Updated May 14, 2015.
Surgeons may tell you, “Hormone blockade helps radiation, but not surgery.” Their negative opinion about hormone therapy is based on the results of several clinical trials performed in the 1990s that showed unimproved cure rates with surgery plus hormone therapy when compared with surgery alone in men with intermediate-risk prostate cancer.
However, before we completely abandon the concept of doing hormone therapy with surgery two additional questions arise: first, what about testing a more extended treatment period?
Maybe three months is too short. And second, how about doing a study in men with high risk disease? After all, they have the most to gain because they are more likely to have micro-metastatic disease and face the highest risk of relapse. The research addressing these questions is limited to three clinical trials that have tested more prolonged hormone therapy in high risk prostate cancer:
1. Dr. Martin Gleave at Vancouver General Hospital tested eight months of hormone therapy after surgery compared to three months. Cure rates using eight months was unchanged for men with intermediate risk disease. However, cure rates were improved in men with high risk disease treated for eight months.
2. In the New England Journal of Medicine, Dr. Edward Messing studied the question of adding lifelong hormone therapy started immediately after surgery in men with proven lymph node metastases compared to no immediate hormone therapy at all. The ten year survival rate was 85% with hormone therapy and 60% without hormone therapy.
3. In the Journal of Clinical Oncology, Dr. Tanya Dorff reported the results of treating men with high risk prostate cancer with two years of hormone therapy started right after the operation. The relapse rate was less than 10% at five years. This is a remarkable improvement over the cure rates reported with surgery alone. (See the list of studies in the following table).
Overall Relapse Rate @ 5 years = 42%
In Dr. Dorff’s study (the one using two years of hormone therapy after surgery) she reported out the freedom from relapse rate (the cure rate) in accordance with the type of high risk disease present. The relapse rate for men in the worst category, the men with positive nodes, is slightly higher at 12.6%, but not much higher. (See the following table).
|NUMBER OF PATIENTS||FREEDOM FROM RELAPSE||OVERALL SURVIVAL - NOT CANCER SPECIFIC|
|GLEASON 8 = OR SEMINAL VESICLE INVASION||199||91.8%||96.7%|
GLEASON 7 WITH POSITIVE MARGIN OR PSA > 10
The benefits of adding long term hormone therapy to surgery in men with high risk disease should not be so surprising because they are the most likely to have micro-metastases. Hormone therapy is the only treatment effective against cancer cells located outside the prostate. Additionally, numerous high-quality studies have validated the benefits of long term hormone therapy in men with high risk disease who are treated with radiation. Also, many high-quality studies have demonstrated that immediate treatment is better than treatment delayed until the time of relapse.
Confusion about giving hormone therapy to men treated with surgery has arisen because the early trials performed to test this concept selected the wrong patient (intermediate risk) and used too little treatment (3 months). The best cure rates result in men with high risk prostate cancer when long term hormone therapy is utilized. In my opinion, these improved cure rates will occur regardless of the type of therapy (surgery vs. radiation) that you combine it with.