Neoadjuvant chemotherapy prior to surgery in higher-risk patients


A combined Russian and German research team has provided some interesting preliminary information on the use of neoadjuvant, low-dose docetaxel-based chemotherapy in treatment of intermediate- and high-risk patients prior to radical prostatectomy.

Nosov et al. report data from a small, pilot study in which 44 patients, all scheduled for radical prostatectomy, were divided into one or other of two groups:

  • A surgery + chemotherapy group (n = 21 patients) in which the patients were all treated with low-dose, neoadjuvant docetaxel (36 mg/m2) every  3 weeks for up to six cycles prior to their radical prostatectomy
  • A surgery only group (n = 23 patients) in which the patients received radical prostatectomy alone with no other neoadjuvant or adjuvant therapy

It is not clear from the abstract whether the patients were randomly assigned to one or other group.

The goal was to evaluate the relative safety, pathologic response rate, and long-term oncologic outcomes of the two forms of treatment in men with intermediate- and high-risk prostate cancer. Note that none of the patients in either group were receiving neoadjuvant androgen deprivation therapy (ADT).

Here are the data reported by the authors:

  • All patients met standard criteria for intermediate- or high-risk prostate cancer (PSA > 10 ng/ml, Gleason score 7 or more, or clinical stage cT2c or more).
  • Average (median) follow-up was 11.4 years after radical prostatectomy.
  • Toxicities were generally mild and grade 3 events occurred in no more than 2/21 chemotherapy patients (i.e., 10 percent).
  • PSA reductions of > 50 percent were observed in 52.4 percent of chemotherapy patients post-chemotherapy and prior to surgery.
  • Prostate cancer-specific survival rates were
    • 90.0 percent in the surgery + chemotherapy group
    • 60.9 percent in the surgery only group
    • This difference was statistically significant (P = 0.042).
  • The biochemical recurrence-free survival rates were
    • 68.5 percent in the surgery + chemotherapy group
    • 37.7 percent in the surgery only group
    • This difference was not statistically significant (P > 0.05).
  • Overall survival rates were
    • 75.5 percent in the surgery + chemotherapy group
    • 54.6 percent in the surgery only group
    • This difference was not statistically significant (P > 0.05).

Nosov et al. conclude that:

The use of neoadjuvant chemotherapy before [radical prostatectomy] in a selected regimen and dose represents a safe strategy and results in benefits in [prostate cancer-specific survival]. Given the limitations of the study, this concept should be evaluated in large, prospective, controlled studies.

It certainly seems like an idea that is worth exploring further.

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