Combined versus sequential chemo-endocrine therapy in advanced prostate cancer: final results of a randomized Southwest Oncology Group study

Effectiveness of Platinum-Based Chemotherapy in Patients With Metastatic Prostate Cancer: Systematic Review and Meta-analysis

BACKGROUND

Taxanes are the only cytotoxic drugs that have demonstrated a survival benefit for patients with castration-resistant prostate cancer (CRPC), but there is some evidence that platinum compounds may also benefit such patients.

METHODS

We performed a systematic search on electronic databases. We sought prospective clinical studies testing platinum compounds for CRPC. Platinum compounds could be delivered alone or in combination with other drugs. Both randomized and nonrandomized studies were included for qualitative synthesis, only randomized studies were included for meta-analyses. Clinical overall response rate (cORR), prostate-specific antigen overall response rate (sORR), progression-free survival (PFS), overall survival (OS), and toxicity were the outcomes of interest.

RESULTS

We identified 53 studies delivering platinum agents for patients with CRPC. cORR varied from 0 to 82%, while sORR varied from 2% to 100%. Response rates were higher in patients who received combination treatments rather than platinum compounds alone. Pooled data from randomized trials demonstrated a statistically significant increase in both cORR (odds ratio = 5.3; 95% confidence interval, 1.89-14.92) and sORR (odds ratio = 2.07; 95% confidence interval, 1.33-3.22) when adding platinum compounds to chemotherapy. PFS varied from 2.1 to 12 months and OS 4.2 to 28 months with platinum-containing chemotherapy. Nausea and myelosuppression were the most common adverse effects. Toxicity was manageable in most studies.

CONCLUSION

Platinum compounds are a safe and active treatment for CRPC. Response rates are higher when cytotoxic chemotherapy containing platinum agents are compared to nonplatinum chemotherapy. Data on OS and PFS are inconclusive. More research is needed to evaluate whether platinum-based chemotherapy results in a survival benefit for patients with CRPC, as well as to establish predictive biomarkers.

Hormonal therapy and chemotherapy in hormone-naive and castration resistant prostate cancer

The management of advanced castration resistant prostate cancer (CRPC) has been rapidly changing and is still evolving. In the last years, there has been an increasing knowledge of prostate cancer biology. New therapeutic agents and approaches have been evaluated demonstrating benefits in survival and quality of life in patients with metastatic prostate cancer.

Why Chemotherapy Should be Given Early for Men with Metastatic Prostate Cancer

Metastatic hormone-sensitive prostate cancer (mHSPC) is an incurable disease, and despite a high response rate to androgen-deprivation therapy (ADT), outcomes have not significantly changed for many decades. Earlier attempts at multitargeted strategies with the addition of cytotoxic chemotherapy to ADT did not affect survival. As more effective therapies are emerging, including cytotoxic therapy for patients with metastatic castrate-resistant prostate cancer (mCRPC), there is increasing interest for testing these drugs earlier in the disease course. The premise is that agents with clinical benefit in advanced mCRPC may have a better effect if used preemptively before the development of significant resistance and to attack earlier de novo androgen resistant/independent clones. The recent results of the phase III clinical trial E3805 investigating ADT with or without docetaxel in mHSPC provide compelling support for this strategy. Docetaxel combined with ADT significantly improved overall survival from 44 to 57.6 months (p=0.0003), particularly in patients with high-volume disease (from 32.2 to 49.2 months; p=0.0006). Longer follow-up is needed to assess the effect on patients with low disease burden. Further studies are needed to further maximize the antitumor effect in patients with mHSPC and to investigate the effects of advancing therapy to this disease setting on the efficacy of respective agents in the castration-resistant setting.

Management of hormone-sensitive metastatic prostate cancer

Targeting gonadal androgen synthesis (often in conjunction with blockade of androgen receptor) is the cornerstone of treatment of hormone-sensitive metastatic prostate cancer (HSPC). Despite the failure of androgen deprivation therapy, most tumors maintain some dependence on androgen or androgen receptor signaling for proliferation. This article reviews the current standard of care for metastatic HSPC, mechanisms of treatment resistance, novel drugs targeting the androgen signaling pathway, biomarkers predicting response to treatment and survival, future directions, and ongoing clinical trials in HSPC.

