Hormonal Therapy: Hormonal therapy is being utilized much earlier in treating prostate cancer than in the past. Work done many years ago by Dr. Fernand LaBrie showed that a combination of two anti-androgenic agents was more effective than any single agent available at that time. This work had been expanded and a number of trials have shown an improvement in disease free and overall survival when an LHRH-Agonist (an injection to deplete the body of testicular male hormone) and an anti-androgen (a pill or pills which block the rest of the male hormone in the prostate cancer cell that is produced by the adrenal gland) are combined. This was first shown to be effective in advanced disease, and now more and more studies are showing that combined hormonal therapy (CHT), when utilized early on, is helpful in better controlling early stage cancer. A number of studies are currently ongoing, showing that patients who receive three months of CHT prior to radical prostatectomy show that about one-third more men have negative surgical margins, compared to patients who go directly to radical, without any hormonal therapy. At this time, there does not appear to be a difference in recurrence rates at 5 years when PSA is used to indicate recurrence. One of the main criticisms of these studies is that the time these patients were on hormones may have been too short to show a benefit. It will be several years before we know whether or not there is a survival advantage for the hormonal group. Other studies have been done utilizing hormonal therapy before, during and after external beam radiation therapy, and those studies have, thus far, shown an improvement in progression free survival and survival as well in some of the studies. However, since radical prostatectomies have been done after even six to eight months of hormonal therapy and the vast majority of patients still have prostatic cancer, hormonal therapy is, in my opinion, not sufficient in and of itself. Metastatic prostate cancer may be either symptomatic or not. The best treatment at present is CHT. It has been clearly shown that CHT improves progression free survival. Patients with metastatic disease who are asymptomatic must consider whether to begin CHT immediately or delay it. A good way to understand these two options is by looking at the data from the NCI Intergroup Trial, which randomized patients with minimal metastatic disease to monotherapy versus CHT. Results show that survival time appears to be much greater with CHT. Furthermore. The survival rate was much greater for the men with widespread metastatic disease using CHT. These two observations and other studies confirming the benefits of the early utilization of hormonal therapy, lead us to conclude that early treatment with CHT in patients with minimal metastatic disease will improve their survival time, compared to waiting until symptomatic metastasis occurs. In fact, there is now a trend in the oncologic and urologic communities to treat patients earlier, before symptoms develop.
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