ASCO - Initial hormonal management of androgen-sensitive metastatic, recurrent, or progressive prostate cancer: 2006 Update of an American Society of Clinical Oncology Practice Guideline – 9 Pages

Authors : Loblaw DA, Virgo KS, Nam R et al

References A systematic review of the literature and consultation with experts, using overall survival as the primary outcome of interest.

Grade The Guidelines seek to answer a number of questions regarding metastatic or recurrent androgen sensitive prostate cancer for which androgen-deprivation therapy (ADT) is considered appropriate.

Coverage What are the standard initial treatment options?

Bilateral orchidectomy or medical castration with an LHRHa (e.g. goserelin), are recommended as initial treatment for metastatic prostate cancer. A full discussion between the patient and practitioner should determine which is best for the patient. Diethyl stilboestrol (DES) should not be considered as a standard first-line treatment option.

Are anti-androgens as effective as other castration therapies?

Non-steroidal anti-androgen (NSAA) monotherapy (e.g. bicalutamide) may be discussed as an alternative to castration, since it shows equivalent survival, but has less toxicity, particularly with respect to loss of libido and physical capacity.
Steroidal anti-androgen (AA) monotherapy should not be offered as monotherapy, since they offer inferior time to progression of disease compared with LHRHa’s.

Is Combined Androgen Blockade (CAB) better than castration alone?

Combined androgen blockade (CAB) should be considered. Using an FDA accepted delta-method for calculating hazard ratios (HR); bicalutamide CAB vs castration alone has an HR of 0.80, which would translate into a potential median survival advantage of 1.25 years. Given that bicalutamide CAB has minimal, if any additional toxicity over castrate therapies alone, patients should be made aware of these findings and it’s use should be considered.

Does Early Treatment improve outcomes over Deferred Treatment?

Strong recommendations for early use of ADT cannot be made. Immediate versus symptom-onset institution of ADT results in a moderate decrease (17%) in relative risk (RR) for PCa-specific mortality, but a moderate increase (15%) in RR for non-PCa-specific mortality and no overall survival advantage.
PSA and other metrics allow the identification of patients at high risk, but further studies are needed 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 be regularly monitored.

What is the role of Intermittent Androgen Blockade?

Currently, data are insufficient to support the use of intermittent androgen blockade outside of clinical trials. Only one small randomised study with a short follow-up has reported and the results of two large ongoing studies ( SWOG 9346 + NCI Canada’s PR7) are awaited.

Source J Clin Oncol. 2007; 25 (12): 1596 - 1605.
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