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Case History

image A 77-year-old man is diagnosed as having prostate cancer. His prostate-specific antigen (PSA) level is 15 ng/ml, there is a nodular, asymmetrical prostate on digital rectal examination, his Gleason score is 8 (4 + 4) and his staging is pT3a N0 M0 on imaging. He lives alone, has no relatives close by, and he walks 4.5–6.5 km every day. He is referred to the oncology clinic from the urology department.

What are the treatment options for pT3 disease?

What drugs are available for hormone treatment?

What are the side effects of hormone treatment?


image The patterns of diagnosis and treatment of prostate cancer have changed in the past 15 years coinciding with the introduction of prostate-specific antigen (PSA) screening in the late 1980s. Between 1984 and 1991, 30–40% of men presented with advanced disease, whereas currently only 5% have distant metastases at the time of diagnosis.1 In contemporary series, approximately 10–12% of men with newly diagnosed disease have locally advanced (clinical stage T3-T4) or metastatic disease at diagnosis.2 Hormone treatment or androgen deprivation treatment (ADT) is the primary therapeutic approach for advanced prostate cancer because the suppression of androgens decreases tumour progression. As the testes are the major source of androgenic steroids, ADT can be accomplished with bilateral orchidectomy or with medical treatments.


What are the treatment options for pT3 disease?

image Locally advanced prostate cancer (cT3) can be treated with radiotherapy and hormone treatment is usually started 2 months before and continued during radiotherapy. Radiotherapy should be delivered in a way that ensures a curative dose to the prostate and minimizes rectal and bladder toxicity. A standard dose is 55 Gy over 20 fractions. The outcome for radiotherapy is as good as for radical prostatectomy, and use of Partin et al.'s tables can help to define the likelihood of organ-confined disease.3

Radical prostatectomy has not been widely accepted but may be appropriate in younger men.4 Pretreatment prognostic variables, using Epstein's criteria,5 may help the selection of a subgroup of men with cT3 disease with the most favourable long-term outcomes following radical prostatectomy. Most men with locally advanced prostate cancer are advised to undergo some form of definitive local treatment (such as radiotherapy) but hormone treatment alone may represent a reasonable option for men who are medically unfit or who have a limited life expectancy.

What drugs are available for hormone treatment?

Hormone treatment or ADT is the primary therapeutic approach for men with T4 and metastatic prostate cancer, alleviating metastatic bone pain in 80–90% and leading to objective responses in serum PSA level, and soft tissue and bone disease. Although ADT may modestly prolong survival,6 it is palliative and not curative. Most of the men who initially respond to ADT progress ...

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