Non-castrate metastatic prostate cancer: have the treatment options changed?

Over the past 7 decades androgen-deprivation therapy (ADT) has been the cornerstone of treatment for metastatic non-castrate prostate cancer (NCPC); however, the mechanisms to achieve this goal have evolved over time to include not only bilateral orchiectomy and estrogens, but also gonadotropin-releasing hormone (GnRH) agonists, antagonists, and the inclusion of androgen receptor (AR) blockade. Despite treatment with ADT, most men will progress to castrate-resistant prostate cancer (CRPC). Over the last decade many new treatment options for CRPC have emerged. These new treatments also could have a meaningful role earlier in NCPC. In this review, we outline the biologic drivers of NCPC, review current standard therapy available for NCPC, and discuss the evolving role of new therapeutics in metastatic disease.

A phase II trial of androgen deprivation therapy (ADT) plus chemotherapy as initial treatment for local failures or advanced prostate cancer

PURPOSE

Long-term hormonal ablation in prostate cancer is associated with decreased overall health and quality of life. Few reports emphasized the role of chemotherapy in the management of early stage prostate cancer. This study analyzed the safety and efficacy of androgen deprivation therapy (ADT) plus chemotherapy as initial treatment for patients identified as local failures or not eligible for prostatectomy or radiation therapy due to advanced disease presentation.

METHODS

Enrolled patients received ADT in the form of leuprolide every 12 weeks for 24 months with bicalutamide initiating after the completion of chemotherapy. Chemotherapy consisted of ketoconazole and doxorubicin for weeks 1, 3, and 5 and estramustine and docetaxel and for weeks 2, 4 and 6. During weeks 7 and 8, no treatment was received.

RESULTS

Forty-six patients were enrolled, and forty-five patients were evaluable. Median progression-free survival (PFS) was 23.4 months. Median overall survival (OS) was 53.7 months. Out of 45 patients with measurable disease, 22 patients had an objective response: 9 patients achieved a complete response; 2 patients achieved a partial response; 10 patients achieved stable disease. Frequent grade 3 adverse events included elevated ALT (17 %), hypokalemia (13 %), and hypophosphatemia (13 %). Grade 4 adverse events were rare and included low bicarbonate (2 %), hypokalemia (2 %), leukocytopenia (2 %), and neutropenia (2 %).

CONCLUSIONS

The treatment demonstrated clinical benefit in all patient subsets with minimal reversible treatment-related adverse events. Subgroup analysis suggests that having prior local therapy resulted in greater PFS and OS.

Preclinical characterization of a novel diphenyl benzamide selective ERα agonist for hormone therapy in prostate cancer

Androgen deprivation therapy (ADT) is the mainstay of treatment for advanced prostate cancer. ADT improves overall and disease-free survival rates, but long-term therapy is associated with severe side effects of androgen and estrogen depletion including hot flashes, weight gain, depression, and osteoporosis. Effective hormone reduction can be achieved without estrogen deficiency-related side effects by using therapy with estrogenic compounds. However, cardiovascular complications induced by estrogens coupled with the availability of LHRH agonists led to discontinuation of estrogen use for primary androgen deprivation therapy in the 1980s. New treatments for prostate cancer that improve patient outcomes without the serious estrogen deficiency-related toxicities associated with ADT using LHRH analogs are needed. Herein we describe a novel nonsteroidal selective estrogen receptor-α agonist designed for first-line therapy of advanced prostate cancer that in animal models induces medical castration and minimizes many of the estrogen deficiency-related side effects of ADT. The present studies show that orally administered GTx-758 reversibly suppressed testosterone to castrate levels and subsequently reduced prostate volume and circulating prostate-specific antigen in relevant preclinical models without inducing hot flashes, bone loss, thrombophilia, hypercoagulation, or increasing fat mass.

