European urology
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Randomized Controlled Trial Multicenter Study Comparative Study Clinical Trial
Randomized comparison of total androgen blockade alone versus combined with weekly epirubicin in advanced prostate cancer.
Hormone deprivation is the gold standard for the treatment of metastatic prostate cancer. However, prostate cancer being primarily a heterogeneous tumor comprising hormone-dependent, hormone-sensitive, and hormone-insensitive cells, at least the latter remain unaffected by hormonal manipulations, thus making disease progression almost inevitable. In quest of a more comprehensive therapy we therefore studied the concept of early combined chemoendocrine therapy in a prospective randomized multicenter trial. ⋯ In conclusion, the combination of TAB and epirubicin was well tolerated by patients with advanced prostate cancer and resulted in a significant extension of progression-free survival. This effect of E-TAB on objective treatment outcome was accompanied by prolonged time without treatment-induced adverse effects and tumor progression, i.e., time with good quality of life. Therefore, further studies with E-TAB appear warranted in patients with advanced prostate cancer.
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There is no debate that both the earlier diagnosis and the treatment of men with cancer of the prostate (CaP) are having an impact on patients with this disease. In many practices there are fewer and fewer patients presenting with the classic diagnosis of 'advanced disease', i.e., stage M (D2). Only a few years ago, a large percentage of men with CaP had bony metastases when they presented to a physician. ⋯ Newer advances, including 3-month depot formulations of luteinizing hormone-releasing hormone analogues, the reversibility of medical castration, the preference of most patients to have medical castration, and the approval of other antiandrogens in the United States, all have further strengthened the use of combined androgen blockade. Hormonal therapy in adjuvant settings, when there is a high likelihood of disease recurrence, is also being used in many clinical situations. In addition, there appears to be a role for certain types of hormonal therapy in chemoprevention.
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Munchausen's syndrome (MHS) is classed among the self-manipulated disease but is frequently not recognized as such. Patients suffering from MHS successfully obtain repeated invasive diagnostic management by the permanent presentation of various symptoms especially in the surgical branches of medicine. In urology, the 'hemorrhagic type', the 'abdominal type' and the 'neurological type' are predominant. ⋯ Consequently, diagnosis gets more and more difficult. In the majority of cases psychotherapy ends after few psychiatric interviews in the initial stage of therapy. Increasing somatic lesions are predominant.
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Review Comparative Study
Innovative approaches to the hormonal treatment of advanced prostate cancer.
Androgen ablation therapy is the treatment of choice for the palliation of patients with advanced prostate cancer. In addition to palliation, maximal androgen ablation (MAA), with a combination of medical or surgical castration and an antiandrogen, has been shown to increase the survival of patients with metastatic prostate cancer in at least three large well-conducted trials. A subgroup analysis of these trials has suggested that patients, particularly those with low volumes of metastatic disease, fared much better when treated with MAA than with castration alone. ⋯ This method reduces the total time of exposure to castrate levels of androgen and, although prostate-specific antigen levels rise during the second phase of therapy suggesting tumor growth, proponents of this cycling method suggest that this should prolong the time to androgen independence of the tumor. Early results with both methods suggest that the time to progression is long and side effects are minimized as compared to MAA. Large scale trials will be needed to determine the exact risks and benefits of these novel methods of androgen ablation.
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The optimal treatment for many unresectable solid tumors involves the combined use of chemotherapy and radiation. Retrospective and prospective randomized trials demonstrating a reduction in failure rates when neoadjuvant androgen suppression is combined with radiotherapy suggest that this is also likely to be true for prostate cancer. The absence of overlapping toxicities, the high response rates to androgen suppression, and the ease with which the prostate is included in radiotherapy portals makes the prostate an ideal site for chemoradiation. ⋯ This neoadjuvant approach also reduces the amount of normal tissue to be irradiated when used prior to 3-dimensional conformal radiotherapy while allowing higher doses to the tumor. It may be particularly important to use antiandrogens to block the 'intraprostatic flare' that may result from the testosterone surge induced by luteinizing hormone-releasing hormone in patients undergoing neoadjuvant (short course) androgen suppression. Men who are at particularly 'high risk' for biochemical failure when treated with radiotherapy alone should probably receive a 'longer' course of complete neoadjuvant and possibly adjuvant hormonal blockade, but the optimal duration and sequence of androgen suppression remain to be defined.