Prostate cancer management shows major shifts in PSA era

Orlando, FL--The management of localized prostate cancer has undergone a significant, dramatic shift in recent years. Both pure and robot-assisted laparoscopic prostatectomy appears to be a viable treatment option that is popular with patients; watchful waiting has declined, despite the stage migration seen in the PSA era; and hormonal therapy has become more widely used in low-risk patients, a source of controversy.

These were among the trends in prostate cancer management discussed by experts at a session of the 2005 Multidisciplinary Prostate Cancer Symposium.

"But there are two downsides. One is that the operation itself takes longer, so patients are in the operating room longer. And second, the technique is potentially associated with a higher rate of impotence than open prostatectomy if excess cautery is used. Nevertheless, patients often prefer that minimally invasive surgical approach, and so it is a frequently used surgical procedure where robotic technology is available," Dr. Sandler said.

Hormonal therapy was discussed by endocrinologist Fernand Labrie, MD, PhD, a pioneer of that treatment modality for prostate cancer, who is head of the Oncology and Molecular Endocrinology Research Center at Laval University in Quebec City, Canada.

Hormonal castration is not always sufficient because 30% to 50% of the male hormones are left behind and continue stimulating prostate cancer. Recognition of that problem led Dr. Labrie to the discovery that adding antiandrogens enhances the effect of LHRH treatment. Randomized studies have shown the benefits of hormone blockade in prostate cancer and resulted in a one-third reduction of death from prostate cancer at 10 years, he said, referring to a meta-analysis by Prof. Richard Peto, FRS, using monotherapy or treatment limited to blockade of the secretion of testicular androgens.

"Even with combined androgen blockade, if you treat for 1 year and then stop, the cancer comes back right away, the PSA comes back right away as soon as you stop the treatment," Dr. Labrie noted. "If you treat for 5 years with a combination of castration (LHRH agonist or surgery) with a pure antiandrogen, it's about 50/50. So in half of the cases, the PSA remains undetectable, indicating that the cancer is probably cured. But if you want to go to 90%, you have to treat for 7 years. If you need to treat for that long period, it means that...short-term hormone therapy is not enough and if hormone therapy is used, it should be combined blockade of androgens. You need to treat for years."