COOPERATIVE GROUP TRIALS - SOUTHWEST ONCOLOGY GROUP (SWOG) INNOVATIONS IN ADVANCED PROSTATE CANCER

The major goals of the SWOG-GU committee in the area of advanced prostate cancer are to improve the survival and quality of life of patients with advanced prostate cancer. SWOG trials have examined the role of combined androgen blockade, intermittent androgen deprivation, and the early application of chemotherapy in castration-naïve disease. In addition, they have contributed to advancing the current chemotherapy standard of docetaxel plus prednisone, and ongoing trials seek to improve upon that standard. Finally, surrogate endpoints have been identified and markers of treatment response or resistance with novel technology are under active investigation. This review highlights findings from recent SWOG clinical trials for advanced prostate cancer, emphasizing the clinical impact and future applications of the data.

Does chemotherapy have a role before hormone-resistant disease develops?

Recent studies have demonstrated a survival benefit for chemotherapy in metastatic hormone-resistant prostate cancer. In other malignancies such as breast or colorectal cancer, use of active chemotherapy regimens earlier in the course of the disease has resulted in improvements in disease-free and overall survival. This review discusses the status of chemotherapy in prostate cancer and addresses evidence regarding the use of chemotherapy in hormone-sensitive disease, alone and in combination with androgen deprivation therapy.

Phase III trial of androgen ablation with or without three cycles of systemic chemotherapy for advanced prostate cancer

PURPOSE

We conducted a phase III trial in patients with previously untreated metastatic prostate cancer to test the hypothesis that three 8-week cycles of ketoconazole and doxorubicin alternating with vinblastine and estramustine, given in addition to standard androgen deprivation, would delay the appearance of castrate-resistant disease.

PATIENTS AND METHODS

Eligible patients had metastatic prostate cancer threatening enough to justify sustained androgen ablation and were fit enough for chemotherapy. The primary end point was time to castrate-resistant progression as shown by increasing prostate-specific antigen, new radiographic lesions, worsening cancer-related symptoms, or receipt of any other systemic therapy.

RESULTS

Three hundred six patients were registered; 286 are reported. Median time to progression was 24 months (95% CI, 18 to 39 months) in the standard therapy arm, and 35 months (95% CI, 26 to 44 months) in the chemohormonal group (P = .39). At median follow-up of 6.4 years, overall survival was 5.4 years (95% CI, 4.7 to 7.8 years) in the standard therapy arm versus 6.1 years (95% CI, 5.1 to 10.1 years; P = .41). Prostate-specific antigen kinetics at the time of androgen ablation and the nadir after hormone treatment were strongly correlated with survival. Chemotherapy significantly increased the burden of therapy, with 51% of patients experiencing an adverse event of grade 3 or worse, especially thromboembolic events.

CONCLUSION

There is no role for ketoconazole and doxorubicin alternating with vinblastine and estramustine before emergence of a castrate-resistant phenotype.

Chemotherapy for hormone-refractory prostate cancer

BACKGROUND

Prostate cancer mainly affects elderly men, and its incidence has steadily increased over the last decade. The management of this disease is replete with controversy. In men with advanced, metastatic prostate cancer, hormone therapy is almost universally accepted as the initial treatment of choice and produces good responses in most patients. However, many patients will relapse and become resistant to further hormone manipulation; the outlook for these patients is poor. Many have disease extending to the skeleton, which is associated with severe pain. Therapies for these men include chemotherapy, bisphosphonates, palliative radiotherapy, and radioisotopes. Systemic chemotherapy has been evaluated in men with hormone-refractory prostate cancer (HRPC) for many years, with disappointing results. However, more recent studies with newer agents have shown encouraging results. There is therefore a need to explore the value of chemotherapy in this disease.

OBJECTIVES

The present review aims to assess the role of chemotherapy in men with metastatic HRPC. The major outcome was overall survival. Secondary objectives include the effect of chemotherapy on pain relief, prostate-specific antigen (PSA) response, quality of life, and treatment-related toxicity.

