Neoadjuvant hormone therapy prior to surgery

In the early 1990s, many urologists thought that they might be able to improve surgical outcomes by treating patients with a short course of hormone therapy prior to the actual surgery.

For a variety of reasons, this idea fell out of favor fairly rapidly, not least because hormone therapy appeared to have effects on the structure of the prostate which could, in many cases, make the surgical procedure more difficult to execute. However, we now seem to have (nearly) definitive data to show that there really is no long-term clinical benefit to this form of treatment.

Yee et al. have reported long-term follow-up data from a small, single-institution, randomized, prospective trial of radical prostatectomy (RP) with or without a 3-month course of neoadjuvant hormone therapy (NHT). It had previously been shown that the use of NHT in this trial resulted in pathological downstaging, but generally no reduction in biochemical recurrence (BCR) on early follow-up (at 3 years).

From December 1992 to June 1996, 148 patients with clinically localized prostate cancer were randomized to RP only or to 3 months of goserelin acetate and flutamide before RP. BCR was defined as a detectable serum PSA level of > 0.1 ng/ml at least 6 weeks after surgery, with a subsequent confirmatory increase.

The median follow-up for BCR-free patients is now 8 years. However:

  • There appears to be no significant difference in BCR-free probabilities between thre two groups of patients (P = 0.7).
  • The probability of freedom from BCR at 7 years was 78 percent for patients undergoing RP only and 80 percent for patients undergoing NHT and RP.
  • Careful statistical analysis showed no significant relationship between NHT and BCR.
  • Overall, two patients had local recurrence only and six developed metastases, and these patients were evenly distributed between the RP-only and the NHT + RP groups.

The authors are careful to point out that their study was not originally powered to detect differences in BCR between the two groups. However, there was no apparent overall effect on BCR-free probability, local recurrence, or metastasis with 3 months of NHT at 8 years of follow-up. They conclude that, “Pending evidence of improvement in patient outcomes, NHT before RP appears to be unjustified outside of clinical trials.”

2 Responses

  1. And some urologist friends told me that NHT prior to surgery resulted in the gland mass becoming sticky and a bit more difficult to deal with.

  2. Chuck: This is the primary efffect I was referring to when I wrote that “hormone therapy appeared to have effects on the structure of the prostate which could, in many cases, make the surgical procedure more difficult to execute” in the second paragraph above.

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