Editor’s Note It might not happen, but it should

The culture of healthcare delivery for patients with prostate cancer is a highly unusual and interesting pocket of oncology therapeutics. From my perspective as a medical oncologist who has observed the evolution of the evidence-based interdisciplinary management of patients with common tumors like breast, colorectal and lung cancer, prostate cancer follows a very different model.

Specifically, men with prostate cancer receive initial systemic therapy from their primary urologist or radiation oncologist, and medical oncologists are not usually involved until patients become resistant to first- or second-line hormonal therapy, often many years later. Simply and humbly put, it is my opinion that this is not in the best interest of current or future patients. More bluntly, I suggest that clinical research is hampered by this management strategy. Equally troubling, patients may be receiving suboptimal care.

A major detrimental outcome associated with this prevailing treatment paradigm is the marginal integration of chemotherapy into the management of patients with prostate cancer. As discussed by medical oncologists Susan Slovin and Joel Picus in this program, studies in patients with advanced disease clearly demonstrate that chemotherapy, particularly taxane-based regimens, is as effective in prostate cancer as they are in many other solid tumors.

Unfortunately, more than 25 years after a mortality advantage was reported in women with breast cancer in the first adjuvant chemotherapy trials, we essentially still have no data about adjuvant chemotherapy in patients with prostate cancer.

At the recent 2004 American Society of Clinical Oncology (ASCO) annual meeting, two randomized trials reported a significant survival advantage for adjuvant chemotherapy in patients with non-small cell lung cancer (NSCLC). For years, NSCLC — like prostate cancer — was considered “chemoresistant,” but in retrospect, trials with adequate statistical power had not been executed.

When adequately powered trials were finally conducted in non-small cell lung cancer, the overall survival curves were very similar to those in the old breast and colorectal cancer studies. At the same ASCO meeting, two other studies demonstrated that docetaxel-based therapy extended survival in patients with metastatic prostate cancer. Those data are comparable to the results we saw 10 years ago in patients with metastatic lung cancer.

I would bet 10 bucks and dinner at Joe’s Stone Crab on South Beach that a similar survival benefit would be observed if an adjuvant docetaxel-based regimen were compared to placebo in men with high-risk prostate cancer.

I believe that clinical trials ultimately will demonstrate that, like breast cancer, the best strategy to remain free from prostate cancer recurrence and death will include short-term adjuvant chemotherapy followed by extended endocrine therapy. Sadly, it could take 10 to 15 years before we have an answer, and in the interim, many men will suffer and die from this disease.

As a corollary, it is astonishing that the research platform for the current use of endocrine therapy in patients with prostate cancer is almost nonexistent. The most common clinical scenario for the use of androgen deprivation involves the patient with a PSA-only relapse, and essentially no prospective randomized clinical trial data exist to support this treatment strategy. Not that treating at PSA relapse is an inherently bad idea, but if I were a person with cancer, I would prefer that research data guide my doctor’s decisions.

My comments are made with the full understanding that I am not a prostate cancer researcher or clinician, just a CME doc who likes to make people think and maybe push a few buttons. Putting all controversies aside, if you listen to Drs Slovin and Picus, it seems obvious that medical oncologists can be helpful at an earlier stage in the prostate cancer treatment paradigm.

Here is my suggestion, which totally ignores the practical obstacles to making it happen:

There are institutions where this happens regularly, but these are primarily large tertiary care cancer centers. In community practice, where most men with prostate cancer are treated, medical oncologists see patients years after the initial systemic treatment decisions are made. This can and should change, and like everything else in the United States, all types of market forces are involved. However, if you’re a man with a prostate, or more importantly, if you’re a man without one, you want to see this happen a lot sooner than later.

— Neil Love, MD
NLove@ResearchToPractice.net

Select Publications

Eisenberger MA et al. A multicenter phase III comparison of docetaxel (D) + prednisone (P) and mitoxantrone (MTZ) + P in patients with hormone-refractory prostate cancer (HRPC). Proc ASCO 2004;Abstract 4.

Petrylak DP et al. SWOG 99-16: Randomized phase III trial of docetaxel (D)/estramustine (E) versus mitoxantrone(M)/prednisone(p) in men with androgen-independent prostate cancer (AIPCA). Proc ASCO 2004;Abstract 3.