SEARCH STRATEGY

Trials were identified by searching electronic databases, such as MEDLINE, and handsearching of relevant journals and conference proceedings. There was no restriction of language or location.

SELECTION CRITERIA

Only published randomised trials of chemotherapy in HRPC patients were eligible for inclusion in this review. Randomised comparisons of different chemotherapeutic regimens, chemotherapy versus best standard of care or placebo, were relevant to this review. Randomised, dose-escalation studies were not included in this review.

DATA COLLECTION AND ANALYSIS

Data extraction tables were designed specifically for this review to aid data collection. Data from relevant studies were extracted and included information on trial design, participants, and outcomes. Trial quality was also assessed using a scoring system for randomisation, blinding, and description of patient withdrawal.

MAIN RESULTS

Out of 107 randomised trials of chemotherapy in advanced prostate cancer identified by the search strategy, 47 were included in this review and represented 6929 patients with HRPC. Only two trials compared the same chemotherapeutic interventions and therefore a meta-analysis was considered inappropriate. The quality of some trials was poor because of poor reporting, low-patient recruitment, or poor trial design. For clarity, trials were categorised according to the major drug used, but this was not a definitive grouping, since many trials used several agents and would be eligible for inclusion in a number of categories. Drug categories included estramustine, 5-fluorouracil, cyclophosphamide, doxorubicin, mitoxantrone, and docetaxel. Only studies using docetaxel reported a significant improvement in overall survival compared to best standard of care, although the increase was small (< 2.5 months). The mean percentage of patients achieving at least a 50% reduction in PSA compared to baseline was as follows: estramustine 48%; 5-fluorouracil 20%; doxorubicin 50% (one study only); mitoxantrone 33%; and docetaxel 52%. Pain relief was reported in 35% to 76% of patients receiving either single agents or combination regimens. A three weekly regime of docetaxel significantly improved pain relief compared to mitoxantrone plus prednisone (the latter regimen approved as standard therapy for HRPC in the USA). All chemotherapeutics, either as single agents or in combination, were associated with toxicity; the major ones being myelosuppression, gastrointestinal toxicity, cardiac toxicity, neuropathy, and alopecia. Quality of life was significantly improved with docetaxel compared to mitoxantrone plus prednisone.

AUTHORS' CONCLUSIONS

Patients with HRPC have not traditionally been offered chemotherapy as a routine treatment because of treatment-related toxicity and poor responses. Recent data from randomised studies, in particular those using docetaxel, have provided encouraging improvements in overall survival, palliation of symptoms, and improvements in quality of life. Chemotherapy should be considered as a treatment option for patients with HRPC. However, patients should make an informed decision based on the risks and benefits of chemotherapy.

Radiation Therapy Oncology Group P-0014: a phase 3 randomized study of patients with high-risk hormone-naive prostate cancer: androgen blockade with 4 cycles of immediate chemotherapy versus androgen blockade with delayed chemotherapy

Currently, approximately 30,000 men die annually of metastatic, hormone-refractory prostate cancer. Androgen blockade is palliative and is generally effective for an average of 2 to 3 years until a patient develops androgen-independent disease. Newer chemotherapeutic regimens can induce remissions in approximately 50% of patients; however, median survival for patients with androgen-independent disease is still 8 to 12 months. The strategy of using chemotherapy regimens after androgen blockade has been proved noncurative, and new approaches are needed to attempt to cure patients with advanced disease. It has been demonstrated in the preclinical setting that androgen withdrawal induces apoptosis in cancer cells in both the Shinogi breast cancer model and the LNCaP prostate cancer model. In both of these models, androgen withdrawal was not curative, and the tumors grew back in a hormone-independent state. It is possible that the addition of chemotherapy at the time of initial androgen ablation will improve cell kill by potentiating apoptosis, thereby killing cells that might otherwise have mutated to the androgen-independent state if allowed to continue to cycle and grow. The rationale behind Radiation Therapy Oncology Group (RTOG) P-0014 is to demonstrate in a randomized phase 3 trial that giving patients chemotherapy at the beginning of androgen blockade may improve patient survival.

