Optimizing the Role of Hormonal Therapy in the Management of Prostate Cancer

INTRODUCTION Optimizing the Role of Hormonal Therapy in the Management of Prostate Cancer Herbert Lepor, MD Department of Urology, New York University School of Medicine, New York, NY [Rev Urol. 2005;7(suppl 5):S1-S2] © 2005 MedReviews, LLC he era of androgen deprivation therapy (ADT) was ushered in by Huggins and Hodges in their 1941 publication reporting that both surgical castration (orchiectomy) and medical castration with diethylstilbestrol (DES) produced dramatic regression and palliation of advanced prostate cancer. Estrogen therapy was considered the more appealing of these options because patients generally preferred to avoid a surgical procedure, particularly one requiring removal of the testes. Subsequently, estrogen therapy with DES was shown to produce unacceptably high rates of cardiovascular toxicity and was withdrawn from the market, creating the need for a safer form of medical castration. In 1985, the first gonadotropin-releasing hormone (GnRH) agonist was approved for the treatment of men with advanced prostate cancer and since then, multiple formulations of 4 different molecules have been marketed. Throughout the world, GnRH agonists have become the first-line therapy for the management of this disease state. Although there is universal agreement that ADT is indicated for advanced prostate cancer, controversy surrounds the optimum dosing and timing schedules T VOL. 7 SUPPL. 5 2005 REVIEWS IN UROLOGY S1 Introduction continued for various patient populations. Because urologists typically are the healthcare providers for men with prostate cancer, it is imperative that the practicing urologist be aware of these controversies in order to optimize management of the disease. The articles in this supplement have been produced by a panel of international experts, known for their contributions to the management of prostate cancer. They will address many of the controversial issues related to ADT. I begin the supplement with a review and comparison of varying options for single-therapy androgen suppression. Dr. Gerald Chodak, of the Midwest Prostate and Urology Health Center, University of Chicago, and Weiss Memorial Hospital, follows with the history of and a clinical update on the efficacy of maximum androgen S2 VOL. 7 SUPPL. 5 2005 blockade. Dr. Leonard Gomella of the Kimmel Cancer Center at Thomas Jefferson University, Philadelphia, PA, then discusses the needs of high-risk patients with localized prostate cancer, how to identify these men, the management of prostate cancer in high-risk patients, and the role of ADT in these cases. Dr. David McLeod of the Walter Reed Army Medical Center follows with information regarding the management of biochemical recurrence in men with prostate cancer and evidence that prostate-specific antigen (PSA) will continue to be the predominant diagnostic and prognostic marker, despite advances in the field. The adverse events associated with short-term ADT are well known. Dr. E. David Crawford, of the University of Colorado Health Sciences Center, pre- REVIEWS IN UROLOGY sents his work with Drs. Ravi Kumar and Al Barqawi on the consequences of and ways to prevent adverse events associated with hormonal manipulation in men with prostate cancer. In 2005, earlier Medicare-mandated changes will dramatically impact reimbursement of hormonal therapies for prostate cancer. Dr. Ray Painter of Physician Reimbursement Systems, Denver, CO, discusses these changes, the short- and long-term consequences for clinicians who treat patients with prostate cancer, and the benefits to be derived from system automation and improved data collection and recording. I am confident that the urology community will find these presentations scholarly, timely, informative, and relevant to their day-to-day clinical practice.