When is the best time to start hormonal therapy for patients with advanced prostate cancer?

This study compared the effectiveness of hormonal therapy when used as early, or as late, treatment for patients with advanced prostate cancer.

Androgens are hormones (such as testosterone) that are produced mainly in the testicles, and can stimulate the growth of prostate cancer cells. For this reason, androgen deprivation therapy (ADT) is the standard of care in the treatment of advanced prostate cancer. ADT may include surgery to remove the testicles, or drugs which prevent the production, or the action, of androgens (referred to simply as hormonal therapy). However, ADT may also cause severe side effects such as impotence or erectile dysfunction, excessive sweating, breast tenderness, mood swings and depression. These may seriously affect the patient’s quality of life. Since prostate cancer is often diagnosed early, and develops slowly, patients often chose to delay ADT until the cancer has advanced to the point of showing symptoms. Whether this delay in treatment affects survival is currently under debate.

This study reviewed 8 different trials examining ADT in the treatment of prostate cancer patients.

Data from this systematic review showed that early intervention with hormonal treatments significantly reduces overall mortality (the number of deaths from any cause). However, this benefit in overall mortality was dependent on the stage of the disease and on patient age. Only young patients (less than 65 years of age) with advanced tumors showed a survival benefit from the early initiation of ADT. Three studies showed that early ADT significantly reduced metastatic progression (spread of the cancer to distant organs). In one study performed on 934 patients, cancer progression to metastasis was reported in 59% of patients who delayed hormonal therapy by only 9 months, compared to 38% of patients who started ADT immediately after diagnosis.

All trials showed that overall survival was significantly longer for patients treated with early ADT. In one study involving 500 patients the average survival time was 5.2 years for patients receiving early treatment, compared to 4.4 years for patients receiving delayed treatment.

This review concluded that early initiation of ADT for patients with advanced or metastatic prostate cancer delays disease progression and improves survival.

This review covered several trials, all employing different therapies, involving patients with different tumor characteristics, and following patients for different time periods. This was not accounted for in the review. Not all trials reviewed here adequately reported follow up times or hazard ratios. None of the studies assessed the effect of treatment on patient's quality of life.

Consult with your physician regarding the benefits and risks of early initiation of androgen deprivation therapy.