The American Urological Association has issued new guidlines for prostate cancer, its first update in nearly 12 years.
"The updated guidelines benefit from an extraordinary increase in the number of completed randomized clinical trials that give us insights into how treatments actually compare," AUA guideline panel chair Ian M. Thompson, M.D., told Drug Topics. Despite the trial results and other advances, no consensus has emerged yet regarding the optimal treatment for a man with localized disease (stage T1 to T2) with no regional lymph node or distant metastasis. According to AUA, of the 234,460 American men diagnosed with prostate cancer annually, 91% have localized disease, making them the most common patients with prostate cancer.
"Hormonal therapy in this setting is used only for symptomatic patients who have a contraindication to surgery or radiation and [it] is their only option," O'Bryant pointed out. William Douglas Figg, Pharm.D., MBA, agreed. Figg, who is the head of molecular pharmacology and clinical pharmacology programs at the National Cancer Institute's Center for Cancer Research, said, "The role of hormonal therapy in localized disease is limited." It is useful, however, as a neoadjuvant or adjuvant treatment in combination with radiation therapy, he explained. There is some evidence that this combination may confer a survival advantage.
The role of the combination of radical prostatectomy along with neoadjuvant hormonal therapy is not recommended, however, according to the new guide. "Although neoadjuvant therapy initially showed a benefit in reducing the numbers of patients with positive surgical margins, it did not show a decrease in chemical [prostate-specific antigen] recurrence or clinical recurrence after follow-up," noted O'Bryant. A small subset of high-risk patients may benefit from this therapy, but it is not clear at this time how to determine most appropriately who qualifies. "Therefore, the extra hormone therapy up front does not show any more benefit than just surgery alone."
The AUA guidelines do not focus on advanced disease, Figg pointed out. For advanced, metastatic prostate cancer, he recommends that pharmacists refer to the American Society of Clinical Oncology treatment guidelines for advice on appropriate therapy. "It is also important for pharmacists to remember that hormonal therapy is the cornerstone of treatment for advanced disease," he concluded.
The Guideline for the Management of Clinically Localized Prostate Cancer: 2007 Update can be accessed on-line at http://www.auanet.org/guidelines/main_reports/proscan07/content.pdf.