The management of high risk prostate cancer

PURPOSE

A major problem that urologists encounter is the recurrence of prostate cancer after local therapy or the failure of primary therapy. There is no consensus on the treatment of these groups of patients. The role of radiotherapy, hormonal therapy or chemotherapy must be defined.

MATERIALS AND METHODS

A comprehensive literature review of the current management of recurrence after primary therapy in prostate cancer was performed using MEDLINE, a review of current urology and oncology journals, and abstracts from recent urology meetings. The data collected focused on the role of radiotherapy, hormonal therapy and chemotherapy in this setting.

RESULTS

Defining a high risk group of patients using Gleason score, seminal vesicle or pelvic lymph node involvement and prostate specific antigen recurrence time is important for treating the problem early in disease course. Adjuvant radiotherapy cannot offer a survival advantage but it provides longer biochemical recurrence-free survival. Early administration of salvage radiotherapy in adequate doses provides a success rate similar to that of adjuvant radiotherapy in patients with low prostate specific antigen. Although there is no good evidence that early androgen deprivation definitely prolongs patient survival, increased time to progression in addition to excellent palliation with early hormonal therapy was reported in the majority of trials. Early trials of the use of chemotherapy showed improved survival rates with adjuvant chemotherapy alone or with a combination of hormonal therapy, especially in patients with nonmetastatic disease.

CONCLUSIONS

Although analysis of current literature revealed that patients who have recurrence after primary therapy would benefit from radiotherapy, hormonal therapy, chemotherapy or a combination of therapies, additional prospective randomized studies are needed to support these findings.

Interferon-alpha prevents selection of doxorubicin-resistant undifferentiated-androgen-insensitive metastatic human prostate cancer cells

BACKGROUND

We determined whether treatment of metastatic prostate cancer cells with doxorubicin (DOX) and interferon-alpha (IFN-alpha) prevented the emergence of highly undifferentiated tumor cells.

METHODS

The state of cell differentiation was determined by analysis of prostate-specific antigen (PSA), E-cadherin, keratin, and vimentin.

RESULTS

Human prostate cancer LNCaP-LN3 cells growing in culture as multicell spheroids expressed higher levels of E-cadherin and E-cadherin-associated beta-catenin than LNCaP-LN3 cells growing as monolayers. Treatment of cells with DOX downregulated PSA, E-cadherin, and keratin, and upregulated expression of vimentin and vascular endothelial growth factor (VEGF) mRNA. While treatment of cells with IFN-alpha did not alter gene expression, the addition of IFN-alpha to cultures treated with DOX produced synergistic toxicity and abrogated the changes in gene expression observed in cells treated with DOX alone.

CONCLUSIONS

Treatment with IFN-alpha and DOX should be further explored as a therapeutic strategy for androgen-insensitive prostate cancer.

Adjuvant mitozantrone chemotherapy in advanced prostate cancer

OBJECTIVE

To assess the role of mitozantrone, active in relapsed prostate cancer, as an adjuvant to hormonal treatment in patients with advanced prostate cancer.

PATIENTS AND METHODS

Between October 1990 and May 1995, 96 patients were entered into a stratified, randomized, single-institution study of hormonal therapy with a luteinizing hormone-releasing hormone agonist and flutamide, with or without four cycles of adjuvant mitozantrone. Of these, 93 patients were evaluable and the results were analysed in June 1999.

RESULTS

Patients with localized prostate cancer receiving adjuvant chemotherapy had a higher initial objective response rate (95% vs 53%, P = 0.008) and median survival (80 vs 36 months, P = 0.04) than patients who were treated with hormonal therapy alone. There was no advantage to adjuvant chemotherapy in patients with metastatic prostate cancer. There were insignificant advantages to chemotherapy in overall response rates (55% vs 39%, P = 0.3) and PSA responses (82% vs 64%, P = 0.11). There was no difference between the patient groups in time to treatment failure.

