Neoadjuvant chemohormonal therapy in high-risk prostate cancer patients

It is clear from a report in the December issue of Urologic Oncology that the neoadjuvant use of chemohormonal therapy prior to surgery or radiation is not going to be a “cure-all” for prostate cancer patients initially diagnosed with high-risk, locally advanced prostate cancer.

Kim et al. evaluated the 2-year progression-free survival of patients treated with docetaxel + estramustine, administered prior to definitive therapy with surgery or radiation. The 24 patients in this Phase II trial were all treated with neoadjuvant docetaxel (36 mg/m2 i.v. weekly) for 3 weeks and estramustine (140 mg orally 3 times daily) for 3 consecutive days every 28 days. The patients all went on to receive either a radical  prostatectomy (RP) or external beam radiation therapy (EBRT).

The results of this study are reported as follows:

  • 22/24 patients were evaluable, of whom 12 had an RP and 10 had EBRT.
  • 21/22 evaluable patients completed the proposed cycles of neoadjuvant chemotherapy with minimal dose reductions or delays.
  • 21/22 patients achieved a > 25 percent reduction in their PSA levels.
  • There were no pathologic complete responses.
  • The 2-year progression-free survival rate was 45 pecent at a median 2 years of follow-up.

In summarizing their findings, the authors state that their data “support the safety, tolerability, and efficacy of neoadjuvant chemotherapy in patients … with high risk, locally advanced prostate adenocarcinoma, although the relative contributions of androgen deprivation therapy and docetaxel cannot be determined.” This statement is certainly true, but the fact that the 2-year progression-free survival was only 45 percent is hardly promising for the long-term potential of this type of neoadjuvant therapy. If neoadjuvant therapy of any type is really to meet the needs of patients diagnosed with high-risk, locally advanced disease, we are going to need to see progression-free survival rates in excess of 50 percent for at least 5 years.

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