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Death of a President EDITORIALS Editorials ence in cancer-specific or overall survival has yet been found (Schroder FH: personal communication). The Mayo Clinic series, which represents the largest ret- rospective series, with a nonrandomized control group and almost three decades of follow-up,5 found that the EARLY ANDROGEN DEPRIVATION survival advantage in favor of immediate androgen- FOR PROSTATE CANCER? deprivation therapy was limited to DNA diploid tu- mors and became apparent only after 10 years. HE dependence of the growth of prostate cancer What explains this difference? It is possible that the Ton androgens is well documented. Androgen ab- effect of the treatment in the study by Messing et lation triggers a cascade of biologic events that ends al. might have been overestimated purely by chance in irreversible damage to the DNA of androgen-sensi- (a type I error). It seems very unlikely that other stud- tive prostate-cancer cells.1 Such treatment, tradition- ies would have missed such a large effect, since the ally reserved for men with metastatic disease, results in hazard ratios ranged from 3 to 12. One concern is major objective and subjective benefits in most pa- that the study never realized its projected goal of 240 tients. However, in approximately 50 percent of pa- patients. This is important, because the outcome of tients, disease progression occurs 12 to 18 months patients with nodal metastases is extremely variable after the initiation of treatment, and as a result, surviv- and can be affected by a number of known and pos- al rates have not increased over the past five decades. 2 sibly unknown prognostic factors.7-9 Such effects on Androgen ablation controls the tumor only tempo- the outcome of trials can be minimized by random- rarily because prostate cancer consists of androgen- ization, but the study by Messing et al. was relatively dependent and androgen-independent clones.1 Tumor small and might have been affected by imbalances of progression after androgen ablation is due to the pro- factors that had not been identified at the time the liferation of androgen-independent cells.1 At present, study began. One factor that might have influenced there is no conclusive evidence that androgen-depri- the outcome is the lack of a central pathological re- vation therapy improves survival. Undoubtedly, effec- view to assess the Gleason scores.5,7,8 The absence of tive control of androgen-independent disease will be a correlation between histologic grade and survival necessary for that to occur. suggests that an imbalance could have been present A major unresolved issue regarding hormonal ther- but unrecognized. apy is the optimal time to initiate treatment. In this How will the knowledge that immediate androgen- issue of the Journal, Messing et al.3 report that men deprivation therapy may be beneficial in men with with microscopical nodal metastasis (stage T1bN1M0 nodal metastases who have undergone radical prosta- or T2N1M0) who underwent radical prostatectomy tectomy affect the treatment of prostate cancer? At and in whom hormonal therapy was begun immedi- present, because of the shift toward earlier diagnosis ately survived significantly longer than men who were with increased screening efforts, less than 5 percent of initially treated by radical prostatectomy alone. To patients who undergo radical prostatectomy have pos- our knowledge, this is the first prospectively ran- itive nodes. Furthermore, as indicated by Messing et domized therapeutic study in such patients. Overall, al., the patterns of treatment have changed during the it was well designed, conducted, and analyzed. The past decade, particularly after their study ended. Pa- treatment groups appear to be reasonably balanced tients with evidence of microscopical nodal involve- with regard to patient and disease characteristics, thus ment are now unlikely to undergo radical prostatecto- supporting the likelihood that the estimate of the my. Although this point does not diminish the merits treatment effect was unbiased. of the study, it may limit its clinical impact. Nevertheless, the main result is rather surprising: How should physicians treat patients with asympto- a fairly large difference in survival between groups was matic metastatic prostate cancer? No study has shown found within a relatively short period. The cancer- conclusively that survival in patients given early andro- specific survival rate in the observation group was only gen-deprivation therapy is longer than when treatment 62 percent at seven years, as compared with a rate of is deferred until the time of symptomatic progres- approximately 80 percent in three contemporary se- sion. No advantage was found in the large randomized ries of patients with microscopical nodal metastases study of patients with prostate cancer, with or with- who were treated with radical prostatectomy alone.4-6 out extranodal metastases, that was conducted by the In an ongoing study by the European Organization Veterans Administration Co-operative Urological Re- for Research and Treatment of Cancer, 302 patients