CONCLUSION

There was a survival advantage in using adjuvant mitozantrone in patients with locally advanced prostate cancer. Although the study comprised relative few patients, the follow-up period was long and the advantage significant. We recommend that the study be extended to include more patients.

Chemotherapy for prostate cancer

The development of chemotherapy for prostate cancer has been limited by the toxicity of treatment in an elderly population. The evaluation of newer agents in the 1990's has allowed chemotherapy to be given which has fewer side effects, and has improved life quality. The investigation of adjuvant treatment may be warranted in an attempt to improve the outlook of this condition.

Orchiectomy and orchiectomy plus mitomycin C for metastatic prostate cancer in patients with poor prognosis: the final results of a European Organization for Research in Cancer Therapy Genitourinary Group Trial

PURPOSE

The outcome of patients with symptomatic metastatic prostate cancer is poor and improved treatment regimens are urgently needed. Theoretically, the combination of orchiectomy and chemotherapy could reduce androgen sensitive and insensitive cells in the prostate. This European Organization for Research in Cancer Therapy Genitourinary Group randomized, multicenter phase III trial demonstrates the outcome of orchiectomy alone versus orchiectomy followed by intravenous mitomycin C.

MATERIALS AND METHODS

A total of 189 patients with metastatic prostate cancer and poor prognostic factors were randomized in this trial by 42 institutions. Of these patients 184 (97%) were eligible for study, including 90 treated with orchiectomy alone (orchiectomy only arm) and 94 treated with orchiectomy followed by 15 mg./m.2 mitomycin C in 1 week (combined treatment arm). Mitomycin C was administered every 6 weeks and treatment was continued as long as tolerance and patient compliance allowed, and no progression was observed. Objective and subjective criteria for progression were clearly defined in the protocol.

RESULTS

Patient and tumor characteristics were well balanced between the 2 treatment arms. At a median followup of 4.2 years 144 patients had died, including 112 of prostate cancer. No significant differences for time to overall (p = 0.17), subjective (p = 0.25) and objective (p = 0.08) progression were found between the 2 treatment groups. For progression-free survival no difference was noted (p = 0.67) between the 2 treatment groups but a trend in favor of orchiectomy alone was observed for overall survival (p = 0.04). Mitomycin C induced considerable hematological, gastrointestinal, renal and pulmonary toxicity leading to discontinuation in 31% of patients with pulmonary toxicity and 7% with renal deterioration. In addition, the quality of life evaluation revealed significant reduction in the combined treatment arm.

CONCLUSIONS

Based on the results of this randomized phase III study orchiectomy plus mitomycin C for metastatic prostate cancer in patients with poor prognostic factors cannot be recommended due to failure of improvement in survival and reduced quality of life parameters.

Evolving strategies of cytotoxic chemotherapy for advanced prostate cancer

Despite the use of cytotoxic chemotherapy for advanced prostate cancer for half a century, its clinical utility in this setting remains undefined. Based on traditional methods of assessment, the list of the most active cytotoxic agents includes cyclophosphamide, doxorubicin, mitoxantrone and cisplatin. With the introduction of more structured methods of assessment, including careful assessment of indices of quality of life and serial measurement of serum prostate-specific antigen (PSA), the role of cytotoxic agents is being re-assessed. In view of the cell cycle characteristics of prostate cancer, there appears to be an emerging role for combination inhibitors of mitosis, including estramustine in combination with the vinca alkaloids, etoposide or paclitaxel.

How is androgen-dependent metastatic prostate cancer best treated?

The principles of management of newly diagnosed metastatic prostate cancer have changed little since the time of Huggins and his colleagues. Modern clinicians have many more weapons in their therapeutic armamentarium than those pioneers, but little progress has been made in improving the survival of men with this disease. The results of androgen deprivation are comparable using any one of a number of different monotherapy approaches. The use of combined androgen blockade may improve survival in men with minimal disease but at considerable economic cost and with significant impairment of quality of life. The benefit of this therapy for men with more extensive disease is uncertain. New modalities such as intermittent androgen blockade or combination therapies are exciting, but unproven.

