Most physicians agree that endocrine therapy is the most effective treatment for advanced prostate cancer. However, there is disagreement on exactly how and when to use endocrine therapy.
Here are some principle questions about endocrine therapy for advanced prostate cancer.
Treatment timing
There has been previous academic disagreement about the timing of endocrine therapy:
- One view is that endocrine therapy should be initiated only after the cancer has metastasized and caused symptoms (e.g., bone pain);
- Another view is that endocrine therapy should be started before symptoms appear because early treatment is beneficial in reducing the incidence of spinal cord compression, urinary tract obstruction, and fractures.
However, a growing body of evidence suggests that in patients with metastatic prostate cancer, early application of endocrine therapy can help improve quality of life and prolong survival.
Therefore, the prevailing view is that endocrine therapy should be initiated early in the diagnosis of metastatic prostate cancer.
In patients with positive lymph nodes who underwent prostatectomy, immediate postoperative androgen deprivation as adjuvant therapy significantly improved progression-free survival, prostate cancer-specific survival, and overall survival.
Course of treatment
The debate over treatment course has centered on whether to use continuous or intermittent therapy.
In early 2012, studies found that patients with intermittent androgen deprivation had the same survival as those with continuous androgen deprivation. Researchers developed a new treatment model that uses androgen deprivation for up to 8-9 months and then stops when PSA levels normalize. Only if PSA levels exceeded 10 during the bimonthly monitoring period should they be treated again.
Notably, in mainstream national and international guidelines, intermittent endocrine therapy is recommended only in patients with asymptomatic metastatic prostate cancer who have a high degree of self-management.
Combination therapy vs. monotherapy
There is also disagreement and inconclusive as to which approach is more effective in treating prostate cancer, combined endocrine therapy or just one anti-androgen drug.
Recent studies have shown that combined endocrine therapy prolongs survival in patients with metastatic prostate cancer compared with debulking (drugs or surgery) alone, but the increase in survival is less than 5%. In addition, non-steroidal anti-androgen drugs alone are not effective in prolonging patient survival compared with denervation (surgical removal of the testes or application of LHRH analogs).
Therefore, treatment with anti-androgen drugs alone is not recommended for patients with metastatic prostate cancer.
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