Correspondence

Duration of Androgen Suppression in Prostate Cancer

N Engl J Med 2009; 361:1212-1213September 17, 2009

Article

To the Editor:

In the trial conducted by Bolla et al. (June 11 issue),1 more than 70% of the patients had clinical T3 disease, and the median level of prostate-specific antigen (PSA) in patients who underwent randomization was 18.8 ng per milliliter, with a range of up to 159.2. Furthermore, about 20% of the patients presented with Gleason scores of 5 or less, suggesting that these tumors were downgraded as compared with current trends in diagnosis.2 Since bone scans were not mandated as part of the study, a clinically significant number of patients were likely to have had metastatic disease at presentation. The study, therefore, has limited applicability for most patients whose disease is diagnosed with the use of PSA screening. For patients with an intermediate risk of disease as defined by D'Amico et al.,3 short-term androgen suppression should not be considered inferior to long-term treatment.

Kas R. Badiozamani, M.D.
Virginia Mason Medical Center, Seattle, WA
kas_ray@hotmail.com

3 References

1. 1

   Bolla M, de Reijke TM, Van Tienhoven G, et al. Duration of androgen suppression in the treatment of prostate cancer. N Engl J Med 2009;360:2516-2527
   Full Text | Web of Science | Medline

2. 2

   Ghani KR, Grigor K, Tulloch DN, Bollina PR, McNeill SA. Trends in reporting Gleason score 1991 to 2001: changes in the pathologist's practice. Eur Urol 2005;47:196-201
   CrossRef | Web of Science | Medline

3. 3

   D'Amico AV, Moul J, Carroll PR, Sun L, Lubeck D, Chen MH. Cancer-specific mortality after surgery or radiation for patients with clinically localized prostate cancer managed during the prostate-specific antigen era. J Clin Oncol 2003;21:2163-2172
   CrossRef | Web of Science | Medline

Author/Editor Response

The statement that more than 70% of the patients in our trial had clinical T3 disease with a median PSA of 18.8 ng per milliliter and that roughly 20% had tumors with a Gleason score of 5 or less is correct. These characteristics are in keeping with those of trials conducted by the Radiation Therapy Oncology Group for locally advanced prostate cancer; in trial 92-02, 19% and 20% of the tumors in the two study groups had Gleason scores between 2 and 5, and the median PSA levels for the groups were 20.8 and 19.9 ng per milliliter.1 No clinical evidence of metastatic spread was detected in our patients after an initial staging that included the use of bone scans as well as computed tomography or magnetic resonance imaging of the abdomen and pelvis. We recommend radiotherapy plus long-term androgen suppression for patients with locally advanced prostate cancer, classified as stage T2c or higher, and a World Health Organization performance status of 0 to 2 (with no contraindicating coexisting conditions). These patients seldom receive a diagnosis by means of individual or mass PSA screening, unlike patients with localized prostate cancer in clinical stages T1c to T2b, who have an intermediate risk of disease and benefit from short-term androgen suppression.2

Michel Bolla, M.D.
University Hospital, Grenoble, France
mbolla@chu-grenoble.fr

Laurence Collette, Ph.D.
European Organization for Research and Treatment of Cancer Headquarters, Brussels, Belgium

2 References

1. 1

   Hanks GE, Pajak TF, Porter A, et al. Phase III trial of long-term adjuvant androgen deprivation after neoadjuvant hormonal cytoreducation and radiotherapy in locally advanced carcinoma of the prostate: the Radiation Therapy Oncology Group Protocol 92-02. J Clin Oncol 2003;21:3972-3978[Erratum, J Clin Oncol 2004;22:386.]
   CrossRef | Web of Science | Medline

2. 2

   D'Amico AV, Chen MH, Renshaw AA, Loffredo M, Kantoff PW. Androgen suppression and radiation vs radiation alone for prostate cancer: a randomized trial. JAMA 2008;299:289-295
   CrossRef | Web of Science | Medline