Maximal androgen blockade in combination with methotrexate for treatment of metastatic prostate cancer

Recently attention has been focused on the optimal timing of chemotherapy within the treatment regimen for patients with metastatic prostate cancer, i.e., hormonal manipulation, preferably maximal androgen blockage (MAB) consisting of chemical/surgical castration followed by treatment with antiandrogens. We have conducted a randomized prospective clinical trial, investigating the efficacy and toxicity of MAB (orchiectomy followed by flutamide therapy) alone as compared to MAB combined with methotrexate (MTX, 50 mg/m2/week) in 53 patients with newly diagnosed stage IV(M1) prostatic cancer (UICC TNM Classification 1987). The observed remission rates (complete + partial) of 42.3% in the MAB + MTX arm and 29.6% in the MAB arm did not differ significantly. The response rates (complete + partial + stable disease) of 73.1% and 66.7% for MAB + MTX and MAB respectively, also showed no significant difference. Neither progression-free survival (median 18/5 and 23.8 months for MAB + MTX and MAB, respectively) nor overall survival (median: 37.4 and 36.1) months in the MAB + MTX and MAB arm, respectively) could be improved by the addition of MTX to MAB Only the extent of metastatic pain reported by the patients was consistently less under MAB + MTX than under MAB alone (P<0.1). Both treatment regimens were well- tolerated with slightly more undesirable effects in the MAB + MTX arm. Our results do not provide evidence for the achievement of marked gains by combining chemotherapy with endocrine therapy in newly diagnosed patients with stage IV (M1) prostate cancer.

Southwest Oncology Group strategies in prostatic carcinoma

The Southwest Oncology Group Genitourinary Committee evolved in 1978 from a combined gynecologic-urologic cancer committee. A significant catalyst in this development was the growing interest in prostatic carcinoma, with an initial focus on hormone refractory disease. Clinical studies have expanded into combined androgen blockade, untreated metastatic disease and localized prostate cancer. Since 1978, more than forty trials in prostatic carcinoma have been conducted. Currently, seven are in progress or under development. Conclusions and future directions are reviewed.

Chemo-endocrine therapy for prostate cancer with bone metastasis. Nagasaki Prostate Cancer Research Group

We analyzed the clinical effects of initial chemoendocrine therapy on 31 prostate cancer patients with bone metastasis. These patients had been newly diagnosed between 1983 and 1991 and had received no previous therapy. As endocrine therapy, the patients received 1 mg ethynylestradiol daily with or without orchiectomy. In addition, they received three courses of chemotherapy consisting of 20 mg/m2 cisplatin given on days 1, 3, and 5 and 20 mg/m2 Adriamycin or 40 mg/m2 epirubicin given on day 5. Subsequently, for maintenance therapy, the patients received 1 mg ethynylestradiol and 150 mg 5-fluorouracil [or 300 mg tegafur plus uracil (UFT)] daily. Patients given our regimen of chemoendocrine therapy had a significantly better prognosis than did the controls treated with endocrine therapy alone (P = 0.05), although treatment was not randomized. The cause-specific survival rates at 5 years for the chemoendocrine-therapy patients and the control group were 65.4% and 37.4%, respectively. A multivariate analysis of possible prognostic factors, i.e., age, histological grade, prostatic acid phosphatase, tumor-related pain, the extent of disease (EOD) on bone scan, and the type of initial treatment, confirmed that the initial treatment (P = 0.03) and the EOD grade (P = 0.05) had a significant effect on survival. On the basis of these results, it is necessary to carry out a randomized trial to compare our chemoendocrine regimen with endocrine therapy alone in untreated patients with advanced prostate cancer.

Blindness secondary to prostate cancer

We report a case of blindness, secondary to hormone-refractory prostate cancer, occurring 7 years after the diagnosis of metastatic prostate cancer and 3.5 years after the clinical onset of the hormone-refractory state. Prolonged suppression of the disease with chemotherapy may have contributed to the unusual clinical findings. We discuss the role of supportive care in the management of prostate cancer.