age and D'Amico risk category appear to be the most potent factors determining if delayed surgery or radiation therapy will be implemented. Younger men have more robust testosterone recovery and faster PSA doubling
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