search Group in the 1960s.10 A more recent Medical with stage D1 disease (which includes nodal but not Research Council study11 reported a significant trend extranodal metastases) who did not undergo radical toward increased survival with early androgen-depri- prostatectomy were randomly assigned to receive ei- vation therapy, largely in patients without extranodal ther immediate or delayed androgen-deprivation ther- metastases. The incidence of spinal cord compression apy. With a median follow-up of six years, no differ- and pathologic fractures doubled in the deferred-treat- Volume 341 Number 24 · 1837 The New England Journal of Medicine Downloaded from nejm.org at NIH Libary on October 30, 2015. For personal use only. No other uses without permission. Copyright © 1999 Massachusetts Medical Society. All rights reserved. The New England Journal of Medicine ment group. The deferred-treatment group had 54 prostatectomy and pelvic lymphadenectomy in men with node-positive prostate cancer. N Engl J Med 1999;341:1781-8. more deaths than the immediate-treatment group. 4. Cadeddu JA, Partin AW, Epstein JI, Walsh PC. Stage D1 (T1-3,N1-3,M0) However, 29 of these men never received hormonal prostate cancer: a case-controlled comparison of conservative treatment therapy, indicating that treatment was often initiated versus radical prostatectomy. Urology 1997;50:251-5. 12 5. Zincke H, Bergstralh EJ, Larson-Keller JJ, et al. Stage D1 prostate cancer too late or not at all. treated by radical prostatectomy and adjuvant hormonal treatment: evi- Data from other clinical trials indicate that the out- dence for favorable survival in patients with DNA diploid tumors. Cancer 1992;70:Suppl:311-23. come among patients with metastatic disease who have 6. deKernion JB, Neuwirth H, Stein A, et al. Prognosis of patients with never received hormonal therapy depends heavily on stage D1 prostate cancer following radical prostatectomy with and without the extent of disease; this factor may have influenced early endocrine therapy. J Urol 1990;144:700-3. 13 7. Scrignoli AR, Walsh PC, Steinberg GD, Steiner MS, Epstein JI. Prog- the outcome of the Medical Research Council trial. nostic factors in men with stage D1 prostate cancer: identification of pa- We need more data on patients with metastatic disease tients less likely to have prolonged survival after radical prostatectomy. before standards of practice can be clearly delineated. J Urol 1994;152:1077-81. 8. Cheng L, Bergstralh EJ, Cheville JC, et al. Cancer volume of lymph How should the results of this study affect the treat- node metastasis predicts progression in prostate cancer. Am J Surg Pathol ment of patients who have elevated serum prostate- 1998;22:1491-500. 9. Bauer JJ, Connelly RR, Sesterhenn IA, et al. Biostatistical modeling us- specific antigen (PSA) levels after radical prostatecto- ing traditional variables and genetic biomarkers for predicting the risk of my? In the study by Messing et al., 80 percent of the prostate carcinoma recurrence after radical prostatectomy. Cancer 1997;79: patients had undetectable serum levels of PSA at the 952-62. 10. Byar DP. Proceedings: the Veterans Administration Co-operative Uro- time androgen-deprivation therapy was initiated. In logical Research Group’s studies of cancer of the prostate. Cancer 1973;32: a recent report, Pound et al.14 described the natural 1126-30. history of 304 patients with an elevated PSA level as 11. The Medical Research Council Prostate Cancer Working Party Inves- tigators Group. Immediate versus deferred treatment for advanced prostatic the sole evidence of relapse after radical prostatecto- cancer: initial results of the Medical Research Council Trial. Br J Urol my. The time at which the PSA level first rose after 1997;79:235-46. 12. Walsh PC. Immediate versus deferred treatment for advanced prostatic surgery, the Gleason score, and the length of time cancer: initial results of the Medical Research Council Trial. J Urol 1997; required for PSA levels to double all predicted the 158:1623-4. probability of distant metastasis. The algorithm that 13. Eisenberger MA, Crawford ED, Wolf M, et al. Prognostic factors in stage D2 prostate cancer: important implications for future trials: results of these authors used identifies patients at high risk for a cooperative intergroup study (INT-0036). Semin Oncol 1994;21:613-9. distant metastasis and death due to prostate cancer 14. Pound CR, Partin AW, Eisenberger MA, Chan DW, Pearson JD, who should be enrolled in randomized clinical trials Walsh PC. Natural history of progression after PSA elevation following rad- ical prostatectomy. JAMA 1999;281:1591-7. of androgen-deprivation therapy and nonhormonal 15. Pollack A, Zagars GK, Kavadi VS. Prostate specific antigen doubling treatments. It also identifies men with a high prob- time and disease relapse after radiotherapy for prostate cancer. Cancer ability of a favorable outcome, for whom watchful 1994;74:670-8. waiting is the most appropriate approach. Although less extensively evaluated, the data on patients with ©1999, Massachusetts Medical Society.
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