Neoadjuvant hormonal therapy (NHT) prior to radical prostatectomy has not been shown to improve disease-free survival despite a 30% reduction in surgical margin involvement on pathological evaluation compared to those not receiving such therapy before proceeding to sur-gery.100-105 The degree of fall in serum PSA seen in these patients does not predict the likelihood of positive margins at surgery.106 Patients with either clinical or pathological extension of prostate cancer through the prostatic capsule (stage T3) do poorly with NHT and radical prostatectomy.107-110 Conversely, neoadjuvant and/or concurrent hormonal therapy improved outcome in patients undergoing radiation therapy in two randomized trials (Fig. 19.3).111,112 Studies comparing cancer control and morbid
Figure 19.3 A: Kaplan-Meier estimate of overall survival. The overall survival rate at 5 years was 79% (95% confidence interval 72%-86%) for the combined-treatment group and 62% (95% confidence interval 52%-72%) for the group treated only with radiotherapy. B: Kaplan-Meier estimate of the disease-free interval. This curve shows the proportion of surviving patients who were free of disease at each time point. The method takes the censoring process into account. The number of patients who are at risk for the event at each time point is the total of patients minus the number in whom disease progressed or who were lost to follow-up. (From Bolla et al.112 with permission.)
ity for radiation therapy combined with NHT and that observed for other treatments used in clinically localized prostate cancer are urgently needed. At present, NHT prior to planned surgery is not recommended outside a trial setting. Several accruing trials are examining the optimal type, timing, and duration of hormonal therapy combined with radiation for clinically localized disease.
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