Health and Prostate

Widespread clinical use of prostate-specific antigen for the early detection and monitoring of treatment outcomes in prostate cancer has resulted in a significant stage migration. It has also helped alter the definition of advanced prostate cancer, with the spectrum ranging from patients with locally advanced stage disease to overt systemic metastases. The past two decades have also witnessed significant technical improvements in the delivery of both local and systemic therapy although several basic questions remain unanswered. One question which continues to be debated is the timing of hormonal therapy. Previously this question was relevant primarily for patients with newly diagnosed metastatic disease. Today, however, it also involves patients who have a high risk of systemic relapse at the time of diagnosis and the growing population of patients with rising prostate-specific antigen levels as the sole manifestation of disease recurrence following local therapy. In the absence of conclusive prospective randomized clinical trials, treatment decisions are at times driven by emotion rather than by Read more [...]

Occult Metastases An important variable in "early hormonal" therapy is the definition of "early." Since the intent is to treat systemic disease effectively to prolong survival and reduce morbidity, it could be argued that the start of adjuvant hormonal therapy in carefully selected high-risk patients will be the earliest point in time for hormonal therapy. This position could be justified by the current data indicating that despite a steady decline in the incidence of newly diagnosed metastatic disease and microscopic lymph node metastases (from 20% in 1972 to 1988 to 3.4% in 1988 to 1991), the risk of extraprostatic disease in patients with clinically organ-confined prostate cancer is still significant (40 to 60%). Depending on the local/regional extent and histologic grade of the disease, approximately 50% of patients with prostate cancer will progress despite definitive local therapy, verifying the presence of early but occult systemic disease. Prostate-Specific Antigen Relapse and Metastatic Disease Serial prostate-specific antigen measurements following definitive local therapy have proven Read more [...]

For half a century, systemic therapy of prostate cancer has centered on suppressing androgenic stimuli by either surgical or medical gonadal suppression. The hypothesis that a tumor clone may be or will become sensitive to lower androgen levels fostered attempts to eliminate all sources of androgens, including the adrenals. Numerous studies conducted during the 1980s and 1990s to resolve this issue produced conflicting outcomes. Irrespective of the type of androgen deprivation, however, median progression-free and overall survival for patients with metastatic prostate cancer remain at 12 to 18 months and 24 to 33 months, respectively, with virtually all patients dying from hormone-refractory prostate cancer. Historically, several major studies conducted by VACURG laid the foundation for most contemporary hormonal therapies in prostate cancer. The first study demonstrated that delaying hormonal therapy did not appear to compromise overall survival. Patients treated with high doses of diethylstilbestrol, however, suffered higher death rates from cardiovascular complications. The second study demonstrated Read more [...]

T1b-T2NxM0: a Case for Hormonal Therapy? The role of androgen withdrawal therapy in hormone-naive, clinically localized prostate cancer has not been adequately or appropriately tested. Nevertheless, it is a concept that is a part of clinical practice worldwide. Several surveys have revealed disparities among urologists' attitude toward treatment of localized prostate cancer and the actual patterns of care. This situation exists in both Europe and North America. While most urologists favor definitive local therapy, many patients receive androgen withdrawal therapy as first-line treatment. In a survey of 656 European urologists concerning treatment of moderately differentiated, localized prostate cancer in a 60-year-old man, 79.9% chose definitive local therapy in the form of radical prostatectomy, external beam radiotherapy, or brachytherapy, while 15.9% chose conservative therapy in the form of hormonal therapy or watchful waiting. Another study of 26 Italian urologic centers reported that during a 1-year recruitment period (June 1994 to June 1995), 16 of 31 (52%) stage A2 patients, 52 of 138 Read more [...]